D: What can I do for you today?

P: I've just had this cough that it that has gotten a lot worse and really short of breath.

D: Uhm, can you tell me more about your shortness of breath?

P: Yeah, just over the past, like 12 hours or so, I've just been finding it more and more difficult to to breathe.

D: OK. What are you able, I guess when do you feel short of breath?

P: Yeah, it's just like right now at rest I can like I'm OK, but it still is feeling increasingly difficult. So like throughout the day, it's just been getting getting worse and the cough has been getting worse also.

D: And before these 12 hours where, did you have any difficulties with breathing?

P: Uh no, I I I had a cough but not, not really any shortness of breath.

D: And can you tell me about your cough? Is it a dry cough or wet cough?

P: I've been bringing up some some sputum.

D: OK, what does it look like?

P: It's like greenish and yellow.

D: Mhmm, OK. And you said that you had a cough prior to the past 12 hours. And that your cough is now worse. How is it worse?

P: Ah, it's been just happening more often and like just like throughout the day usually, my cough is only in the morning. I'll bring up some some sputum in it and I'm ok, but it's carried on throughout the day.

D: OK, uhm, and, was your sputum and greenish yellow before as well? Or was it just starting yesterday or, or couple days ago?

P: Yeah, that's new. That's just starting new. It was more like, I don't know, whitish? Or yeah, white I guess, before?

D: OK, alright and I guess has this ever happened to you before?

P: Uh, no, this is the first time that that this has happened before.

D: OK, and you have any other, I guess symptoms are until I ask you about a couple. Do you have any, do you feel confused or fuzzy?

P: No, that that feels OK.

D: Any headaches?

P: No.

D: Any stuffy, stuffy nose or runny nose?

P: No.

D: Sore throat?

P: No.

D: Any chest pain?

P: Ah, yeah I did. I do have a, uh, uh some, well, I guess I guess it's not really pain, it's more like like just chest tightness. I'm really having a hard time with that, with breathing.

D: Uhm, I see, OK. Do you feel like your heart's beating very fast?

P: No.

D: OK. Do you have any belly pain or any nausea or vomiting?

P: No.

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

P: No.

D: Any muscle aches?

P: No.

D: Fevers or chills?

P: No.

D: OK, uhm, alright. And uh, in terms of your past medical history, any medical problems that you've been diagnosed with?

P: Yeah, I was diagnosed with COPD uh, two years ago. Umm yeah, this is at I went to my family doctor for this and I had some testing done when I was diagnosed at that time.

D: OK. Any other diagnosis?

P: Yeah, I have high blood pressure. Aortic stenosis, uh, and uh, and high cholesterol.

D: Are you taking any medications?

P: Yeah, I I take a uh, a statin medication. I think some type of blood thinner, as well as something for the blood pressure as well, I can't remember the the names of them.

D: Why were you on a blood thinner?

P: Oh I, I heard that it was, it was umm, oh good for me for a friend since I've I've had uh aortic stenosis.

D: OK, sure. All right and have you had any surgeries?

P: Uh, no I haven't.

D: OK, and any hospitalizations?

P: No, I haven't.

D: OK. Uhm, do you have any allergies to food, environmental allergies, or any allergies to medications?

P: No.

D: OK. Do you have a or what's your current living situation? Are you living in an apartment or house? Do you live alone? Do you live with other people?

P: Yeah, I live alone in a in house, here in town.

D: OK. And are you currently working, are you retired?

P: Yeah, I I do, I currently, well, I just do some volunteering at the golf course in the summer, but otherwise, retired.

D: What did you do for work?

P: Uh, so before, I worked at the Beer Factory in in town, Labatt.

D: OK, and have you ever had any exposures to any chemicals or any anything that you, any irritants that you think any smoke that might affect your lungs? Or your, yeah.

P: Uhm, no, I don't think so. I mean, working in the factory environment, I, I'm sure things years ago weren't as clean as they are now, but yeah, I'm not sure.

D: OK, alright. And are you, you said you live alone, are you able to take your things like getting groceries or cooking or cleaning the house or do you need help with that?

P: I I do uh, get some help from my son who lives, who lives nearby, and umm, I able to to get them to to help make some meals and and bring some food over and then I'll go visit them as well. You can take care of the house so and all that not OK on my own, but it certainly gets gets lonely there.

D: I'm sure. What about what about things like walking? Do you use a cane or a walker?

P: Uhm, no, I don't.

D: OK and do you are able to bathe on your own, dress on your own? Do you need help?

P: Oh yeah, those things are OK.

D: OK, have you ever have you been on oxygen at all?

P: No, I haven't, but I feel like I could be right now. It's like, really, I'm short of breath.

D: Yeah, yeah, we can definitely do that here. Uhm, alright. So, given your symptoms, it sounds like maybe you're having a COPD exacerbation, potentially. Do you feel like you might have had contact with anyone who was sick?

P: Not that I can think of.

D: OK, have you traveled at all, outside the country or outside the province?

P: No, I I've just been helping out at the golf course, but that's all. Kind of outside.

D: Are you wearing a mask and maintaining social distancing?

P: Yeah, we are like, I'm like helping out with cleaning the carts and kind of helping out with the grounds.

D: Mhmm, OK, alright. So we'll do a Covid swab here just in case. And seeing that you're not feeling very well, you might require oxygen, we're going to keep you here in the ER, and we might have to, you might have to be hospitalized. We'll measure your vitals, do a physical exam, do a chest x-ray and you might be having, as I mentioned earlier, in exacerbation, upper COPD or a worsening of your COPD, potentially because you might have an infection, either a viral infection or bacterial infection that can sometimes worsen your COPD symptoms. You might be started on an antibiotic we'll be putting you in oxygen and giving you some steroid some, are you actually about that, are you, are you using any puffers at home?

P: Ah, yeah, so yeah I have been using uh, sorry I I have been using ventolin and there was a daily inhaler, Spiriva, I believe. I've been using that each day.

D: OK great great yeah so we'll be, we'll be giving you some puffers here as well, and yeah, we'll see how things go. Do you have any questions?

P: Uh, no, that that sounds good. Thank you.

D: OK, alright.


D: so I hear you've been having some some nausea vomiting, diarrhea. Can you tell me a little more about that?

P: Yeah, so uh, like around three or four days ago I started, uh to get really nauseous and since then I've been vomiting every few hours and really I don't know. Just yesterday started to started to have some diarrhea as well.

D: OK, so that's three or four days ago for the nausea and vomiting, is that correct?

P: Uh yeah yeah the nausea start kind of started three or four days ago and then after that that the vomiting came. So yeah maybe the vomiting was more like 2 days ago it started, and then diarrhea kind of the last day.

D: OK OK. OK, and before that you were feeling well?

P: Yeah, well I was feeling maybe like a little tired for a day or two before, but um, I don't know. Sometimes you just feel like that, so I didn't really think much of it, but.

D: Sure, OK. And since it started, have, I know these all kind of started at different times but has have your symptoms gotten worse overtime?

P: Yeah, they they. They've gotten worse. At first they were kinda really spread it like far enough apart that I would thought it was just going to go away on its own and then it it hasn't so has me concerned.

D: OK, I'm just going to ask you a few more questions about the vomiting. Have you noticed any blood in your vomit?

P: No, it's been kind of yellowish.

D: OK, and just if you notice like a like a really bright kind of yellow green substance in your vomit.

P: Umm not really bright, but I mean maybe more like dark green or yeah nothing bright.

D: OK And you said now it's it's happening every couple hours for you?

P: Um yeah every few every few hours it's been ah. It seems to be what I'm like like after eating, it is just making me making me nauseous.

D: OK, OK, so have you been able to eat anything? When's the last time you actually had something to eat?

P: Yesterday I did, I had some soup and was able to to keep most of it down, but um. But it's been mostly liquid's I've been drinking.

D: OK.

P: My appetite really hasn't been there.

D: OK, uh. In terms of diarrhea, so that started a couple days ago, if you only had diarrhea since then, or have you had like any form stools?

P: No, it's it. It was started more like yesterday and it's really only been diarrhea since. So yeah, like twice last night and then like three to three times this morning.

D: OK. Have you ever had anything like this before?

P: No, I haven't been sick like this before.

D: OK, have you traveled anywhere recently?

P: I just got back from a trip in the US was there for work.

D: OK, and how did you travel there?

P: I I. Traveled by a train.

D: OK, and how long were you there for and when did you get back?

P: I was there for one night and got back five days ago.

D: OK. Um, OK, five days ago and when you were there, were you in contact with anyone?

P: I well, I stayed in a hotel so. I, I guess that the people, uh, that um yeah, the people that were staying at the hotel.

D: OK. Have you been in contact with anyone since coming back that's been sick?

P: Um No. I I, I haven't been in contact with anybody, anybody who's been sick.

D: OK. In addition to the symptoms that you're describing to me, have you had any fevers?

P: I've I started to feel hot this morning.

D: OK, have you had any chills?

P: Nothing like that.

D: Any shakes?

P: No.

D: K night sweats?

P: Um no night sweats.

D: Have you had any cough?

P: Umm no, I haven't really had a cough by my throat's felt a little like scratchy though.

D: OK, scratchy throat OK. Have you had any sore throat?

P: No, I wouldn't really say it's sore, but. Yeah, I mean we just kinda like like itchy.

D: OK. OK, have you noticed any changes to your sense of smell or taste?

P: No, I haven't noticed any changes to those.

D: OK. Mmmm. And you live, do you live alone or with family?

P: I I live with family. I live with my wife and two children.

D: OK there. How are they feeling right now?

P: They were. They've been feeling fine.

D: OK. OK, um, so just in terms of your general health, are there any conditions that you see your family doctor for regularly?

P: I have anxiety and back pain. So, uh, I do get ah. Some hydromorphone for for that.

D: OK

P: For the back pain anyway.

D: OK. Um, and what medications do you take besides the hydromorphone?

P: Uh, uh, Escitalopram.

D: OK.

P: And that we've been working on trying on decreasing the hydromorphone now over the last year. So it's a work in progress though.

D: OK, and have you ever had any surgeries?

P: Uh, yeah on my on my back I was in an accident a few years back. So, um. Well, that's where the pain is from.

D: OK, sad to hear that. Do you have any allergies?

P: Um yeah, to penicillin. I had a hives when I was a kid.

D: OK Um, OK um. Let me see, uh, so in terms of your family history. Do you have any family history of your digestive system problems or respiratory problems?

P: Um Yeah, no one in my families had any problems with their stomach or I haven't heard of any like colon cancer. I mean my my dad had a heart attack when he was in his late 60s, but that's kind of the only thing that I can think happened in my family in terms of health.

D: OK. And it sounds so. It sounds like you live at home with your family, do you? What do you do for work?

P: Yeah, I I work for a tech company so I was going down to meet a potential buyer for one of our products.

D: OK. OK, and just in terms of your lifestyle. Do you drink alcohol?

P: Um yeah I will have wine. Maybe one or two glasses on on the weekend.

D: OK, do you smoke cigarettes?

P: Umm no but I I used to, I I quit about seven years ago. Yeah, so I quit about seven years ago.

D: Um OK. So do you use any other substances, like cannabis?

P: Um I will have a joint every once in awhile if I with friends, but that's been it's been awhile. 'cause of the pandemic haven't really been hanging out with anybody.

D: Sure. Um OK, I think that's all the questions that I had for you today. So it sounds like there's probably some kind of infection going on. What it is exactly, it's hard to say. There are some cases of COVID-19 that, that are more like GI symptoms then than simply respiratory symptoms. So I think we should probably give you a COVID swab and then we ask that you and everyone in your house self-isolates for a few days until you've got it in a negative result and in a few days without symptoms.

P: OK, that sounds good.

D: So yeah, we'll get that started for you, and otherwise, really, we want to know if it's COVID is just for infection control purposes, but I think that essentially you should be drinking lots of fluids and getting a lot of rest. And it's something that likely should go away on its own. I mean, if things start to become a lot worse and you get really dehydrated and you have fevers that you can't control with Tylenol, then please come back to the emergency Department. But I think in general it will just be kind of supportive treatments for what you're experiencing.

P: OK, that sounds good. I'll get some Gatorade on the way home.

D: Perfect. Actually, don't go into the store. Have someone else get it for you, but.

P: OK will do. Thank you.

D: Have a good have a good day. Thanks for chatting with me.

P: Thank you.


D: What brings you in today?

P: I can't, I can barely breathe for like 2 days now and I've been coughing and been having like a little bit of pain in my chest.

D: OK, the pain in your chest, uh can you point point out or can you describe the pain to me, is that sharp or is it dull?

P: Um, it's hard to say, I haven't really had this before. Um, it's more like it just kind of hurts just in the middle and it gets worse like when I cough and when I if I take like a really deep breath, it will hurt, yeah. Does that make sense?

D: Yeah, so the shortness of breath and chest pain, they occurred simultaneously right? On the same day, like 2 days ago?

P: Yeah, I mean now that I think of it, I maybe started coughing a little bit earlier than that. But when it got harder to breathe is pretty well around the same time that I started feeling more the pain.

D: OK, alright so let's focus on the coughing first. Are you coughing up any blood at all?

P: Uh, no, I haven't noticed any blood.

D: OK. And how about sputum?

P: I guess I guess it feels like there's some like mucus, I don't know kind, kind of like spit looking, but maybe like thicker than that.

D: OK, is it yellow?

P: Yeah, yeah. Yeah well yeah, it's creamy yellow.

D: OK, sure, and are you wheezing with the cough?

P: I I don't think so.

D: No, OK, um and is it is your shortness of breath worse with exertion?

P: I haven't been doing much really 'cause I've just been so wiped out. Um, till probably I guess it's kind of, I'm really, you know, haven't been getting up very much. I'm normally really active like I I train for triathlons and I I'm not like a couch potato, right? And I feel like I've been just kind of sitting down.

D: OK. Um, do you have the chest pain at rest as well, or is it just with the coughing?

P: Like if I take a deep breath I'll have it. But no, I don't think not not like right now. Not like just sitting here.

D: OK. And the coughing, how often are you coughing?

P: Oh, like it kind of varies. I feel like I get up in the night kind of sweaty and I'll cough for for a while. And it it'll keep me up, and then during the day, it's like I might go, you know, a couple hours without, but then I'll cough and I'll kind of keep going for a few minutes so, it's a lot, like probably, yeah, I probably don't go more than like 2 hours without.

D: OK, OK. And how far can you walk before you start feeling shortness of breath?

P: I mean, I haven't been walking very far. Like I I walked in here from the parking lot and that was fine, but I'm tired.

D: OK, OK, and I just want to ask you some other questions. Um, Jessica, so have you had any fevers race recently?

P: I don't actually have a thermometer at home that works, but I like I said, when I've been getting up in the night coughing, I've been like really hot and sweaty. Kinda gross like feel like I just I feel like soaked and but yeah, I don't have a thermometer.

D: Um, OK, so these night events that you're describing, are they more chills or night sweats?

P: Well, I don't know, it just feels like when you know when you're, I don't like when you're a kid and you get really sick and your parent tells you have fever like I don't have an actual temperature.

D: But do you feel hot?

P: I feel hot, yeah.

D: OK, OK. And have you lost any weight recently?

P: No, I mean I'd like to, but no, no.

D: OK and any changes in your vision?

P: Uh, no.

D: Hearing?

P: No.

D: Smell?

P: No.

D: Any, do you have like a stuffy nose? Runny nose?

P: Maybe a little little bit. It's been more the coughing that's that's bothered me. So I haven't thought that much about it.

D: OK, sorry you said your nose was stuffy or runny?

P: So it's a little stuffy, maybe a little.

D: OK, OK um, and have you had any like pressure behind your eyes in your head?

P: No no no.

D: OK, no headaches?

P: No no.

D: No dizziness or fainting spells?

P: Like I feel tired but I haven't I don't know I haven't like fainted.

D: OK, so you're tired, do you feel weak at all like you can't move a certain limb?

P: Oh no, that that's all fine.

D: That's all fine, OK?

P: I haven't like wiped out like I said.

D: OK, OK, um do you get this shortness of breath or difficulty breathing when you're laying down?

P: I mean, I've mostly been laying down lately, um, so yeah, like I kinda have it all the time.

D: All the time? OK, but it's not worse when you're laying down or standing up?

P: Don't think it's worse, no.

D: OK, and have you noticed any swelling?

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

D: OK, any palpitations like you feel like your heart's racing?

P: No.

D: No um, and then how about in terms of like your abdominal system? Any pain there?

P: Oh no, nothing. I mean it's like a little sore just 'cause I'm coughing all the time but yeah, but yeah, not not like, not anything like noticeable.

D: OK, and then how about your stools? Have they been normal?

P: Yeah yeah.

D: And then how about your urine, is that, has everything been normal from that standpoint?

P: Yeah yeah.

D: OK OK um, and then, have you had any issues with breathing or coughing in the past?

P: No, I mean, I like I said I'm really active. I do a lot of like right, I've been like training for a triathlon, like I haven't had any problems before.

D: OK, OK um, any any past medical conditions that you know of?

P: Uh, I got like I am a type 1 diabetic.

D: OK, OK, have you ever, OK, have you ever had a pulmonary function test in the past?

P: Well, maybe when I was like kid or like a teenager.

D: And any recent chest X-rays ECG's any other investigations you've done so far?

P: No, like I have been, I've been really healthy.

D: OK, good and are you on any medications?

P: Um, like I take a, my insulin.

D: Yeah.

P: And like I take I take a statin. Is that what it's called?

D: OK. Is that because you have high triglycerides or like cholesterol?

P: Uh, I, they just said 'cause I like had diabetes that I should probably start taking it.

D: OK yeah alright.

P: There's no like a big problem. It was just, you know, my family doctor. I think my my dad has diabetes and he he he had heart problems so, like she also my family doctor knows my dad too so I don't know if that has something to do with it.

D: OK. OK, and then yeah, I guess I will talk about family history since you brought it up. Any lung issues in the family?

P: Uh, not that I know of like.

D: OK.

P: Just I mean the heart like my dad had a heart attack. I don't know if that counts as like it's close to the lungs.

D: How old was he?

P: Um? It wasn't that long ago he was like in his 60s.

D: OK.

P: Yeah.

D: OK. Um, I'm gonna name a few things and you let me know if this is in your history, OK, in your
family history. Asthma?

P: Maybe like my cousin, but yeah, not like my mom or dad.

D: OK, cystic fibrosis?

P: No.

D: OK alpha one antitrypsin deficiency?

P: I don't think so, no.

D: Pulmonary fibrosis?

P: No no.

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

P: Like I I always I always got like the ones I was supposed to. Um, I normally like normally where I go into work, there's like a pharmacy outside and I would get my flu shot. But this year it's like I'm working from home, I haven't even been around there so I didn't get it this year. But I have all the normal ones.

D: OK, and then do you smoke Jessica?

P: No.

D: No? Do you smoke marijuana?

P: No no.

D: Any other recreational drugs?

P: What like alcohol?

D: Um, no other than alcohol, like cocaine or meth, anything like that?

P: Ah, no.

D: OK no? OK, and yeah, do you drink alcohol?

P: Oh like if I'm like with friends, maybe on a weekend.

D: OK OK.

P: Couple drinks or something.

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

P: Like I said, I work I work from home so I've been seeing very many people. Um, I like I, geez. I my my sister, I saw my sister and like she, I guess she works she works in like a retirement home.

D: OK.

P: Like she, I don't think she was sick.

D: OK. OK, is it possible that she was in contact with someone who may have been sick?

P: I think it's I mean it's possible like that's what she does for her work, right? She works at like a retirement home, so yeah possible.

D: OK, and what what kind of work do you do Jessica?

P: I'm an accountant.

D: OK, and have you traveled anywhere recently? I know with COVID obviously that's hard.

P: I wish I wish, but you know I haven't been anywhere. Like I said, I've just been at home.

D: OK. Um, in particular, have you been in a country where TB is endemic and have you been in any of those countries in the past, like 5 to 10 years?

P: I don't know like I've been to the like the states before COVID. I I don't, I didn't really haven't traveled anywhere cool in a long time.

D: OK, OK. Um, so just kind of going through what it could be that you have right now. I'm thinking
a few things and we kind of like to go through and make sure we're not missing anything. So in terms of like vascular stuff it could be something like like CHF or pulmonary embolism and that stands for congestive heart failure, but you're very young. You seem like you're very healthy, so that's probably lower on our differential obviously.

P: OK, yeah hopefully.

D: An infection would be the biggest one right now with the cough with it seems like you have chills and night sweats. Yeah, so would have to do more in terms of taking your temperature, and see if you can do like more
work up like a chest X-ray to see what's happening in there. Um autoimmune stuff could be like sarcoidosis but unlikely 'cause it seems like this is an acute issue for you.

P: See I never come in besides like because I you know need my insulin. I never even go to the, I didn't even want to come in and just like it wasn't going away.

D: Yeah yeah. And then other things like COPD, pulmonary fibrosis, and like like cancer stuff is super
low on the differential right now, so. Yeah, so um. So yeah, so for right now we'll start. We can start by doing some blood work. First I do a physical exam, of course. And then from there we would kind of do some blood work to see if your white blood cell count is high. And then we can do a chest X-ray to see if there is like a consolidation if there's pneumonia, or you know or, or anything viral? Um, do you have any questions?Anything that you wanted to add that I missed?

P: I don't think I don't think so, um yeah, I just hope I can get feeling better. Hope it's not anything serious like I I think yeah, I just hope it's like I hope like you said it's like I got like an infection or something and it will just be gone soon.

D: Yeah yeah it does sound like it from the timeline like you started coughing two days ago, and then the difficulty breathing or shortness of breath also two days ago and then the chest pain just seems like it's from you coughing a lot.

P: It can do that?

D: Yeah.

P: OK, yeah.

D: Yeah, OK, so I guess we will see you at our follow up and after all of these investigations are done.


D: How may I help you?

P: Hi, I'm here with my 3 year old daughter and she's been holding her elbow awkwardly and um she seems like she's in pain and so I was just wondering if like something happened to her elbow and if you can fix it.

D: Yeah for sure. OK so. Is she holding her arm, like any particular position, like with her elbow, kind of flexed or is her arm extended?

P: It's it seems kind of flex is holding it awkwardly and she can't she she's not, she's not stretching it.

D: OK, uhm. And when did this start, when did you first notice?

P: I notice this yesterday.

D: OK. And and I, had she been holding her, her arm, kind of like this the whole time?

P:  Yeah, there's just like a slight bend to it. It's not fully straightened. It's not fully like fully flexed. It's just kind of hanging out her side.

D: OK, um and. Has there been anything that's made the pain worse?

P: Uhm no, I don't think so, I think. No, I think she she's just been holding it awkwardly like that I I'm assuming so it doesn't cause more pain.

D: OK, and is the pain sharp, burning or achy?

P: I think it's it's. It's sharp.

D: A sharp pain, OK and does the pain radiate anywhere else like pain in the hand or wrist, or pain up into the arm or shoulder?

P: I don't think so.

D: OK, and has there been like was there anything that happened around the time that you first noticed her holding her arm like this, such as a fall, or maybe like somebody pulling on on her hand like swinging her from her arm or anything like that?

P: Um I know her father was swinging her arms yesterday, They were playing in the park, so maybe.

D: OK, so just uh, she's swinging from arms yesterday, OK and. Has she talked about having any numbness or tingling?

P: No.

D: OK. And any muscle weakness that you've noticed?

P: Ah no, no muscle weakness.

D: OK. And has she had any?

D: Fevers or chills.

P: No.

D: OK, and it has she had any headaches?

P: No.

D: Has she had any sensory changes like any issues with vision or hearing?

P: Uhm no.

D: any issues with sense of smell or taste?

P: No.

D: How she had a cough or sore throat.

P: No.

D: OK, has she had any night sweats?

P: No.

D: And has she had any weight loss?

P: No.

D: OK.  And you has she had a runny nose or sore throat?

P: No.

D: How about a cough or shortness of breath?

P: No.

D: Has she had any wheezing or chest pain?

P: No.

D: Alright, and any abdominal pain?

P: No.

D: Any nausea or vomiting?

P: No.

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

P: No.

D: Any changes to her urinary patterns?

P: Um no.

D: OK, and as you had any appetite loss?

P: No.

D: How is your energy been?

P: It's been the same she's just not doing as much because her arm is in pain.

D: OK, but no fatigue?

P: No.

D: I see OK. And how about any memory loss or confusion?

P: No, nothing like that.

D: Does she have any muscle aches or body pains or or any joint pains anywhere else?

P: No.

D: OK, and how about skin changes such as rashes or any changes to her hair or nails?

P: No, nothing like that.

D: OK. And in the past, has she had any medical problems or has she been diagnosed with any medical conditions before?

P: No, she's been pretty healthy otherwise.

D: OK, does she take any medications?

P: No.

D: Did she have any allergies?

P: No

D: And has she been hospitalized for any reason or has she had any surgeries?

P: No.

D: OK, any concerns for reaching developmental milestones such as walking, talking and like social interactions.

P: No. No issues there.

D: No problems?

P: Yeah.

D: OK and then how about like just growth and and development? Is she getting taller and I'm gaining weight?

P: Yeah like that's been pretty good.

D: OK, well that's good and were there any concerns with the pregnancy with her? Any like gestational diabetes, high blood pressure or infections?

P: No everything went smoothly.

D: OK, was she at term or where she pre term?

P: She was at term. She was like a 37 1/2 weeks or something like that.

D: OK, And was it vaginal delivery or c-section?

P: It was vaginal.

D: OK, and was there any reason for her to stay in hospital afterwards?

P: No.

D: OK. And can you tell me a little bit about the living situation currently like who is the primary caregiver for her and like who she who she's living with then whereabouts?

P: And she's living with both her parents and myself as well as her dad. And she has a 7 year old brother and we live in a house just outside of London.

D: I see OK and is she going to daycare right now or anything like that?

P: Umm no she's she's at home with me.

D: OK, she been around anybody who's been sick,

P: No.

D: And have you traveled anywhere?

P: No.

D: OK, an any concern for like physical or emotional violence in the home?

P: No nothing like that.

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

P: Uhm no, no one smokes at home.

D: OK. And are there any musculoskeletal or neurological conditions that run in the family?

P: Uhm no.

D: How about any heart or lung conditions?

P: No.

D: OK, so I ask you to just have a look at her elbow now and.

P: Sure.

D: Let me know the if you're seeing any swelling or redness?

P: OK. And so the elbows look fine, neither elbow appears red or swollen.

D: OK, and. Are you seeing any muscle atrophy or any joint deformity or or malalignment?

P: No, I don't see that. I also actually it might be slightly. It looks a little bit awkward the way she's holding it, so I can't tell if it's misaligned.

D: OK, and any skin changes over the elbow?

P: No.

D: Alright Ann. If you were to press over various portions of the elbow, are there any areas that cause pain like the lateral side, medial side, or anterior posterior?

P: It hurts she's in pain whenever I touch anywhere near the elbow area.

D: OK, and um is there any pain with with movement?

P: Yes. Whenever I tried to bend it or straighten it out all the way she she complaints of pain.

D: OK, how about moving the rest or shoulder?

P: No, that's fine.

D: OK, so that that was everything that I wanted to ask about and and look for on the physical today. Did you have anything else that perhaps I forgot to mention that might be important?

P: Uhm no that was kind of it, I just was wondering how we can fix her elbow.

D: I yeah certainly so. It will be so when I get an elbow X Ray. And. But typically to fix this type of injury, so currently I'm thinking this could be a like a radial head subluxation, and possibly a radial head fracture, but most likely I radial head subluxation, where there's a mechanism of pulling on a child's arm. And it's just that the what could happen is the part of the radius, which is that a forearm bone can pull out of the ligament that's holding it down.

P: OK.

D: An just because of the structures there, not yet fully matured and strong, and somebody who's that young. And so it will cause pain reduced range of motion at the elbow and you won't really see much swelling or redness, and with just the physical exam maneuver you can reduce it and then put the head of the radius back into place and things will be usually back to back to normal. But if there is a fracture which will look for an X-Ray then there the pain might be last a little bit longer, but immobilization of the arm is not required and most kids will regain full mobility in in a short time after the reduction.

P: OK, that sounds good, thank you.


D: What brings you in here today?

P: Hi, I’ve come in today because I had this cough. It started three days ago and since that time I've also started to have um these headaches and been feeling really kinda achy all over.

D; OK, So what what kind of started first to cough or the aches?

P: The cough started first.

D: OK and is it dry cough or a wet cough?

P: It's dry.

D: OK so you're not bringing up any sputum or blood or anything like that?

P: No, I'm not coughing up any sputum or or blood.

D: OK, that's good. And the muscle aches, uh, so were you doing anything recently? Like anything strenuous increased exercise? Lifting anything or any injuries at all recently.

P: No, not nothing I can think of like that.

D: OK, and where are you getting your muscle aches?

P: It's like kind of all over the feel, just generally achy.

D: OK, generally ache, OK. And are you getting any kind of headaches or anything like that?

P: Yeah, I've had this headache as well. It's kind of come and gone a little bit over the last couple of days, but had a little bit of a headache each day.

D: OK, and the headache where where is it exactly located?

P: I feel it right at the front of my my forehead, kind of on both sides of my head. It feels like a band just squeezing around.

D: OK and um. Is it? What kind of pain is it? Is it like aching pain? Is it kind of like a pulsating pain pressure like pain? How would you describe it?

P: It's more like pressure,

D: Pressure, OK, and have you do you are you? Are you someone that usually has headaches?

P: Every once in awhile, but I mean I don't get them that often. Maybe when I'm sick or don't sleep very well.

D: OK, have you tried anything for your pains or headaches?

P: Uh, yeah, I did take some Tylenol and it it helps take that the eye drop a bit. I tried some Advil too. It's so mean that the headaches kind of come and gone a little bit, but I think once that wears off it the headaches come back.

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

P: Um no, I haven't tried anything for the cough.

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

P: Um I have I I have felt a little bit feverish. Yeah, I haven't had any chills though.

D: OK, and um. When did you start feeling feverish?

P: Um yeah, maybe within the last couple of days as well.

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

P: Uh, no. I've just felt really hot.

D: OK, uh any other symptoms like runny nose, sore throat, uh chest pain, anything like that?

P: Um. No I haven’t uh had any any sore throat or chest pain, no runny nose either.

D: OK, any shortness of breath?

P: No.

D: OK, any recent travel or contact with someone who's been ill?

P: Um yeah, I don't. I don't think so. I mean, I I haven't traveled anywhere. I'm in in my nobody in my family's been sick at home.

D: OK, um any nausea or vomiting?

P: No.

D: OK, any loss of taste or smell?

P: Um. Ah no.

D: No. Any night sweats or fatigue?

P: I. No no no..

D: OK um, any changes in your bowel movements, like any diarrhea or constipation?

P: Uh yeah, I have had I actually had um. You mentioned diarrhea for the past. A day as well.

D: OK, a diarrhea for. So just for the past day, have you notice any changes in color or have you noticed any blood in it?

P: No blood in the stool. I'm just, it's just been really loose.

D: OK. Um have you had any foods recently that a? That you've tried, maybe like for the first time? Or have you eaten outside at all?

P: No, it's been pretty stable. So yeah, I haven't had any changes like that.

D: OK. Any changes in your appetite or weight?

P: Uhm. I've been less hungry for sure. Yeah, so I I've had a decreased appetite, but my weights been stable recently, so no changes in weight.

D: OK. And any exposure to fumes or dust or animals within your home environment or work environment?

P: No, nothing like that.

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

P: No, I've been healthy.

D: OK uh, do you take any medications?

P: No, just I. I'm a multi vitamin and vitamin D.

D: OK, any allergies to any medications at all?

P: No no allergies.

D: OK any allergies to any environmental factors or foods?

P: I I do have an allergy to peanuts and so I carry an EpiPen for that, but uh that's the only food.

D: OK um, and any hospitalizations or surgeries in the past?

P: Um I did have surgery like an ACL repair and repaired knee and knee surgery about 10 years ago. And but that, yeah, that's the only surgery.

D: OK. Any family history of any longer heart conditions.

P: Uh. My dad had high high blood pressure and my. Yeah, my Grandfather I had had lung cancer actually when he was in his 80s when he passed away from that and he was a smoker's whole life.

D: OK. Currently, do you work at all?

P: Yeah, I I have been working. I work for a. A pharmacy company so I've been having to go into the office sometimes to help kind of prepare. Stuff.

D: OK, and in your workplace have you notice anyone sick at all?

P: Um. No, I don't think I don’t, haven't noticed anybody been who's been sick, but we've been there. Have been other people who have been going into the office as well.

D: OK, and do you usually wear masks around other people?

P: Yeah, we've been wearing masks and and there are cleaning protocols and distancing protocols as well. Trying to keep everybody safe.

D: OK, and since you've had these symptoms, have you gone into work at all?

P: No, no, I've actually. I've been off for the the last couple of days.

D: OK.

P: Yeah I've just been been doing what I can from home,

D: OK. And what's your home situation like? Who do you live with?

P: Yeah, so I live with my I live with my wife and we live in a townhouse just right in the city here.

D: OK, and has she been displaying any symptoms at all?

P: Uh no she hasn't. She's been been feeling good.

D: OK, that's good, and currently do you smoke?

P: No, I'm not a smoker,

D: OK. Any recreational drugs like marijuana?

P: I will sometimes use like the CBD or yeah like the oils, but that that's it.

D: OK, and do you drink alcohol?

P: Yeah, I'll have a few beers on the weekend sometimes like, but that that's that's about it. Maybe like 3 or 4 beers a week.

D: Alright, OK, so yeah those are all the questions I had for you today. Do you have any questions at all?

P: Yeah, I was just worried that it could be covid with how everything's going on, and that's just sort of what I was wondering about today.

D: Yeah, so that's something we definitely want to rule out. Your symptoms definitely overlap with the cluster of symptoms that someone may get with covid, so we will do a swab on you today and recommend that you isolate for two weeks until your symptoms have gone and the test result you will get you will get back in the next 24 to 48 hours. And alongside your test results. So you will also get further instructions from public health about whether or not you need another swab later on and when to return to work.

P: OK that yeah, that sounds good. Thank you.

D: Yeah no worries and it can definitely also be another viral infection as well, even if it's not covid, in which case it just you just need to get some rest stay hydrated and let it take its course.

P: OK, now that sounds that sounds good, so it could be covid or like another viral illness.

D: Yeah,

P: OK, thank you.

D: Welcome, take, care, take care.

Hey.


D: What brings you in today?

P: Hi uh so I just came in today uh I've kind of put it off for a bit, but I've been having this cough uh for the last five to six months and it seems to be getting worse and over the last month I've also been becoming more short of breath, so I just wanted to come and check if I need to do anything.

D: Yeah, that that it's it's really good that you decided to come in. Um how bad is your shortness of breath?

P: Um, so usually like I I would be able to walk a few blocks, um no problem, but now I have to take a break and catch my breath and even going up and down stairs has been tough.

D: Um Do you feel that uh do you feel that your, uh, difficulty with breathing is worse when you're exerting yourself?

P: Um, yeah, it's definitely worse, but I also just like normally even when I'm resting, I feel like I have to um take in like much deeper breaths.

D: Do you ever wake up in the middle of the night gasping for air?

P: Uh no, nothing like that.

D: Do you feel like you have to raise your head or have multiple pillows to sleep at night so you don't feel short of breath?

P: No, nothing like that.

D: OK. Uhm and this cough that you've had for the past five or six months, did you say it's getting worse?

P: Um yeah it it's, both the shortness of breath and the cough are getting worse and also just I've been having some even some discomfort and pain when taking those deep breaths now too. So, and that's been happening for probably the last couple weeks.

D: I see. Um is it a dry cough that you have or or do you bring up any gunk or any mucus?

P: Um it's mainly just a like a like a dry cough.

D: Have you ever coughed up any blood or anything like that?

P: No, I haven't, I don't think I've seen any blood.

D: OK, uhm do you have any other symptoms? Do you have any fevers or chills?

P: Um not fevers, but I I have been getting night sweats um for the last couple weeks to maybe even a month or once or twice a week, I just wake up completely drenched.

D: And have you had any unintentional weight loss?

P: Yeah, now that you mention it, I probably lost 15 pounds in the last two months.

D: OK. Uhm, have you had any muscle aches or joint pains all over your body? Do you feel achy?

P: Yeah, but I've probably felt like that for the last five years, um so I have uh osteoarthritis.

D: OK.

P: So I don't think that's anything new.

D: Um have you had any changes in your bowel movements or any urinary symptoms?

P: No.

D: Any abdominal pain?

P: No, not that I've noticed.

D: OK. Any headaches?

P: Um no, nothing like that.

D: Uhm, OK. Uh have you had any falls in the past or in the past couple of months or years?

P: No, no, I've been lucky.

D: Good. Any confusion?

P: Nope.

D: Uh any time when you've lost consciousness?

P: Not that I know of, no.

D: OK. Um and any medical conditions that you've been diagnosed with?

P: Um, so I have osteoarthritis. And then I also have um this condition with my prostate, uh BPH. And um I also take medications for my blood pressure.

D: Um what medications do you take?

P: Um I take um this medication called uh Lisinopril.

D: Anything else?

P: Um I do take uh just pain medications like Advil.

D: Um OK. Do you take anything to protect your stomach when you're taking the Advil, any other medications?

P: Yeah, I was given um this other medication for, for, to take with my Advil like, but it's only when I'm taking Advil like every day. Um and, um I haven't really been taking that, um I probably took, the last time I took it was probably a month ago.

D: OK, OK. That's good. Um are you taking anything for your uh BPH?

P: Oh yeah, sorry. So I'm taking uh this medication called Tamsulosin.

D: OK, alright, any allergies, to medications or otherwise?

P: Uh mot that I know of, no.

D: OK, any um I guess social history, who do you currently live with?

P: Uh I live alone right now in my apartment I, um but I have pretty good support from my kids, they just live a few blocks away and come visit me.

D: That's good. That's really good. And uh do you, are you able to um take care of yourself or do you need help with things like um finances and groceries and cleaning?

P: No, I'm I'm fairly independent in those matters.

D: OK, do you require any assistance uh with walking any cane or walker or wheelchair, anything like that?

P: No, not yet.

D: OK good good. Do you smoke at all or did you ever smoke in the past?

P: Yeah, I've been smoking for my whole life.

D: How long and how much and for how many years?

P: Um probably for almost, I guess 50 years or maybe even more, maybe like 55 years and uh I've been smoking, at one point I even smoked up to like two two packs a day, but now, like for the last, at least 20, 30 years, it's been like one pack a day.

D: OK. Have you ever been diagnosed with any lung conditions?

P: Uh no.

D: OK, have you um had any marijuana or any recreational drugs?

P: Uh no, nothing like that.

D: Alcohol?

P: Nope.

D: OK, uhm, alright, um you mentioned that the cough started 5 to six months ago. Have you had a cough before that?

P: Um, it's here and there, like maybe just when I wake up sometimes, but this is kind of uh more frequent and, I I do feel just kind of this discomfort in my chest when I take these deep breaths as well. Um yeah so, I I don't really know what's going on.

D: Um do you go to your family doctor for your uh health checkups?

P: I haven't been for a while, for the last few months, but yeah, I generally do go to my family doctor.

D: You do, OK. Um have you been, uh, sometimes for people who have been smoking for a long time, they do uh these scans of the lungs, uhm, have you been getting those?

P: No, I don't remember the last time I had one.

D: OK Alright. Um OK, those are all the questions I had for you. Uhm, we'll we'll do a physical exam and uh do your vitals um and see if you uh, do some labs, and then go from there.

P: OK, sounds good.

D: You're welcome.


D: What can I do for you?

P: Hey I I came in here today I I just was feeling just a bit short of breath over the last few days and I've had a so I normally have a cough, but I've just been coughing a lot more over the last week and I don't know if it's if it's something else. I I do have a COPD diagnosis which I was diagnosed with like a couple years ago, but this is this seems to be much worse.

D: OK, you said you were diagnosed with COPD couple years ago. Was that two years ago? Three years ago?

P: It was almost, probably five years ago.

D: Five years ago, OK, and have you always had this cough since then?

P: Yeah I’ve probably had a cough for the last 10 years, I think.

D: OK.

P: Yeah.

D: And you you’ve mentioned that this cough has gotten worse over the last week?

P: Yeah, I've been coughing a lot more. Even just walking down the stairs from my bedroom to even the kitchen I just have to take a little bit of a breather, just start coughing.

D: OK. And is it a dry cough or are you bringing up any phlem?

P: No, I'm bringing up like this. It's usually before this week. It was like kind of a clear to yellow. Sorry clear to white material, but this past week it's been more yellow in color.

D: OK, any blood in there?

P: No, I mean notice any blood.

D: OK and you said you were also short of breath, uhm when did that start?

P: So that's just in the last few days. But just to clarify, I do get short of breath here and there sometimes I have to use puffers, but the last few days I've just been really short of breath, even even if I walk a little bit after like sit down and, can't really catch my breath.

D: OK. Alright, and do you get short of breath when you're laying down?

P: Uhm no, not really, it's mainly just when I'm moving around and doing stuff.

D: OK, how about when you're asleep? Does it wake you up and kind of make you gasp for air?

P: No.

D: No OK. So no orthopnea or PND. Alright, and the puffers that you're on, can you remind me which ones you're on again?

P: So I'm on this one called Ventilin for the which I’ve been using a lot more recently just for relief and then, I'm on this other puffer thing. It's called spiriva.

D: OK, how often? How? How many times this week have you had to use your ventilin?

P: Uhm, Ventilin are probably used. Probably almost like 10 times this past week.

D: OK. Alright, any chest pain?

P: Uhm? Just when I'm having like those coughing fits in with the breathing, I feel some discomfort, but that's it.

D: OK, OK. Alright and then any palpitations or feeling like your heart's racing?

P: Uh no.

D: OK. Alright, and do you ever feel like your calves hurt after you walk awhile?

P: No, not really.

D: No OK, any dizziness or fainting spells?

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

D: OK. Numbness or tingling?

P: No.

D: Confusion or memory loss?

P: No.

D: Headaches?

P: No.

D: Changes in your bowel movements?

P: No.

D: Uhm nausea or vomiting?

P: Uh, no.

D: Changes in your appetite?

P: No, not really. Eating about the same.

D: OK, changes in your urine?

P: No.

D: Runny nose or stuffy nose?

P: Uh, no. I don’t have that.

D: OK, sore throat?

P: No.

D: Any changes in your vision or hearing?

P: No.

D: Changes in your smell or taste?

P: No, not really.

D: OK, how about weight loss?

P: No, my weights been pretty steady.

D: OK, chills?

P: Uhm, maybe a few times this, like from that last couple days I've been feeling a bit chilly. But I I don't know if I have a fever or anything like that.

D: OK, so you haven't actually measured your temperature right?

P: No.

D: OK, we can do that today. Any rashes?

P: Uh no.

D: Fatigue?

P: No.

D: OK, um and besides the COPD do you have any other longstanding medical conditions?

P: Uhm. I I have a like high cholesterol.

D: OK.

P: And. Just I, I used to take blood pressure medications but I don't right now.

D: OK. And what kind of blood pressure medications did you use to take, and how come you stopped?

P: I was on like a diuretic. Then the doctor said, like my blood pressure was really well under control, so I just stopped taking it.

D: OK, OK, and the doctor was OK with that.

P: Uh no, I just stopped taking it. I didn't really like ask the doctor.

D: OK, well, we'll keep checking your blood pressure and that's something you should keep an eye on as well, just in case ou have complications with your kidneys. Does that sound OK?

P: Yeah.

D: OK uhm? And are you on any medications other than the puffers?

P: Just a Torva Staten.

D: For your cholesterol OK, and are you up to date with your immunizations?

P: Yeah, not even a vaccine.

D: Pardon me?

P: I even got the coronavirus vaccine.

D: OK, good Congrats. Did you also get the shingles vaccine and the pneumococcal vaccine?

P: Yeah I got them.

D: OK, OK good, any allergies?

P: Uh, no, not that I know.

D: How about a family history of lung or heart conditions?

P: Uhm? My father had lung cancer but he smoked a lot, I also smoke so I sometimes worry about that, but he had cancer and my mother, she was perfectly healthy. Yeah, so just my father.

D: Just your father OK. How much do you smoke?

P: Probably half a pack a day. It used to be one pack, even 2 packs at one point in time, but right now it's half the packaging.

D: OK, alright, well, it's good that you're cutting down. And if you need more resources to help you do that, we have some available that we can refer you to. Do you take any other recreational drugs like cannabis, heroin, cocaine?

P: No, nothing like that, no.

D: OK. And do you drink alcohol?

P: Um just probably maybe like a couple times a month.

D: Couple times a month OK. And are you currently married?

P: Yeah, I currently live with my sorry, wife, in an apartment.

D: OK, and any reason for you to believe you have old carpets, mold, dust, asbestos, pets, anything that could be triggering your symptoms?

P: No, nothing like that. We live in like a fairly new apartment.

D: OK, OK, good, and have you been in contact with any sick people recently?

P: No, not not really. Wie’ve been just to ourselves.

D: OK, and have you traveled anywhere recently?

P: No, just been on our house.

D: OK. Alright, well those were all the questions that I had. Did you have any questions of your own?

P: Uh, yeah I was just wondering what this can be.

D: Yeah, you know it sounds like you have a cough and shortness of breath, and both of these things you've had for a while, but now they're getting worse and based on your past history of COPD I would say this sounds like a COPD exacerbation. So for that we will start off with some basic blood work like CBC, electrolytes, your kidney function, ABG’s, as well as like a chest X Ray. And basically we should treat it we're going to take your oxygen saturation an give you some extra oxygen if you need. We’ll continue to use your bronchodilators an and in addition to both of that will also give you some steroids as well as antibiotics. And just to prevent any infections or if you already have it then it can help with that as well. And because your symptoms somewhat overlap with those of Covid will also do a covid swab just to make sure it's not that. And you should hear back about those results in 24 to 48 hours. How does that sound?

P: That sounds good. Thank you.

D: OK, yeah, no problem.


D: Can you tell me what brought you in here today?

P: Sure, I've been feeling very short of breath for the past, uh, two weeks, but even before that, I started feeling a little bit short of breath and I can't stop coughing and it just feels like it's really hard for me to breathe.

D: OK, so this started two weeks ago?

P: Yeah, it started two weeks ago.

D: OK, and you're also coughing?

P: Yeah.

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

P: The same amount of time, it started about, maybe three weeks ago, I started coughing more, um, but now it's worse.

D: OK, and what kind of cough are you having? Is it a wet cough or a dry cough?

P: It's definitely wet. My phlegm looks green.

D: OK, and how long have you noticed it being green?

P: It's been like that for the past two weeks.

D: OK, and before that, were you having coughing as well?

P: Yeah, before that I was still coughing but not as much.

D: OK, uhm, and was there anything that happened, uh, did you get sick at all recently, or were you in contact with anyone who was sick?

P: No, not that I know of.

D: OK, any kind of fevers at all?

P: No, no fevers.

D: OK. Have you noticed any kind of, uh, coughing up blood or blood tinged sputum at all?

P: Uhm no not that, no blood.

D: OK, and how much sputum are you bringing up in an average day now?

P: Uhm, I'm bringing up about, I'd say it would fill like two, two of my palms, like the inside of my palm.

D: OK. Alright, and is your coughing like constant or does it come and go?

P: It's pretty constant now.

D: OK. And have you had at all any kind of, uh, fevers or anything like that?

P: No fevers.

D: OK, and how about your shortness of breath? Is that, when does that happen? Is it mainly with exercise and exertion, or can it happen even when you're just going on about your day?

P: Uhm, its, uh, ok, its more with exertion, but right now even at rest, I'm coughing and feeling short of breath.

D: OK. And are you feeling at all any kind of, uh, chest tightness or pain?

P: Uh, yeah, some chest tightness.

D: And is that mainly when you're coughing and short of breath or, uhm, at other times as well?

P: Uhm, other times as well.

D: OK. Are you having any other, any other like, can you describe your chest pain a little bit? Is it kind of a pressure pain or is it a sharp pain, aching pain? How would you describe it?

P: Uhm, I would say it's a, uh, it's a tightness in my chest. And it feels, I guess throbbing or achy?

D: OK, and does this pain, uhm, move to anywhere else or does it just stay in your chest?

P: Uh, it just stays in my chest.

D: OK, have you been feeling dizzy or have you fainted at all?

P: Uh, no.

D: Have you been feeling increased sweating and confusion? Anything like that?

P: No.

D: OK, have you felt your heart racing and anything like that?

P: No.

D: OK. Alright, and is there anything that makes your symptoms better or worse?

P: Uhm, I guess activity makes it worse, un, and like cold air, things like that.

D: OK. And other than that, have you recently at all traveled outside of the country or outside of the province?

P: Uh, no. No, not recently.

D: OK, now are you having any wheezing at all?

P: Uhm, some wheezing, yeah.

D: OK. And any kind of headaches or nausea or vomiting.

P: No, nothing like that.

D: OK, and any fevers or chills.

P: Ah, nope, nothing like that.

D: Any night sweats?

P: Ah, sometimes I feel sweaty, but that's just with the shortness of breath.

D: OK, and how long does your shortness of breath usually last?

P: It lasts about, uh, I don't know, I kind of feel short of breath all the time, but when it's really bad, it lasts about five-ten minutes and then it goes back to like my normal shortness of breath.

D: OK. And has this happened to you before?

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

D: OK.

P: Like not, not this bad, I've always had some shortness of breath but nothing like this.

D: OK. And , uh, do you have any kind of diarrhea or constipation?

P: Uhm, no nothing like that.

D: OK, how about fatigue?

P: Yeah, I feel fatigued.

D: OK, and is that just about today or is it, do you think it's because of your shortness of breath?

P: Yeah, it's probably cause of my shortness of breath.

D: Are you having any of these symptoms when you're trying to sleep?

P: uh yeah, I think its, yeah when I'm laying down sometimes I feel more short of breath than usual, but once I shift positions it goes back to it's normal.

D: Ok. Is it, do you ever have to wake up at night to catch a breath or anything like that?

P: Ah, no, it doesn't wake me up.

D: And have you noticed any kind of, uh, significant weight loss or anything like that recently?

P: No.

D: OK, and have you at all had any changes in your appetite or anything like that?

P: No, no change in appetite.

D: OK. Any exposures to any like dust, fumes or any irritants recently

P: No.

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

P: Uhm,  just COPD, uhm, and, I also have some congestive heart failure.

D: OK, and when were you diagnosed with both of them?

P: COPD I've been, I got diagnosed about seven years ago, CHF about two years ago.

D: OK, and uh, right now do you have any symptoms of any swelling in your extremities like legs, hands or anything like that?

P: Some swelling in, some swelling in my legs, yeah?

D: OK, and do you have any kind of shortness of breath when you're lying down, at all?

P: Uh, a little bit. Yeah, a little bit I would say.

D: OK. And any other medical conditions?

P: Nope, no others.

D: Any allergies?

P: No.

D: Any medications you're on right now?

P: Yeah I'm on, uh, an ACE inhibitor, I'm on, uh, Spironolactone, uhm, I'm on, I have some puffers for my COPD. I believe, what do I have, I have, um, I have a long acting beta agonist. And I guess I have a short acting as well for when I need it.

D: OK. And do you have, so is it just the two, two puffers?

P: Mhm.

D: OK, and are you using, like the blue one, the blue one more at all, are you having to use the short acting one more?

P: I'm definitely using the short acting more, like I'm using it almost every day.

D: And does it help at all?

P: Uh I4 think so.

D: OK yeah, so other than that, are you on any other medications?

P: No.

D: No, OK. And have you been taking your Spironolactone?

P: Yeah, I've been taking all my medications.

D: OK, any previous hospitalizations or surgeries?

P: I was hospitalised two years ago for shortness of breath and some low oxygen, that's when they diagnosed me with CHF.

D: I see OK and did they say at all, It was caused by, like your COPD or what was it caused by? Do you remember?

P: Uhm,  I guess just, yeah, I'm not really too sure, they said I had some heart condition and my heart isn't functioning as well as it should be. They did an echo on me.

D: OK, and have you at all had any kind of heart attacks or anything like that?

P: No.

D: No, OK. and did they, when you were having shortness of breath, did you have a like a pneumonia or infection that you had to get antibiotics for any or anything like that?

P: Uhm, no. Actually I might have gotten some antibiotics at one point, but not during that visit.

D: OK. OK, And currently right now do you smoke?

P: No, I stopped smoking two years ago.

D: Yeah no, that's really good. And definitely with these symptoms and your condition that definitely helps to quit smoking whenever you can, so congratulations for that. Any alcohol at all?

P: I drink some alcohol. I drink maybe once a week.

D: OK, and any recreational drugs like marijuana?

P: I smoke once in a while.

D: OK, how often would you say you smoke marijuana?

P: I smoke about a joint a week.

D: OK, and uh, do you use a, like the provincial marijuana, or do you have any other source, what would you say you use?

P: I use uhm, Pardon me, what was that? Do I use?

D: Like uh, do you get it from a store that sells the joint?

P: Yeah, I get it from like a medical dispensary.

D: OK, OK, I see. Yeah, I just want to make sure because some, if you get it from other sources there might be more irritants in there that can cause some of your symptoms and for them to get worse as well. So yeah.

P: Oh I see, I see, OK.

D: Yeah, and other than that, do you have any questions or concerns at all?

P: No, what do you think I should do from, For now?

D: Yeah, so right now what we're going to do is because you're having the coughing, shortness of breath, and you have a history of COPD & CHF, we definitely want to make sure that you're not having, uhm, what I think you might be having isn't just an exacerbation of your COPD, and especially with the green sputum it might be like a bacterial infection that's causing your symptoms to get worse, so we'll do all the appropriate testing, we'll do, a chest X-ray, we'll get some blood work done as well, w'ell give you some uh, Ventolin as well while you're here, and we might give you like a steroid medication as well. So we'll do some of those things right now for you to kind of help you right now, as well as do some of those tests that I mentioned. Depending on what comes back, you might require an admission to the hospital just because we want to make sure you don't go home with an exacerbation, especially with the CHF as well, we need to, we will need to get that under control because that can get worse with your COPD exacerbation as well. So we need to make sure some of that, swelling goes down, if we need to adjust your medications while you're here. So yeah, let's just, I'll get back to you, we'll do some of those testing and then see where to go from there. Is that OK?

P: Yeah, that sounds great. Thank you.

D: You're welcome.


D: How may I help you today?

P: Yeah I've had, a fever and a cough that started just like four days ago.

D: OK, when did you, when did you start having your, so the cough started four days ago, what about the fever?

P: I think, like, last night was when I checked, it was high, like over thirty eight.

D: I see, OK. And, did you check your fever before that? The night before?

P: Yeah, I just checked it last night. I felt hot previously, but, I don't know, I thought I was going to just get better, but this morning still, well, feeling a bit a little bit worse.

D: OK, and the cough that started four days ago, has it been a dry cough or wet cough?

P: It's been dry.

D: OK, so there's been no sputum or any, or blood?

P: No sputum or blood

D: OK. Has it gotten worse over the past four days?

P: Uh, a little bit, yeah.

D; And, other than the fever and the cough, do you have any fatigue?

P: Uhm, yes.

D: We do, OK. Any muscle aches?

P: Uh, no.

D: OK, Sore throat?

P: No.

D: Any difficulties breathing?

P: No.

D: Any wheezing?

P: No.

D: Any chest pain or pressure?

P: No.

D: OK, any runny nose?

P: Yeah, my nose has been a little bit runny.

D: OK, that started over the past four days as well?

P: Yeah.

D: OK, what about pain in your belly?

P: No pain.

D: OK, any diarrhea or Constipation?

P: Uhm, no.

D: Any nausea or vomitting?

P: No.

D: Any urinary symptoms?

P: No.

D: OK, any rash that you've noticed on your skin?

P: No.

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

P: Uh, yeah, I haven't been able to smell as well.

D: You feel like you have a runny nose, but is it sort of congested?

P: Not really, it,  yeah, just kind of running, and yeah, I haven't been able to smell very well.

D: OK, and do you have any past medical, any conditions, medical conditions?

P: Uh, depression and anxiety.

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

P: Uhm, no

D: OK, are you taking any medications, including over the counter pills?

P: I do take a multi-vitamin.

D: And, uh.

P: sorry I do take, um, I take, uh, an SSRI, Citalopram as well.

D: OK, that's good. OK, any allergies?

P: No allergies

D: OK, specifically allergies to medications?

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

D: Good, ok, and do you currently smoke or have you ever smoked in the past?

P: Uhm, I smoked when I was in high school very briefly, but I haven't smoked anything in the last twenty years.

D: Alright, do you consume marijuana?

P: Uh, we'll use edibles every once in a while. I buy them from the, like, I guess government store, OCS.

D: I see, OK, any recreational drugs?

P: No,

D: OK, and do you currently live alone or do you live with others?

P: I live with others, I live with my girlfriend, and a dog.

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

P: Uh, she just came back from a work trip. I've been working from home but she was, uhm, in Saskatchewan, and just got back last week.

D: OK, and has she had any symptoms?

P: She's been fatigued since coming back, but I mean, we thought that was maybe just from the travels, but, maybe not.

D: Has she been quarantining, or are you both spending time together?

P: Well, we've been, I mean, trying to distance in the home, but I mean, we've been living together in an apartment so.

D: Fair enough, fair enough. OK, have you had any travels?

P: No, I've been working from home.

D: OK, alright, and uh, any, you don't have any asthma or COPD or any lung conditions, right?

P: Right, I don't have anything like that.

D: OK, and, any conditions that run in your family?

P: Uhm, no, nothing that runs in the family.

D: Alright, OK, so if I understand correctly, you've been feeling tired and you've had a cough and a runny nose and changes in your sense of smell for the past three or four days and you also were feeling a little bit hot and yesterday you noticed that you had spiked a high fever. Is there anything that I'm missing?

P: No, I think that covers all the symptoms.

D: And you might have potentially had, some exposure through your girlfriend potentially, so it's possible that, well, it's possible that you just have a cold, but it's also,  we'll still have to rule out covid as a cause, and so we'll have to do a covid swab and go from there and we'll check your temperature here as well. Just, uh, I think something that I forgot to ask, have you taken any medications that has helped you with your symptoms?

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

D: OK, alright, well, thank you, I'll go talk to my attending and we'll come back and discuss this further with you.

P: That sounds great. Thank you.


D: How may I help you?

P: Hi, I'm here because I've had this numbness and tingling in my feet for awhile now and I started to notice these open wounds on my feet as well and I'm not feeling it, but it's there.

D: OK, and when did you first notice the numbness and tingling?

P: It's been on going for the past like 2 years, but recently I've seen the past like 3 months it's gotten worse.

D: OK, and do you feel it in in both feet?

P: Yes.

D: OK and, where about do you feel the numbness and tingling tingling. Do you feel like all the way up your up your leg, or is it only part way?

P: It it goes right up until my ankles.

D: OK. And do you have wounds on your feet that like you, you don't notice them because you can't feel it?

P: Yeah, I don't notice it because I can't feel it, but then I'll see them and they look bad.

D: OK, do you recall hitting your foot or off of anything or stepping on any objects that could have caused trauma to your feet?

P: Um I mean it's possible um, but I didn't feel anything, so I'm not too sure about that. It is the summer, so I've been like going to the beach and when I'm at the park like I'll take off my flip flops.

D: OK, have you had any like muscle weakness, to your legs or feet?

P: Hum, maybe a little bit of muscle weakness in my legs.

D: OK, have you had any problems with balance or have it you had any falls?

P: No.

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

P: No.

D: Have you had any night sweats?

P: No.

D: And have you had any unexpected weight loss?

P: No.

D: OK, have you had any headaches?

P: No.

D: Alright, have you had any sensory changes like changes to your vision, hearing or sense of smell or taste?

P: No.

D: Have you had any any sore throat or cough?

P: Nope.

D: How about um any shortness of breath?

P: No.

D: OK, have you had any wheezing?

P: No.

D: Have you had any chest pain?

P: No.

D: Any have you had any dizziness or lightheadedness?

P: Nope.

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

P: No.

D: Have you had any nausea or vomiting?

P: No.

D: How about any abdominal pain?

P: No.

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

P: Nope.

D: OK. And have you had any urinary problems like frequency or painful urination?

P: No.

D: OK, and have you had any rashes on your skin?

P: No.

D: OK, and any muscle aches or joint pains?

P: No, nothing like that.

D: OK, and do you have any numbness or tingling to any other parts of your body?

P: Maybe a little bit in my fingertips as well.

D: OK, and when did you first start noticing that?

P: Um in the past year.

D: OK, and have you had any like like clumsiness or like dropping objects?

P: Um yeah, definitely some of that like I'll find it hard to like open cans and bottles.

D: OK, any weakness in the hands?

P: Um only when, only sometimes when I'm trying to grip things pretty hard.

D: OK, uh. And. Have you had any memory changes or any confusion?

P: No.

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

P: No.

D: OK, in the past have you been diagnosed with any? Or sorry before that and have you had any neck pain?

P: No, no neck pain.

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

P: Um yeah, so I've been diagnosed with diabetes. Hypertension. Hypercholesterolemia. Obesity. And and I think, yeah, I think that's that's about it.

D: OK, and are you currently on any medications? Like do you have? Do you use insulin?

P: I do so. I'm on insulin, short acting and long acting, I'm on Ramipril, I'm on Atorvastatin, yeah.

D: OK. an, and do you recall any like what your A1C has been in the past or, an have you had your eyes checked and kidneys checked?

P: A1c has been pretty high. Especially recently I think it was eight point 8.1 or something. The last time I got it checked. I haven't had my eyes checked in awhile, and in terms of my kidneys, I think I did a urinalysis recently and everything came back normal.

D: OK. And do you have any allergies to medications?

P: No.

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

P: No, I don't believe so.

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

P: Yes.

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

P: I live in a house downtown with my wife.

D: OK, and are you working currently?

P: I am, I work from home though.

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

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

D: OK, and have you traveled anywhere recently?

P: No, not outside the province.

D: Alright, and do you drink alcohol?

P: Um yeah, I'll have some alcohol every day.

D: OK, OK how many drinks per day would you have for and how many drinks per week?

P: I'll have about 5 beers a day.

D: OK, do you feel as though that's a lot?

P: Yeah, I. I'm hoping to cut down.

D: OK, that's good, and if at any point you need help or I would like to discuss that, just please let me know. OK, and do you smoke cigarettes?

P: I do.

D: OK, how much do you smoke?

P: Talk about half a pack a day.

D: And for how long have you been smoking for?

P: For the past almost 20 years.

D: OK, have you thought about cutting down?

P: Ah yeah again, that's something that I'm hoping to quit doing in the future as well.

D: Certainly OK. And are you currently sexually active?

P: I am.

D: OK and. Could you tell me about your partners or partner?

P: Yeah, just my wife. We've been together for the past five years.

D: OK, any concerns for a sexually transmitted infection at this time?

P: No.

D: OK. And any a musculoskeletal or neurological conditions that run in the family?

P: No.

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

P: No cancers that I know of.

D: OK, and how about heart conditions or or lung conditions?

P: No, nothing like that.

D: OK, so next. Just wanted to move on to their physical exam piece of the appointment today, so just looking at your um, the, at your feet and at the joints of the ankle and toes are you seeing any swelling, redness, or yeah, any swelling or redness?

P: Um no no swelling or redness.

D: All right, are there is there a temperature change to your feet or any of the joints? Are they feeling hot or cold?

P: No.

D: OK. And is there any deformities or misalignment of any of the joints?

P: No.

D: OK, and any scarring from any of the trauma?

P: Uhm, there are like. Yeah, there's some scarring from like ulcers.

D: From previous ones that have that have healed?

P: Healed. Yeah, that's right.

D: OK, and. And is there any pain to palpation over the um ankle joint, over the ankle joint?

P: No.

D: OK, then how about over any of the joints of your toes?

P: Um no not nothing like that. No pain, just um I can't feel it.

D: OK. And how is the range of motion of your feet and toes?

P: Um pretty good. I can move them all.

D: OK, and then how about your knees?

P: My knees are also the same.

D: OK, uh, an any ankle like instability with any special tests?

P: No

D: OK, and and on walking is there any limp or does it appear, how does the walk appear?

P: I'm pretty normal. I'm not limping.

D: OK. And. OK, so that was everything that I wanted to ask and and check today. Did you have any questions?

P: Just what do you think is going on with my feet and how do I get some sensation back?

D: So it does sound like it could be related to diabetes where what happens is you get like a peripheral neuropathy overtime and you can lose sensation to your feet in a glove and stocking distribution, which sounds like the history history you're saying today with having sensation reduced on your feet and also your fingertips as well.

P: Mmmm

D: Where you lose sensation and you can't feel pain. And so But other things to consider could be. Possibly like vitamin deficiencies or things like that, but I would be much much lower down on the differential. And. So to regain sensation I think. Really, the only thing that can be done now is to help prevent further damage to the nerves, and that would be to make sure that the diabetes is under good control and. Trying to monitor your feet as regularly as you can, making sure that the. There aren't any kind of open wounds or sores that are are not healing. If things are not healing, it will be important to check to see if there is an underlying infection such as osteomyelitis, which will prevent wound healing. And so if there are any, is anything like that it would be important to have that checked out. So feet hygiene is extremely important. As we're working on improving the diabetes control as well as things like cutting down alcohol could could also help as well.

P: OK OK, thank you.


D: How are you?

P: I'm not so good, these last few days I haven't benn able to reallykeep anything down and not feeling so good.

D: OK, I'm sorry to hear that. Um, when you say last few days, did you mean the past two days? 3 days?

P: Well, I feel like maybe the last five days I just haven't been feeling so good and I haven't really felt like eating. But these last two days I've been really nauseous and I've thrown up a few times.

D: OK, when you say you haven't been feeling good for the past five days, is it that you feel achy? Do you feel hot like you have a fever, or do you feel weak?

P: Yeah, I do feel hot and um, yeah, maybe a bit tired.

D: Tired? OK. And nausea and vomiting. Are you throwing up or just feeling nauseous?

P: Mostly nauseous, but yeah, yesterday I threw up like three or four times and then again today I threw up like two or three times.

D: OK, are you throwing up any blood?

P: No, I didn't see any red. It was mostly like yellow and umm, liquidy beacuse I haven't been eating much solids or like just like food. I've been mostly just having drinks.

D: OK, um, and so mostly fluid you said?

P: Yeah.

D: OK, and what color is it?

P: Uhh, yeah, usually usually kind of like yellowish clear.

D: OK. Are you having any abdominal pain?

P: Maybe like after I vomit it kind of feels like squeezing a little bit. But I think, yeah, I think yeah that's just really just with when I'm heaving.

D: Right, um, are you, do you have any changes in your bowel movements?

P: Umm, no, I haven't noticed anything there.

D: OK. And so no diarrhea, no constipation?

P: No, nothing like that.

D: OK, no blood in your stool?

P:No blood, I haven't seen any red.

D: OK, and how about issues swallowing food?

P: Oh yeah, no problem swallowing. Just haven't felt hungry.

D: OK, so you don't have much of an appetite then.

P: No, not not really.

D: OK, alright, so um, any changes in in taste?

P: Um, maybe I mean, yeah, I think I might not be really tasting things the same.

D: OK, how about smell?

P: Now that you say it, I might, uh, yeah I think my smell has been impacted as well. I can't really smell anything.

D: OK.

P: I thought that was kind of weird, but didn't think anything of it actually until you just asked me.

D: Yeah for sure. And how about any changes in your vision or hearing?

P: No changes to vision or hearing.

D: OK, any discharge?

P: Uh, nothing like that that, but I mean my eyes were a bit, they've been a bit red these last two days.

D: OK, have they been in any pain?

P: Nope, no pain and I've been able to see everything OK. It's just I just noticed they were a little bit more red. I just thought maybe I don't know I was, I've just been tired.

D: Yeah for sure. Any coughing?

P: Uhh, yeah I haven't had a cough but um, I've had a cough for a few years now, so yeah, that's not really a change for me.

D: Alright, so no change in your cough. Is it a dry cough or a wet cough?

P: It's uh, oh, a dry cough usually.

D: Dry cough, OK. Any blood that you produce?

P: No blood, no blood.

D: OK, any shortness of breath?

P: I'm not really able to exercise and stuff like that.

D: OK, have any wheeziness?

P:: Um, no, I haven't had a a wheeze.

D: OK, how about any fatigue or tiredness?

P: Yeah, I've definitely felt a little bit more kind of groggy and tired this last week, really.

D: OK, and muscle aches to go along with that?

P: Yeah, bit in my like kind of upper arms and legs a little bit.

D: OK, you said you've been feeling groggy. Do you feel dizzy at all?

P: Not dizzy, just maybe that I'm like moving in slow motion.

D: OK yeah, any confusion or memory loss?

P: No, I think I've been OK.

D: OK, any rashes?

P: No, I haven't noticed any rashes.

D: OK, how about headaches?

P: Yeah, these last few days I've had a bit of a headache as well.It hasn't been very intense, so, um, I'm not worried about it too much.

D: Right, OK. It hasn't been intense you said? So have you had headaches like this in the past?

P: Yeah, I had similar headaches before I think. They come like this. Like if I didn't get a good sleep or from not drinking enough water or something, I'll kind of get a headache like this. Kind of feels like it's squeezing.

D: Yeah, that's understandable. But it's not like the worst headache you've ever had?

P: No, no, it's pretty similar to headaches that I've had before.

D: OK, OK, good, and are you otherwise healthy?

P: Yeah, well I have high blood pressure and also, high cholesterol, so I do take medications for both of those. So yeah, I take a statin and Amlodipine I think.

D:OK, OK, good. It's good that you're on both of those. Do you take any other medications like over the counter medications or herbal supplements?

P: Yeah, I've been taking vitamin D and also a multivitamin. I heard that that we don't get enough vitamin D throughout the winter.

D: Yeah, it's a great idea to take that, especially as we get older and if we live in a country where we don't get a lot of sun exposure like Canada, so that's good. And sorry before I move on, I forgot to ask you earlier if you have experienced any weight loss or night sweats recently?

P: No, my weight's been, uh, about the same unfortunately and I haven't had any night sweats. But I mean now that you asked if I felt more hot than than usual, maybe.

D: OK, and did you take your temperature?

P: Uh, I did and the last time I checked it was a few days ago and at that time I didn't have a fever, but I mean, I'm still feeling hot so I'm not sure.

D: Yeah, OK. Alright, so I'll go back to your past medical history. Have you been hospitalized or have you ever needed surgeries in the past?

P: Um, no. Like the last time I was in the hospital with, it was for a colonoscopy a few years ago which came back normal.

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

P: Uh, yeah, actually got the shingles vaccine a few months ago.

D: OK.

P: Probably closer to a year ago now, actually.

D: Oh great, OK, that's awesome and are you allergic to anything?

P: Just peanuts.

D: Peanuts, OK. Do you know if you have a family history of any lung or heart conditions?

P: Yeah, my son has asthma. But nobody in my family's had a heart problem, though.

D: OK, how about any stomach problems or liver problems? Colon problems?

P: Yeah, my dad actually had colon cancer. He was 70 and so that's why we went and decided to get a colonoscopy instead of just doing the immunohistochemistry test.

D: OK, yeah, that's a good idea. Um, so it sounds like you're, you know, preemptive with your health, which is good. Any other cancers that run in the family?

P: No, just my dad had colon cancer.

D: OK. And do you smoke at all?

P: No, I don't.

D:OK, how about marijuana?

P: Um, no, I don't smoke marijuana.

D: OK, how about other recreational drugs?

P: I mean, I briefly like dabbled in the past at parties and stuff like that but that was when I was way younger, like in in my college years.

D: OK, what kind of drugs?

P: I think maybe we used cocaine a few times and MDMA, uh, but that was like a long time, probably like 30 years ago.

D: OK, were any of these drugs injected IV?

P: No, no, I've never done that.

D: OK, OK, that's good. Do you drink alcohol?

P:I have like maybe I don't know a couple of drinks a week.

D: OK, that's good. What kind of drinks do you have and how much of it do you have?

P: Usually, it'll just be one or two glasses of wine at a time and maybe two nights a week.

D: OK.

P: And I usually stick with red wine.

D: OK, great, and who do you live with?

P: So um, it's just me and my son.

D: How old is your son?

P: Uh, he's 18.

D: OK, and do you live in a house or an apartment?

P: Um, yeah, we live in an apartment. Yeah, on the 8th floor.

D: On the 8th floor, OK, any issues in terms of like old carpet or mold or asbestos in the apartment?

P: It's a newish building so there isn't really any carpet actually in the unit, so yeah, it's pretty clean that way.

D: OK good. That's good. So those were all the questions that I had for you. Did you have any questions or concerns that you wanted to bring up before we ended the interview?

P: Well, I'm just hoping to to get this sorted out and feel better.

D: Yeah for sure. So you know, right now we're thinking it could be a viral GI viral infection because of your complaints of nausea, vomiting, loss of appetite and fever. But it could also be COVID and we are going to have to do a swab for you and run that test because you have a lot of symptoms that overlap with those symptoms. Um, and then, so just going off of that, we'll wait for the swabs to come back. If they come back positive, we will notify public health and they'll do a trace to see where you could have gotten this infection from. And then meanwhile, we do suggest that you isolate for two weeks so that you don't spread the illness, and even if the swab comes back negative, there is still a chance that you may have COVID and it's a false negative test. So we'll start there. If it turns out you don't have any of those viral illnesses and you have more of a, you know, bacterial picture, we can work you up for that and prescribe antibiotics. So that's where we will start. How does that sound?

P: Yeah, that sounds like a great start. Thank you.

D: Alright, great.


D: Could you tell me what brought you in today?

P: Sure um so my my son. He's 2 1/2 months old an were we're in the ER because he's had this cough, fever an seems like he's breathing too fast. It's been happening for the past two days and we weren't sure what else to do for him.

D: OK, uh, so the first thing here would be, uh, like vital signs and assessing kind of stability. So is there, do we have this information?

P: We're going to say vitals stable. He is on 2 litres of oxygen right now.

D: OK. So when did the symptoms specifically start?

P: Two days ago.

D: OK, and what started first?

P: Um so. I guess he was coughing first and then we took his temperature and it seemed like he had a fever. It was over 38 and then over the past couple of hours it seems like he's having a hard time breathing. He's breathing too fast.

D: OK, so with this cough has there has there been any sputum come up?

P: Um yes yeah yellow sputum yeah

D: OK any blood that you notice in the sputum?

P: No.

D: OK, uh and how was the fever checked?

P: We did, we did a rectal.

D: OK and it has the temperature uh, Like has it, has there been a fever the entire time?

P: We checked twice. We checked on the first day and then again last night.

D: OK, um, and in regards to the difficulties breathing as there been any like changes to like is there been any noisy breathing?

P: I would say he sounds slightly wheezy.

D: OK, have you been hearing any like whistling sounds when, when he's breathing in?

P: I wouldn't say whistling no, no.

D: OK. And has he been experiencing any other symptoms?

P: Um, no. He actually. He hasn't gone through as many wet diapers as he normally does.

D: OK, um has he been like, well, how's this appetite been?

P: Um not the greatest, no.

D: OK, so not not eating, eating as much or drinking as much?

P: Yeah.

D: OK. How has his behaviour been?

P: He's been very, very fussy.

D: OK and inconsolable, would you say yes?

P: Yeah.

D: OK, And any bowel problems?

P: No, not that we noticed.

D: OK, any vomiting?

P: No.

D: OK. And, uh, have you guys been around any anybody who's been sick?

P: No.

D: OK, so everybody else has been and been well, alright. Any travel recently?

P: We haven't traveled recently, um. My mom, so his grandma had traveled recently and he saw her last week.

D: OK. Where did she go?

P: Mexico.

D: OK, and how is Grandma doing now?

P: She's doing fine, yeah.

D: OK. And, uh. And he saw her, he spent some time with her?

P: Mmhm, he spent the day with her.

D: OK, I see. And I. So in regards to a past health. Has he had any symptoms or like this before?

P: I guess last month he kinda had similar symptoms and they said it was a viral infection so he was just given some puffers to help his breathing and he got better on his own.

D: OK, did they tell you what the diagnosis was at that time, or just say that it was a viral infection?

P: No, they they said it could be bronchiolitis or just an upper viral infection.

D: OK, um any reasons for hospitalizations?

P: At that time that he had the bronchiolitis or viral infection, he was hospitalized for two days just to help his breathing.

D: OK, um and. Any any medications that he takes regularly or uses regularly?

P: Uh he, no no.

D: OK, any allergies to medications that you're aware of?

P: No.

D: OK, and in regards to birth and prenatal history. Were there any complications throughout pregnancy?

P: No, I wouldn't say so, no, It was normal. Everything was normal and he was a healthy baby.

D: OK. And has Mom had any complications with any prior pregnancies?

P: No, he's he's the first one. He is the first one.

D: OK. And, uh, was mom well throughout the pregnancy, like no infectious symptoms during?

P: No. No.

D:OK. Any concerns with his growth or development so far?

P: No, he's been normal.

D: OK, and then any concerns with either his vision or or hearing?

P: No.

D: OK, so if you um. OK, And And are his immunizations up to date?

P: Uh, yes they are.

D: OK, and, could you tell me a little bit about the living situation, uh who's in the home currently and where you guys are living?

P: Yeah, so we live in a house, it's him, myself, and my husband his dad.

D: OK, any pets at home?

P: No pets, No. Just, well actually a goldfish.

D: Oh cool. And are there any concerns for like verbal abuse in the home?

P: No.

D: How about any physical abuse in the home?

P: No.

D: OK, and does anybody smoke cigarettes in the home?

P: No.

D: OK, and then how about drink alcohol?

P: Mmm, we have like a glass of wine once a week.

D: OK, and who's the primary caregiver for him?

P: I guess we both are. Yeah, we both are.

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

P: Um, my sister. So his aunt has asthma.

D: OK, and Um. Does anybody, um is there any congenital diseases that run in the family?

P: No, no.

D: OK, How about any genetic diseases?

P: No.

D: OK. And. So um it's sounding like, I wanted to do a work up for His symptoms right now for breathing heavily and with the fever that's concerning for a type of infection and with being under three months it would warrant some investigations. So we'd want to check, do some blood tests. Yeah, and check his cerebrospinal fluid as well to make sure that there's no infection um in the brain I guess and what kind of go go from there?

P: Sure, yeah, that sounds good.

D: OK, um in the meantime, yeah, we'll give him some inhalers and keep the oxygen on to help with the lungs and breathing and then keep monitoring for how he's doing symptomatically.

P: OK, thank you.

D: You're welcome. Were there any, was there anything else that I I missed to ask about?

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

D: OK. Um, that sounds good. So if there was nothing else that you wanted to share, we will get that started and I I will be back shortly.

P: OK, sounds good, thank you.


D: How may I help you today?

P: Yeah, so I have like a really sore throat, started last night.

D: Oh I'm sorry, uh. Can you, can you tell me a little bit more about that? So you, um, you've only had this sore throat for one night?

P: Yeah, I just I think it's getting worse. It's at the back of my throat and it's kind of burning.

D: Mmm, OK. Do you have um, do you have any other symptoms?

P: Um, like I think my voice is kind of like raspy. I feel like I might be losing my voice.

D: OK, do you, do you have a runny nose?

P: No, not that I've noticed. I said it hurts when I swallow, right. I don't have a runny nose.

D: No, OK. And do you have any pain in your ears?

P: Uh. I haven't noticed no.

D: Any any sinus headaches, any sort of pain in and around your cheeks or pain in your forehead as you're trying to bend over?

P: Uh, no. No headache.

D: Nothing like that, OK. Have you had any pain in your chest?

P: No.

D: Any difficulties breathing?

P: No.

D: OK um. Any cough?

P: No.

D: Alright, so all you've experienced so far is since yesterday evening you've had a sore throat with difficulty swallowing, and hoarse voice. Have you experienced any malaise, or do you feel feverish? Or do you have any chills?

P: I definitely feel like really tired. I think I had. I think I had chills like yesterday. And I think when I first got here, they took my temperature and said it was like it was like pretty high. The nurse when I first got here.

D: I see I see, um. Have you, um. I'm just going to ask you about a couple other symptoms. Just um. Just to rule out some causes. Um, have you had any difficulties breathing?

P: No, no, that's OK.

D: OK, um, you have been, have you had any muscle aches or pains?

P: No, not not that.

D: OK, have you noticed that your eyes have been more runny, more red? Anything like that?

P: No. No, nothing in my eyes.

D: OK, any pain in your belly?

P: Uh, it's like my whole belly's been like a little like sore or but it's it's pretty much like mild.

D: When did that start?

P: Yeah, just like this morning I don't know. I haven't been eating a lot 'cause it just hurts to eat. I don't know if I'm just hungry. Like I've just been eating like ice cream 'cause it feels nice.

D: Yeah.

P: But I probably shouldn't just eat ice cream.

D: Ahaha. Um have you have you had any changes in your bowel movements? Any diarrhea, any constipation?

P: Uh, no.

D: Alright alright, any nausea or vomiting?

P: Uh, no vomiting. I feel like my throat. It just feels so like swollen but when I'm trying to talk with makes me feel a little bit nauseated.

D: Your throat feels swollen, have you have you noticed any changes in, have you found that it's difficult for you to talk? Is your speech slurred?

P: Uh, no, it's not slurred. It's just like sore because it's kind of like when I'm swallowing. You know.

D: Have you noticed any changes in your sense of smell? Do you feel like you can smell less?

P: I think that's pretty normal.

D: OK, what about taste? I know that you're not eating much 'cause you can't swallow, but do you feel like you can taste, your sense of taste is decreased?

P: Uh, uh, no. I think that's good. Yeah, yeah, I think, I mean mostly eating like really cold stuff, but I can taste it all.

D: Alright alright, um has it ever happened to you before?

P: Uh, no. Like I I had a cold like 2 weeks ago, but it wasn't like this though. That was more like runny nose and stuff.

D: I see. Um, have you done anything recently? Have you had contact with um with anyone who is sick?

P: Uh, my my girlfriend said that she was kind of, that her throat was feeling a little sore. I don't think it was as bad as as this but yeah, she said that.

D: Have you, um, have you been spending time with her recently?

P: I haven't. I haven't seen her in a few days, but yeah, like I saw her I saw her really a few days ago.

D: OK, OK Um, have you traveled anywhere?

P: No.

D: OK.

P: No, I wish.

D: Do you feel like you've had any contact with anyone with who might have COVID?

P: Oh, I don't. I don't think so. Mostly just to my girlfriend and my roommate right now.

D: Yeah yea, And do do you, do you know if they've been recently tested or if they might have had contact with anyone? Um, who maybe...

P: Um, I dont think so.

D: OK.

P: They're. They're pretty like they're pretty they just have online classes and they only really like leaves to get groceries and like go exercise outside.

D: I see, OK, alright, um. Alright, I'm just going to ask you a couple of questions about your past medical history. Do you have any medical conditions?

P: Oh no, no, I'm like pretty healthy. Alright, alright

D: Nothing like asthma or COPD or any respiratory problems?

P: No, no.

D: No, and. Are you taking any medications, including any over the counter medications or herbal medications?

P: Um no.

D: Alright um, do you have any allergies, including environmental allergies?

P: Oh, again, a little bit of a runny nose, like in the spring, but that's it.

D: OK um. Alright, and do you smoke?

P: Uh, no.

D: No, Ok. Do you consume alcohol?

P: I drink like a couple beers on the weekends, but. Like I I yeah I play sports a lot and I don't like a lot of time on the weekends so I don't go out.

D: OK, alright do you consume any other drugs?

P: No, no.

D: No, OK. And you mentioned that you live with your roommate and you haven't had contact with anybody other than your roommate and your girlfriend. OK um. Have you...

P: All my classes are online.

D: Alright alright um OK, well I'll I I'll go speak to my attending and we will I will discuss your medical history and with him and I will come back and discuss the plan with you.

P: OK, cool, thank you.