The Importance of Taking an Occupational History
to the editor: I read with great interest the case report1 in American Family Physician presented by Dr. Mycyk and Ms. Hettmansberger regarding a patient with “occult” lead poisoning. It was interesting to note that even after an extensive three-day work-up as an inpatient, the patient finally revealed at discharge that he was a welder who was exposed to lead fumes.
Because the most common exposure to lead among adults is occupational, this case illustrates that a thorough occupational history is essential in any patient who presents with a constellation of unexplained symptoms. An occupational history would most likely have revealed important diagnostic clues regarding the nature of this patient's illness and may have prevented a lengthy diagnostic work-up and delay in treatment. Furthermore, an exposure history should be elicited with a particular focus on personal hygiene, such as eating or smoking on the job, and the habits and general health of his coworkers who also may experience similar exposures.
Ideally, a work-site evaluation should include a walk-through of the patient's work space, with particular attention paid to engineering and administrative controls. An inspection of the patient's personal protective equipment would ensure that it is functioning properly and is appropriate for the type of work that is being performed. Because most physicians are not trained in workplace evaluations, the inspection should be performed in conjunction with a certified industrial hygienist or a health and safety officer who is familiar with health and safety protocols, the Occupational Safety and Health Administration's regulations, and appropriate fit testing of personal protective equipment.
Finally, it is important to establish whether the patient might be unknowingly placing others at risk by wearing work clothes home and exposing family members to lead dust or other contaminants.