D: To start, could you tell me a little bit about what brought you in today?

P: Really I just don't I I don't feel quite right like I've had this pain in my chest for five days now and I've been just feeling kind of out of breath.

D: Oh OK, um where are you feeling this pain?

P: Um, it's it's kind of um. On the left side of my chest and it's just like a tiny. It's like a lingering sharp pain. I don't really feel it anywhere else. It's just kind of there all the time right now. I I've never had anything like this before.

D: OK, so you're not feeling the pain radiate any to any other locations. You're just feeling it sort of in the one spot on the left side?

P: Yeah, yeah, exactly.

D: OK, and since this pain started 5 days ago, has it gotten any better, any worse, or stayed the same?

P: Like when I when it started I was just I was just like sitting on my couch. Um and now it's harder if I'm, it's worse if I'm walking around, like if I walk just down the street to get the mail. But otherwise it's kind of kind of just there, like I took some Tylenol and Advil, and they maybe take the edge off a little bit, but it's always there. And it's worse when I, when I take a deep breath then I really feel it.

D: OK, so it's worse. Is the pain worse when you're walking as well? Like out to get the mail?

P: It's I don't the the pain is, but I I'm not I can't catch my breath when I'm doing that.

D: OK, and how far could you usually walk, or um?

P: Oh yeah, usually walk before I go for long walks like every day, like probably like 5 kilometers or something.

D: OK, so prior to this happening you were feeling well?

P: Yeah, totally. I've not ever had any problems with my heart or lungs or anything. I thought it was maybe just like a chest infection. But I I don't know anymore.

D: OK, so you've had that, the difficulties breathing and the pain. And have you had any other symptoms?

P: Mmm I think it's just those those, the two things that I said.

D: OK, so have you been experiencing any fevers or chills?

P: No. Nothing like that.

D: OK, how about any nausea or vomiting?

P: No.

D: OK, and um, how is your energy been? Have you experienced any like significant fatigue?

P: Um. Not. Well, I mean, I've been doing less stuff because it's harder to breathe like I'm getting kind of like I can't catch my breath. So I guess maybe maybe a little bit like fatigue.

D: I see OK, but feeling fine energy-wise prior to the two 5 days ago?

P: Yeah, totally.

D: OK, uh and, have you been having any night sweats?

P: Uh, no, no I haven't.

D: OK, how about any unusual headaches?

P: No.

D: Alright, and have you felt as though your heart is racing or beating out of your chest at all?

P: No, no, it's just that like sharp that sharp pain.

D: OK, have you had any episodes of lightheadedness or feeling like you, you might might faint?

P: No, no, just the difficulty breathing that scares to me, but it hasn't been like that.

D: OK, have you had a cough?

P: No, no, that's the thing, that it seems weird, right?

D: OK, um sometimes things can be associated with a cough so we'll absolutely look into what the causes of your symptoms are today. But you haven't brought up any any blood or any sputum?

P: No no.

D: OK, and have you had any wheezing with your with your breath?

P: I don't know. I don't think so.

D: Alright, and how about any abdominal pain?

P: No, I mean the pain is like, yeah, it's in my chest. Yeah, that's not in my it's not in my belly at all.

D: OK, and have you had any urinary problems?

P: No, I mean so I had. I had a I had a hysterectomy. Weeks ago, maybe like maybe like a month ago now, um? So after that it was, you know, feeling a little. Like I was kind of not drinking as much and that so I wasn't peeing as much then, but I think it's normal now.

D: OK um. And how have you recovered since the hysterectomy? Were you like bedbound for quite awhile afterwards or were you up an active?

P: Really, it was not really long that I may be a few days, I wasn't. I wasn't walking as much, but I thought it was like back to my normal self.

D: OK, well that's good. I'm glad that you recovered from that surgery quickly. And what was the surgery for?

P: Uh, I uh. I mean I, I'm done having kids and I, uh, I had. I was just having really heavy periods still so, uh, and you know a lot of pain there, so hat's why I had hysterectomy.

D: OK, um, and have you had any bowel problems?

P: No no.

D: OK, how about any skin changes or or rashes?

P: No.

D: OK, how about any joint pains or or leg pains or muscle pains?

P: Uh, no, I don't think so.

D: OK. Um, so in regards to past health, any previous medical diagnosis?

P: Uh, no. Just like I had the hysterectomy but I I don't like take any medications I don't have like high blood pressure or anything.

D: OK so no prescription medications or over the counter medications you take regularly like supplements or?

P: No, just just to those like the Advil and the Tylenol I was taking for the pain.

D: OK. And any other surgeries besides the hysterectomy?

P: Uh, like I have my wisdom teeth out when I was like a teenager. That's it though.

D: OK, then, how about any allergies?

P: None.

D: OK, and are your immunizations up to date?

P: I think so, um. Yeah, yeah I don't. Yeah, I don't think, I didn't get anything that was supposed to.

D: OK, well, that's good. And, uh, has anybody in your family experienced anything like this before?

P: My mom had a heart attack when she was like in her 70s. Uh. Other than that, I don't. I don't know. I don't think so.

D: OK, any, um, cancers in the family or or bleeding disorders or coagulations disorders?

P: Um, no, I don't think so.

D: OK, so I haven't heard of anybody in the family having like a blood clot, or or a thrombosis anywhere?

P: I think my mom's like cousin, but not no one like not like my parents or anything.

D: OK, um, so the next few questions I just wanted to ask about your personal and kind of lifestyle habits a little bit. But first, could you tell me about your living situation?

P: Uh, yeah I live. Um, like I said like I'm done having kids but I have 2 two kids. They're teenagers. I live um, with them and my husband and, uh. We live not far from here.

D: OK, and what do you do for work?

P: Um, Im an accountant.

D: OK, and do you drink alcohol?

P: Um maybe a glass of wine on like the weekends but? Not other than no.

D: OK and do you smoke cigarettes?

P: I do, I'm trying to stop. I smoke maybe like. I don't know like 5 per day or something at this point.

D: OK, but it sounds like you've been working on cutting down which is great. Um and have you used any other recreational drugs?

P: Um, no, no. I mean, when I was like younger I sometimes like would use marijuana, but I haven't really recently.

D: OK, and have you been any been on any like long trips recently?

P: No I wish.

D: Fair enough, vacation would be great. Um, OK so. But that was all the questions that I wanted to ask on on history, were going to run some investigations. I am concerned that you might have a pulmonary embolism, and so we're going to do some lab work and imaging to investigate that.

P: OK I yeah. Is that scary? Is that bad?

D: It can vary from being mild to severe, and so that's what we want to get. Some of the imaging and lab work to see well to first confirm if that's what you actually have, and if so, offer the right treatment.

P: OK thanks doctor.

D: Welcome will get that started.


D: Uh, what brings you in here today?

P: Yeah, so my daughter, she's had this hoarse voice for the past like two or three days. It doesn't seem to be getting better. In fact, it's getting worse and she just doesn't sound like herself anymore and she's not speaking as much.

D: OK, and when did this start?

P: OK, so she had a cough like four days ago, and she's still coughing a little bit, but not as much as she was before, but it's more her voice that I'm concerned about. It sounds very hoarse and harsh.

D: OK, and so how many days has she had the hoarse voice for?

P: I'd say about two or three days now.

D: Two or three days, OK. And when she was coughing, you mentioned like previously was she coughing up any sputum or was it more of a dry cough?

P: It was more of a dry cough

D: And the cough has pretty much resolved by now?

P: Yeah, she still gets them once in a while, but yeah, it's pretty much gone.

D: OK, and when she was coughing, did she at all bring up any kind of blood or any green or yellowish material?

P: No

D: No, OK. Did she have any fevers at all, recently?

P: Uh, no, no fevers.

D: OK. And does she have any kind of, uh, along with a hoarse voice, does she have any pain with talking?

P: Yes, I think so.

D: OK, and does she have any pain with swallowing any foods or liquids?

P: She's eating and drinking ok, but I suspect there is some pain.

D: OK, So how long has she, so she has a sore throat, how long has she had that for?

P: The sore throat? Uhm I would say for the past two or three days as well.

D: OK, and was there anything that, so she had kind of like a cough previously, but anything else, anyone sick around her, or anything you think might have precipitated some of her symptoms?

P: No, not that I know of. I don't think she's had any contacts with sick people recently.

D: OK. Are there any, have you tried any medications over the counter, that has helped her?

P: Uhm, not over the counter medications, but like I tried to get her to like gargle with like salt water and all that kind of stuff, but that didn't seem to help.

D: OK. And have her symptoms been just constant or do they come and go?

P: They've been pretty constant.

D: OK, and you think her symptoms are getting worse?

P: Uh, no, they've been pretty consistent, but maybe the harsh voice is getting worse.

D: OK. And other than the symptoms that you've mentioned, has she had any kind of shortness of breath, wheezing, chest pain or anything like that?

P: No, nothing like that.

D: OK, and no fevers, right?

P: No

D: OK. Has she traveled at all recently outside of the country or outside of the province?

P: No, no, nothing like that.

D: OK, and any headaches at all?

P: Uhm, no.

D: No, any nausea or vomiting?

P: Uh, no, nothing like that.

D: OK, any runny nose or congestion?

P: No.

D: No, OK. And have you had a chance to at all, look into her mouth and throat? And if you have, have you noticed any kind of redness, swelling?

P: I haven't looked in there too much, like, just an inspection the other day, it looked a little bit red, but I didn't see any discharge.

D: OK, and have you noticed any kind of swelling around her neck, ears, like, around her lymph nodes?

P: Uhm, I haven't actually taken a look there.

D: OK, we can do that. Other than those symptoms, has she been experiencing any kind of like fatigue or have you notice her being just very tired?

P: Um, she has seemed a little bit more tired than usual.

D: OK, and right now is she going to school or is right now all like virtual? Is she at home?

P: Uhm, she's at home right now.

D: OK, and does she have any symptoms of, any chest pain at all?

P: No chest pain.

D: OK, any changes in her bowel movements, any Constipation, diarrhea?

P: No.

D: OK, any urinary problems?

P: No.

D: OK, has she been able to sleep well or does she wake up a lot more at night?

P: Uhm, she's been able to sleep well, yeah

D: OK, how about her appetite?

P: Its been pretty normal. She's not eating as much as she used to, but she's still eating and drinking ok.

D: OK, and have you noticed any kind of weight changes at all recently has she lost any weight?

P: No

D: OK, and, has she had any loss of taste, of smell or sorry, loss of sense of taste or smell at all.

P: Uh, no.

D: Any muscle aches or anything like that?

P: Uh, no, nothing like that.

D: OK, any exposure to fumes, dust, animals or Pets at Home?

P: Uh, no, nothing like that.

D: OK, has this happened at all in the past?

P: Uhm, no.

D: No, OK. Does she have any medical conditions at all that she's been diagnosed with in the past?

P: Uhm, no, nothing like that.

D: Any like asthma or any other conditions?

P: No.

D: OK, any allergies that you know of?

P: I know she has seasonal allergies, but that's about it.

D: OK, and does she take any medications at all on a daily basis?

P: Uh, no, she just takes multi vitamins.

D: OK, and currently or previously has she had any surgeries or hospitalizations?

P: No.

D: No, OK. Are there any family history of any lung or heart conditions?

P: Uh, no.

D: Any cancers?

P: There's some colon cancer on her dad side of the family.

D: OK, and is there any, so do you remember who the person is and also like when they got diagnosed with the colon cancer?

P: So it was her uncle. He was diagnosed when he was forty five.

D: OK, other than that, were there any developmental challenges at all while she was growing up? Did she, was she meeting her milestones? Any concerns at all?

p: No concerns, she was meeting all her milestones from what I remember.

D: OK, and uh, in terms of her pregnancy, were there any, or your pregnancy with her, were there any complications at all either during the pregnancy or after she was born?

P No, no complications.

D: And right now, where does she live, and who does she live with?

P: she's at home with myself, my husband and she has one younger sibling.

D: OK and, is everyone at home well, does anyone have any of these symptoms?

P: No, OK.

D: Right, so, and in terms of the home environment, does anyone smoke in the house?

P: No.

D: No OK, alright so I think that's all the questions I had right now. Do you have any questions or concerns?

P: No, no questions, but uhm, actually, what do you think she has and how can we treat her?

D: Yeah, so it seems like that the hoarseness of voice and the sore throat and her symptoms mostly align with what's called laryngitis, and this is usually caused by like just a viral respiratory infection. The hoarseness of voice will usually last more than a week and up to like ten days and it should resolve on its own. But we'll definitely take a better look and do a proper physical examination, see if I see any kind of swelling, redness, or any like white streaks or exudates around her pharynx as well. So after we take a look, we'll see what we can do. It doesn't seem like, it can also be a bacterial infection, in which case we would need to give her antibiotics, but usually it's a viral infection that should go away on its own. So we would just kind of wait and see and potentially just give her voice some rest during this period, and just go on from there. Do you have any other questions or concerns?

P: Uh no, that sounds great, thank you.

D: You're welcome and yeah, we'll, just do a full examination and then go from there.

P: OK, sounds great thanks.

D: You're welcome.  Take care.

P: You too.


D: So what brings you in here?

P: Yeah, I've had this sore throat. It started, really, yesterday and I've been having problems with eating and drinking.

D: OK, so it just started yesterday. Has it occurred before?

P: Not this painful before.

D: OK, are you were having any trouble swallowing just solids or liquids as well?

P: It hurts to swallow both. When I have something really cold it helps, I mean, it's easier to drink, but it still hurts.

D: OK, and are you having any other symptoms besides the sore throat?

P: Yeah, I've been nauseous and I vomited a couple of times.

D: OK, just within the last day?

P: Yeah, this is over the last day. I vomited three times yesterday and once today.

D: OK, and uh, what was the color of the vomit? Was it just food that you had eaten? Or was it green? Can you describe it a little bit?

P: Yeah, so the first two times it was more of what, like, the food that I had eaten and then the last two times it's been more yellowish green, cause I haven't really eaten much since yesterday afternoon.

D: OK, and did you notice any blood in it at all?

P: No blood.

D: OK, and do you have any idea what caused the nausea or vomiting? Was it after eating? Or, like, were there any triggers?

P: I think the first time was associated with like, after eating, but I'm not sure about the other ones.

D: OK, and with your sore throat, are you having any kind of like a gag reflex or anything like that?

P: Yeah, maybe a little bit, maybe that's what prompted it.

D: OK. And has your sore throat been just constant or does it come come and go?

P: It's been pretty constant, yeah.

D: And how much would you rate the pain out of 1 to 10? 1 being the least pain you've felt in your life, 10 being the worst.

P: Uh, I would say, uh, a 6, it's pretty painful.

D: OK, um, have you noticed any kind of like swelling around your neck? Or any redness in your throat?

P: Yeah, I felt my neck this morning in the front of it, it does feel swollen.

D: OK. And are you coughing at all?

P: No, I haven't had a cough.

D: OK, so no cough but are you producing any sputum or yellow material?

P: No, nothing like that.

D: OK, are you coughing up any blood at all?

P: No.

D: Is there anything that makes it better or worse that you have tried?

P: Just cold drinks.

D: OK. And, uh. So you've also had nausea and vomiting. Are you having any kind of diarrhea or Constipation?

P: No, but I've had a sore stomach.

D: OK, and did that also start yesterday?

P: Yeah, it's just been, like, fairly generalized. Feels sore.

D: OK, so not in any particular area, just kind of all over your stomach?

P: Yeah, like, I mean, I guess sort of like in the center, more so, but I can't really put one finger on the spot.

D: OK, and is it constant or does it come and go?

P: It kind of comes and goes.

D: OK, and uh, is it associated with eating food at all, or does it get better when you defecate?

P: I haven't noticed anything like that, maybe it's worse after vomiting, those few times.

D: I see OK, yeah. So yeah, sometimes with the vomiting you can also get some some discomfort. So no diarrhea or Constipation though, right?

P: No.

D: Uh, so are you having any other symptoms like shortness of breath or chest pain, or like a runny nose? Any any of those symptoms?

P: No, nothing like that. I've just had a headache as well, but it's pretty mild.

D: OK, have you tried any medications at all, over the counter?

P: yeah, I took a Tylenol cause I started feeling a little bit hot as well, to help me sleep last night

D: OK, have you been having any fevers or chills?

P: Yeah, I felt hot but no chills.

D: And did you manage to get like a temperature at all?

P: No.

D: OK, we can do that here today. So you just felt like a bit hot last night?

P: Yeah, last night I felt pretty hot, sweaty.

D: OK, have you been in contact with anyone who's been sick, or any recent travel at all?

P: I mean, not that I can think of.

D: OK, uhm, so I'm just going to list a few symptoms just let me know if you have any of them. Do you, do you feel fatigued?

P: No.

D: Do you feel that you have any kind of swelling in your extremities, or any rashes or skin changes?

P: No, I haven't noticed anything like that.

D: OK, any changes in your urinary pattern?

P: No.

D: OK, any changes in your sleep or appetite?

P: No.

D: OK, any significant weight loss over the last month?

P: No, my weight has been the same.

D: OK, and have you, before this all started, have you had any like, Congestion, runny nose, or any other cold like symptoms?

P: No, I've felt well otherwise.

D: OK. Uhm, do you have any past medical conditions like asthma Or anything else?

P: Uh, no.

D: OK, so you're healthy?

P: Yes.

D: OK, do you have any allergies?

P: No, I don't.

D: OK, are you currently taking any medications regularly?

P: No.

D: Any previous hospitalizations or surgeries?

P: No.

D: Any family history of any lung conditions or heart conditions or any cancers?

P: No, nothing like that.

D: OK, and currently do you work?

P: No, I'm just going to school.

D: OK, and so, currently where do you live and Who do you live with?

P: Yeah, so we live in a house with my parents and younger brother and we've been both back at school now Part time and doing some of it at home online as well.

D: OK, so anyone at all that you notice at school that was sick around you?

P: No, not that I am aware of.

D: OK. So yeah, this is just a question that we ask everyone. Do you drink alcohol or smoke cigarettes or use any recreational drugs?

P: Uh, no.

D: Ok, so those are all the questions I had to ask you. Anything that I may have missed or anything you want to tell me?

P: No, that's everything that's been happening over the last couple of days.

D: OK. Alright, so yeah it seems that, from your age and some of your symptoms we will definitely do a testing for strep throat. It seems that you meet that criteria. And we also want to make sure that, since you're having other symptoms as well, just to do a covid test, just in case. We'll take your temperature as well, and we might give you some antibiotics as well to treat you and relieve some of those symptoms. So yeah, just hang tight, we'll get the swab done for you for the Covid test, as well as strep throat and then we'll go from there.

P: Great, thank you.

D: You're welcome, take care.


D: What brings you in?

P: My child has been having a sore throat and chills yesterday as well.

D: OK, so you mentioned the sore throat started three to four days ago and the chills started yesterday. And is he having any issues swallowing food or fluids?

P: Yeah, it seems like appetite's gone down, like a lot of pain in his throat, especially when swallowing solid foods.

D: Have you taken a look into his throat? Is it red? Do you see any yellow streaking white stuff, anything like that?

P: I definitely did take a look yesterday and definitely saw a lot of redness. I don't know if I saw any white or yellow streaks, but definitely looks very red in there.

D: OK, do his tonsils look enlarged?

P: Uh, everything looks swollen in there, I don't know what's what, but it does look very angry in there.

D: OK, OK. And has he had a stuffy nose or runny nose?

P: No, not really, no.

D: Any loss of taste or smell?

P: No, nothing like that.

D: OK, how about changes in vision or hearing? Any changes in her nails or skin like rashes?

P: No, no rashes.

D: OK. Have you taken his temperature at home?

P: No, I think he might have had a fever yesterday, but we didn't really take a temperature.

D: OK. And, any fatigue or exhaustion?

P: Energy's pretty much the same, just really complaining a lot about the throat.

D: OK, OK, have you noticed any swelling in in the neck area?

P: Uhm, I think there might be like a few lumps near his neck, so I don't know if that's swelling, but definitely there is. There's a few that I felt over the last few days.

D: OK, coughing?

P: No, hasn't been coughing at all

D: OK, um, and how about shortness of breath or wheezing?

P: No, nothing like that.

D: Chest pain?

P: No.

D: Feeling like his heart is racing?

P: No.

D: Swelling in his limbs?

P: No. I haven't noticed anything like that.

D: OK, dizziness or fainting spells?

P: No.

D: Headaches?

P: He was complaining of a headache a few days ago, but it kind of went away on its own.

D: OK. So the headache's gone completely now.

P: Yeah, yeah.

D: OK. Have any confusion or memory loss?

P: No, not that I know.

D: Joint pain or muscle aches?

P: No.

D: OK, how about his bowel movements? Have those been normal?

P Yeah, they've been normal. No diarrhea or constipation.

D: OK, how about in nausea or vomiting?

P: No, no, he hasn't told me anything about that.

D: Any appetite changes?

P: Yeah, just with the trouble swallowing I'm trying to make sure that he gets like liquids because over the last few days he can't tolerate like solid foods at all.

D: Yeah, how about a weight loss over the past few weeks?

P: No, not really. t's just been over the last few days that he hasn't been eating like himself.

D: OK. Alright and has he been healthy otherwise?

P: Yeah, otherwise he's a very healthy child. We have rarely gone to a doctor for him before, so yeah, nothing. Nothing else with him.

D: OK, have you tried anything for his sore throat? Anything over the counter?

P: We did try, uh, like Tylenol cold. It helped with this headache, but it didn't really help with his sore throat

D: OK, and has he ever experienced anything like this in the past?

P: No, not that I know of.

D: OK. Any hospitalizations or surgeries in the past?

P: No.

D: Any medications that he's on?

P: No, no medication.

D: OK, is he up to date with all his immunizations?

P: Yeah, all his immunizations are up to date.

D: OK, any allergies?

P: No, not that I know.

D: OK, family history of lung conditions or heart conditions?

P: No, no lung or heart conditions. His father does have diabetes though.

D: OK, how old was he when he was diagnosed with diabetes?

P: I think probably in his late 30s with type 2 diabetes.

D: Type 2, OK and then any sick contacts recently that he may have had?

P: I don't think at home at least, uh, but maybe at school, like you never know who they are in contact with, so I'm wondering if he just picked it up somewhere from school.

D: OK.

P: Yeah, yeah, they're all wearing masks right now, but I don't know if he picked something something up from his classmates.

D: Yeah for sure. OK, and then any travel to anywhere recently?

P: No, we've been at home, haven't left even to go to like a different city, have been in London the whole time.

D: OK, yeah, and who does he live with at home?

P: So he lives with myself and his dad.

D: Any siblings?

P: No, he's an only child.

D: OK, any reason to believe you have old carpets, mold, asbestos, anything that could be triggering his symptoms?

P: You know we don't have any pets. We don't have any like old carpets, it's a fairly new apartment, so I don't think any of that should be an issue.

D: Okay, well, I think those are all the questions that I had for him. Anything that you wanted to add or anything that I missed today?

P: Uh, no, I think those are everything I wanted to talk about but I just was wondering if he needs to get tested or like if there's anything we can do today for him.

D: Yeah, so he does seem to be checking off some of the criteria for strep throat. So just to make sure, because he does have a score of right now at least three or four, or maybe even five, definitely over four, we can prescribe him some antibiotics. But we will do a rapid strep test first in the clinic here today just to rule out in or rule that out. If it comes back positive and I guess even if it isn't positive because he checked off a lot of the boxes for strep throat, we will give him a prescription for penicillin or amoxicillin for 10 days. And then you can take that if his symptoms don't go away in a day or two. Because his symptoms also overlap with COVID, we will. do a swab for that as well and you should hear back within 24 to 48 hours and then you should isolate for 14 days. Does that sound good?

P: Yeah, that sounds good.

D: OK, great thank you.

P: Thank you.


D: How may I help you?

P: Um I'm here because I've had some numbness in my right hand and uh doesn't seem to be going going away, so I thought I should get it checked out by you.

D: Yeah, certainly so, so when did this exactly start?

P: Um so it's been pretty gradual, I would say over the past month or two months um is when I first noticed it, but the numbness is definitely worse now than it was at the start.

D: OK, and uh where is this um the pain and numbness, where are you feeling it exactly?

P: Um it's particular, it's the worst on my thumb and index finger.

D: OK, do you feel it on your ring finger or uh, or sorry or your middle finger?

P: Um there is a little bit on my middle and ring finger, but it's like it's very very mild.

D: OK. Uh, and uh, like how long, is, are the symptoms constant or or are they intermittent?

P: Um I would say it's somewhat constant, but it's worse when um when I'm trying to like hold the steering wheel or using my phone, or you know, reading a book.

D: OK, I see, and um is there anything that you do uh at those times, to try to help get the symptoms to go away?

P: Um I guess I like shake out my hand um or yeah, try to put pressure on those numb, numb areas.

D: OK, does flicking the the wrist or anything like that, does it help?

P: Uh maybe slightly.

D: OK. And uh like how would you describe the the pains in your hand, like dull, achy, sharp?

P: I would say the pain is more like a tingling sensation. Um so I guess the tingling is is like a sharp feeling, um I wouldn't call it so much pain as I would just like tingling and numbness.

D: OK. OK, and uh is is there anything, so you mentioned sort of the driving and using your phone, are there any other activities that make it worse?

P: Recently I found it's hard for me to hold things um in my right hand, so like if I'm trying to open up a jar um like it's hard for me to hold it, and sometimes I find uh like it'll just fall out of my hand.

D: OK, so you're like dropping items and stuff?

P: Mhmm, yes.

D: OK, and do you feel any, uh, like the numbness or tingling, does it radiate anywhere? Like to your forearm or up into your like upper arm or shoulder?

P: Uh no, I don't think so. No.

D: OK. And do you have any neck pain?

P: No.

D: OK, and have you had any trauma or injuries to your wrist or hand?

P: No, nothing that I can think of.

D: Alright. Um and, have you had any weight loss recently?

P: No.

D: How about any fevers or chills?

P: No.

D: Have you had any night sweats?

P: No.

D: OK, have you had any changes to vision or hearing?

P: No.

D: How about other senses like any changes to your sense of smell or sense of taste?

P: No.

D: Alright, have you had a runny nose or felt congested?

P: Uh no.

D: Alright, have you had a sore throat or a cough, perhaps?

P: No.

D: Alright, have you had any shortness of breath?

P: No.

D: Have you had any chest pain or feeling like you're uh like feeling like you have heart palpitations?

P: No.

D: OK. Have you had any lightheadedness or dizziness?

P: Uh no.

D: Alright, and have you had any nausea or vomiting?

P: No.

D: How about any abdominal pain?

P: No.

D: Alright, how about any urinary problems?

P: Uh no.

D: Have you had any changes to your bowel movements like diarrhea, constipation?

P: No.

D: OK, and have you had any changes to your hair or nails?

P: No.

D: And any skin rashes or um anything like that?

P: No.

D: Alright, and uh have you had any other pains in your joints or any joint swelling?

P: No.

D: OK. Uh, and have you been diagnosed with any medical conditions before?

P: No, not that I can think of, yeah no, when I was younger I had like childhood asthma but nothing since.

D: OK, do you use any inhalers now?

P: No, not for a long time.

D: OK, do you take any other medications?

P: No.

D: OK, um and how about, do you have any allergies?

P: No.

D: OK, and have you had any surgeries or hospitalizations?

P: Uh no.

D: OK. Um and, uh, could you tell me a little bit about uh where you're living and who you're living with?

P: So um I live with my boyfriend and we live in a rented basement apartment downtown.

D: OK. Um and are you working currently, or are you in school?

P: Um I am a grad student.

D: OK, excellent, and um do you smoke cigarettes?

P: I don't.

D: OK, and uh do you drink alcohol?

P: Um I'll have a glass of wine once a week.

D: Alright. Um and do you use any recreational drugs?

P: Uh no.

D: OK. And in the family, uh, are there any, is there a history of like hypothyroidism or other autoimmune conditions?

P: Um there's rheumatoid arthritis in the family, but that's about it.

D: OK, um but you don't have any other joint swelling or pains, right?

P: No.

D: OK. Uh, and so next I would like to just um uh do a physical exam, and for the first part I'll ask you to just have a look at the hand and wrist and, are you seeing any swelling, erythema or redness or like any muscle wasting or or atrophy?

P: Um so, in my right hand, um I guess the you know the fleshy part of your thumb just above your wrist, um that seems to be um I guess atrophied compared to my left hand.

D: OK so, OK, so the muscle bulk is um reduced there.

P: Mhmm.

D: OK, and are you feeling any temperature changes, like does the, any areas of the hand or wrist feel warm or hot?

P: Um no.

D: Alright. Um and are there any areas if you uh palpate that cause pain, like over the wrist or any of the joints?

P: No pain. Um yeah, no pain.

D: Alright, um and, are you able to uh flex and extend your wrist?

P: Uh yeah I can do that.

D: Alright, and and how about making a fist and and then also extending your fingers back out?

P: That hurts, or like that causes the tingling.

D: OK, um are there any any issues with like moving your elbow or your shoulder?

P: No.

D: OK, and if you take your opposite hand, um with just your uh kind of pointer finger and middle finger and just really tap, um right near the wrist crease called the Tinel's test, you tap there. Do you feel any reproduction of symptoms?

P: Yeah, that that causes the tingling.

D: OK, so you're positive Tinel's test, and um if you kind of place your wrist so that um like the backs of your hands are facing each other so that your wrists are flexed downwards and your um, your wrists are flexed and your fingers are pointing towards the ground and you just hold that position for a period of time. Um do you feel any pain?

P: Uh I guess a little bit of tingling.

D: OK, so that would be a positive Phalen's test as well. Um and range of motion of the neck, do you have any problems with that or any pain there?

P: No.

D: OK. Um I think that was everything I wanted to ask about and check on the exam. Did you have any questions for me?

P: Um no, no questions. Thank you so much.

D: Alright, you're welcome, yeah, so it sounds like this could be uh carpal tunnel syndrome and uh so we we may depending on uh kind of like nerve studies to confirm the diagnosis, and um things that you can do in the meantime would be to use like a splint or um yeah, try to use like nighttime splints and activity modification as well.

P: OK, yeah, that sounds good.


D: What brings you here today?

P: Hi, I bring you my son today because I've noticed he's had been having this cough sometimes he’ll have it at night and and, he'll have some wheezing and difficulties breathing as well.

D: OK, and when did this all start?

P: So I I've been noticing it over the last several months. It's been happening um a couple of times per week where he'll get this cough and that at night time and yeah so over the last several months.

D: OK, and what did it start with coughing or like the shortness of breath? What would it kind of start with?

P: Are more the, uh, the coughing, yeah, he just get it at night time and then sometimes he would get it um like it at at school as well. Or even if you went over to one of us, his friends houses, sometimes he would come home and or afterwards he would have a cough and wheeze and and be short of breath.

D: OK, and so is it. Usually after he's worked himself up and like exercise or like just been really active?

P: Yeah, that definitely. I noticed that after those times for for sure.

D: OK, and are these like the coughing? Is it wet or dry?

P: It's it's a dry cough.

D: Dry cough OK, so no yellow green material or blood coughed up/

P: No, nothing like that. Uh coughed up.

D: OK, and you're saying you also hear wheezing, right?

P: Yeah, I'll hear a wheeze. He has this like high pitched whistling sound when he exhales.

D: OK, and has he at all had this happen before? Or is this the first time this is happening?

P: Um like when he was really younG I think like two he had like bronchiolitis or something like that. I think it was called you had a cough and um like a wheeze at that time, but I think it was because of a like an infection or viral a viral illness.

D: I see. Um has he had any uh sore throat, runny nose, cold like symptoms at all recently?

P: No, he hasn't had anything like that.

D: OK, OK, so his symptoms mainly occur when he's very active um, so they kind of come and go, and have you tried it at all anything that has helped with the symptoms?

P: No, I haven't tried anything.

D: OK, any kind of dizziness, changes in his behavior at all from being very irritable to very fatigued? Anything like that?

P: No, nothing like that.

D: OK, um any fevers or chills?

P: No.

D: OK, any recent travel or contact with someone who's been sick.

P: No.

D: OK, any nausea or vomiting

P: No.

D: OK, any changes in his bowel movements?

P: No, he hasn't had any diarrhea, so no diarrhea, no constipation.

D: OK, and um any changes in his appetite at all?

P: Um no he's been eating and growing well.

D: OK any changes in his weight?

P: Yeah yeah, he's been gaining weight uh over the last over the last little while. I think he's been gaining
weight appropriately.

D: OK, um do you find that his symptoms get worse in any particular season like the winter or anything like that?

P: Um. I yeah. I mean sometimes I guess like in the in the fall or when the seasons change she does get like itchy eyes and like a runny nose. I think he does have maybe some environmental allergies.

D: OK, OK, and at home or at school any exposure to like fumes, dust or animals?

P: Um no animals at at home, but the friends house he goes over to sometimes they have um a cat there.

D: OK and does does he get those symptoms at his friends house?

P: Yeah, sometimes he'll come, he'll um he'll have a bit of a cough and you can hear a wheeze sometimes that after, it goes away uhh relatively quickly we like within 30 to 60 minutes and, but um yeah.

D: OK. Any past medical conditions that he's been diagnosed with?

P: No, he just had that yeah the episode of I think bronchiolitis when he was young, but that was it.

D: OK, any um medications that he has to take regularly?

P: No.

D: No, any allergies, training medications?

P: Uhm, no.

D: No, or any allergies to any environmental or food factors.

P: Uhm, no, I don't think so.

D: OK, have you had any rashes at all previously?

P: Uhm. No, yeah he hasn't had any rashes.

D: OK. And um. Any hospitalizations or surgeries?

P: Uh nope.

D: OK. And any family history of any heart lung conditions? Any history of asthma at all?

P: Um yeah, his mom has a has asthma um and she uses a an inhaler like daily for it.

D: OK has, when did um the mom get diagnosed with asthma? Was it during childhood?

P: Yeah, she was younger. Um ever since I've known her, she said she's had she's had asthma. It hasn't had any like real I guess exacerbations that that I've noticed or been able to control her symptoms with with um inhalers.

D: And um for him, how many times would you say he's having these episodes in an average week now?

P: Uh I would say 2.

D: 2 and is he getting Any of these symptoms at night time, like him waking up?

P: He is yeah it's it. It is happening at night.

D: OK, and then as he missed any days of school due to this?

P: Yeah um. He's missed a couple of days in the past month because uh he just didn't sleep well and then not feeling good the next day. So um yeah, he has.

D: OK. Yeah, so and any issues with the mother's pregnancy with him at all?

P: No, she's healthy and the delivery was at term with a normal body weight or birth weight rather and he he was healthy when he was born.

D: So no prolonged stay in the ICU or hospital after that?

P: No, he was able to go home, luckily.

D: OK, and afterwards has he been meeting all his milestones like his motor gross motor, fine motor, social skills and growth and all of those have been meeting them well.

P: He has, yeah yeah. He's been meeting all of his milestones and growing well.

D: OK, and um any at all issues from the school in terms of learning difficulties or anything like that?

P: No, he's been doing well uh in school.

D: OK, that's good. Um does he have any siblings?

P: Um no, he's a it it's just him. He's our only child

D: And what's the home situation like? Who does he live with?

P: So it's myself and my wife, which his mom, and so it's just us three and we live in a um in a house.

D: OK. Uh, and anyone in the household uh? Does anyone smoke at all?

P: No, there aren't any smokers in the home.

D: OK, and any new carpets or any dust running or mold or anything like that in the house?

P: That there is a carpet and in the basement that, he uses that as his playroom, sometimes

D: OK. OK. Yeah, so those are all the questions I had. Do you have any questions at all?

P: Yeah, I was just wondering like if this could be maybe asthma as well?

D: Yeah, so definitely. That's something that's at the top of our head right now, especially due to his age and the symptoms that he's been having after exertion in particular. And the family history of asthma as well. So definitely that's something that we want to investigate. So what we'll do for him is first, we'll do like a full physical examination. Listen to his alongs. And just assess his breathing and then afterwards we will order some tests for him, so he's six years old, right?

P: He is yes.

D: OK, so we'll see if we can do something called a pulmonary function test. Sometimes it depends on the child
if they're able to follow instructions, and so that test requires a completely breathing out and following some instructions during the test. So since he's six, he might be able to do that. We we can try that. And then afterwards we'll see if he requires anything like an allergy testing or we will we might need to help manage his symptoms with a puffer, for example, like Ventilin and an  inhaled Cortico steroid, but those are just some discussions will have in the near future after we've done all these investigations.

P: OK, great, thank you.

D: You're welcome alright, take care

P: Bye.


D: So I understand you have been experiencing some abdominal pain?

P: Yeah yeah stomach hurt, started hurting more last couple of days, maybe 3 days ago I think.

D: OK, so for three days ago, for the last three days you said it's been hurting more. Did you have pain before that?

P: It felt weird, like crampy. I just, I just thought I was constipated, 'cause I've been haven't been able to be able to go to the bathroom as well. I just thought I was kind of bloated a bit, but yeah, about about that time, started to feel a little bit more painful.

D: Can you tell me kind of where you're feeling the pain the most?

P: Yeah, kinda like near my right hip like lower where my stomach is that kind of right and below my belly button. Sometimes a little bit on the top just below my belly button, but mainly just in that right lower side yeah.

D: OK, have you ever had pain like this in the past?

P: No, never.

D: OK. And for the last three days, has it been pretty constant? Has it been on and off?

P: I feel it's been getting worse to be honest.

D: Is there anything that you can think of this made it feel better?

P: Honestly, just resting flat makes it feel a little bit better, but nothing much, no.

D: OK, is there anything that makes it worse?

P: Touching it. Also I puked the the other day and that made it definitely feel worse, just that whole contraction in my body was nasty.

D: OK, was it just the one time?

P: Yeah.

D: OK, you had the nausea associated with the pain?

P: Mhm, mhm.

D: Um, did the pain stay in that same spot or does it move anywhere else?

P: It has pretty much stayed in that one spot, yeah.

D: Have you noticed any fevers lately?

P: Felt a bit hot the other day, didn't take a temperature though.

D: OK, OK, and what specifically prompted you to come in today to the emergency department?

P: I thought it was just going to get better when it first started. Maybe just a bit of gas, but here we are kind of Thursday now and it's still pretty bad.

D: OK, have you been in contact with anyone that's been sick lately?

P: Not off the top of my head, no.

D: And have you traveled anywhere recently?

P: No.

D: And I forgot to ask, did you notice any changes to your bowel habits?

P: Yeah, yeah. Before it was fairly regular, about once a day. Five days ago, I started getting constipated, it backed up and pretty much the picture I think last time I went to the bathroom was two days ago I think, yeah.

D: OK, I'm just gonna ask you some questions about your overall health. You have any chronic conditions that you see your family doctor for, or any other doctor?

P: I got diabetes, type 2.

D: And has that generally has that been well controlled for you lately?

P: Most part, doctor checks my sugars. I'm not too regular on them myself, but last time he changed medications was a couple years back and I've just been on the same ones ever since.

D: What medication are you currently taking?

P: Metformin? Metformin.

D: And have you ever had any surgeries in the past?

P: No, I had my teeth pulled as a kid, but no.

D: OK, still have your appendix?

P: Yeah, yeah, I never had that problem as a kid.

D: And do you have any allergies?

P: No, sometimes get a little bit congested during the fall, but that's it.

D: Do you have any family history of gastrointestinal problems?

P: Gas, like no. I think my grandma died of breast cancer fairly early, but no, not not that not that I can think of.

D: OK, and just in terms of your lifestyle, do you live here in town?

P: Yeah yeah, I live here.

D: Living alone or with family?

P: No, no, I got family. Me, the wife, got two kids, one of them is college bound now but yeah.

D: Nice, and what do you do for work? Or are you retired?

P: I'm still working, I am a production overseer, production manager over at Fairbanks.

D: OK, you're a big boss.

P: It took awhile to get here.

D: I'm sure it was very hard work. In general, do you drink alcohol?

P: Oh yeah, like, well, plan on drinking on the two four but not regular, special occasions mainly. Hot days, sometimes I'll have a beer or two.

D: Sure, and do you smoke cigarettes?

P: No.

D: Have you ever smoked in the past?

P: No.

D: Do you cannabis?

P: No.

D: Any other substances?

P: No.

D: OK, is there anything else you wanted to bring up today that I didn't ask you about or any other questions that you have?

P: No, just hoping to get an answer to whatever is going on.

D: OK, well at this point I will do a quick physical exam. We may want to have blood work done, maybe some other tests based on what we find out from there and then we can kind of let you know after that, what the next steps will be. So I'm just going to take this and go over it with the physician that I'm working with and will get back to you shortly. Thanks for chatting with me.

P: Thanks doc.


D: What brings you in here today.

P: I I've had this cough that's been ongoing and and getting worse, and and now I've been having this like sharp pain in my in my chest.

D: OK, and when did the cough first start?

P: So yeah, like the cough started, uh, started maybe a couple of weeks ago.

D: A couple weeks ago, OK, and has it gotten worse since then, or has it stayed about the same?

P: Uh it, it got worse initially, but it's been about the, uh, well, actually yeah, it's been getting worse 'cause now I've I've started to notice blood in the sputum that wasn't there at first.

D: OK, and when did you first notice that?

P: So I, I first saw some blood, uhm, two days ago. It was a really small amount so I didn't worry too much, but I I brought up blood yesterday and again this morning. It's been just about enough to cover a tissue, so it's not a lot of blood each time, but it's pretty red.

D: OK, and before that were you getting any production throughout your coughs for the last few weeks, like were you producing any sputum?

P: Uh, no.

D: No, OK. Can you just describe your cough currently? Is it more of a wet cough or dry cough?

P: Uh it, yeah, it's it's dry mostly with the exception of bringing up some of the blood.

D: And is the blood just in like sputum that you're bringing up? Or are you coughing up blood into the tissue, for example?

P: Blood is, I'm coughing that up into the tissue.

D: OK, and do you remember 2 weeks ago prior to that, were there any factors that might have caused this, like for example, did you travel anywhere or see or was in contact with anyone that was sick?

P: No I haven't uh, traveled anywhere. I have been doing volunteering and and things at the homeless shelter here in in town. It's been really cold out.

D: OK, uh, and how long have you been volunteering there?

P: Uh, I started this winter, so the last three, three or four months.

D: OK, and were you in contact with anyone there that was sick or was having similar symptoms at all?

P: There are certainly some people around that that had some that would have a cough, or were not feeling very well but, uh, and sometimes I would see people who would even have a hospital gown on, that that that uh came from the hospital. So yeah, there were definitely some people who weren't feeling well.

D: OK, and do you know if anyone at the homeless shelter or anywhere else around your surrounding has had tuberculosis?

P: No, not that I'm aware of. I haven't heard of that.

D: OK, are you having any other symptoms at all besides the the coughing and the blood, like coughing up blood as well?

P: Yeah, I've been uh, starting to get like this sharp chest pain as well. I kind of feel it on the left sides and in center I guess kinda more so.

D: OK and your chest pain, when did that start?

P: So, uh, this started, yeah, 'bout a few days ago as well. It's been within the last week.

D: OK, and uh, would you describe it as, so you said it's kind of a sharp pain, does it move around anywhere?

P: No, the pain I feel it about in the same spot each time.

D: OK, and are you feeling the pain when you're coughing or is it when you're exerting yourself, like when do you feel the pain, and how long does it last?

P: I, yeah, I will feel it when I cough. I also feel it uh, if I'm maybe moving around as well. Like changing positions or things like that. It hurts for a few minutes and then it it will kind of settle down. If if I'm, if I stay stationary and sort of lean forward a little bit it will it will start to feel better.

D: Sort of feels better? OK, and besides, besides like leaning forward, has anything helped reduce that pain at all?

P: Yeah, well if I lie flat, uhm it, it's uh, or sorry. No actually, the pain gets worse if I I lie flat or if I'm if I'm taking a deep breath in. But really, the only thing that helps the pain is if I try to lean forward when I'm sitting down.

D: OK, I see, and do you have any pain when breathing in or out?

P: I do, yeah it it gets worse if I if I'm taking a deep breath in, and even more so after I after I cough, if I'm trying to catch my breath, I'll feel it then too.

D: OK, and uhm, other than these symptoms, do you have any kind of shortness of breath? Do you have any dizziness or increased sweating, any of those symptoms?

P: I have been sweating at night, but, uh, yeah that's it.

D: And how about any fevers or chills?

P: I I have felt a bit hot. That's more so yeah, maybe when I've been having night sweats, but I feel OK now.

D: OK, and when you say night sweats, are your sheets and blankets like soaked your pillows?

P: Yeah, there there have been a few few nights for sure, but it doesn't happen every night. But over these last several months, it's been weird, I've woken up soaked.

D: OK, uh, do you have any other symptoms like a headache or nausea, vomiting?

P: No.

D: Have you measured a temperature at all?

P: Uhm no I haven't.

D: OK, we can do that today. Do you have any other symptoms like feeling like pounding your chest, racing heart, anything like that?

P: No, nothing like that.

D: Have you noticed any swelling in your extremities, like your legs and hands?

P: No.

D: OK, and do you have any issues with your bowel movements? Any Constipation or diarrhea?

P: No.

D: Any urinary issues?

P: No.

D: OK, any issues with your sleep and appetite?

P: Uh, no. Sleep's been OK, and I've been eating well, but I have uhm, lost some weight and and I've been more fatigued over the last couple months.

D: OK. Before the two weeks or a couple of weeks that you had this, were you sick at all recently? Like with a cold or any flu like symptoms?

P: No, I I uh, I guess I've been fatigued over the last couple of months, but I haven't had any flu like symptoms.

D: OK, and do you have any exposure to dust, fumes, animals anywhere in your surrounding?

P: I do have uh, two cats at home, but I've had them for seven years now and I've been tested for allergies and and I'm clear there.

D: OK? Do you live with anyone right now?

P: Yeah, I live with my husband and we have three daughters as well.

D: OK, and are any of them sick at all or have any similar symptoms.

P: Yeah, my my husband's had a cough uh, as well, he hasn't brought up any blood or anything though. But my my daughters have felt OK.

D: OK, and do you have any past medical diagnosis like high blood pressure, diabetes, asthma, anything like that?

P: Yeah I do have uh, type 2 diabetes, as well as high blood pressure. I've been diagnosed with depression before as well. I do take a few medications for diabetes and blood pressure. I'm not on insulin though.

D: OK, and do you know what medications you take?

P: I think an ACE inhibitor and, and I think Ramipril and uh, metformin.

D: OK, and do you take anything for depression?

P: I used to take a a citalopram, but I stopped and and things have been been stable.

D: That's good. Any hospitalizations or surgeries in the past?

P: I had two C sections for my second daughter and and 3rd.

D: OK, any complications at all with those C sections?

P: No, everything was was good.

D: OK, any other surgeries or hospitalizations?

P: No.

D: OK, do you have any family history of any lung conditions, heart conditions, any cancers?

P: My dad had a stroke when he was in his late 60s, but that's the only thing I can think of.

D: OK, and I know you said you volunteer at the homeless shelter, but do you do anything else for work at all?

P: Yeah, I've been doing some administrative work from from home because of covid, so with the extra time I've been trying to to do some extra volunteering.

D: That's really good. And so besides, so you live with your husband and three kids, does anyone in smoke in the house or do you smoke at all?

P: No, I don't. No one smokes in the house.

D: OK, does, uh, do you take any recreational drugs like marijuana?

P: No.

D: And how about alcohol?

P: Sometimes I'll have some like red wine with dinner, but that's only on like Christmas or an occasion.

D: OK. Yeah, alright so uh other than that, sorry, I think I might have forgotten to ask you a couple questions. So no fainting spells, no shortness of breath, nothing like that?

P: No, I haven't had anything like that, just a stern cough.

D: OK, and no chest pain on exertion?

P: No, it's the chest pain, well, I guess if I'm like moving around a lot, but it's not, it doesn't come on uh, like because of like physical activity. I just feel it like anytime I'm, like when I'm breathing in or even just moving my body around in the chair.

D: And any like fatigue or increased tiredness.

P: Yeah, I've had some fatigue for sure.

D: OK, and have you lost any weight recently?

P: Yeah, I I have actually. I'm I'm down 20 pounds. I thought that was great. I I was 200 pounds just two months ago.

D: And have you been trying to lose weight or that 20 pounds just went away spontaneously?

P: Uh, I mean I I guess I've tried to make changes to my diet here and there because of the diabetes, but I don't really think that it would be enough to lose 20 pounds.

D: OK, I see. Yeah so, do you have any questions? Those are all the questions I have. Do you have any questions or concerns?

P: No, I was just, I guess just concerned about the the blood in the, in the cough.

D: Yeah, so definitely that's something concerning. We want to make sure there was no, so you work at a homeless shelter, where there may be a tuberculosis case, and your symptoms of coughing up blood as well as losing a significant weight recently, and some of the other symptoms that you described as well, point towards uh TB as one of the causes. No lung cancer history right, in your family?

P: No.

D: OK, uhm so we definitely want to do testing for TB. Will do us a smear today of your sputum and we will, since you have been in contact with your family, we will have to contact a public health if the tests come back positive, and it seems that, we'll also do some other testing. Sometimes with tuberculosis you can get something called pericarditis, and some of the symptoms you are having may point to pericarditis as well, so we might have to do an EKG. We might have to further do an ultrasound, an x-ray, for example. So first we'll just get the TB test done and then if it comes back positive, you will need to isolate, be admitted to the hospital as well, and be on a course of antibiotics. So I know this is a lot to take in. Do you have any questions or concerns at all?

P: Not right now. Guess will wait until some of the results come back and yeah, get started.

D: Yeah, so we'll just do the TB test first, alright?

P: Alright, thank you.

D: Welcome, take care.


D: How may I help you?

P: Hi, yeah, I'm here because I'm over the past like couple of months I've been losing a lot of weight. Uhm, but I didn't really have any other symptoms, but since like 2 weeks ago I've been coughing up some blood and now I have a fever as well.

D: OK, so you mentioned you notice the weight loss first. How much weight have you lost? Or roughly?

P: I've lost about 30 pounds in the past, past like 8 months.

D: OK. So, and have you been trying to lose weight?

P: No.

D: OK and, any, like any changes to your diet or exercise?

P: No, nothing like that.

D: OK, and more recently you started to have a cough. When did that start?

P: The cough started two weeks ago.

D: OK. And prior to this, did you have a cough?

P: No.

D: No. And are you bringing bringing up any sputum or phlegm?

P: Uh yeah it's yeah, there's sputum for sure and it looks bloody.

D: OK. So you're, you're, you're coughing up blood as well.

P: Yes, that's right.

D: OK, uh, and that's been going going on for the last two weeks too?

P: Yes.

D: OK. And how much blood have you been bringing up roughly? If you can think of it in like terms of tablespoons or teaspoons.

P: Like every time I cough, it's about the size of a teaspoon.

D: OK, and are there any triggers for your cough that you can think of?

P: Uhm, I don't think so. They just happen throughout the day.

D: OK, and have you tried anything for the cough?

P: I tried this cough suppressants. I tried like salt water rinses, like just like at home remedies and over the counter products, but nothing is helping.

D: OK. And so have you had any like viral infectious type symptoms, such as like eye, eye discharge or red eyes or runny nose or even a sore throat?

P: No, nothing like that.

D: OK. And, and have you had any any headaches?

P: No, no headaches.

D: OK. Have you had any, have you had a runny nose?

P: No.

D: OK, how about any, have you had any loss of smell or, or taste?

P: No.

D: OK, have you had any shortness of breath?

P: Uh, no.

D: Have you had any wheezing?

P: Uhm, no. No wheezing.

D: OK, have you had any chest pain?

P: No.

D: OK. Have you had any dizziness or fainting?

P: Uhm, no, nothing like that.

D: Heart palpitations?

P: No.

D: OK. And have you had any any nausea or vomiting?

P: No.

D: Have you had any abdominal pain?

P: No.

D: Have you had any diarrhea or constipation?

P: No.

D: Have you had any pain with urination or, or frequency?

P: Uh, no.

D: OK, have you had any rashes?

P: No.

D: How about muscle aches or body pains?

P: Uhm, muscle aches, yeah. Yeah, that's been happening.

D: Any particular muscles? Or is it more general?

P: It's more general.

D: Have, have you been having any bone pain like any in your back or anything like that?

P: No.

D: OK, and, uh, how has your energy been?

P: Ah, pretty low.

D: OK, and how is your appetite been?

P: Uhm, also pretty low.

D: OK. And in the in the past have you been diagnosed with any medical conditions?

P: Uhm, no, I've been pretty healthy so far.

D: OK. Uhm, so do you take any medications regularly for anything?

P: No.

D: OK. And do you have any allergies to medications or, or anything environmental?

P: Uh, no.

D: OK, and have you had any prior hospitalizations or surgeries?

P: Uhm, no.

D: OK. And, uh, could you tell me a little bit about your living situation currently? Like who you're living with an ah, whereabouts you're living?

P: Uhm, I live alone by myself. I live in an apartment downtown.

D: OK, and are you working currently or in school or?

P: Um, I'm working from home right now.

D: OK, have you been around anybody who's been sick?

P: No.

D: Have you traveled anywhere recently?

P: No, not since I moved here.

D: OK, when did you move here and where did you move from?

P: I moved here a year back from Sri Lanka.

D: OK. And, and in Sri Lanka, were any of your family members or people that you spent time around ever diagnosed with tuberculosis?

P: I mean, it's pretty common in Sri Lanka. None of my immediate family members were.

D: OK. And do you smoke cigarettes?

P: No.

D: And ah, do you smoke cannabis or use any cannabis products?

P: No.

D: OK. And do you drink alcohol?

P: I don't.

D: OK, how about the use of any other recreational drugs?

P: Uh, no.

D: OK. And uh, any family history of heart or lung problems?

P: Heart or lung? Uh, no, not that I know of.

D: OK, and how about any cancers in the family?

P: No, no cancers.

D: I see, alright. Did you have any other questions for me today? I think that was everything I wanted to ask about for now.

P: Ah no, what do you like, what do you think I have, and how do you think I should treat it?

D: So, uh, yeah, it's sounding like, like it could be tuberculosis based on the kind of timeline of your symptoms and so and cough and hemoptysis and so we'll do a test for that, like an acid fast test of the sputum. Get a chest X Ray. And if it is tuberculosis, it will require a prolonged course of antibiotics, so that I'll be over several months. Umm, and so I we'll get the infectious disease team involved to help kind of guide our management with the appropriate antibiotic choice, if it does come back to be tuberculosis.

P: OK. OK, that sounds good, thank you.


D: What brought you in today?

P: Hi, um so I've had this terrible fever for the past three days um and just before that I had a stuffy nose um and I had a sore throat, well I still do, um and it's just not going away, so I thought I should just come in and see if I have covid or what it is.

D: OK, so if I understand, it started with a stuffy nose?

P: Yes.

D: OK and that kinda progressed to a fever?

P: Yes, that's right.

D: OK, have you been feeling any other symptoms aside from the fever?

P: No.

D: Nothing really, have you had any nausea, any vomiting at all in the last little while?

P: No.

D: Any pain anywhere else in your body?

P: Uh, no.

D: OK, do you have any neck stiffness?

P: No.

D: Any headaches?

P: Um no, no headaches.

D: OK, and have you been able to eat and drink during this time period?

P: Yes.

D: Excellent. OK, you've had a cough at all?

P: No cough.

D: No cough, OK and then how about abdominal pain, any pain in your tummy?

P: Um no.

D: Nothing like that, what about other changes in your body? Have you noticed any fevers or any rashes, any skin changes?

P: Uh no, nothing like that.

D: OK. What about any pain in any of your joints and your knees, hips?

P: Oh, actually um not in my joints, but I've just, there there has been some muscle ache.

D: OK, how long has that been going on for?

P: Uh for the past two three days.

D: So around the same time that you've had this fever?

P: Mhmm.

D: OK.

P: That's right.

D: Now have you had any contact with anyone who's been sick in the last little while?

P: Um no, not that I can think of.

D: OK, have you had any recent travel anywhere else?

P: No, I did go hiking um last weekend, um and it was about 2 hours away, um there were some people on the hiking trail that I passed by, but um other than that, no travel outside the province.

D: OK. Does anyone around you or in your immediate circle come down with anything similar recently?

P: Um my husband has also been experiencing similar symptoms for the past week.

D: OK, how's he doing?

P: Uh the same as me.

D: OK. And have you had any covid swabs recently?

P: No.

D: OK, and aside from the weekend hike, have you been mainly self isolating or?

P: Uh yeah, just me and my husband at home.

D: OK, and do you leave the house for work at all?

P: No, I work from home.

D: OK, sounds good. So you have some muscle aches, little bit of fever, stuffy nose, sore throat, do you have any difficulty swallowing?

P: Uh no, it just hurts.

D: OK, so you're still able to swallow food, swallow liquids?

P: Yes, that's right.

D: It doesn't feel like anything is going down the wrong way or have any coughing after you swallow?

P: No.

D: OK. And just in terms of coming back to this sore throat, do you feel like you have any swelling around your neck? Does it feel inflamed or swollen?

P: No.

D: Nothing like that?

P: No.

D: OK, alright, excellent. So you're eating well, doing well, any changes to your bowel movements recently?

P: Uh no, no.

D: OK, alright, I'll just kind of go into other things, just in terms of anything else that you might have had in the past, uh have you ever been hospitalized for any reason in your life?

P: I had my gallbladder taken out five years ago.

D: OK, so that was around when you were 50 years old?

P: Uh yes.

D: OK. And any other surgeries you've had in your life?

P: Uh no.

D: No, anything you've had to see a doctor for?

P: Um I, in the past couple of years uh just for things like like this I guess um colds, um I'm pre diabetic, so I've been checking my glucose levels, yeah other than that nothing else.

D: So no high blood pressure?

P: No.

D: No cholesterol issues?

P: No.

D: OK, so it sounds like you've been pretty healthy otherwise.

P: Yeah.

D: Excellent, OK. Do you have any allergies? To medications or otherwise.

P: Penicillin.

D: Penicillin, what happens when you take penicillin?

P: Um I get a rash.

D: OK. Any trouble breathing?

P: No.

D: And what medications, if any, are you on?

P: Um I'm, I just take multivitamins, that's it though.

D: And you said you lived with your husband in a house, um in London?

P: Um yes, that's right.

D: What do you two do for work?

P: So I work from home as a digital marketing agent and my husband is a computer programmer.

D: OK. And do you smoke?

P: No.

D: Do you drink alcohol?

P: Uh I drink once once in a while.

D: OK. And when you drink, how many drinks do you have?

P: Um about one or two glasses of wine.

D: Got it. Any other recreational drugs, substances?

P: Um no,

D: So no marijuana, heroin, cocaine?

P: I've tried marijuana before, just like edibles, but not, not regularly.

D: Understood. And have you ever used IV drugs?

P: No.

D: OK, and when was your last menstrual period?

P: It was um a year ago.

D: A year ago?

P: Mhmm.

D: OK. And then otherwise, so we talked a little bit about recent travel. It sounds like you have the hiking trip last week and you passed some people, but it sounds like your husband also has kind of similar symptoms that you do right now.

P: Yeah.

D: Sounds good, now we've already talked about kind of past medical issues. Moving on, I think what we'll do next is move on to a physical exam. But before I do that, do you have any questions for me? Anything else you feel I should know?

P: No, do you think I have covid?

D: It's a possibility. It's always good to rule these things out, so we'll be ordering a covid swab no matter what. Obviously with any presentation where we have someone come in with a fever and sore throat, we want to rule out anything infectious. So it sounds like if your husband got it, and you have it, covid would be our first thing that we want to rule out. So just while we're trying to investigate, work this up further, I want to have you and your husband self isolate. The other question I suppose I should ask is, have you gotten your flu shot this year?

P: No, I haven't.

D: So it's also a possibility it might be influenza, just the seasonal flu. But until we, I suppose rule out covid, it'd be best just to keep to yourself just in case you are infectious for the meanwhile.

P: OK, sure.

D: Alright, well I'm going to go talk to the Doctor and I'll be coming back in to see you, OK?

P: Alright, great thank you.

D: Take care.


D: How can I help you?

P: Hi so I brought my 6 year old son in today because yesterday during soccer practice, he he developed this pretty severe cough and he couldn't catch his breath.

D: OK, so this happened yesterday, you mentioned?

P: Yeah, it happened yesterday afternoon.

D: OK, uhm so you mentioned a cough. Is it a harsh barky cough, or is it more like a muffled cough?

P: I would say it's more muffled.

D: OK, and is it a dry cough or is it bringing up any phlegm?

P: Dry

D: Dry OK. So no blood in the with the coughing?

P: No blood.

D: And does he sound wheezy to you?

P: He does, yeah, he's still sounding a little bit wheezy now. It's it's better than last night. He was a bit more wheezy last night.

D: OK. Uhm how about shorter breath? Does he sound short of breath at all?

P: No, that that's gotten a bit better, that resolved about an hour. Like after he stopped playing but he was, he was short of breath yesterday.

D: OK, and have you tried anything for his cough, for his shortness of breath or wheezing?

P: No, we haven't

D: No OK. Does he have a fever at all?

P: No, he doesn't mention anything about feeling hot or or or having chills either.

D: No OK, and any rashes that you've noticed?

P: No

D: No, weight loss over the past few weeks?

P: No, he's been gaining weight well.

D: OK good, has he had a stuffy nose or runny nose?

P: Well, sometimes he will get a runny nose. He takes like Reactin or Claritin or some sort of allergy pill for that sometimes, but that's usually like the changing of seasons that will happen more often.

D: OK OK. Does he have any allergies?

P: Yeah, to mostly environmental triggers. I'm not sure if the specific things are, but I just know it gets worse. Maybe in the spring, springtime?

D: OK. And does he have asthma?

P: He's never been diagnosed, but he has had uhm or his sister has asthma.

D: OK, OK. And has he? Have you noticed any changes in his vision or hearing?

P: No.

D: No, OK. How about change in his smell or taste?

P: No

D: No, how about like does he seem like he has any chest pain?

P: No, he hasn't mentioned anything like that.

D: Any dizziness or fainting spells?

P: No

D: No, confusion or memory loss?

P: No.

D: OK, Uhm how about confusion or sorry you said no headaches?

P: No headaches.

D: No, OK, any joint pains, muscle aches?

P: No.

D: OK, and how about changes to his bowel movements?

P: No, everything's been normal there.

D: OK, how about nausea or vomiting?

P: Nothing like that.

D: OK, OK, so you mentioned he has asthma. He might have asthma. He was never formally diagnosed. Does is he otherwise healthy or does he have any longstanding medical conditions?

P: He's been healthy. Yeah, I know he did have like he would get some itchy skin when he was a bit when he was like a baby, but he hasn't needed any creams for that for a long time.

D: OK so he might have something like eczema, you think?

P: Yeah, yeah I think he did.

D: OK, OK and is he on any medications right now?

P: No, he doesn't take anything right now.

D: OK, Uhm during his mom's pregnancy with him, were there any complications?

P: No, she was uhm healthy and he was born at term with a normal weight and able to go home relatively quickly, so there weren't any concerns.

D: OK, that's good and was he healthy like after birth?

P: Yeah, so he's he's done well. There weren't really any concerns with development or or growth, and he's doing well in school.

D: OK, OK, good. How about uhm so was he a full term baby and was it a vaginal delivery?

P: Yes. Yes for both

D: OK, any complications during the delivery?

P: No,

D: OK, and he didn't need any hospitalizations like right after birth as an as a newborn?

P: No

D: No, OK good. Uhm Is he up to date with all his immunizations?

P: He is, yeah

D: OK. And you mentioned that he may have some seasonal allergies. Any other allergies that you know of?

P: Not that I know of.

D: No, OK. You mentioned that his sister has asthma. Any other lung conditions or heart conditions that run in the family?

P: No, nothing like that.

D: No, OK. OK. Uhm and does anyone at home smoke?

P: No

D: No OK. Any old carpets? Does mold, asbestos, anything like that at home?

P: We we took out the carpets and stuff when his sister was diagnosed with asthma, so it's good from that perspective.

D: OK, good, and who lives at home with him?

P: So it's myself, his mom and then his sister.

D: OK, OK, any pets at home?

P: He's got a fish.

D: A fish, OK. And has he has come into contact with anyone sick recently?

P: No, I don't think so. I mean when at school, they've been pretty diligent with I mean covid and everything right now, so I think he's been OK.

D: Ok, uhm has he traveled anywhere recently?

P: No.

D: No, OK. OK, those are all the questions that I had for you today. Did you have any questions of your own for me?

P: Yeah, I was just wondering if if my son had asthma as well and if like you need a prescription for inhalers.

D: Yeah, so we're gonna since he's never been diagnosed before, we're gonna do some investigations for him just to start so we can do, we can start by doing a pulmonary function test for him to see what his lung activity is like uhm so we'll start there and then we'll also, because you're saying he's short of breath, we'll take his oxygen saturation as well, and maybe even do some like some basic blood work for him, and if it turns out he has asthma, which in this case I do strongly suspect, we'll prescribe him some bronchodilators like a short acting beta agonist as well as an inhaled corticosteroid because his symptoms do seem somewhat severe this time around. And then I should also mention because some of his symptoms overlap with that of COVID, he will also get a covid swab and you should hear back about that in 24 to 48 hours. How does that sound?

P: That sounds good, thank you.

D: Alright great, thank you.


D: How may I help you?

P: Yeah, so I'm I'm George, the father, my daughter is 5 years old and I noticed just a few days ago that she was walking a little bit funny and kind of having a limp when she came back from school. And since since that then, she's been saying that it just hurts too much to put any weight on on that leg, on the right leg. And since then I've been like carrying her around. It's been very painful for her. So I just wanted to come in and check what might be going on.

D: OK and so so. And this, when did this exactly start?

P: So just two days ago.

D: OK, an um did she have any trauma to her right hip or or to hurt your right leg like a fall or any injuries?

P: Sorry um no. Not that I know of at least and she hasn't told me anything like that. She does do some activities, some sports, but I haven't seen her fall anywhere.

D: OK. Um. Alright, and uh, has she has she not not been able to walk then?

P: Yeah, so I've I've been carrying around for at least like she's missed school too, but been carrying her around for the last 1 1/2 to two days. As soon as I had like ask her to walk she starts kind of a hopping and saying that there's a lot of pain near the top of her leg and by your hips whenever she puts her foot like a foot down. So yeah, she's in pain crying, so I kind of have to carry her.

D: OK. And, uh, how has her behaviour been recently like her mood and things like that?

P: She's definitely been more just, a bit anxious about the pain. Very scared about putting her foot down and just overall, I think also more irritable crying more because of the pain so but I I guess I understand if there's something going on it must be very painful.

D: OK, and. Alright, has she had any fevers or chills?

P: Uhm I. Did notice a couple of days ago she felt a bit warm but we didn't really measure her temperature. Over the last few weeks, though, she has had a. Kind of a runny nose and a cough and I think she might have had a fever last week as well so she has been sick recently.

D: OK, so it sounds like she might have had a cold last week and did like the runny nose and cough go away?

P: Yeah, the runny nose and cough are gone. Fever was gone too, but she did feel a little bit warm yesterday so I'm not sure about that.

D: OK, so she's at a a bit warm now still OK.

P: Yup.

D: Has she had any any headaches?

P: No, no headaches.

D: Any sensory changes like things to her vision or hearing or taste or smell?

P: No.

D: OK. Any um sore throat or cough?

P: No.

D: Alright, any shortness of breath?

P: No.

D: Any chest pain?

P: No.

D: Has she had a loss of appetite?

P: No.

D: OK, and has she had any unexpected weight loss?

P: Oh no, nothing like that.

D: Any night sweats?

P: No.

D: Any nausea or vomiting?

P: No.

D: Any abdominal pain?

P: No abdominal pain.

D: OK, any diarrhea or constipation or blood in the stool?

P: No, nothing like that.

D: Alright, and any problems with urination like pain or frequency?

P: No, not that she's mentioned, no.

D: OK. And any skin rashes or changes?

P: No.

D: OK, and any muscle aches or body pains or any other pains anywhere else?

P: No, it's mainly just her upper right leg and hip.

D: OK, I have she had any numbness or tingling?

P: No, not that she's mentioned no.

D: OK and and, how about a muscle weakness?

P: No.

D: No OK. And any confusion or or memory loss?

P: Um no.

D: OK, I'm and in the past has she been diagnosed with any medical conditions?

P: She did have this condition with her hips. Dysplasia, like developmental dysplasia of the hip. So when she was born she she was getting like this clicking noise and her, in her hips and so she was in this splint for probably almost two months at the start, like after she was born.

D: OK, and did her hips, did like was she able to walk afterwards?

P: Yeah, yeah. And we were seeing a specialist, an orthopedic surgeon and they were managing her and after one year they stopped following her. She was well like she was walking, no issues.

D: OK, so she's walking around one year.

P: Mmm

D: Have you had any other concerns about her, either social or physical development?

P: No, she's been really great. She's good with people, she's has great social skills. She has grown well, met all her milestones, she's doing really well at school and gets along well with her peers as well.

D: OK, excellent. And were there any concerns throughout pregnancy, such as gestational diabetes or hypertension or any exposures to infections?

P: No, her mom's pregnancy was perfectly normal. She was born, like she was delivered vaginally at 39 weeks. She was breech at that time, which the doctor said might have to do with her clicking hips. But yeah, but since then or during pregnancy, no other complications.

D: OK, that's great. And. Uh, in regards to, you mentioned her hurt hip any other past medical history?

P: Um no other than that she's been healthy.

D: OK, and does she take any medications regularly over the counter or prescribed?

P: No no, no medications.

D: OK, any allergies to medications?

P: No, not that I know.

D: And sorry has she taking anything for the, the pain?

P: No, I haven't really given her anything, I didn't know what to give.

D: OK all right, we'll talk more about that. Has she had any prior surgeries or hospitalizations?

P: No.

D: Can you tell me about who she's living with and whereabouts she's living?

P: Yeah, so she's currently living at home with me, my wife, and she has an older brother. We live in a small house just near near the city.

D: OK, and what do you guys do for work?

P: Yeah, so I'm a lawyer and my wife is a music teacher.

D: OK, is there anybody who smokes in the home?

P: No, none of us smoke.

D: OK um, OK, And any family history of heart or lung conditions?

P: Uhm, no, no family history our family is pretty healthy.

D: OK, how about any family history of any autoimmune conditions such as hypothyroidism?

P: No nothing like that.

D: OK. And then any musculoskeletal or neurological conditions in the family?

P: No.

D: OK, so next on um just the exam. Um when you're looking at the right hip are you seeing any swelling, redness?

P: Uh, no, not that I see anything.

D: No OK, and is there any like muscle atrophy around the hip?

P: No, not that I see at all.

D: OK and then is there any misalignment or deformity of the joints that you can see?

P: No, I can't. Yeah, I don't see anything in the hips or legs that really points out to me.

D: OK um and is there any pain to palpation over the hip or or knee?

P: Uh, if I if I press on it, I don't think she's in that much pain. It's mainly just when she's trying to walk or put put weight on it.

D: OK, and is she able to move the hip in a full range of motion of like flexion, and extension, abduction, adduction?

P: Uhm, so she does. She is able to move it if she really tries. But it's mainly just the putting her weight on it and anytime she puts her weight on it is is when it really hurts.

D: OK, so more about the weight on it, and is she able to move that her knee with a full range of motion?

P: Yeah.

D: OK, and any any muscle weakness when testing around the joint?

P: No.

D: No, OK. So I think that was everything that I wanted to ask on history and check was there anything I maybe forgot about you thought would be more important today,

P: No I think that's all just just was wondering what might be going on?

D: Yeah, certainly, so a couple of things that it could be. One is that it can be common in this age group is something called transient synovitis. Where, which can happen in the hip where there's some inflammation and it causes some pain following a viral infection. And it sounds like she had a viral infection last week with the cough, fever and and runny nose and her. She was feeling a bit warm and maybe feverish today as well, which could be a sign with the lower kind of slightly elevated temperature, pointing towards transient synovitis, which is a condition that will be self limiting and can use anti- inflammatories to help with the pain such as ibuprofen, but also something that would be important to rule out would be is septic arthritis because it could could lead to damage of the joint, but this will be lower on the differential and then finally something to consider is Legg-Calve-Perthes disease. And, but this would be more of progressive  onset, but if she's not getting any better and or if she becomes more sick like develops a really high fever or a red hot swollen joint, then we'd be thinking more along the lines of septic arthritis and we want to reassess.

P: OK, sounds good. Thank you so much.


D: How may I help you?

P: Hi I'm, I have been having this nasal obstruction and discharge for the past week and it doesn't seem to be going away and it's bothering me so I thought I would get it checked out by you.

D: OK, for sure. Uhm, could you describe the discharge?

P: Yeah, it's a. It's mostly clear, it doesn't, it doesn't have a color to it.

D: OK, so no yellow, green or or red to indicate any blood?

P: No.

D: OK, and you mentioned, so with the obstruction, have you had difficulties breathing?

P: Um a little bit, I just need to, and is mostly at night. I just need to shift to one side or the other to like unblock my airways.

D: I see OK and have you been having any pain on your face? Like I like kind of over your cheeks or over your forehead?

P: No.

D: OK, how about any headaches?

P: No headaches.

D: All right, have you had any changes or to your sense of smell or any loss of smell?

P: Uhm no, maybe a little bit, but no, not really. I can still eat. I can still smell like candles and things like that so, maybe go with no.

D: OK. Have you had any changes to your sense of taste?

P: No.

D: OK. Have you had any eye redness or or any eye pain?

P: No.

D: Any ear pain or ear discharge?

P: No.

D: Any changes to the vision or hearing?

P: Uh, no.

D: OK, have you had a sore throat?

P: No.

D: Have you had a cough?

P: No.

D: Have you had any shortness of breath

P: Uh, no.

D: Have you had any wheezing?

P: No.

D: OK. And have you coughed up any blood?

P: No.

D: OK, and have you had any chest pain?

P: No.

D: Have you had any lightheadedness or dizziness?

P: Uh, no.

D: Have you felt like your hearts beating really fast or racing?

P: No.

D: OK, have you had any fevers or chills?

P: No.

D: Have you had a night sweats?

P: No.

D: Have you had any unexpected weight loss?

P: No.

D: OK, have you had any loss of appetite?

P: Uh, nope.

D: OK, have you had any nausea or vomiting?

P: No.

D: Have you had any abdominal pain?

P: No.

D: Have you had any diarrhea or constipation?

P: No.

D: Have you had any painful urination or urinary frequency?

P: No.

D: OK, have you had any skin rashes?

P: No.

D: Have you had any muscle aches or joint pains?

P: No.

D: Have you had any memory loss or confusion?

P: No.

D: OK, and how has your energy been? Have you had fatigue or malaise?

P: No, nothing like that.

D: OK. Uhm, and have you had any sneezing?

P: No.

D: OK. Uhm, and, uh, are you healthy? Or, or have you been diagnosed with any medical conditions in the past?

P: No, I'm actually pretty healthy.

D: OK. Have you had any prior surgeries or hospitalizations?

P: Nope.

D: OK, and any allergies like to any medications or any seasonal allergies? Like do you get symptoms like this that change throughout the year?

P: No.

D: OK and sorry, no allergies to medications as well?

P: No allergies to medications.

D: OK, and do you take any medications regularly, either prescribed or over the counter?

P: No, I don't take any medications.

D: OK, and can you tell me about where you're living currently and who you're living with?

P: Uhm, I live by myself right now. I live in an apartment downtown.

D: OK, and are you, got working right now or are you going to school or both?

P: I'm working right now, but I'm working from home.

D: OK, uh, have you been around anybody who's been sick?

P: No one personally, but I do go to the grocery store and the bank and all the essential things.

D: I see, OK. Uhm, and have you have you traveled anywhere recently?

P: No, I haven't.

D: OK. Are you in a relationship?

P: I am.

D: Are you sexually active?

P: I am.

D: OK, could you tell me a little bit about your partner or, or partners?

P: Uhm yeah, so we've been together for the past five years. And yeah, he's the only sexual partner I have.

D: OK, and do you use condoms or birth control?

P: Birth control.

D: OK. Uhm, and any concern for a sexually transmitted infection?

P: No.

D: OK and you smoke cigarettes?

P: I don't.

D: Do you smoke cannabis or use cannabis products?

P: Uh, nope.

D: OK, how about the use of any recreational drugs?

P: No.

D: OK, do you drink alcohol?

P: I do, I'll have like a glass of wine every day.

D: OK. And in the family, are there any heart conditions or lung conditions that run in the family?

P: No.

D: How about things like diabetes or or high blood pressure?

P: Uhm, I don't think so.

D: OK, and uh, are there any cancers in the family?

P: Uhm, there's colon cancer in the family.

D: OK, and who was that and how old were they?

P: Uhm, my grandfather, he was 55.

D: OK. Uhm, alright, and so that was everything that I wanted to ask today on history. Was there anything else that I was maybe forgetting?

P: Uh, no, I think that was it.

D: OK, so with the prominent symptoms of being nasal discharge and obstruction without fever and without, like changes to smell and also without pain, it's most likely a viral rhinosinusitis. Uhm, however, this could have symptoms that overlap with, with COVID, and so we will still end up doing a swab even though the most likely diagnosis is going to be a viral acute rhinosinusitis.

P: OK.

D: Do you have any other questions?

P: No thank you or yeah, thank you.

D: Thank you.


D: What brings you in?

P: I just bringing my son in today because he's had this cough that's been going on for a few days now and for these past two days, I've noticed that he's been just tugging at his ear more as well.

D: OK, so you said the runny nose started two days ago?

P: Yeah, yeah he had a cough yeah cough and runny nose started about yeah 2-3 days ago

D: Okay, the runny nose, what color is the discharge?

P: Pretty clear and watery

D: OK, and the coughing is it dry, or is it bringing up any phlegm?

P: It's been dry.

D: It's been dry OK. And does it sound harsh?

P: Not really,

D: No?

P: I don't know. It sounds kinda like a typical cough.

D: OK, has he lost his sense of taste or smell?

P: He's been a bit more irritable and not eating as much but I'm not sure.

D: OK, how about changes in his vision or hearing?

P: No

D: OK. Any fevers?

P: Uhm, I don't think so. But he, we haven't checked and he's been, yeah, as I said, kinda, a little bit irritable.

D: OK, any weight loss recently?

P: Uhm no, he's been gaining weight. Actually, sorry, I think it. Yeah, he has had a fever. The fever. Yeah the fever started like yesterday.

D: Oh OK, did you take his temperature?

P: Yeah, my my wife just texted me and told me that she checked it, checked it and said it was over 38.

D: Oh OK. Yeah, we'll definitely take a temperature here as well just to make sure. Has he had any rashes?

P: No,

D: No rashes OK. And how about shortness of breath or wheezing?

P: No, I haven't heard that.

D: No, OK. And then have you actually taken a look into his ears?

P: No, I haven't. He has just been tugging at the right one.

D: Is he itching it at all?

P: Uh yeah, I guess just kind of like really rubbing it around the outside and pulling on the lobe a little bit.

D: OK, any discharge? Oh sorry go ahead

P: Sorry I'm just gonna say yeah he's been kind of fussy and pointing at it and no discharge from the ear.

D: No discharge, OK. Does it look swollen?

P: No, the outside of the ear looks normal.

D: OK, OK, and how have his bowel movements been?

P: That's been normal, .

D: Normal. Any changes in his urine?

P: No, it's been normal.

D: Nausea or vomiting?

P: Nope.

D: uhm headaches?

P: No, I don't think so.

D: OK, how about dizziness or fainting spells?

P: No.

D: No, any confusion or memory loss?

P: No, I don't think so.

D: No OK, is he an otherwise healthy child?

P: Yeah, he he is. I mean he, uhm about six months ago he had uhm croup I think but he recovered quickly from that and he didn't need to be hospitalized or anything.

D: OK, and his mother's pregnancy with him, was it complicated in any way?

P: She had gestational diabetes, but it was diet controlled and she's healthy now from that perspective.

D: OK, OK, that's good. Uhm and then was he born at term?

P: He was yeah he was born over like 38 weeks I think

D: Oh OK, good and was it a C-section or a vaginal delivery?

P: Uhh vaginal.

D: OK, any complications during the delivery?

P: Uhh no.

D: No, OK, how about uhm after birth? Was he hospitalized for any reason?

P: No, he wasn't. He was able to go home.

D: OK, that's good. Uhm and has he been developing normally in terms of his motor movements, like behavior wise, social wise, like is he on par with his peers in terms of milestones?

P: Yeah he is. Yeah, everything's been normal that way and he's been growing well too.

D: OK, good. growing while gaining weight well, OK, is he on any medications?

P: No, he's not.

D: OK. Is he up to date with all his immunizations?

P: He is, yeah, we've been following along with with that.

D: OK, does he have any allergies?

P: I don't think so.

D: No, Ok. Any family history of lung or heart conditions?

P: Uh, no.

D: No OK. Does anyone at home smoke?

P: Uhm I do but not like in the house or anything like that, usually just well, it will always be either outside or when I'm at work.

D: OK OK, any old carpet, dust, mold, asbestos, anything like that in your home?

P: No.

D: No. OK. Who does he live with?

P: So yeah, he lives with me. It's just me and my wife.

D: OK. Any pets at home?

P: We have a a dog.

D: OK. Has he been in contact with anyone sick recently?

P: Uh. Not that I can think of.

D: OK is he in like daycare?

P: No, no my wife's been, been looking looking after him at home. She's the primary caregiver, well while I'm at work.

D: OK, any trouble recently?

P: No no.

D: No, OK. Well, those are all the questions that I had for you today. Did you have any questions of your own?

P: Uhh no, just was wondering what what might be going on?

D: Yeah, for sure, so right now it sounds like a viral picture. It sounds like he has a cold and possibly an ear infection. I'd have to take a look into his ear to be able to tell more uhm because some of his symptoms overlap with those of covid we'll probably do a swab and you should hear back in about 24 to 48 hours. Uhm and so after I take a look into his ears, we can do one of a couple of things, so if his tympanic membrane looks like it's been perforated, or if there's pus in there, then we'll prescribe him a 10 day course of antibiotics, and if I see like middle ear effusion or his tympanic membranes bulging, and he seems really sick like he has a high fever, what she does, I will again prescribe him 10 days of antibiotics. And if he has a middle ear effusion or a bulging tympanic membrane, just one of those two, and he doesn't seem to be too sick, we can reassess him in 24 to 48 hours. Uhm An antibiotic that we usually prescribe is amoxicillin. Uhh how does that sound?

P: That sounds really good. Thank you.

D: OK, no worries. Take care.