A pregnant 28-year-old with cough and dyspnea
A 28-year-old pregnant female comes to your office in the late afternoon with complaints of coughing spasms, chest tightness, and a sensation of being unable to breathe. These symptoms began about 6 hours earlier, while she was repainting a disassembled bicycle with an acrylic lacquer spray paint in a small, poorly ventilated basement area. The painting took about 2 hours to complete.
The patient also experienced nausea, headache, dizziness, and lightheadedness, which cleared within an hour after leaving the basement area. The chest complaints, however, have persisted, prompting the office visit. She is concerned that her symptoms are related to the paint spraying and may affect her pregnancy.
Vital signs include blood pressure 116/80, heart rate 90/minute at rest, respiratory rate 22/minute, and temperature 98.8°F. There are no orthostatic changes in pulse or blood pressure. The HEENT examination is negative except for very mild scleral injection. There are mild expiratory wheezes throughout both lung fields but no rales or no abnormal findings on percussion. Spirometry shows an FEV1 of 72% of predicted value and a moderately decreased peak expiratory flow rate of 275 L/minute. The FEV1/FVC is 75%. Cardiovascular and neurologic examinations are normal. The abdomen is soft and nontender, and a bimanual pelvic examination reveals a 16-week gravid uterus. There is no vaginal bleeding, and no adnexal masses are present.
On questioning the patient further, you discover that 2 years ago she was exposed to fumes of toluene diisocyanate (TDI) from an accidental spill during employment as a bookkeeper at an industrial research laboratory. The patient had only eye and upper airway irritation at the time of the accident but developed severe shortness of breath and coughing 4 hours later. She was hospitalized for several days but recovered.
(a) What further information and history would you attempt to elicit?
(b) One of the ingredients in the spray paint is toluene. Could this be responsible for the patient’s symptoms?
(c) The patient is concerned about possible effects on the fetus. What advice would you offer?
(d) How will you treat this patient?
Answers can be found on page 15.