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Discussion

New case study

Hm. They get harder as we go along. Fun.

A 25-year-old maintenance worker is brought into emergency by his co-workers. They have been hired to rehab an old house. The guys say Mike has been working in the basement doing mold abatement - the house had a leak for years and now the new owners wanted to have the basement disinfected and prepped for painting. Mike had seemed fine during the morning coffee break, but by lunch, they notices he wasn't looking good. He tried to pour coffee into his cup and missed. He was having difficulty breathing. Despite breathing very rapidly, the breaths were very shallow and labored. When asked if he was OK, he didn't respond right away, seemed kind of out of it, and complained about his chest hurting. One of the guys took his pulse and discovered it was 125 beats per minute, and they immediately dragged him in. He has crackles. A series of tests were run and gave the following results:

RBC's 5.2X106/ %2Fd2l%2Ftools%2Fimg%2Fsymbols%2Fmu.gifL

WBC's 7000/%2Fd2l%2Ftools%2Fimg%2Fsymbols%2Fmu.gifL

Differential WBC

neutrophils 62%

eosinophils 3%

basophils 0.6%

macrophages 5%

lymphocytes 30%

blood pH 7.3

arterial blood gases

PaO2 55 mmHg

PaCO2 30 mmHg

Mike is put on supplemental oxygen and his blood gases retested 15 minutes later, producing the following results

PaO2 50 mmHg

PaCo2 47 mmHg

I'm leaning toward asthma, a couple people say PE, and another says pulmonary edema. What we all find odd is the continued low PaO2. Part of me says that maybe it is edema and the fluid is keeping the O2 levels down, but wouldn't that then cause elevated CO2 levels, as well? No idea what his pH does after the initial ABG, which might be helpful.

Ah well. More fun for the geeks on the board!

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dont know about the crackles etc, but what about CO poisoning?

  • Author
dont know about the crackles etc, but what about CO poisoning?

Eh, I could see it if he were alone, but since he was working with a group, wouldn't they all show signs? I like to think she'd mention his coloring then, but maybe not..

Eh, I could see it if he were alone, but since he was working with a group, wouldn't they all show signs? I like to think she'd mention his coloring then, but maybe not..

frankly, i think there are too many things that wouldnt fit,,,but when i saw basement+elevated CO2 i think leaky furnace......good luck

He's not getting oxygen into his blood stream, or CO2 out of it.

Sounds to me like it could be a problem related to both circulation and lungs.

i was originally leaning toward co poisoning. the case states that mike was working in the basement (didn't say his co-workers were), and co is heavier than air, so it sinks as low as it can get. his lack of muscular coordination, rapid pulse and mental confusion also were indicative of co poisoning.

however, i would have expected some of his co-workers to have experienced some co symptoms, given the acute-ness of his situation. also, according to emedicine.com, pao2 levels are usually normal in the case of co poisoning.

i wouldn't be concerned about no information regarding his coloring. according to the emedicine article, "classic cherry red skin is rare (ie, "when you're cherry red, you're dead"); pallor is present more often."

http://www.emedicine.com/emerg/topic817.htm

i'm not convinced one way or the other, but asthma doesn't seem likely to me. having a husband who had asthma, i can tell you that when he was in the midst of an attack, he was acutely aware of the fact that he couldn't breathe and he was very mentally alert. he also kept verbalizing his inability to get a full breath, and this guy doesn't seem to be doing much, if any, of that.

interesting (and fun!) as always!

  • Author

Interesting. But that still wouldn't explain the low PO2 after supplemental O2, would it? I can't figure how his CO2 came back to normal but his O2 didn't.

Seems to me that it would be CO2 poisoning.

But it makes me wonder if it's not something to do with breathing in the mold?! They didn't say he had been wearing a mask, but did say that he had been working with mold, but didn't specify a time frame. This one is a stump for me! GL!

  • Author

Yeah, the mold really has me going with some kind of reaction, but I am starting to think you guys are right about the CO2. Gah! I'd be more likely to go with rxn if I had a timeframe or hx of allergies, but since I don't, I can't assume.

  • Author

Wait, though, his PCO2 was never elevated, it went from low to normal. So it'd have to be hypOcapnia...

  • Author

Okay this gets weirder: his PCO2 is low, which means his pH *should* be elevated, but it's not. wha-? Unless I screwed up and used venous numbers instead of arterial for the pH, which I probably did. But even so, I'm not sure the numbers would be that different, at least enough to take him from low to high. I feel like there must be a value that's off here.

I keep thinking his chest hurting is an important clue. I don't know if that's typically present in CO poisoning???

I know you can have an allergic reaction to mold, especially if you already have asthma. Aspergillus can cause a burning sensation in the lungs of asthmatics. But other aspects of the case don't fit neatly into the allergic response... uh.. mold. Pun not originally intended! :chuckle

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