D: What brings you in?

P: Yeah, I've had uh, a cough that's been um, bugging me for the last several months now, and more recently I've noticed that I've started to bring up a bit more, or a little bit of blood as well.

D: Okay, well that's not good. So you said the cough started several months ago, how many months ago do you think, like three, four, five?

P: Uh, yeah I would say, yeah, maybe like, like five or six, and it kind of started um, it was really infrequent and so it didn't really, well I thought it was just the usual smoking, but it's been getting worse over these last, over these past six months.

D: Okay and um, the blood in the cough, when did that start?

P: So that started about, uh, about two weeks ago.

D: Two weeks ago, okay. Um, how much blood are you coughing up like, if uh, like is it the size of your palm, is it more than that, less than that?

P: Uh, I would say less than that, like each time there's maybe to about the size of I don't know, uh, like a looney. So like inside of the palm.

D: Okay, sure. Um, and are you experiencing any shortness of breath along with your cough?

P: Yeah, now that you mention it, I have been. It's uh, you know, I thought that was just kind of me getting older and the smoking, but I've certainly been able, I haven't been able to walk as far and even uh, to the end of the driveway getting the mail now is, is pretty, I'll get short of breath. Before I used to be able to walk a lot further than that, just a couple of years ago.

D: Yeah, for sure. Um, and sorry you said, you mentioned, you mentioned you had some wheezing as well, right?

P: Um, I haven't really had any, noticed any wheezing.

D: No, okay. Um, and have you had a fever recently?

P: No.

D: Weight loss?

P: Um yeah, now that you mention it, maybe, maybe a little bit, like 5 to 10 pounds over the last, the last month.

D: Last month, okay. Um, any chills, fever, sorry, chills, or night sweats?

P: No um, no, I haven't had anything like that.

D: Okay, any rashes?

P: No.

D: Changes in your vision or hearing?

P: No.

D: Um, how about a stuffy or runny nose?

P: No, I haven't had any symptoms like that.

D: Okay um, and then change in your smell or taste?

P: No, that's been normal.

D: Okay, and how about chest pain?

P: No, I haven't had any chest pain.

D: Okay. Um, and do you ever feel like your heart's racing?

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

D: Okay, how about calf pain when you walk, like more than a block or two?

P: No, I haven't had any symptoms like that.

D: Okay, any changes to your bowel movements?

P: No things have been normal there.

D: Okay, any nausea or vomiting?

P: No.

D: Uh, changes to your urine?

P: No.

D: No. Uh, headaches?

P: Every once in a while, I'll get a headache, but it's, they're pretty mild. Usually I'll take an Advil and they go away.

D: Sure, um, how about dizziness or fainting spells?

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

D: Okay, um, any confusion or memory loss?

P: Uh, I guess I um, forget things a little more easily now, but, that's just part of getting older.

D: Okay, sure. Um, and then other questions I have for you, are um, are you otherwise healthy? Do you have any major medical, medical conditions?

P: Uh, I have arthritis um, in my knees and uh, hands, um so I have a lot of pain from that sometimes, and I also have high blood pressure and um, GERD.

D: Okay.

P: Or acid reflux, yeah.

D: Sure. Do you take any medications for these things?

P: Um, yeah, I'll take Tylenol um, for the arthritis, and sometimes use some like, topical creams for my knees. Um and uh I, I take amlodipine as well, I think, for the blood pressure.

D: Okay. Okay, and um, are you up to date with all your immunizations?

P: Yeah, yeah, I remember getting one not too long ago, actually. Well, seven years ago I guess now, but I didn't realize, that we uh, had to get anymore.

D: Um, so yeah, after you turn 65, they should've given you the Shingrix for shingles and pneumococcal vaccine, does that sound familiar?

P: Yeah it does. Yeah, I just didn't know about them until that time.

D: Okay yeah, sure. Any allergies that you have?

P: Uh, I don't think so.

D: No. How about family history of lung or heart conditions?

P: My uh, grandfather had, had lung cancer. And he was in his uh, 70s when he, when he passed away, I remember.

D: Okay, okay. And do you currently smoke?

P: I do, yes. Yeah, I, I smoke um, I don't know, maybe half a pack a day now, which is, it's a lot less than I used to. I was smoking two packs a day at one point.

D: Okay, well congratulations on cutting down. Um, yeah, if you need help cutting that down even more, let us know, we have resources that you may be able to use.

P: Yeah, absolutely. Thank you.

D: Yeah, no problem. Do you do any other recreational drugs like marijuana, cocaine, heroin, anything like that?

P: Yeah since I, oh CBD drops, I, at night I find that helps with uh, sleep and, and the pain in my knees.

D: Oh okay, are those prescribed drops?

P: Um. well I do buy, I get them from uh, like the uh, the OCS store, I think they're called.

D: Okay yeah. Okay, that's good that you're getting them from, like an official store.

P: Yeah they're for, they were, uh, my friend said that they worked for her, and so I just gave them a try and I, I found that they've helped.

D: Okay, good. Um, and where do you live right now? And who do you live with?

P: Yeah, so I live in uh, in an apartment with my, with my husband.

D: Okay, And any like, old carpets, dust, mold, or asbestos in this apartment?

P: No, I don't believe so. It's relatively new. We just moved out of our house, uh, just to make it a little easier on us.

D: Okay yeah, for sure. Um, have you been in contact with anyone sick recently?

P: No, I don't think so. I've been spending a lot of time at at home uh, with my husband, and he's been okay.

D: Okay, good. How about travel?

P: No, we've been pretty scared with uh, COVID and all that, so we've been staying, staying home for the most part.

D: Okay, okay, good. Um, those were all the questions that I had for you today. Did you have any questions of your own for me?

P: No, I was just really concerned when I started to see um, the blood coming up more recently, and so I was just hoping to get this figured out.

D: Yeah, for sure. Um, so they're a couple of things we're gonna work you up for. Um, because some of your symptoms overlap with COVID, we'll start by getting a COVID swab and you should hear back in about 24 to 48 hours. Um, we will also do a chest x-ray um, to look for any signs of lung cancer. Um, and then if we see consolidation or anything that would indicate um, like a mass in your lungs, we will discuss options for like biopsies which is the gold standard for diagnosing lung cancers. Also, I know you haven't had any recent travel or anything like that and your symptoms have been going on for a long time, but uh, it may also be worthwhile to uh, also check for things like TB, which could also cause you to cough up blood. Um, so we'll start, we'll start from there, and then if those come back negative, then we'll work you up further for other things that you may have, but are like more rare. How does that sound?

P: That sounds like a good plan. Thank you.

D: Okay, great. No problem.


D: What brings you in here today?

P: I've just been feeling really short of breath since this morning, and I don't, uh yeah I don't know what's going on.

D: It just started this morning.

P: Yeah.

D: And uh, did you wake up feeling short of breath or was it after you had woken up and we were doing activities?

P: It was when I was doing activities.

D: OK, and what were you doing before you had the shortness of breath?

P: Oh, I was just going to the kitchen to make breakfast.

D: OK, and uhm can you describe the shortness of breath? Is it more so that you're having trouble, deep breaths, or are you taking shallow fast breaths? How would you describe it?

P: Uhm? I guess just shallow, fast breaths, I feel like I've run a marathon and I just yeah and all I've done is just walked to the kitchen.

D: OK and has this happened to you before ever?

P: No.

D: No? OK. Are you having any other symptoms like off sore throat, chest pain, anything like that?

P: No.

D: So it's just the shortness of breath.

P: Yeah, that's it.

D: OK. And so it it started this morning, is it still continuing, or is it, uh?

P: Still there.

D: OK, is it worse at all than it was this morning?

P: Uhm, kind of the same, I'd say.

D: OK, are you getting any kind of chest discomfort or anything at all with breathing?

P: Maybe when I take a very deep breath, then yeah. It just kind of I feel like this sharp pain.

D: OK. How have you, having I've been having any chills or fever or anything like that?

P: No.

D: OK, any dizziness or fainting spells?

P: No.

D: OK, do you feel that your heart is racing at all?

P: No.

D: OK, And, and have you tried anything that's helped you improve those symptoms, like taking a rest or laying down flat? Anything like that?

P: No, haven't really tried much. It just started this morning so I I just decided come in. Right away.

D: Ok. Have you traveled at all recently?

P: Um, no.

D: Any uh contacted someone who's been sick recently?

P: I don't think so.

D: OK.

P: I did just say sorry, I I did just get out of the hospital so maybe I could have had some contact. There's some exposure there.

D: OK, so so when did you get out of the hospital?

P: Uhm, two days ago.

D: Two days ago, OK, and what were you in the hospital for?

P: Uhm? I had, I broke my hip.

D: OK, and did you have a surgery for your hip?

P: No. They didn't think it was, surgery was needed.

D: OK, so how long were you in the hospital for?

P: About 4 days.

D: Four days, OK. And in those four days what were they doing for you there?

P: Just trying to help me just doing physiotherapy and helping me sort of get up and get out of bed.

D: OK.

P: And like giving me pain medications.

D: And since, or like when you went home today, set up any kind of home care for you or anything like that?

P: Yeah they did. A nurse comes in once a day.

D: OK, and how about uh physiotherapy?

P: Yeah, I don't know. They haven't really been coming in and I I asked the nurse and she said she's gonna look into it. Maybe something went wrong there.

D: OK, Um, and after you've been discharged, have you been moving around at all, or if you've been pretty immobilized?

P: I try, but it's been it's been hard like, specially the first couple of days. I don't think it did much. But since then, I've been, I've been trying to move around a little bit more.

D: OK. Have you noticed any kind of swelling in your legs at all?

P: Uh, no.

D: No, nothing like that?

P: No.

D: Have you previously had any kind of clots, like a deep vein thrombosis or pulmonary embolism? Anything like that?

P: No.

D: Have you had any previous diagnosis of cancer?

P: I did in the past. About 10 years ago I had leukaemia.

D: Leukaemia, OK. And are you still on any kind of treatment or do you see an oncologist or a mythologist?

P: No, not anymore.

D: Not anymore? OK. Um and so are you experiencing any kind of coughing up blood or anything like that?

P: Uhm, no.

D: No. OK. Um do you feel any pain in your caps at all?

P: No.

D: No, OK. Alright, other than that, are you having any symptoms of nausea and vomiting at all?

P: Uhm, no I don't.

D: OK, any fevers or chills?

P: No.

D: OK. Any night sweats or fatigue?

P: No.

D: Ok. Any diarrhea or constipation?

P: No. None of those.

D: OK. And besides the cancer, any previous medical conditions that you've been diagnosed with?

P: No, I was pretty healthy before that.

D: Ok, any history of any clotting or clotting disorders at all?

P: No.

D: OK. Do you take any medications currently?

P: No, no, not anymore.

D: OK, any allergies to any medications?

P: Uhm, no.

D: Ok. Um any family history of any lung or heart conditions?

P: Um, no lung or heart conditions, no.

D: OK. And currently right now do you work at all?

P: Yeah I do. I um, I'm a banker.

D: Banker OK. Uhm. And what's your living situation like? Where do you live with anyone or inward? Where do you live?

P: I live at home with my husband and my two kids.

D: Ok, and you smoke it all?

P: No, I don't.

D: OK. And do you use any recreational drugs like marijuana?

P: Uh, sometimes I'll have marijuana with my friends, but I haven't really done that since the pandemic started.

D: OK, and you drink alcohol?

P: Yeah, I do come. I'll have maybe two or three glasses of beer on the weekend.

D: OK. Alright, so these are all this questions I had for you today. We'll do a full physical examination next. Do you have any questions or concerns?

P: No.

D: OK, so yeah, right now one of the main things we want to rule out, especially since you had the sudden shortness of breath today after a history of just recent discharge and the hip fracture or injury, and you're immobilized we need to make sure you haven't developed a clot that has traveled to your lungs. So we'll do a full physical examination and get some blood work done initially and then see if you require any medications for if you need thrombolysis for to break up the clot. We'll, we might do some imaging as well, so yeah, well, we'll just start with that, and then we'll go from there.

P: Sure.

D: So you'll be in here for a few hours until we get all those things done and see if you need any admission at all to the hospital.

P: Sure.

D: Alright.

P: Thank you.

D: Welcome, take care.


D: What brings you in here today?

P: Hey, I just, um, I just kind of came in to talk about my stuffy nose. It's yeah, it's been a problem for, I don't even know how many years it's always been there. And now that school is a little less busy and things are virtual and have more time, I decided I'll get something done, um, to get it fixed.

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

P: Since I was young, um like maybe years, couple years.

D: OK, and then do you like how often are you getting the stuffiness? Is it like every day? Is it during the day at night? When do you usually get it?

P: It's kind of uhm, it's kind of all the time, to the point that I've somewhat gotten used to it. And it's just my, it's only on the left side and it's just always kind of stuffy. Initially I would have trouble falling asleep 'cause it would, I would just find it a little bit bothersome, but now I'm kind of just used to it.

D: OK, and so it's just on the left side. It never moves to the right side.

P: Well, like sometimes when I get ill its on both sides, but usually it's on the left side.

D: OK, and so you have stuffiness. But do you ever get any kind of discharge or drainage from your nose?

P: Sometimes I get a little bit bleeding.

D: Are you, OK. Um, bleeding? Is it blood mixed into the discharge or drainage? Or is it like you get nosebleeds?

P: I get nosebleeds like maybe yeah. Like maybe when I'm exercising or something I'm like at the gym. Uhm, fom doing the gym class. Yeah, yeah when playing with my friends.

D: OK, and how often do you get these nose bleeds?

P: Uhm? Maybe once a month or once in two months.

D: OK. And umm, and is there any, do you have any other symptoms? So like, do you have any pressure, sensation in your face around your jaw, cheeks, forehead?

P: No.

D: No, so OK. And do you find yourself having more congestion when you wake up?

P: Uhm? Not really, maybe a little bit.

D: OK, so it's not worse when you're lying flat or anything like that?

P: No.

D: OK, um, and do you find that you have to constantly clear your throat at all throughout the day?

P: Uhm, no.

D: OK, and do you at all feel that some stuffiness drains back into your throat at all anytime during the day?

P: I don't think so, no.

D: So it's just the congestion that's been going on for quite some time and does it change with the seasons at all?

P: No, it's just there all the time. Like I can't even tell. This is like my normal now, but my mom said I should get it checked out.

D: OK, uhm. Have you tried anything for it like either medications or the neti pot or steaming and has anything helped you at all?

P: I tried steaming but it didn't do much. It kind of got better. Maybe for an hour maybe, but then yeah, it didn't do much.

D: OK, and otherwise, are you having any other symptoms like fever, chills, cough, sore throat, anything like that?

P: No.

D: Are you having any loss of sense of taste or smell?

P: Uhm, no.

D: Any shortness of breath at all?

P: No.

D: OK, uh. And otherwise, any recent travel or in contact with anyone who's been sick?

P: Uhm, no.

D: Have you previously been diagnosed with any medical conditions?

P: No, I'm pretty healthy.

D: And do you know if you have any allergies to any medication?

P: Uhm, no, no allergies to medications.

D: OK, and any allergies to any environmental issues like factors that cause more stuffiness, sneezing, itching, red eyes, runny nose anything like.

P: I'm allergic to cats.

D: Cats? OK.

P: But I haven't been around one for awhile.

D: OK, uh, anything else like in your house or environment like carpets, dust, like anything that might irritate, give me more irritation?

P: No, not really.

D: OK. So it's just a cat that you know, but you haven't been around. Do you have any other animals at home?

P: Uh no, I don't.

D: No OK. Do you have any headaches at all?

P: No.

D: Any changes in your bowel movements?

P: No.

D: Any urinary problems?

P: Nope.

D: Has this affected your sleep or appetite?

P: I snore at night sometimes, but that's, that's about it.

D: OK, and do you snore, would you say most nights or is that something like has someone told you that?

P: My mom told me and sometimes I, I sleep with my mouth open.

D: I see, OK. And do you know how long you've been doing this for?

P: Uhm, again, it's been like months or years.

D: OK. And do you ever get, do you ever wake up at night trying to take a breath like just gasping for air?

P: No.

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

P: No.

D: Yeah, OK. On any family history of any heart or lung conditions.

P: Uhm, just heart disease.

D: OK, then who has it? Or who had it?

P: My my dad. My dad has, had a heart attack and my mom has high blood pressure.

D: OK. And how old was your dad when he had a heart attack?

P: He was 50 years old.

D: 50 years old? Ok.  And I'm currently right now, uh, are you a student? Do you work?

P: I'm a student.

D: And what's your living situation like?

P: I live with my parents.

D: Ok. And do you smoke at all?

P: No.

D: OK, have you ever smoked?

P: No no no.

D: Uh, any, any recreational drugs like marijuana?

P: Oh God no, never.

D: No? Ok. And do you drink alcohol?

P: No.

D: OK, and how, how's your home environment? Do you generally feel safe in your home environment as well as outside of your home?

P: Oh yeah, it's great.

D: Ok. So yeah, so mainly yeah. So there's all the questions I had for you. Do you have any questions or concern?

P: Nope.

D: Ok so there can be many different reasons for this chronic congestion and we'll do a full physical examination for you today. Uh and some of the possible things that can be happening is you might be having a sinus issue like a chronic sinusitis. You can be having an allergic rhinitis or with the snoring and just the chronic congestion. You may be also having something called obstruct, obstructive sleep apnea. And there can be structures in your mouth, throats that can cause you to kind of obstruct and snore at night as well, and that even the congestion might cause that as well. So yeah, we'll do a couple test first and then if required, we might need to do some imaging and even perhaps send you to an EMT specialist if we think it's obstructive sleep apnea there. For now, we'll just do the physical examination to go from there.

P: Great, thank you.

D: Welcome, take care.


D: I would just like to start with what brought you in here today to the family clinic?

P: Yeah, so I've been coughing for a few months now and so that's the problem.

D: OK, and how many months have you been coughing for?

P: Just over two, I would say, and it's been I've been bringing up this yellow, greenish sputum. It's kind of gross.

D: OK, and how, how much of the sputum would you say you're bringing up in an average day? Like a teaspoon? Tablespoon?

P: : Oh I see OK. I don't know, maybe a few teaspoons throughout the day.

D: OK.

P: At first I thought I I I had a, a chest infection, but even after antibiotics from my GP, or or my family doctor, It never cleared up.

D: OK, and so when did you go on the antibiotics?

P: Ah so this is about, uh, about a month ago.

D: Mhmm.

P: And yeah, so I went to see my family doctor about the cough then and dad was prescribed some antibiotics. I think azithromycin and it, it still didn't, it didn't do anything.

D: OK, I see. And do you find that your cough has been getting worse since then?

P: Uh, I would say the cough has been about the same.

D: OK. But how about the sputum that you're bringing up, has that increased?

P: Uh, it's about the same, but it definitely I would say there's a pink tinge in the sputum now. Every once in awhile I've noticed more than than before.

D: OK. And did this all start after the chest infection or did you have something like this occur before?

P: Um, yeah, this all started after.

D: OK, I see. Was there anything that happened around that time? Any new environment that you were exposed to?

P: Ah, well, I did go to India a few months ago.

D: OK, and how many months was that? Was that also like two months ago?

P: Yeah, about that, probably closer to three or four, but yeah, right around the time that that I think this, uhm cough started or just before I got back.

D: OK, I see. And how often are you coughing in a day?

P: Ah. a few times an hour.

D: OK. Anything that makes your cough go away now you've tried?

P: Uh, no nothings really helped it go away.

D: OK, and is it better or worse? During good morning as opposed to night?

P: Uh, it's pretty, it's pretty bad all day actually and it's been impacting my sleep because I've been coughing at night too.

D: I see. And, um, in terms of things that make it worse, anything you do around the house or at work that makes the coughing worse?

P: Uh yeah, I guess if I'm just moving around a little bit more it might bring it on a little bit more, but it's pretty bad all day.

D: I see. And in terms of any other symptoms you might be having, uh, do you have any shortness of breath, runny nose, any chest pain?

P: Um, no, not really.

D: OK. Besides the pain tinged sputum, have you ever coughed up blood, like red blood?

P: Not anything that was really bright red. More pink.

D: More pink. OK. Yeah, so you traveled to India just two months ago. Do you remember what kind of place you stayed in India? Was it a, a in a crowded place or were you by yourself?

P: Well, I mean there is a lot of people around. Yeah, there was not a lot of room where I was was staying, so it was pretty crowded.

D: OK, and was there anyone that was ill around you or any exposure to tuberculosis?

P: Uhm, not that I'm not aware of. I was around my family but, umm, I guess it's possible.

D: OK. And once you came back did anyone else, in your family get sick? Or was it just you?

P: Oh yeah, I spoke to my relative went when I got back and they they didn't tell me about one of my cousins there that was feeling sick.

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

P: Yeah, I feel I feel like I've been pretty pretty hot sometimes.

D: OK, and how about night sweats?

P: Yeah, the coughs been messing with my sleep, and I've been waking up with night sweats.

D: OK. And have you been having any headaches?

P: Ah no headaches.

D: Any do you feel that you've lost any weight recently?

P: Uh, maybe a few pounds, but um.

D: Have you tried to lose weight, or was that unintentional?

P: No, I, I was kind of surprised. I thought I would have gained weight 'cause I've been a bit more lazy recently, but the weight seems to be down anyway.

D: I see, OK. Have you noticed any wheezing sounds when you breathe out, or breathe in?

P: No wheezing.

D: OK. And you mentioned no chest pain, right?

P: Yeah, no chest pain.

D: OK, have you noticed any kind of swelling in your legs or hands or anywhere else in your body?

P: No swelling.

D: OK. Any bowel movement changes, any constipation or diarrhea? Any of those?

P: No.

D: OK, any urinary problems?

P: Uh, no.

D: OK, any changes in your appetite at all? Do you feel that you've lost any appetite?

P: Um yeah, yeah maybe eating a little bit less.

D: OK. And in your current environment right now, are you exposed to any fumes or dust or any animals?

P: Uhm, we have a dog, but um, no fumes or anything like anything like that.

D: OK, have you experienced any kind of dizziness or fainting spells?

P: No.

D: OK. In terms of your past medical history, have you been diagnosed with any medical conditions?

P: Um, yeah I meant, uh, high blood pressure. Type 2 diabetes and high cholesterol.

D: I see. And are you taking any medications for any of those?

P: Yeah, I'm taking uhm, a few medications for blood pressure and uh, and and diabetes right now, and I think I Rosuvastatin for for the cholesterol. I'm not sure of the other ones though.

D: OK, no worries. And do you know if you're allergic to any medications or do you have any environmental allergies?

P: I think I I got a rash to penicillin when I was when I was younger, but that's it.

D: OK, any previous hospitalizations?

P: Uh, nope.

D: OK, any surgeries?

P: No surgeries.

D: OK, and in your family has anyone ever had any cancers or died of a heart attack?

P: Yeah, my mother out a heart attack when she was 48.

D: OK. And has anyone ever had anything like pulmonary fibrosis or any autoimmune conditions?

P: Uhm. What are those?

D: So pulmonary fibrosis is a condition in your lung where you start getting like these nodules.

P: I see.

D: And it can run in the family and that can cause some of the symptoms like a chronic cough. It can cause sometimes shortness of breath and it can sometimes be associated with the like some connective tissue disorders that can run in the family. Umm, any of those ring a bell?

P: No, I haven't heard of anything like that in my family.

D: OK. Yeah, and other than that, where do you currently live? Do you live by yourself or with anyone else?

P: Yeah, I live with my husband and three sons just outside of town here.

D: OK. And have any of them been sick?

P: No, everybody's been feeling well at home.

D: OK. And do you work currently?

P: Uh, no, I'm I retired.

D: OK. And currently do you smoke? Cigarettes?

P: Yeah yeah, I smoke about a half a pack of cigarettes per day and ah, I've been trying to cut down.

D: OK, and how long have you been smoking for?

P: Ah probably like 30 years.

D: I see and do you use any recreational drugs like marijuana or cocaine?

P: Ah, no I've never used anything like that.

D: OK, and how about alcohol? Do you drink alcohol?

P: Uhm, no.

D: No, OK. Alright, so yeah those are all the questions I had for you today. Do you have any questions for me or any questions or concerns?

P: Um, not right now.

D: OK, so we'll be doing some investigations since you recently traveled to India, we need to make sure that you don't have tuberculosis, as that's prevalent in some parts of India. So we will do some, we might get like a chest X-Ray for that, you may have a pneumonia as well and then we'll go from there. Does that sound good?

P: Yeah, for sure.

D: OK alright well, yeah, well, after those tests have come back, we'll see you in the next appointment for follow up.

P: Thank you.

D: You're welcome.