P: My back, it just really hurts. I feel really stiff in the morning and um yeah, it's just been going on for a few months now.

D: Ok, so for a few months, stiffness in the morning. So your back hurts, where exactly would you say it hurts?

P: It kinda hurts all over. I can't really pinpoint any specific locations that hurts most, kind of hurts like all down my my back.

D: OK, all the way up to I guess your neck and all the way down to your lower back?

P: So I wouldn't really say the neck, and I guess more of the the lower parts. Maybe like the middle of my back and...

D: I see.

P: And down.

D: Ok and what kind of pain would you say it is, is it like a dull aching pain? Is it a sharp stabbing pain? How would you describe it?

P: It's a dull pain.

D: Dull pain, ok. Ok, and on a scale of 0 to 10 with 0 being the least amount of pain you felt in your life and 10 being the worst, how much would you rate it?

P: It's about a four or five. I mean some days it can be better, but yeah, some days it can be worse.

D: OK and when did this start?

P: I think this started about like four or five months ago. It's been going on, yeah, for probably about half a year now.

D: OK, and when it first started up, was there anything that caused the back pain? Like any kind of trauma or injury, anything that you can think of that might have led to this?

P: No, nothing that it's I I can think of. It's sort of it's come on so slowly like when I first started noticing the back pain it it was maybe like a 0 to a one. I didn't really notice it too much, but over these last 5, 6 months it has gotten has gotten a bit worse.

D: Ok, so it kind of came on progressively. Didn't just come on suddenly at some point?

P: Right, yeah, it's been getting worse.

D: Ok, and have you ever had any previous episodes that are similar to this?

P: Uh, not not in my back pain. I do get pain in my right knee and in my hands sometimes. But those pains just kind of come and go.

D: Ok, and when did those pains start?

P: Uhm, those ones started, probably similar timeline around six months ago.

D: Ok, ok. And in the back pain that you're having, does it radiate or move to any other part of your body?

P: No, I don't feel it anywhere else.

D: Ok, and have you tried anything that has helped relieve some of the pain? Any medications or anything?

P: Yeah, I've tried some Tylenol and Advil, and that the Advil is actually helped taking the edge off a little bit, but the next morning I I have the stiffness and and pain again.

D: Ok, and for your pain, are there any kind of factors that make the pain worse, like bending down or standing straight up or laying down anything that makes your pain worse?

P: Uh no nothing that I can think of that really makes it any worse.

D: Ok, and is your pain worse when you wake up in the morning or is it worse as the day progresses?

P: It's worse in the morning. It gets a bit better as the day goes on. I asked about it, an hour into the day, I feel my best. It takes a little bit of time to to move around a little bit first.

D: Ok, approximately how much time would you say after you wake up, the stiffness and pain goes away?

P: I would say maybe 30 to 60 minutes.

D: Ok, alright. And no, you haven't had any trauma injuries in recently, right?

P: No trauma or injuries.

D: Ok and no fevers or chills?

P: No.

D: Ok, any night sweats?

P: No.

D: Any fatigue or malaise?

P: Yeah, I have been a bit more fatigued than usual, and yeah, I I've had some malaise as well.

D: Ok, and for how long have you had this?

P: It's been similarly getting a little bit more progressive. I mean some days I'm just feeling like I just want to lay around and rest 'cause I'm feeling just so burnt out and other days I'm ok but, I'm certainly more tired than usual.

D: Ok, I see. Other than that, have you noticed any kind of rashes or skin changes or changes in your nails at all?

P: Uhm, no, I haven't noticed any any rashes or any nail changes.

D: Ok, any shortness of breath?

P: No.

D: Any changes in your bowel movements or urinary patterns?

P: No, I haven't had any diarrhea or any any urinary problems.

D: Ok, have you noticed any changes in your appetite or your weight?

P: No, my appetite's been normal and my weight's been stable.

D: Ok, and have you noticed any difficulties or changes with your vision or any eye problems?

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

D: Ok, have you noticed any kind of numbness or tingling sensation in your limbs specifically like your back and your legs?

P: No, no tingling or numbness.

D: Ok, any muscle weakness at all?

P: Nope, I haven't noticed any muscle weakness.

D: Ok, and have you been sick at all recently with any viral or bacterial infections?

P: Um I had a uh, and then I was diarrhea like several months ago and I had some antibiotics, but that was a yeah, so a few months ago.

D: Ok, and other than that, currently are you sexually active?

P: Yes I am uh I I have a girlfriend then we've, uh, we started dating about about, uh, six months ago.

D: Ok and do either of you have any history of any STI's at all?

P: Uh, no history of STIs.

D: Ok, alright and is your partner fine or is she having any symptoms at all?

P: No, she she hasn't been having any symptoms then we we've been using a condom mostly.

D: Ok, alright and otherwise are you generally healthy or do you have any medical conditions?

P: Uhm, yeah, I'm I'm generally alright. I do have asthma actually and just, I had diarrhea a few months ago after eating at a buffet. So I think maybe it yeah, it was food poisoning or maybe something like that.

D: Ok.

P: But yeah, so asthma and that's it.

D: Ok, and do you use any medications for your asthma?

P: Yeah, use that blue inhaler sometimes. I guess that just when I when I need it, but that hasn't been very often.

D: Ok and do you have any allergies to any medications or any environmental factors?

P: I do have environmental allergies, I I'm not sure if it's like ragweed or or pollen, but something like that.

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

P: Uhm, never.

D: Ok any family history of any medical conditions, any autoimmune conditions or any musculoskeletal conditions?

P: Yeah my mother has a uh psoriasis.

D: Ok.

P: Yeah, and so she's had to, I know use like like creams and stuff like that for her skin.

D: Ok, and currently right now, do you work?

P: I do, yeah I work uh, at a bank.

D: Ok, and your mother, so she had psoriasis. Did she ever have any joint pains alongside the psoriasis?

P: I don't believe so. I think she had just more issues with her with her skin.

D: Ok, and so you work and then what's your living situation like?

P: Yeah, so I live with my girlfriend in a condo in the city here.

D: Ok, and do you use any recreational drugs like marijuana?

P: Yes, sometimes yeah, I'll smoke like once or twice per week, with that with a friend or something like that.

D: Ok, and do you smoke?

P: No cigarettes, no never.

D: Ok and you drink alcohol?

P: Sometimes, yeah, I'll have a beer or two on weekends or or a cocktail with friends.

D: Ok, alright, so those were just some of the questions I had. Now I'm just going to quickly uh, ask some specific questions. So have you noticed any kind of swelling in the areas that you are having pain or redness or anything like that?

P: Uhm no, I haven't noticed really any any uh redness or or swelling

D: OK and no so, are you able to bend down and stand up straight or extend backwards so without pain or are you in any pain?

P: Uhm, I do get it. It's a bit stiff. Uhm I, uh, yeah, I'm not really too sure it's like, not really, it's more more more stiff.

D: Ok, and yeah, other than that, do you have any questions or concerns?

P: Uhm, yeah, I was just wondering, yeah, like like what what this could be possibly?

D: Yeah, so definitely what so this this seems like it started off like 3 months or six months ago, and it's been going on and it's happening in the morning. And how old did you say you were?

P: Uhm I'm 26.

D: OK, yeah, so uh, it seems progressive and you're getting some pain in your other joints as well and it's mainly from your middle to lower back. It can be multiple things that we would have to rule out. So you first you have a family history of psoriasis so it can be psoriatic arthritis. You don't have any other skins, changes or any other symptoms. It can also be since you have had a you were sick for months ago with a what might be gastroenteritis. It can be sometimes a few months afterwards you can get something called reactive arthritis - where you get this progressive pain in your joints and stiffness. And otherwise it can also be something called ankylosing spondylitis, which can present in men your age and it's kind of like a progressive, dull back pain and that has some morning stiffness as well. So yeah, there's definitely multiple things that it can be. So first we would need to do a full physical examination and book an appointment or for that in person. And we will get some lab work done as well, as well as a X Ray of the of the spine and your sacroiliac joints. And we'll also get some blood work with CBC, CRP and ESR. So those are just inflammatory markers as well as the rheumatoid factor antinuclear antibodies. Those are just some things that will test for different kind of rheumatological issues and to see if you have any arthritis. So yeah those are and then will also get an X Ray of your hands and knees since you're having pain there as well. So yeah, those are some steps that we'll take. Do you have any questions or concerns?

P: No, that that sounds, that sounds great, thank you.

D: Alright, yeah, so I will get in touch with you shortly.

P: Sounds great, thank you.

D: Alright, take care.

P: Bye.

D: Bye.


D: What brings you all in today?

P: Hi. So I just brought in my son he's 5. Essentially, when he, so today is Friday when he got home from school on Wednesday, he seemed fine, but he I don’t know that night he started to have a bit of like a cough. It just seemed like a little dry cough, but obviously I just wanted to keep him home, keep him safe and not like spread anything if he was sick. So he stayed at home on Thursday and he was like having a bit of a cough. Then yesterday it seemed to get a little bit worse and he was really tired, uh sorry. Today, today is Friday. He was like his cough is like getting a bit worse and I've been taking his temp the whole time and it got like a little high today, what was it? My thermometer says it was high. I'm just like trying to remember it was it was. It was like over 100 though.

D: Oh OK.

P: Uh, 101 or something or maybe 100.1 if. But anyways it was so I I just thought I should probably bring him in 'cause I was really worried about him and you know so he could have maybe got covid and like at school or something.

D: Yeah for sure. Um OK, so just to clarify, he's had this cough and fever for the past five five days.

P: Mhm.

D: OK, OK so let's focus on the cough.

P: It’s Friday. Its been more like like 3 days.  Wednesday is when he came home, and then um he. And then today is Friday. So yeah, sorry.

D: Today is Friday OK. And um. OK, yeah sure uh so. Is this cough a productive cough, or is it kind of a dry cough?

P: Uh I think it's dry. I haven't noticed him like spitting up anything. Yeah he yeah, its just like little cough.

D: OK, And. He is he. He's not bringing up any sputum or blood?

P: No.

D: No OK good. OK, and does he sound wheezy at all to you?

P: No, no, not that I've noticed.

D: OK, how about short of breath?

P: Um I don't think so like he usually he's a really active kid and he has. He hasn't been running a lot outside in the past couple of days, so maybe he maybe he could have been having a harder time breathing. But also I think he's just been tired in general.

D: OK, yeah. OK, Uhm. Is his coughing getting worse with certain times of the day? Like is it worse at night, in the morning?

P: Mm I think it kinda just there the whole day.

D: OK, and it does it, how does it sound? Does this sound like a barky cough? Does it sound? Uhm? Like harsh, what is what would you say the quality of it, of the sound of the cough is?

P: Uh, I, just sounds kind of dry. It's not like super loud.

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

P: Um like he's had colds before, but I haven't like. I haven't like you this time he kind of had the fever, which is different than you know, having a regular cold.

D: OK. And are his symptoms getting worse?

P: I think so 'cause yeah, the first day he just seemed like a little dry and then yesterday is coughing and today he actually has a fever.

D: OK, and is he complaining of anything like chest pain? Or feeling like his heart's racing?

P: No, I don't think so.

D: No, OK. Does he have a sore throat?

P: Mm I don't think so.

D: OK, and is he having any issues swallowing food or fluids?

P: I don't know if he's having trouble swallowing, but he doesn't seem to have a big appetite right now.

D: OK, and is he, does he have a blocked nose or runny nose?

P: Maybe a bit of like a look at runny nose.

D: OK, and does he have any issues with smell or taste?

P: He, this morning he really seemed like he wasn't like into his breakfast and I wonder if he's losing his sense of taste a little bit.

D: OK, how about vision or hearing?

P: I think those are fine.

D: OK, and is he complaining of any chills or night sweats?

P: No.

D: OK, any changes in his hair, nails or skin like rashes?

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

D: Any changes in his bowel movements. Pardon?

P: Um sorry no changes.

D: OK, no diarrhea, no constipation, no blood in the stool?

P: No

D: OK, any nausea or vomiting?

P: No.

D: OK, any changes in his urine?

P: I haven’t really been looking, but I don't think so.

D: Any dizziness or fainting spells?

P: No, just like fatigue.

D: OK, any confusion or memory loss?

P: No.

D: And is he and is he an otherwise healthy child?

P: Yeah, actually he hasn't decided to like a vaccine that he hasn't had to go to the doctor like ever like. I mean, he broke his arm once, but that was it.

D: OK, um so no past illnesses and I guess no hospitalizations or surgeries except for the broken arm.

P: Exactly, like nothing.

D: OK, and were things normal with your pregnancy with him?

P: Yeah totally.

D: OK um. And then how about as a newborn, any complications after birth?

P: No, no, like everything is things really good.

D: OK, and then did he hit all his milestones up till now?

P: Yeah totally.

D: OK. Any, does he have any allergies?

P: Um. No, no, I don't think so. I mean like he hasn't really taken a lot of medicine, so it's hard to say, but like nothing.

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

P: Yeah.

D: Yeah OK. And. In terms of family history, are there any lung conditions or heart conditions?

P: Uh no everyone is really healthy.

D: OK, and. And are there and who does he live with and where does he live?

P: Um he lives with just me and my husband, and he has a little sister, like this in town here.

D: OK and, is she healthy?

P: Yeah, I think she, yeah she's healthy.

D: OK um? Any concerns for old carpets, mold, asbestos or any environmental issues like that in the home that you're in?

P: No.

D: No, OK. Has he been around any sick contacts recently?

P: Not, not like outside of school. I like we know for sure, not outside of school, um but he goes to school right now so. Kinda hard to say.

D: OK.

P: But they haven't. They haven't like contacted us about anything.

D: OK, sure. And has he traveled anywhere recently?

P: No.

D: No OK. OK, well those are all the questions I had for you today. Were, was there anything that I missed that you wanted to chat about today?

P: I don't think so. Um, like I, I realized that I can often times like you don't really do much for kids when you know when it's just like a virus or something. But we do, I guess need to have a covid test to go back to the school, even if you know either way 'cause they want us to be able to say. It's like the other kids have had an exposure.

D: Yeah for

P: yeah, like. Sorry, go ahead,

D: No go ahead.

P: I’m just basically wanted to see if it was bad. I mean he doesn't receive your so scared. That's kind of what makes him in like it's gonna be a little bit.

D: Right, yeah, OK, so first thing is, first we need to do a covid swab just to make sure that he either has it or it doesn't have it and those results will come back in 24 to 48 hours. Um we do suggest because his symptoms are allowed with symptoms of covid that he isolate for 14 days and that includes from his his younger sister possible. And then if the swab comes back negative, there is a chance for false negatives. But also it could be another viral illness that's going around nowadays, and if his symptoms get worse, so if he has a really high temperature, if he has any neurological symptoms, like seizures or. If he's feeling weak, dizzy if he has any fainting spells, please do take him to the ER and. And so for now I'll just wait for those covid swaps to come back. How does that sound?

P: Yeah, sounds good.

D: OK great yeah, yeah no worries and. I I should have mentioned if it was just the cough or if he was just short of breath or something like that and he didn't have the fever, we would add other things like asthma to the list of things he could be worked up for, but um right now it sounds like it sounds like an infection.

P: OK yeah, that's good to know.

D: Alright, sounds great. Have a good day.

P: You too thanks.


D: How may I help you today?

P: Umm, yeah so I just came in today with, I've been having a few symptoms for the last I would say 5 days. So I've had, it started with a sore throat just five days ago, kind of just very irritating sore throat sensation that's kind of gotten worse over the last few days. And then I started getting a fever four days ago and it has been going on for the last couple of days as well. And the highest temperature I measured on myself was 38.8 degrees Celsius and yeah, so that, that's, that's my main concern right now.

D: OK and, since the sore throat started 5 days ago has it been getting better, worse or staying the same?

P: I would say it's getting worse. I have some pain with swallowing food as well as, like now, even when I'm talking a little, I'm getting some pain as well.

D: OK, have you been able to maintain your appetite?

P: I do feel like I've lost a bit of my appetite over the last three to four days.

D: OK, and have you noticed any changes to your voice?

P: Uhm, I don't think so, not yet, I, but I think, like the way it's hurting right now, I feel like it's coming.

D: Alright, so have you notice any like neck swelling?

P: Yeah, now that you mention it, I, I do have like these two lumps on the right side of my neck, like kind of right below the jaw.

D: OK. Are they painful?

P: Uhm, not, not really. Like when I'm pressing on them they don't really hurt, but I definitely have two lumps.

D: I see, OK. We'll, certainly look into that on the physical exam. OK, and uh, and you mentioned that you've also been really tired over these last few days?

P: Yeah, I've, I haven't really had much of an appetite, kind of just, I've skipped work, just trying to take it easy like just napping the whole day, as much as I can.

D: OK, and so you've been experiencing fatigue. Have you had any, any headaches?

P: No headaches, no.

D: Alright, how about any eye redness or runny nose, or?

P: Uh no, no runny nose, or, so I, I don't have headaches, but I, I, I think I was having some body aches just yesterday.

D: OK, so any particular area that, that's aching?

P: Uhm, not really. It's kind of just like a general, like I don't know if it was, it was because I was lying around the whole day, but just kind of a general pain throughout the body.

D: OK. And have you been experiencing any difficulties, or sorry, have you been experiencing any cough?

P: No, not really.

D: OK, how about any shortness of breath or trouble breathing?

P: No.

D: OK, have you had any wheezing?

P: No wheezing.

D: Alright, and how about any chest pain?

P: No, no, no chest pain.

D: Have you had any heart palpitations or, or feeling like your heart's racing?

P: No.

D: OK, uhm, and, maybe you had any lightheadedness or, or dizziness?

P: Uh, no, not really.

D: Have you had any abdominal pain?

P: Uhm, actually, yeah, yesterday when I was, uhm, like when I was having the body pain, I also noticed a little bit of abdominal pain just, like on the upper, I would say upper left side.

D: OK, and, and how would you describe this pain and how long has it been going on for?

P: Just since yesterday. It's, it's not really like, I would say it's more of a discomfort than a pain, but I definitely do feel like like something's just not right in that area.

D: I see, is there anything that you do that, that makes that, that feeling worse, or make, that make it better?

P: Yeah, like I, I try not to lie on that side. I have to go on to the other side.

D: Alright, did you notice this in the last couple of days as well?

P: Yeah, that, that just started yesterday.

D: OK. Have you had any nausea or vomiting?

P: No.

D: How about any diarrhea?

P: No.

D: Alright, and have you had any fevers or, or sorry, yeah, you mentioned you had a fever of 38.2. And have you had any chills?

P: Uhm, no chills, well, yeah, I would say a couple nights ago I might have had some chills, but mainly it's just been, I've been feeling more hot and I have been kind of getting like night sweats.

D: OK, you've been having night sweats this week or have they been going on longer?

P: No, just, just this week.

D: Alright, have you had any changes to your weight over the last several months?

P: No, it's been pretty steady.

D: Alright, and the fever this week, has it been there the whole time, or has it come and gone?

P: It kind of comes and goes. I've probably taken temperatures like every day. But I would say it's definitely, for the last few days it's been more of a fever, like the nightsweats sensation. Before it was a bit fine, like, but the highest temperatures have been in the last few days.

D: OK, have you noticed any skin changes or rashes?

P: Uhm, just like, I, I don't know, like I don't think there are any changes, but I did notice some, like kind of just pink, pink spots on my arm the other day.

D: OK, well uh, were they itchy?

P: No, they weren't really itchy. Just like a couple I would say like raised, not raised spots, just like flat, kind of pinkish spots.

D: OK, and has that, has that spread anywhere or has it gone away?

P: No, hasn't really started spreading yet, I just noticed it on, on my arm, and I, I don't think it has really spread at all.

D: OK, this is on, on one arm?

P: Yeah.

D: OK. And you've had some body aches, uh, have you had any joint pains?

P: No join pains, no.

D: OK, and are you currently sexually active?

P: Yes.

D: Alright, and could you tell me a little bit about your partners or, or partner and I, and I was wondering if you use condoms?

P: Yeah, so I, I just have one partner right now, my fiance, and we Uh, I actually like have in an IUD, so like we, we don't use condoms, but like we're pretty honest and safe with each other. I fully trust him, like he doesn't have any partners or anything like that and I only have, I don't have any other partners as well.

D: OK, have you had a sexually transmitted infection before?

P: No, never.

D: OK, any concerns currently? Any vaginal discharge or itchiness or, or pain?

P: No, nothing like that.

D: OK, and have you been pregnant before?

P: No, I haven't no.

D: OK. And have you been diagnosed with any medical conditions before?

P: Uhm, just uh, I have had just eczema in the past, but that, that's fairly stable. It's been treated, I don't really have it anymore.

D: OK, do you take any medications regularly?

P: Currently, no, no.

D: Any allergies to medications?

P: No.

D: Alright, uhm, and any hospitalizations or surgeries in the past?

P: No.

D: OK. And could you tell me a little bit about your living situation currently, like, who you live with, and, and where?

P: Yeah, so I'm just living with my fiance and that's, we're living in like a small apartment. And right now we're not really seeing anyone else really during the pandemic.

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

P: I just had to go into work like one day last week just to grab some of my stuff, but didn't really come into contact with anyone. My fiance does go to his work like a couple, like three or four times during the week, so I don't know if he got into contact with anyone, It's, it's hard to say.

D: Has he been sick at all? Like any, any cough, sore throat, anything, like that?

P: He did have a sore throat last week, but it kind of just went away on its own in a couple of days and compared to me, like, his was nothing really.

D: OK, uh. And have you traveled anywhere?

P: No.

D: And do you smoke cigarettes?

P: No.

D: How about do you smoke marijuana or use any cannabis products?

P: Uh, probably smoke marijuana, just maybe once or twice a month.

D: OK, so it sounds like socially?

P: Yeah.

D: Do you use any other recreational drugs?

P: No, nothing else.

D: OK. And do you drink alcohol?

P: Yeah, I, Probably have some red wine every other day, I would say.

D: OK, and this is like one glass or two?

P: Yeah, no, It's just like a normal glass of wine. Maybe, like we probably go through like a bottle between both of us, like every two weeks, maybe.

D: OK. And in the family, has there been anybody who's had any cancers?

P: No, no, no cancer is in the family.

D: OK, how about any genetic diseases or anything congenital that runs in the family?

P: Not that I know of.

D: OK. So that was everything that I wanted to ask about on history, and so next we'll go ahead and get vitals and do a physical exam. But did you have anything else that maybe I forgot to ask about, or any other symptoms maybe?

P: No, I don't think so. Do you think it can be covid at all?

D: Uhm, so covid does present in a variety of non specific ways and so it certainly could be on the differential for causing a sore throat and abdominal pain and as well as a fever. However, it could be caused by other things as well. Uhm, currently your constellation of symptoms, with the enlarged lymph nodes in the neck, sore throat, it sounds like you may have uhm, an inflamed spleen as well, which could all be signs and symptoms of something called EBV or, or mono. And it sounds like you might have had an exposure, like your husband or fiance rather may have had this last week with the sore throat. All that being said, today we'll do the monospot test to check for that as well as some blood work. And we will do a covid swab as well, just in case.

P: OK, that sounds good. Thank you.

D: Thank you.


D: Can you just tell me what brings you in here today?

P: Yeah, my chest is really hurting.

D: OK, and where where does it hurt exactly?

P: It's hard to say the exact location, but more on the left side of my chest.

D: OK, and is it like what kind of pain is it? Is it like a dull aching pain, or is it as sharp or stabbing pain?

P: The pain is. It's stabbing, but also it feels really really tight in my chest.

D: OK, and if you're to rate it on a scale of zero to 10, zero being the least amount of pain you felt in your life and 10 being the worst, how much would you rate it?

P: I think at 6.

D: Six, OK. And when did it start?

P: It started this morning just right after I got out of bed.

D: OK, so you weren't doing anything like you weren't doing any activities, you just woke up from sleep?

P: Yeah I got outta bed. I was just trying to get dressed and all of a sudden I got this tightness and and stabbing pain on the left side of my chest.

D: OK, approximately how many hours ago was that?

P: I I would say about. Six hours ago.

D: OK, and has it been as a pain getting worse at all?

P: Uh, it's it's getting worse.

D: It's getting worse, OK. And have you had any similar sort of pain in the past before?

P: Um nothing like this before.

D: No, OK. And is the pain going anywhere else or is it just staying in your chest?

P: The pain is just in my chest.

D: OK. And does anything that you do make it feel better?

P: Sitting up tends to make it feel a bit better.

D: OK, and does anything you do make it get, make the pain get worse?

P: It gets worse every time I breathe in.

D: OK, and what kind of pain do you get when you breathe in?

P: It's a sharp stabbing pain.

D: OK and apart from the pain, are you having any other symptoms like a cough or shortness of breath and anything like that?

P: Yeah, with the pain, I'm having a hard time breathing.

D: OK. OK, I just have a few other questions. Uh, have you recently had any kind of trauma or injury to your chest at all?

P: Um no.

D: OK, have you traveled at all recently?

P: I was in in Italy for the past three weeks actually, just got back last night.

D: OK. And have you been experiencing any kind of nausea or vomiting, or fever or chills?

P: No. No nausea or vomiting. I did take my temperature, no. Sorry I did not take my temperature, but I've been having chills the last few days.

D: OK, uh, and uh, yeah, just curious have you been having any kind of swelling at all in your feet or ankles?

P: Ah, my legs felt a bit swollen on the way back on the airplane, but they tend to swell so I didn't think anything of it.

D: OK so they have swollen up before but you saw them swollen this time as well?

P: Yeah.

D: OK. And have you been feeling at all fatigued at all?

P: I've been really tired with all of the traveling, so I think maybe I'm just jet lagged.

D: OK, have you noticed that all your heart racing, like any palpitations?

P: Yeah, since this morning it's felt like my heart is is racing.

D: OK, have you noticed any skin changes at all? Any rashes?

P: No rashes.

D: OK, have you noticed any cough, coughing at all?

P: I've had a cough since last week, but it feels much worse today.

D: OK, and has there been any kind of green slimy mucus in your cough at all?

P: No, it's been a dry cough.

D: Dry cough, OK. and have you noticed at all coughing up blood?

P: No blood.

D: OK. And have you recently had any infections in the last month?

P: Yeah, a couple of weeks ago I had a runny nose and sore throat and a little bit of a headache but. I feel better from that now.

D: OK, and to just go away by itself, or did you have to take any medications?

P: It just went away on its own

D: OK. Have you been feeling any kind of dizziness at all?

P: I have a little bit of yeah, um dizziness when I when the pain gets really bad.

D: OK, and I know you mentioned some swelling in your legs and your ankles, but have has any of your legs been hurting at all?

P: My left leg hurts really bad right now, but my entire body has been achy these past few days.

D: OK, and then you're right, like do you know where it hurts?

P: Um. I think just like in the calf.

D: In the calf, OK. OK, and do you have any past medical history any like hypertension that like diabetes? So any conditions that you've been diagnosed with?

P: No, I I'm healthy.

D: OK, any allergies to medications?

P: No allergies.

D: OK, do you take any birth control or multi vitamins?

P: Yeah, I take a daily birth control pill and also a daily multi vitamin.

D: OK, and how long have you been on the birth control pill?

P: Um, for two years.

D: OK, any hospitalizations recently?

P: Um none that I can think of.

D: Any ill Contacts?

P: No.

D: Any surgeries in the past?

P: No surgeries.

D: OK, in your family, has anyone had any conditions like has anyone passed away from a heart attack any cancers, anything like that?

P: No cancer, but my mother died of a heart attack when she was 43. And my grandma also had a heart attack when she when she was younger. I wanna say in her 50s but I don't exactly remember how old.

D: And currently right now, where do you live? Do you live in like a house, apartment?

P: Yeah, I live in an apartment by myself.

D: OK, and do you currently work?

P: Yeah, I'm in charge of um a retail store as a manager there.

D: OK and do drink?

P: Sometimes on weekends or if I'm socializing with friends, but not very often.

D: OK, and do you use any recreational drugs like marijuana?

P: Never.

D: OK, and do you smoke?

P: Yes, I smoke about 2 packs of cigarettes per day. And I've been smoking since I was 12.

D: OK. Alright and in terms of your daily routine like do you get any exercise?

P: Uh, not really. Life's a bit too busy and hectic right now right now, unfortunately.

D: OK. And how about your diet like what is your regular diet look like?

P: A lot of fast food. I know I could work on that, but again, with the busy lifestyle we tend to eat a lot of fried foods and fatty foods. I know I could do better.

D: OK. Great thank you.


D: What brings you in today?

P: Hi, I am just coming in because for the last couple of months but I've been having this, these coughing fits. Are there like when I'm going to the gym or even at home, like during the weekends when we're vacuuming and cleaning the house.

D: When did this start?

P: Um, I would say started, uh probably 3 months back, but it's gotten worse, so like before I used to like just have some irritation in my throat and cough a little, but now, I would say probably every other day I'm having these episodes where I can't stop coughing when I'm exercising.

D: Hmm, um and is this cough a dry cough, or do you bring up some mucus?

P: It's usually, it's usually a dry cough and sometimes I do bring up like this light material, but usually it's mostly a dry cough.

D: You never notice any blood, right?

P: No, no blood.

D: OK and uhm, it started about three months ago, I guess before that did you ever have a problem when you would exercise or when you were vacuuming or cleaning, has this been a problem that has occurred for years and that's just something that you that got worse and now it's come to your attention? Or was it just very new and sudden, three months ago?

P: Um, it's fairly new. I've never really had this issue before although I have been like so like after the new year in the winter I, I, I wasn't much of the person who ran or exercised a lot. But I, I kind of needed a new goal to become more fit and active. So I notice that, I don't know, maybe that's why like, it is something new that I've been trying, but yeah, it's not been an issue before.

D: OK, and other than the the cough, have you noticed any other symptoms like a sore throat or itchy eyes? Itchy nose? Stuffy nose or runny nose? Anything like that?

P: No, none of those, but I did it, initially I used to get just an irritation in my throat. But now it's just more of a cough.

D: OK. Do you have, do you get any pain in your chest at all?

P: Uh, when I'm usually it goes away in 10-15 minutes but when I'm coughing a lot I do get some tightness.

D: OK. Do you ever feel like you're short of breath when you're coughing or otherwise?

P: I do find that it's harder to take a breath at those times.

D: Ok. Uhm and how long do these last for? Episodes last for?

P: Probably, uh 15 to 20 minutes and yeah, it's it's mainly just after I like often times over the last few weeks I've had to just stop doing what I'm doing, like exercising and just come home and rest.

D: Do you feel like your hearts beating really fast when that happens or you're sweating?

P: Yeah, yeah, I I feel like it's usually, I don't know if it's because of the exercise, but I have like a Fitbit and it's my my heart rate is much faster.

D: Uhm, OK. Alright. Have you had any other symptoms so anything, any pain in your belly or any nausea or vomiting?

P: No, nothing like that.

D: Any changes in your bowel movements or any urinary symptoms?

P: Nope.

D: Any headaches or fevers or chills?

P: No, nothing like that.

D: Unintentional weight loss?

P: No.

D: Any night sweats?

P: No.

D: Muscle aches, joint pain?

P: No.

D: Have you been diagnosed with any medical conditions?

P: No, I've I've been very healthy.

D: Uhm, you mentioned that you started going to the gym more often earlier this year, and that is when you sort of notice some of these symptoms? Is there anything else that changed in your life? Any big changes that you think could be related to this?

P: Um no, not really, I've I've been really, umm, I moved back to my parents' home just for a bit right now.

D: Ok.

P: Now, while the University has closed down, and by that I've lived there all my life before, so I don't know if that had anything to do with it.

D: Do you feel like they may have put new curtains or or like there's old carpets or new a new pet, or something that could have caused some irritation for you?

P: No, but I have noticed that when I when we vacuum. I, I do get some of those symptoms as well. Just more of an irritation mores than the cough.

D: OK. OK, and do you feel that you're particularly anxious when these episodes are occurring? Do you have any new stressors in life?

P: Uh, no, not really.

D: Any medical conditions that run in the family?

P: Uhm, I don't think so. Not that I know of.

D: OK, and I guess a little bit more about you. So have you had in the past when you were younger, did you have a rash like eczema or did you have allergic rhinitis where you would sneeze and, to feel ill when you were outside or at certain times of the year? Anything like that?

P: I didn't have a, I didn't have any like exam or rashes, but I do generally have umm, get allergies during the spring time when I go outside.

D: Do you take any medications for that?

P: I just take Reactine usually during the spring.

D: Do you have any other allergies? To food or medications?

P: No, not that I know.

D: And other than Reactine, do you take any medications, including over the counter meds?

P: No.

D: Nothing else? OK. And. In your family, you said no one has asthma or allergic rhinitis or eczema or anything like that, right?

P: Not asthma, my dad also gets those allergies and irritations just like me.

D: Uhm, OK. And you mentioned that you're staying with your at your parents place. Are you uh, are you doing things from home? Are you like doing school from home or working from home?

P: Yeah, I'm not currently working, just studying from home.

D: OK, and have you had contact with anyone who might have been sick?

P: No.

D: Traveled anywhere outside the province, recently?

P: No.

D: OK, and do you smoke or have you ever smoked?

P: No, never smoked.

D: Marijuana?

P: No.

D: Any recreational drugs?

P: Nope.

D: Uh, do you drink alcohol or have you ever had alcohol in the past?

P: Yeah, alcohol I've had like at University, but generally, maybe just on the weekends. Not anything regular.

D: Alright. OK, well, uh, those are all the questions I had for you. We will do a physical exam now and I'll go talk to my attending and we'll uh come talk to you right after. I guess before before I do So what exactly are you hoping to get out of today's visit?

P: I just wanted to like I really do you want to become fit and it's just these symptoms are stopping me and kind of affecting my daily routine, so I just wanted to know what I can do to stop like having these symptoms.

D: Have you ever tried any puffers?

P: No, I haven't.

D: No, ok. Right, yeah, let's talk a little bit.

P: OK.


D: How may I help you?

P: I'm I'm here because my right knee is very painful. It looks kind of swollen and it's it's also a little bit warm so I'm just worried, I'm worried about it and I was wondering if you could look at it.

D: Yeah, certainly, um. So where are you feeling the the pain exactly?

P: So it's where, so right in the middle of my knee. So just below the bone that, the big knee bone.

D: OK, so like underneath the kneecap, like below that?

P: Yeah just just a little bit below.

D: OK, so slightly below the Patella. Sounds like somewhere in the region of the tibial through tuberosity.

P: Right.

D: OK, and when did this pain start?

P: It started about two weeks ago.

D: OK, two weeks ago when the pain started, was there any trauma or could you remember any movement that that caused the pain?

P: Nothing like that, but I recently found out that I had some osteoarthritis on my left knee, so I was trying to put more pressure on my right knee one whenever I was doing like gardening work um and I think something something may have happened when I was doing that, something maybe, maybe I put too much strain on it.

D: OK, I see an. Alright, like are you doing a lot of kneeling on on or during the gardening work?

P: I am.

D: OK. Um, and. How long has the pain been going on for, has it been constant over these two weeks?

P: Yes, it has been.

D: OK, and how would you describe the pain, is it sharp, burning, achy?

P: I would say mostly achy, but it can be sharp.

D: OK, and do you feel the pain radiate anywhere else?

P: No, just it's pretty local.

D: OK, have you tried anything to make the pain better?

P: I tried some topical like what are those like ice and fire gels. Those seem to help temporarily, but the pain comes back.

D: OK. And. Have you tried, has anything made the pain worse?

P: I guess like when I kneel down on it, it gets painful or If I touch it or palpate it, I guess painful if I'm I'm flexing my knee too much that hurts as well. Kind of keeping it straight and not touching it makes it feel better.

D: OK, and. What would you say the severity of the pain is with 10 being the worst pain you've ever felt and one being the least pain?

P: I give it about a 6.

D: OK, and have you had a pain like this in your right knee before?

P: No, nothing like this and I have osteoarthritis in my left knee but it feels different.

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

P: Uhm, no.

D: OK, and how about any night sweats?

P: No.

D: OK, and have you had any unexpected weight loss over the last several months?

P: No.

D: Have you had any headaches?

P: No.

D: Have you had any changes to your senses like vision or hearing?

P: No

D: Any changes to your sense of smell or taste?

P: No.

D: OK, have you had any sore throat or cough?

P: No.

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

P: No.

D: Have you had any wheezing?

P: No.

D: Have you had any chest pain?

P: No.

D: Had any lightheadedness or dizziness?

P: Um no.

D: Have you had any heart palpitations?

P: No.

D: OK um an 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, or blood in the stool?

P: No.

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

P: No.

D: OK, and have you had any like muscle aches or joint pains anywhere else?

P: No.

D: OK, and have you had any neurological symptoms such as numbness or or tingling or reduced sensation?

P: No.

D: OK, and how is your energy been recently have you had any fatigue?

P: No, not really. It's been the same.

D: OK, and in the past have you been diagnosed with any medical conditions?

P: Uhm I have Class 2 obesity. And then also arthritis in my left knee. As well as high blood pressure.

D: I see and. Do you take any medications?

P: Currently I'm on Ramipril and I take some ibuprofen sometimes for the osteoarthritis in my left knee.

D: OK and, do you have any allergies to medications?

P: No.

D: Have you had any surgeries before?

P: Nope.

D: Or have you had any hospitalizations for any reason?

P: No.

D: OK. And. Have you been pregnant in the past?

P: Um I I have one, one child, she was born through c-section.

D: And are you currently sexually active?

P: I am.

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

P: Yeah, so just with my husband of 10 years.

D: OK, any concerns for a sexually transmitted infection like vaginal discharge or or pain or itchiness?

P: No.

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

P: Um I live in downtown London I live in a house with my husband and my daughter.

D: OK. And have you been around anybody who's been sick recently?

P: No.

D: And have you traveled anywhere recently?

P: No.

D: OK, are you currently working right now?

P: I yes I am.

D: OK, well then what what do you do?

P: I work as a full time gardener for a landscaping company.

D: OK, I see. So you're spending a lot of time doing kind of like repetitive kneeling type movements to do your job?

P: Yes, that's right.

D: OK And do you smoke cigarettes?

P: I don't.

D: Alright, and do you drink alcohol?

P: I'll have a glass of wine every other night.

D: OK, and do you use any recreational drugs?

P: No, I don't.

D: Have you used anything like that in the in the past.

P: No

D: like IV drugs, no, OK. And in the family or is there a history of any musculoskeletal or neurological conditions?

P: No.

D: OK. So next I just wanted to do the physical exam portion and ask you to have a look at the knee first and let me know if the if you're having any swelling, redness or warmth to the knee compared to the other side.

P: Sure.

D: Sorry so you are having, having swelling, warmth and redness to the right knee?

P: Yes.

D: OK and are you having pain to like palpation is there a specific spot you can press on that causes a sharp pain?

P: Um so just below that kneecap area there is some swelling there and when I press down on that swollen area, it causes a bit of pain.

D: OK. And are you able to fully bend, bend and straighten the knee?

P: I can do that, but when I bend my knee it really hurts.

D: OK. And are you able to walk normally or do you have a limp?

P: Um I can walk normally, it just hurts.

D: OK. So that was a everything that I wanted to ask today on the history and and physical. Was there anything? That you maybe I forgot about you wanted to add?

P: No, I don't think so.

D: OK, so right now it's sounding like this could possibly be a knee Bursitis. Or Prepatellar, or sorry, infra patellar bursitis or a prepatellar bursistis which are the kind of the more common types. One thing to make sure that we rule out would be a septic Bursitis. Although you're not having any fevers or chills so that makes it a little bit less likely.

P: Mmmm

D: But if your symptoms are getting worse and you're developing a fever, it's becoming even more painful then certainly will have to rule out infection. And as well if things are not improving, potentially a structural disease and any, such as a meniscal injury, or like a ligamental injury from all of the like kneeling and and repetitive movements. But right now I think it's mostly sounding like a knee bursitis.

P: OK.

D: OK, and treatment for that will be activity modification as well as using things like as um NSAIDS and icing to help with um the inflammation.

P: OK, that sounds good, thank you.


D: What brings you in?

P: Yeah, so I've had this chest tightness and and been short of breath and bringing up sputum with this uh cough.

D: OK, so um lets start with the cough. When did that start?

P: So I've had a cough now for a few years, um but over this past uh three days it's gotten quite a bit worse.

D:: OK, for the past three days, three three years. OK.

P: Yeah.

D: Um are there any triggers for your cough?

P: Uh, yeah, if I'm doing, um, like if I'm really active like if I run to catch the bus or uh or if I'm shovelling snow, maybe I can make, become short of breath, but um not if I'm just walking around the block or anything like that.

D: OK, and what caused this cough initially three years ago? Do you know?

P: Uh yeah, I think um I think it's just a smokers cough. I think that my family doctor told me I had like chronic bronchitis before.

D: OK, OK. How often were you coughing before it got worse recently?

P: Uh I would usually cough every day, but the cough would be, usually just in the morning, I I'd get up um, there, I would cough up some sputum and and then maybe, and then I'd usually be OK.

D: OK, um and does anything make your cough better? Like do you take any over the counter cough syrup?

P: Um yeah, I've tried some over the counter uh cough syrups in the past, but it hasn't helped.

D: OK, OK, and if you were to talk about the quality of your cough, is it is it barky? Does it sound harsh? What does it sound like?

P: Uh yeah, I would say it sounds pretty harsh. You can kind of, it sounds like there's um mucus moving around, I guess with with the cough in my chest, I can I can kind of feel it

D: OK, OK and you mentioned that you're producing a lot of sputum with your cough. What colour is that sputum?

P: Greenish

D: Green, OK. Any blood?

P: No blood.

D: No blood, OK. And you mentioned, you've never produced sputum with the cough, especially not green sputum in the past three years, right?

P: I would bring up sputum, but it's usually clear and white.

D: OK, OK, and do you have any wheeziness associated with this cough?

P: Uh, yes I do

D: Yes, OK. And you mentioned you were short of breath. Were you short of breath prior to your cough or did that start um when when this cough got worse?

P: I think the shortness of breath has gotten a bit worse over the um last few days uh as the cough has gotten worse.

D: OK, OK. And if you were to rate the severity of your symptoms, of how you're feeling, 1 to 10, 10 being the worst, where would you put yourself at?

P: Uh I would say an 8, it's been really tough, it's been getting really difficult to um breathe.

D: OK, yeah. And have you ever experienced anything to this severity in the past?

P: No, I haven't had uh this difficulty breathing before.

D: OK. OK. Um do you have any chest pain?

P: Uh, my chest is, it feels tight.

D: OK. Uh it feels tight, OK, does that, does it hurt though?

P: Uh no, no, it doesn't really hurt. It's just uncomfortable.

D: OK. And do you think it's tight because of the coughing or um the shortness of breath?

P: Yeah, I kind of feel it um with the coughing.

D: OK and have you noticed any swelling in your limbs?

P: Uh yeah, maybe a little bit in my in my feet, more than usual.

D: OK, and do you feel like your heart's racing?

P: Uh, no.

D: No, OK. Any dizziness or fainting spells?

P: Uh I haven't had anything like that.

D: OK. Um any changes to your vision or hearing?

P: No.

D: No, um, do you have a stuffy nose or runny nose?

P: No.

D: Um how about a sore throat?

P: No.

D: No, any changes to your smell or taste?

P: No.

D: Um any fevers or chills?

P: No, I've felt OK.

D: OK, any weight loss?

P: Um yeah, maybe I mean over the last few years I've um lost a few pounds, but maybe maybe 10 pounds over the last last couple of years

D: Last couple of years, OK. Was it intentional weight loss or unintentional?

P: Unintentional.

D: OK, um alright, and any changes to your hair, nails or skin, like rashes?

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

D: OK, and how are your bowel movements? Everything normal there?

P: Yeah, that's been normal.

D: OK, everything normal with regards to your urine?

P: Yeah, that's been normal.

D: OK. Any confusion or memory loss?

P: No.

D: No, OK. Any fatigue?

P: Yeah, I've been feeling well, really tired these last three days.

D: Yeah, OK. Any joint pains or muscle aches?

P: No.

D: No, OK um and are you otherwise healthy?

P: Um, well, I use uh these inhalers um and I think I've been told I have COPD before.

D: OK, Um other than your COPD, do you have any other longstanding medical conditions like high blood pressure, diabetes, anything like that?

P: Um yeah I have uh high blood pressure and um I had my gallbladder taken out uh a few years ago.

D: OK. OK, any other surgeries or hospitalizations?

P: Uh I had an ACL repair like when I was a teenager.

D: OK, and besides the inhalers, are you on any other medication?

P: Yeah, there's one for blood pressure um and I take vitamin D, um and that's it.

D: OK, which one, which um medication are you on for the blood pressure?

P: Uh amlodipine.

D: Amlodipine, OK. When did you start taking that?

P: About uh seven years ago.

D: OK, and then for your uh COPD, which inhalers are you on?

P: Uh, there's one that's for, um, like short acting. And then there's one that I use everyday, uh Spiriva, I think.

D: OK, yeah. And how long have you been on these inhalers?

P: Uh it's been a couple of years for well, for the the short one that I I use for rescue therapies been for like a long time, but Spiriva's been the last several years.

D: OK, OK, and do you find that your inhalers are helping?

P: Yeah. They um, I definitely notice a difference when I, if I miss a dose or something.

D: Yeah, OK. And um, do you have any allergies?

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

D: No, OK. How about um immunizations, are you up to date?

P: Yeah, I believe so.

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

P: Um, uh no.

D: No, OK. Um do you currently smoke?

P: Uh I do, yes. I've been trying to quit, I um I smoke about a pack of cigarettes per day now. I used to smoke like 2 packs per day.

D: OK, well it's it's good that you've cut down, um if you need any additional help cutting down we have resources that we can refer you to.

P: Yeah, that would be great.

D: Yeah, um how much, for how long have you been smoking? Like how many years?

P: Uh well, I started when I was a teenager, so probably like 35.

D: OK. Um and do you do any marijuana?

P: Uh no.

D: No, OK, OK, um how about alcohol? Do you drink alcohol?

P: Yeah, a few beers on the weekend.

D: OK. Um and then where do you live currently?

P: I live in an apartment by myself.

D: OK. Um and any reasons to think that there are any old carpets, mold, or um asbestos or anything like that that could be exacerbating your symptoms?

P: Uh I mean I do have a carpet in the bedroom so, but I mean that that's the only carpet in the apartment.

D: OK. Um and do you live with anyone?

P: No, it's it's just me and my dog.

D: OK. Uh have you, have you been around any sick contacts recently?

P: Um maybe, I mean I I usually will see uh, a couple of friends, we'll meet up to grab some coffee
in the morning in the morning um but I feel like they have been uh OK.

D: Yeah OK, how about um travel, have you traveled anywhere recently?

P: No.

D: No, OK. OK, well I think those were all the questions that I had for you. Did you have any questions or concerns or anything that I missed that you wanted to discuss?

P: Um no, I just wanted to, um, yeah, come in because it's been really difficult to breathe.

D: Yeah, so OK, well we'll do a physical exam on you um to try to understand um how bad your COPD exacerbation is. Um we'll also try to get an um oxygen saturation on you, and we do want that reading
to be between 88 to 92%. If it is less than that um and we think you have a mild exacerbation, we'll just suggest that you use your short acting beta agonist puffer um more often, and then if you,
if we think you have moderate, um moderate exacerbation we'll also prescribe uh antibiotics and or steroids to go along with the short acting beta agonist. And if it is severe, or if it becomes severe, um please do seek out aid um in the ER and they'll try, they'll probably put you on um uh some sort of, um oxy like um some sort of supplemental oxygen, whether it's BiPAP or CPAP. Um and again they'll continue giving you your bronchodilators and steroids, as well as antibiotics to um make sure that you don't have any bad complications of uh pneumonia. Um and it does sound like it is a COPD exacerbation at this point, but if you develop any other symptoms like um fevers, or any symptoms that overlap with uh viral viral illnesses, we'll we'll we'll work you up for that, we'll do, I think we will still do a covid swab on you just to make sure you don't have that, uh but we'll start with um working you up for COPD. How does that sound?

P: That sounds great. Thank you.

D: Alright. Take care.


D: Would you mind by starting to tell me what brought you in?

P: Yeah, absolutely. Uhm, I don't know, I've just been feeling a little feverish, uhm, and I also have a, a bit of a sore throat.

D: OK, when...

P: I just came in, I just came in to see what's going on, cause I was worried, you know, with covid going on, uhm, going everywhere.

D: Certainly, when did the, the sore throat start?

P: Last night actually.

D: OK.

P: Yeah.

D: And uhm, have you had any, uhm, problems with swallowing, like food or liquids?

P: No, I don't think so. I just had breakfast this morning and no problems there.

D: OK, uh, any like, changes that, uhm, other symptoms that you've been having with the sore throat?

P: Yeah, I'm just feeling a little feverish.

D: OK, and when did that start?

P: This morning.

D: OK, did you take your temperature?

P: No, I don't have a thermometer at home.

D: OK, and have you had any, any cough?

P: No.

D: OK, how about any, like red eyes or runny nose?

P: No, neither of those.

D: OK, have you had a headache?

P: No.

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

P: I don't think so.

D: OK, and how about any loss of taste or loss of smell?

P: Yeah, I don't, uh, yes, I said I was eating breakfast this morning, but it just tasted really bland.

D: OK, so maybe loss of taste, so you feel like your nose is really or that you're really congested?

P: I guess yeah, now that I think about it.

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

P: It's alright.

D: OK, and so you haven't had any cough or shortness of breath, but have you noticed any wheezing?

P: No.

D: OK. And have you had any chest pain?

P: No.

D: Have you felt as though your hearts's been racing at all or, or beating out of your chest?

P: No.

D: OK, have you been dizzy or lightheaded?

P: No.

D: OK. Have you had any nausea or vomiting?

P: No.

D: Any abdominal pain?

P: No.

D: Have you had any diarrhea or constipation?

P: Uhm, I'm often constipated but nothing new there.

D: OK, have you had any urinary problems?

P: No.

D: Alright, and then how about any muscle aches or, or body aches?

P: Sort of, like I just, I found it really hard to get out of bed this morning.

D: OK. How has your energy been? Have you been, like really fatigued?

P: Yeah.

D: OK, and when did, uh, you said the muscle ache started this morning, uhm, how, when did the fatigue start?

P: I'd say this morning as well, yesterday was just like a little tickle in my throat and I thought it would just go away you know, and I woke up this morning and I just felt horrible. And the sore throat was just worse and I felt feverish and tired and I felt really crappy.

D: OK, yeah, and have you had any symptoms like this before?

P: Well yeah, I usually get a cold once a year in the fall. It does feel similar to that.

D: OK.

P: But I still wanted to be careful and come in, just in case.

D: yeah, certainly. Have you had, have you been diagnosed with any medical conditions before?

P: I have migraines.

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

P: No, no, I'm not. It's not bad. I sometimes just take like, Advil whenever my headache's coming on.

D: OK. Any allergies?

P: Uh, nope.

D: OK. And do you smoke cigarettes?

P: I smoke, uh, two or three a day.

D: OK, and have you tried to quit?

P: No.

D: OK, if at any point this is something that you wanted to talk about, we, we certainly could later.

P: sure.

D: Do you drink alcohol?

P: Uhm, a glass at night with dinner.

D: OK, and do you use any other recreational drugs?

P: No, no, no, nothing like that.

D: OK, have you in the past?

P: No.

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

P: Uhm, oh, my, like my little granddaughter had, uhm, you know, they're always having a runny nose, right, the little ones.

D: Mhm.

P: But no, nothing, nothing else. I've just been at home for the most part.

D: OK, have you traveled traveled anywhere?

P: No.

D: OK, and, uh, does your granddaughter go to daycare? Or is she in school?

P: She, she does go to daycare, yeah.

D: OK, and has there been anybody else around that, that's been sick that you're living with, or you see often?

P: No, that's about it.

D: OK, I, I think, I don't think I asked this, but have you had any surgeries before?

P: I had cataract surgery done.

D: OK, and the left, right eye or right eye?

P: Both actually, it runs in my family. We get it pretty early on.

D: OK, and are there any other conditions that run in your family like heart conditions or cancer?

P: Diabetes.

D: Diabetes, OK. And who had diabetes?

P: Lets see, my mom, my sister, my brother, yeah, yeah.

D: OK. And just to, get to know you a little bit better as well. I was wondering if you could tell me a little bit about your living situation?

P: Sure, yeah, I live with uh, I live with my son and daughter and my grandson.

D: OK, uhm, and, uhm, OK, yeah, I think that's all I wanted to ask about today. Was there anything else that you wanted to tell me or maybe that I forgot to ask about?

P: Uh no, I don't think so. Do you think I have covid?

D: It's, it's certainly possible. It will be something we test for.

P: Sure.

D: Although the symptoms that you're experiencing, with feeling or having a fever, sore throat, and not feeling well with the muscle aches and fatigue, uhm, its relatively non-specific, so as you mentioned, it could be something like the common cold, that you've experienced in the past, so we can't rule that out either at this time, but we will do some investigations including a nasal swab for covid and kind of go from there.

P: OK, sounds good.

D: All right, we'll get that started.

P: Great.


D: How may I help you?

P: Hi, yes I've had this pain in my left elbow for a couple of weeks now and it's not getting any better so. I'm just here to kind of figure out what it is.

D: OK alright are you feeling this pain on the lateral side of the elbow, on the or on the medial side of the elbow?

P: It's on the medial side.

D: OK and sorry, when did this pain exactly start?

P: So it's been on going for like the past three months. But it's gotten worse over the last, I'd say three weeks.

D: OK, and. Has the pain been getting worse, any better?

P: Oh the pains been getting worse.

D: Yeah, OK. Was there any triggers or precipitating events to the pain, such as like a fall or any types of trauma to the elbow?

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

D: Have you had any pain or injury to the elbow in the past?

P: No.

D: Could you describe the character of the pain. Is it sharp, achey or dull?

P: It's usually achey, but it can be sharp.

D: OK. Does the pain radiate anywhere?

P: No, it's pretty. It's pretty much in that one area.

D: OK, just on the medial side of the left elbow?

P: Yeah.

D: OK, and is there anything that you've done to help make the pain go away, or any alleviating factors?

P: I am taking some NSAIDs that helps with the pain temporarily.

D: OK. And uh. Are there any factors that make the pain worse?

P: Um when I. I. I guess when I like extend my elbow out it gets worse.

D: OK, so it's a movement OK, and straightening the elbow?

P: Yeah.

D: OK, I mean, what is the severity of the pain on a scale of 1 to 10, with 10 being the worst pain you've ever felt.

P: I'd say about 5.

D: OK. And um. So did you have any other symptoms associated with the elbow pain?

P: Um no, um not really I. I'm otherwise pretty healthy.

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

P: No.

D: Have you had any night sweats

P: No

D: Or any any weight loss?

P: No.

D: OK, have you had any any headaches?

P: No.

D: Any sensory changes like changes to your vision or or hearing or even your smell or taste?

P: No.

D: OK, have you had any eye redness or eye discharge or your ear pain?

P: No.

D: OK. Have you had a runny nose or sore throat?

P: No.

D: Have you had a cough or shortness of breath?

P: No.

D: Have you had any wheezing?

P: No.

D: OK. Have you had any chest pain?

P: No.

D: Any lightheadedness or dizziness?

P: No.

D: Have you had any heart palpitations?

P: No.

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

P: No.

D: Have you had any abdominal pain?

P: No.

D: Any diarrhea or constipation.

P: No.

D: Have you had any urinary problems?

P: No.

D: OK. Have you had any skin rashes?

P: No, no.

D: OK, have you had any numbness or tingling?

P: No.

D: And how about any muscle weakness?

P: No.

D: OK, and any joint pains anywhere else?

P: No.

D: OK, and any changes to your memory or or any confusion?

P: No.

D: OK, and have you had any fatigue?

P: No.

D: OK and, have you had any changes to your appetite?

P: No.

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

P: No.

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

P: Um no, I just take some multivitamins.

D: OK, and do you have any allergies to medications?

P: Um no.

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

P: I I had a fracture when I was younger. It was in my humerus bone on the right side.

D: OK, so it's the to the fracture was on the other arm?

P: Yes.

D: OK, and did that heal OK?

P: Yes.

D:  Alright then. Can you tell me about your living situation? Currently, like whereabouts and who you're living with?

P: I live with my partner of five years. We live in an apartment together.

D: OK, and are you working currently?

P: I am.

D: And what do you do?

P: I work on the assembly line for Chrysler.

D : OK, uh, and uh. Do you do repetitive tasks at work?

P: I do.

D: OK, yeah, do you notice this, uh pain after, more so after a shift or after after a long day?

P: Yes, definitely.

D: OK, and what types of hobbies do you have, like do you play golf or tennis or or any kind of like, sports I guess?

P: Yeah, I used to play golf before this pain in my arm and my elbow, so I haven't played it in the past like six months.

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

P: I don't.

D: And do you drink alcohol?

P: Um I'll have a glass of wine every other day.

D: OK, and how about the use of any recreational drugs like cannabis or or anything else?

P: I'll smoke a joint once a week.

D: OK, alright and. Is there any family history of any heart or lung problems?

P: No.

D: Any musculoskeletal or neurological diseases?

P: Um no.

D: OK, I got any autoimmune diseases like thyroid disease or diabetes?

P: No.

D: OK, um and so next I wanted to walk through a physical exam, so when you look at the elbow yourself, do you see any swelling or redness?

P: No.

D: OK, does it look like there is any muscle atrophy either in the forearm or the biceps or triceps?

P: No.

D: OK, and how about any misalignment or joint deformity?

P: No, I don't see any of that.

D: OK, and are there any scars?

P: No.

D: OK, and when you press on the medial part of the the elbow, do you feel pain?

P: I do.

D: How about over the olecranon or the, yea any pain over the olecranon?

P: Um a little bit.

D: OK, and is there any pain over the lateral part of the elbow?

P: No.

D: OK, an any pain over the forearm, or biceps, or triceps muscles?

P: No.

D: OK, and does the joint feel like it's hot?

P: No.

D: OK, and any pain with shoulder or elbow movements?

P: No.

D: OK.

P: Actually, sorry with the elbow when I straighten it out all the way it hurts a little bit.

D: OK, when are you straightening it out all the way OK, But no pain with shoulder movements and full range of motion?

P: No, no pain with shoulder.

D: OK. And how about pain with pronation and supination?

P: With pronation it hurts.

D: OK, at the medial side?

P: Yes.

D: OK and how about with wrist. So with resisted uh, yeah, wrist flexion?

P: Wrist flexion yeah. That hurts too.

D: OK, and then how about if you passively extend your your wrist as far down as as you can go?

P: Down uh yes. That hurts too.

D: OK. And is there any numbness or tingling anywhere?

P: No, no, no numbness or tingling.

D: OK. OK, so that was everything that I wanted to ask about today. Was there anything else that you wanted to mention?

P: No, that was that. What do you think I have and how can I fix it?

D: Yeah, so it. It's certainly it it sounds like with the medial aspect of your elbow having pain there over the last several months and some of the physical exam maneuvers, such as like passive wrist extension, resisted wrist flexion as well as pronation and the point tenderness over the medial elbow this could be a medial epicondylitis or a tendinopathy in that area. And so this is typically treated with activity modification, so this could be trying to avoid repetitive movements that that cause pain. And using medications such as Advil and Tylenol and doing strengthening and stretching exercises, which you can learn from a physiotherapist or or on your own as well. And also other things that that the medial side of the elbow that it could be is an ulnar ligament injury. Um or yeah, or the other thing to be considering is and ulnar ligament injury and so if the pain isn't going away, then we might consider an ultrasound or something to look at the structures there.

P: OK, that sounds great. Thank you.


D: Would you mind by starting with what brought you in?

P: Yeah, so over the last week I've just been feeling some symptoms. It kind of first started with, like a runny nose. That was around like 5 days ago and then it turned into just a lot of congestion, like around my nose and like my throat. And now over the last two days I've been just feeling so much pressure around my nose and around my jaw so I've been getting a lot of pain there as well.

D: OK, is your nose still running?

P: Yeah, I'm still getting some discharge and I also feel like I'm getting some dripping at the back of my throat too, especially when I wake up.

D: OK, and could you describe the discharge? Is it clear, yellow, greenish?

P: Uh, it's fairly clear and sometimes, like a bit white, but like, it's not like green or yellow.

D: OK, uh, and have you felt that it's difficult to breathe in through either of your nostrils, like it's obstructed?

P: Yeah, so at night sometimes I have to like turn because one side of my nose gets difficult to breathe from and then it kind of balances out on the other side. So yeah, I do have some obstruction.

D: OK, and have you had any changes to your sense of smell?

P: Yeah, so just in the last three days when the congestion got really bad I started losing the ability to smell.

D: OK, have you had any changes to your sense of taste?

P: No, taste is fine.

D: OK, and have you had any cough or sore throat?

P: Uh, no. No cough or sore throat.

D: OK, and the symptoms have gone on for five days. Have you had a period of time where you got better and then got sick again?

P: I did kind of have a runny nose last week as well, so probably like 8 days ago but then the runny nose discontinued a little bit but really got worse 5 days ago, but all these other symptoms just happened in the last few days.

D: OK, and you have pain. Do you feel it in your jaw or do you feel it in the in the front of your nose?

P: Yes, I would say mainly over the cheeks. It can kind of go near the front of my teeth as well, so like I would say like mostly around the cheeks, jaws and up to the front of my teeth.

D: OK, And do you grind your teeth at all at night? or have you had, TMJ issues before?

P: No nothing like that. I think it's not so much on and around my teeth, it's more so just to right below my nose, above my teeth and just around my cheeks.

D: OK, so no pain in your mouth or anything like that?

P: No, not inside my mouth.

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

P: Uhm, I Don't think I've had a fever. I did feel some chills over the last few days, but just very brief episodes.

D: OK, and over the last few weeks have you had any weight loss?

P: No.

D: OK, and you said you didn't have a cough or a sore throat, but have you had any wheezing?

P: No wheezing.

D: How about any shortness of breath?

P: Uh, not shortness of breath. Just sometimes when my nose gets like really congested, I just turn into like a mouth breather, but that's about it.

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

P: No, no chest pain.

D: Alright, and any lightheadedness or feeling dizzy?

P: No.

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

P: Nope.

D: Any abdominal pain?

P: No.

D: Have you had any diarrhea?

P: Sorry, what was that?

D: Have you had any diarrhea?

P: No diarrhea.

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

P: Uh, no.

D: And have you had any rashes or skin changes?

P: No, not that I know.

D: OK, then how about any muscle aches or joint aches?

P: Uh, no.

D: OK, and have you had any muscle weakness?

P: No.

D: And how has your energy been? Any fatigue?

P: Uhm, it's been mainly OK, just maybe sometimes difficult to get to sleep with all the all the congestion, but I don't think my energy has been affected too much, no.

D: OK, and, uh, sorry to go back to this, I don't think I asked. Did you notice any discharge from your eyes or any eye redness?

P: Not discharge, but yeah, maybe a little bit of redness.

D: OK, have your eyes been itchy?

P: Uhm Yeah, a little bit. I would say they have been a bit itchy.

D: OK, alright then, do you have any medical conditions that you see a physician for regularly?

P: Uh, just uhm, its called dyslipidemia.

D: OK, I see, and any medications you take for that?

P: Just like a Statin medication.

D: OK, do you take any other medications? over the counter? prescribed?

P: No, other than that I take multivitamins.

D: OK, and do you have any allergies to medications or like environmental allergies that might be getting worse?

P: Uh, no, not that I know.

D: OK, so you don't experience any symptoms like this when the seasons change?

P: I don't think so. I have had this happen to me, Uh, I would say like once before. It happened like two years ago. It was pretty similar.

D: OK, uhm, and what was done at that time?

P: At that time it kind of just went away on it's own. It got better. I feel it's definitely worse this time. But at that time I didn't even go to the doctor, it kind of just went away.

D: OK, I see. Any recent hospitalizations?

P: No hospitalizations.

D: Any surgeries?

P: Nope.

D: Alright, and could you tell me where abouts you're living currently and who you're living with?

P: Yeah, so I'm currently living in an apartment by myself, just outside of London.

D: OK, and anybody that you've been around who's had any symptoms?

P: Uh, no, not that I know of.

D: OK, so no sick Contacts. And have you traveled anywhere out of the city or province?

P: No, I've tried to stay home, besides going to work. I just work at the grocery store. Besides that, no, nowhere else.

D: OK, and any of your coworkers have any symptoms? Or any coworkers being off sick?

P: No, we're pretty careful right now with the pandemic.

D: I see, yeah, that's great. OK, and do you smoke cigarettes?

P: No, I quit just a couple of years ago.

D: Oh, that's great. It's not easy to quit, so that's awesome. And do you drink alcohol?

P: Just maybe like red wine a couple of times a week.

D: I see, OK, and do you use any recreational drugs?

P: Uh, just, in a month, maybe once or twice, I smoke a joint.

D: OK, uh, and anybody in the family have any lung or heart conditions?

P: No, not that I know of.

D: Alright, and how about any cancer in the family?

P: Uh, no, no cancers.

D: OK, I think I that was everything I wanted to ask about today. Was there any other symptoms or anything else that you wanted to make sure I knew about today?

P: No,  I think that's all. I just didn't know if I needed any, like, medications or if I needed to get tested. I just wanted to make sure.

D: Yeah, so well, certainly check your temperature to see if you have a fever. And if you do and it's high enough, that will increase the chance that you have a bacterial sinusitis,  and if so, with some of your symptoms, including the discharge, obstruction, loss of smell, and facial pain, that all fits the picture for it and also you had a period where you felt a little bit better and then worse again. So that might require antibiotics, but we will check your temperature and go from there.

P: Alright, sounds good, thank you so much.

D: Thank you.


D: What brings you in here today?

P: So my back has been killing me it's been hurting for the past two months, but recently it's gotten worse. I'd say over the past week or two weeks it's gotten really bad and no over the counter medication is helping with the pain. It's I'm finding it hard to walk. I can't feel anything in the groin area and I'm having so many bladder accidents.

D: OK, and so this pain started two months ago, but it's progressed to like these other symptoms as well?

P: Yes, that's right.

D: Where did the pain start?

D: Uh, it started in my lower back.

D: Started your lower back OK and does the pain, how would you describe the pain, is it like aching. sharp?

P: It's sharp.

D: OK and did anything happened prior to the pain, any injuries at all that you experienced?

P: Two months ago I was in a motor vehicle accident um an I think my back started hurting then but they did some imaging it's and turned out like one of the discs there was a slip in a disc or something, but at that point the pain was just achey and I don't really have any in any of these other issues. But over the past two weeks it's gotten sharp and I'm having all these other symptoms.

D: OK, um and. So you're having the set like what's called, some numbness in your groin. Is that unilateral, like on one side or both sides?

P: Uhm, it seems like it's both sides.

D: OK, and. So and then you're also having the urinary incontinence. How long is that been going on for?

P: The past week.

D: OK, and what about the numbness in your groin area?

P: That's been going on for the past week as well.

D: OK, and OK, and how would you describe your pain right now on a scale of 1 to 10, 10 being the worst pain you've felt?

P: Um I would say it's like an 8 or 9.

D: Eight or nine OK, and does it get worse with any, any motions at all?

P: I think it's worse with um, I don't know like, it's worse with anything, anytime, anytime I tried to move it, it hurts.

D: OK, so you just improved with rest complete rest.

P: Yeah.

D: OK. Does it travel in, does the pain travel anywhere else, does it shoot down your legs at all?

P: Yeah, so it does shoot down my legs and I'm having a hard time walking because of that.

D: Is it both legs or just one?

P: It's mostly on my right, but the left one isn't the same as it used to be either.

D: OK

P: Yeah, I'm having a hard time like getting up from a chair and things like that.

D: OK, and anything that you've tried that has helped relieve some of your symptoms.

P: I've tried like over the counter counter and ibuprofen. I've tried some topical analgesics and nothing seems to be working.

D: OK. And. Have you experienced any trauma? So you mentioned you had a car accident rate two months ago?

P: Yes, that was. Yeah, that was two months ago.

D: OK and then. Were you in the hospital, admitted to the hospital for for a while, or how, what happened in your treatment?

P: Yeah, I was. I was taken to the ER. They did like a full work up on me. The only thing on my back that they found was a slipped disc and then they said that should that shouldn't cause me too much pain. But if I was having any of these symptoms that I'm having now I should go back, or see a doctor at least. And and otherwise I was fine like I didn't lose a lot of blood or I didn't need any surgical interventions at that point.

D: OK, I see. And have you been having any other symptoms or any any pain in any other joints or muscles?

P: Uhm, No, no, nothing like that.

D: OK, any fevers or chills.

P: No.

D: Any night sweats?

P: No rashes or skin changes.

P: No.

D: Any kind of chest pain short of, ah sorry shortness of breath?

P: Um no.

D: Any cough or cold like symptoms?

P: No.

D: Uhm, any so you have some urinary incontinence, any fecal incontinence?

P: No.

D: OK, how's an any recent changes in your weight?

P: No.

D: Have you been sick at all recently?

P: No.

D: OK, any tingling sensation either in your back or shooting down your legs?

P: No.

D: Any burning sensation?

P: Little bit of burning sensation.

D: Yeah OK do you have any numbness in your lower limbs or just numbness around the groin?

P: Just numbness around the groin area but my lower limbs do seem weak.

D: OK so you have muscle weakness. Is it just one like that's ah weak or both legs?

P: So both like seem weak but the right more than the left.

D: OK, I see. Uhm, and does this weakness seem to get worse, or is it around the same as it was when it started?

P: It's it's it feels like it's getting worse.

D: OK, do you have any past medical conditions you have been diagnosed with?

P: I had hypothyroid, so I've been taking Synthroid for that.

D: OK, any other medications?

P: No.

D: OK, any allergies to any medications?

P: No.

D: OK. Any hospitalizations or previous surgeries?

P: No.

D: Any family history of any musculoskeletal or rheumatologic conditions?

P: Um no.

D: OK. Currently, do you work?

P: I do. I work from home right now, I'm a teacher.

D: OK, uh. And do you, did you do any work previously that required heavy lifting or strenuous activities regarding your back at all.

P: Um no no, nothing like that.

D: And what's your home and living situation like right now?

P: I live at home with two of my children.

D: OK. And are you able to do things at home that you were before look like, or do you need some extra help from it, your family members, or extra help from other workers. Anything like that?

P: Yeah, my family's definitely been helping me out a lot over these past few weeks because. Yeah, like I said, like I'm having some weakness in my legs. I can't move around as much because I'm in so much pain. Um and then like there are all these like bladder accidents so. Yeah, they've been helping me out with everyday things.

D: OK, I see. And currently, do you smoke?

P: No.

D: OK, do you drink alcohol?

P: No.

D: And any recreational drugs like marijuana?

P: No.

D: OK. I'm just getting at you to do a few things on just just as part of the physical examination.

P: Sure.

D: Are you able to bend down or extend your back at all, or is it too painful?

P: Yeah, I can't do that. It's too painful.

D: Do you notice any kind of redness, swelling in and around your back?

P: Um not that I can tell.

D: OK, and how about if you press down on the your lower back, does it hurt?

P: Yeah, that hurts.

D: OK. And are you experiencing the numbness right now and in your groin area?

P: I am.

D: Are you able to raise your legs when in a lying position with straight legs, knees not bending at all, they are able to raise without any pain?

P: No, I can't do that. It's yeah, it's too painful.

D: I see, alright, so those are all the questions I had for you so it seems. It's great, it's good that you came to the emergency Department. Do you have any questions at all?

P: No, just like how can I fix this?

D: Yeah, so based on your symptoms, it's something that's pretty urgent. It's seems like you may be having something called cauda Equina syndrome that may be caused by your back pain and that's why you're feeling that groin would be called saddle anesthesia and then the urinary incontinence. So this may be from the injury that you had with the car accident. And it may be due to some compression of what we call like compression of the nerves in the area which might be giving you some of these symptoms. So the first thing we do need to do is get an MRI of your lower back just to make sure there's nothing going on like for example, like any masses in the area or any kind of abscesses that might be. We may be worried about just to make sure. Well, just to see what's going on in there that's causing these symptoms. And then based on what we find, uh, we will, we will target like the cause of the symptoms, like for example if it's an infect infection that's causing this, you might need to be admitted and require antibiotics. If there is any masses causing it, you may require surgery. For example if it's mainly related to your back it is something that we will have to treat with with an admission so it's good that you came in here today. Do you have any other questions or concerns?

P: No, that was it. Thank you so much for your help.

D: You're welcome and will get back to you shortly.


D: What brings you in today?

P: This afternoon, I'm just here because I've been experiencing some breathlessness as well as a bit of cough.

D: OK, when did it start?

P: So I think it's a it started around three months ago and I believe it's just been getting worse.

D: OK. Um, how often are you experiencing the shortness of breath?

P: I feel it like a lot of the time, especially outside when I'm in the cold or at at night when I go outside at night, my chest feels a little tight too at the same time.

D: OK, and how long does it last?

P: I would say it lasts up to an hour every time I'm out in the cold and then once I come back in. So I'd say it lasts at least one hour.

D: OK, does anything else make it worse, like dust? You know, laying down anything like that?

P: Sometimes when I'm near dust, sometimes when I'm running during gym class, increased activity does make it worse.

D: OK, OK. And if you were to describe the quality of your breathing difficulties, is it more like a burning kind of feeling? Is it like you can't catch your breath? What does it feel like?

P: I think it's more just a I can't catch my breath and it feels like my my throat is just kind of like closing off and I can't take deep breaths.

D: OK, yeah, that's scary. And one to 10, 10 being the worst, how bad is your shortness of breath?

P: It can get up to I would say like an 8 at times. It can get pretty scary. And sometimes, like I feel like heaviness in my chest too when it happens.

D: Yeah, and the coughing, has it been going on for as long as your breathlessness?

P: I would say around the same same time frame like 3 months, but I'm not always coughing. It comes and goes.

D: OK, and for your coughing, is it kind of like the same triggers, the cold, dust, things like that?

P: Yeah, I would say so.

D: And do you ever have do you ever cough up blood?

P: No, I don't. It's mostly just a dry cough. I don't cough up anything.

D: OK so no sputum or phlegm, no? OK, do you ever feel wheezy?

P: I I I do hear like a like a weird sound when I breathe out sometimes, I I think it might be wheeziness.

D: OK, OK. Do you have a sore throat?

P: Uh, no I don't have a sore throat, no.

D: No? Um, how about a runny nose or stuffy nose?

P: No, nothing like that.

D: Any changes in your smell?

P: No, no changes in my smell, no.

D: OK. How about hearing?

P: Uh, no hearing is fine.

D: OK and like no pus or liquid's coming out of your ear or anything like that, right?

P: No.

D: No ear pain?

P: No.

D: OK, and how about your vision, everything OK there?

P: Yeah, everything is OK.

D: OK, any fevers?

P: I don't know about a fever, I haven't checked, but some nights I do, especially in the last week I have woken up feeling a bit chilly. I haven't really checked.

D: OK, so you woke up feeling chilly, any night sweats?

P: Uh no.

D: OK, any weight loss?

P: No no.

D: How about changes in your skin? Like have you noticed a rash anywhere?

P: Uh, not that I've really noticed no, no rashes.

D: OK and any chest pain at all?

P: No, just sometimes when I I'm coughing a lot I feel a little bit of just tension and heaviness in there. But that's just when I'm like really coughing a lot.

D: Yeah OK, and any any feelings like your heart's racing?

P: Nope.

D: No? OK. And how about swelling? Have you noticed swelling anywhere in your body?

P: No, nothing like that.

D: No? OK um, OK, how about um, does your shortness of breath get worse when you're falling asleep?

P: No, nothing like that. I think it's mainly just worse if I go out in the cold or I'm like running around, doing more activities.

D: Does it ever wake you up at night?

P: No never.

D: OK and any nausea or vomiting?

P: No, no nausea or vomitting.

D: OK, how about changes in your in your bowel movement?

P: No, bowel movements are normal.

D: How about in terms of urinating, any changes there?

P: No no.

D: OK any headaches?

P: No.

D: No? Any dizziness or fainting spells?

P: No.

D: Confusion, memory loss?

P: No, nothing like that.

D: OK, good are you otherwise healthy?

P: Yeah, I don't have any other condition, I I do remember my doctors saying I have hay fever before, but that's about it.

D: When was that?

P: I think that was like more than three years ago.

D: OK, um, any recent surgeries?

P: No.

D: No? Are you on any medications?

P: I just take some Tylenol sometimes for the like Tylenol cold, sometimes for the symptoms. I don't think it has really helped.

D: No? OK, do you have any allergies? Not just to medications, but to anything else?

P: Uh just like hay fever but nothing, nothing else that I can think of, no.

D: OK. Um, are you up to date with all your immunizations?

P: As far as I know, yeah everything's up to date.

D: OK, any family history of lung conditions?

P: Uh, don't think so. My sister, I think she they were saying she might have asthma and she also has eczema. No one else in the family has any other conditions.

D: Not not even like heart conditions, cancer?

P: No, uh no, not that I know.

D: OK, OK, have you been in contact with anyone who's been sick recently?

P: No.

D: No, OK, and any travel recently?

P: No, I've been here in Ontario.

D: OK, and where do you live?

P: So I currently live in London, but I just recently moved into a new flat around two months ago.

D: Two months ago, OK. Um, is it more is it an older flat?

P: Uh, no, it's fairly new. But one thing I did notice, I don't know if this has anything to do with it, but my flatmate actually smokes. Sometimes that can really irritate and make me cough more sometimes at night.

D: Yeah, any any pets?

P: Oh no, I don't have any pets.

D: OK and and do you smoke?

P: No, I don't smoke, no.

D: OK. And do you smoke marijuana?

P: Nope, never tried marijuana.

D: OK, any recreational drugs?

P: No, I don't smoke marijuana or cigarettes.

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

P: Um, just like, maybe sometimes at parties, but very rarely. Maybe I would say once a month.

D: OK, OK. Um, and is there anything that you wanted to discuss today that I missed?

P: Uh, so no, I think that that was all like just the shortness of breath was scaring me a lot. But yeah, just the coughing, but other than that I just want to know what's going on.

D: OK, yeah, and you mentioned you are otherwise healthy so you don't have any history of asthma or anything like that, right?

P: No, no ones ever told me that, but my sister has asthma, so I was wondering, maybe?

D: Um, have you ever experienced shortness of breath when you were younger with like exercise?

P: Uh, not really. Just maybe like the normal amount. Like if I'm running around too much, I feel shortness of breath, but I think it just got worse over the last few months.

D: OK and then have you ever had any imaging done in the past like a chest X-Ray or investigations like a pulmonary function test?

P: No, I don't recall having any of that done.

D: OK alright well those are all the questions I had for you. If you didn't have anything else to add, I guess we will conclude by saying that what you have, we have a differential diagnosis for this. Um, it sounds like what you have is asthma. Since your symptoms started three months ago when you moved into a flat with your friends, and it seems like this smoking and cold is triggering that and so we'll work you up with a pulmonary function test to start and we'll see if bronchodilators will help with your symptoms. And if it doesn't, we'll also rule out other things like pneumonia or like allergic rhinitis. How does that sound?

P: Yeah, that sounds good.

D: OK, sounds great. Well, we'll see you soon then.

P: Alright, thank you.

D: Take care.

P: You too.