D: How can I help you?

P: I've had, uh, worsening, uhm, shortness of breath, uhm, for the past couple of days.

D: OK, and, this has just been getting worse over the last couple of days?

P: Yeah.

D: OK, how far are you able to walk before getting shorter breath?

P: A couple of stairs, two to three stairs.

D: OK, and how far were you able, to, to walk before that?

P: Hmm, I'd say about ten or eleven stairs.

D: OK, and have you had shortness of breath like this before?

P: Yeah, uhm, six months ago.

D: OK, could you tell me about what happened six months ago?

P: Yeah, yeah, I was feeling all, I was feeling, just like this was feeling awful. I went to the hospital. They started me on a water pill, kept me for a couple of days and then sent me back home. Uhm, they changed some of my meds, I think, increased the dose of something and yeah that's what happened.

D: OK, I see and have you been having, uhm, any swelling?

P: Yeah, Oh my goodness, it's so bad I couldn't wear my shoes this morning. It's gotten worse over the past, one month.

D: Have you, have you had any changes to your weight?

P: Yep, gained five pounds in the past two months.

D: And have you had any changes to your appetite or, or diet or exercise?

P: I can barely exercise. I feel so short of breath. My dad's the same.

D: OK, uhm, and have you had any, uh, instances where you've woke up in the middle of the night extremely short of breath?

P: Yeah, that happened last night, couldn't fall asleep.

D: Did it help, uh, sitting up?

P: Yeah, I just went and sat on my chair and slept on the chair.

D: OK, and do you, uh, typically have problems with shortness of breath if you lie flat?

P: I do, I have to, uh, started using two pillows.

D: Is this a nightly thing?

P: It's, it's fine with the two pillows now.

D: OK. Yeah, and have you been experiencing any cough?

P: No.

D: Alright, and, uhm, how about any, any chest pain?

P: No.

D: Have you been having any, uh, instances feeling as though your heart's racing or beating out of your chest?

P: No.

D: Alright, have you had any fainting or dizziness?

P: Uh, no.

D: Alright, have you had any wheezing?

P: No.

D: OK, have you had any infectious symptoms such as uh, eye redness, eye discharge, nasal discharge or, or sore throat?

P: Not recently, I had that about two months ago, but that got better.

D: OK, did you need antibiotics two months ago?

P: No, no, just lasted a couple days and got better on its own.

D: I see OK and, uhm, have you been having any abdominal pain?

P: No.

D: How about any changes to bowel habits such as diarrhea or Constipation?

P: Uhm, no.

D: Any urinary problems?

P: I do, I, I uhm, I leak urine sometimes, actually quite often.

D: OK, and do you use any medications?

P: No I, I, well I do, I use a lot of medications, uhm, but I  don't remember their names. Uh, I have this blister pack and I just take everything in it. Uhm, I also I brought the list of prescriptions, I can give that to you.

D: For sure, yeah I could go through, go through that, uhm here, uhm so, but first, have you been diagnosed with any medical conditions in the past?

P: Yeah, I have uh, heart, heart failure and uh, had two heart attacks and have high cholesterol, high blood pressure and, uh, I'm also overweight.

D: OK, do you know what your BMI is currently?

P: What's that?

D: So this is a measure of body mass index and, uhm, can help give an indication about weight ranges, uhm, whether, uhm, being in a healthy weight range or, uhm, a weight range that's associated with, uhm, risk of certain diseases such as high blood pressure.

P: No, I, I, I don't know. I, I've never heard of that. I, I know my weight, I could tell you that.

D: Sure yeah.

P: I'm 250 pounds.

D: OK, and yeah we can check that, uh, with your height today.

P: My height is 5'2".

D: OK, thank you. And, uhm, so just looking at the medications here now, I see a variety for uhm, cardiovascular protection, so things like aspirin, beta blocker, ACE inhibitor, statin, uhm and, uhm, do you have any allergies to medications?

P: No.

D: Uhm, and have you had any, uh, so you mentioned surgeries to your, to your heart? Do you have a stent placed?

P: Yeah, I had to stent put in after the first heart attack about five years ago and then another one, uh, three years ago.

D: OK, and have you, have you been stable in regards to your, uh, like chest pain? Have you had any?

P: No, I haven't had chest pain. I have a, uhm, a heart doctor who, uhm, I went to see after the last hospitalization six months ago. Things were looking OK at the time. He ordered a bunch of tests. I Haven't done all of them yet.

D: OK, do you know, uh, by any chance, what the, uh, last ejection fraction was on your echocardiogram?

P: I don't know, I, I don't know all of that. I don't know, you have to ask my daughter, she knows much more about me.

D: Yeah, no problem, well, we could look into, uh, some of those old, uh, older tests that you've done. OK, and, uhm, so can you tell me a little bit about your living situation currently? You mentioned your, your daughter, are you living with your daughter?

P: Yeah, I live with my daughter. My husband passed away, uh, three years ago, and so I've just been staying with my daughter. It's just the two of us now.

D: I see, I'm sorry to hear that about your husband. Uhm, are you currently, uh, like functioning independently around the home, or does your daughter help with a lot of the tasks?

P: Oh, she, she, she has to help me out, uhm she has to help me out. I uhm, I sometimes need help with the showering, simply because I get really short of breath and then, so I have to stop and it's just, she's just worried that it's unsafe, so she helps me out with that. Uhm, she gets most of the things done at home. She does the groceries and everything.

D: OK, I see, and do you, do you smoke cigarettes?

P: I, I don't.

D: And, do you drink alcohol?

P: Not anymore.

D: OK, do you smoke marijuana or use any cannabis products?

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

D: Alright, then, uh, do you, uhm, use any other recreational drugs?

P: No, no I don't.

D: Alright, uhm, have you been around anybody who you think might have been sick?

P: No, I've just been staying at home. My daughter's been working from home too.

D: OK, so uh, you haven't had much contact with, uhm.

P: No.

D: With others recently? OK, have you, so you haven't traveled anywhere?

P: No.

D: Alright, uh, and uh, and in terms of family history, has anybody had any heart or lung conditions?

P: Oh yeah, everyone in my family has high blood pressure. My mom had a heart attack. My brother had a heart attack. My sister had a heart attack. Everyone, everyone has heart problems.

D: OK, certainly sounds like something, uh, common in the family. Has there been any other, uh, conditions that run in the family?

P: No.

D: Alright, uhm, I, I don't, I don't think I asked. Have you had any fevers or chills?

P: No.

D: OK and or, or any night sweats?

P: No

D: OK, and, uh, I might have asked, but just to, to be complete, did you have any nausea or vomiting?

P: No.

D: OK, uhm, so were there any other symptoms or anything else that, that I may have forgot to ask about?

P: No, I don't think so. It's just the, the difficulties with breathing and the swelling.

D: Yeah, so the first thing, I'll speak to your daughter and we will, uhm, get a look at some of the old or some of the reports from, uhm, over the last several months from, and from the cardiologist you see. But it's, uh, and then, uh, also we'll get some blood work and a chest x-ray. But it is sounding like this could be a heart failure exacerbation. Which, so some of the shortness of breath, it could be coming from fluid, uhm, that has accumulated in your lungs and so, uh, we'll give you, oh, another type of water pill now, Furosemide, to try and help get rid of some of that fluid so it will help with the breathing. And in the meantime, we'll wait for the investigations to come back.

P: Sure, Thank you.


D: What can I do for you today?

P: Um yeah, so I'm here because I've had this fever, this cough, and now my head hurts. That's been going on for about the past four days and I just want to make sure um it's nothing too serious.

D: Yeah, yeah, that's great. So can you tell me, have you, did you measure your temperature?

P: Uh no, I haven't actually measured it, I just feel hot and feel chills.

D: OK, but we can take your vitals here um and uh you you said that you've had a cough for the past four days, dry cough or wet cough?

P: Um it's been pretty dry.

D: Um, any uh no blood or any um sputum um coming up right?

P: No, no.

D: OK and has the the cough gotten worse or better or the same, has it been the same since the past four days?

P: Um it's it's actually getting worse.

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

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

D: OK. Uh have you tried anything for your cough?

P: I've tried like decongest like cough suppressants but it doesn't seem to have helped.

D: OK. OK, and then tell me about your headache. That started four days ago as well?

P: Yeah.

D: And uh where exactly is it?

P: So it's like just on the front part of my head.

D: And does it feel like uh, what does it feel like? Is it like a throbbing sensation? A band like sensation? Um is it sharp, is it dull?

P: Uh it feels pretty throbbing right now.

D: Is it both sides or on the uh left or right?

P: Uh it's it seems like it's both sides.

D: If you had to give it a number from 1 to 10 with 10 being the most severe pain ever, what number would you give it?

P: Uh I would give it about like a seven.

D: Oh wow, OK. And how's it changed over the past four days?

P: Uh, it's just gotten a little bit worse.

D: Um is it uh is it, what was I gonna say, is it constant or does it come and go?

P: Um It seems pretty it seems pretty constant.

D: Have you taken anything for it?

P: I tried like some Tylenol for it and it seems to help a little bit.

D: Does it, is there a certain time of the day when it's worse? Before going to bed, at the end of the day, waking up, anything like that?

P: No, nothing like that.

D: Have you had a similar headache in the past?

P: Uh yeah, I guess I have, a little bit in the past, but that was also when I was like sick.

D: Sure, um does it wake you up in the middle of the night?

P: Uh no, it hasn't woken me up.

D: OK, um I guess other than the headache, I'll ask you about, and the cough and fever, I'll ask you if you've had any other symptoms. So have you had any confusion?

P: Uh no, no confusion.

D: Any changes in your vision or your hearing?

P: No.

D: Um any um redness in your eyes?

P: No.

D: Any loss of taste or loss of smell?

P: No

D: Um any runny nose or stuffy nose?

P: Uh nope.

D: OK, any sore throat?

P: No.

D: OK. Any chest pain or difficulties breathing?

P: No.

D: Any palpitations? Do you feel like your heart's racing?

P: No.

D: OK, any belly pain?

P: No belly pain.

D: Diarrhea?

P: No.

D: OK, any aches or pains in your body?

P: No.

D: Uh any rashes that you've noticed?

P: No, no rashes.

D: Any discolouration of your fingers or toes?

P: Uh I don't think so.

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

P: No, I think I'm healthy otherwise.

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

P: Uh, no.

D: OK, um what about medications? Are you taking any? Over the counter or otherwise?

P: Uh I take some multivitamins, that's it though.

D: OK, any family history of lung or heart problems uh or anything else, or cancers?

P: No.

D: And do you currently live alone or do you live with someone else or with other people?

P: I live with um my husband and our our daughter.

D: OK, have you had any, have you traveled anywhere?

P: No, not recently.

D: Have you uh, what do you mean by recently?

P: Uh like I have traveled in the past two years.

D: OK, that's fine, that's fine. Have you had any contact with anyone who might be sick? Either you or your husband or your daughter?

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

D: Have you gone out of the home at all?

P: Uh just to do like essential things like groceries and the bank and things like that.

D: Do you wear a mask and maintain social distancing?

P: Yes.

D: OK um alright, uh do you drink alcohol?

P: I drink like once once in a while, have a glass of wine.

D: OK, how, I guess how often would you say?

P: Uh once a week.

D: OK. And do you smoke?

P: Um no, not anymore.

D: Uh how much did you smoke in the past?

P: I I'd have like half a pack, um but I only smoked between like the age of 20 to like 25.

D: OK. Do you smoke marijuana or have any edibles with marijuana in it?

P: No.

D: Any recreational drugs?

P: No.

D: OK um alright well uh, and you said that you don't have a family history of any problem?

P: No.

D: Yeah OK, alright, I think that's all the questions I had for you. So uh looks like you've had a fever, cough, and a um and a headache that's gotten worse in the past four days and your headache's pretty bad, a seven out of ten. Um and uh it could be that you have uh some sort of an infection, uh including um, with Covid being one of the possibilities, and so um continue to take Tylenol and and um monitor your uh fever. If it continues to get worse, or you um notice that your symptoms are just not getting better, um you should come back, you should uh, we'll also do a Covid, we'll also send in a request for a Covid swab. Um and uh we'll ask you to quarantine for the for the next 14 days and try to stay away from your husband and daughter as well, if you can at home. Um and uh I guess a couple of other questions that I wanted to ask and I should have asked earlier, do you have any um any stiffness in your neck or any difficulties moving your neck?

P: Uh no, nothing like that.

D: OK alright, and um do you have any questions?

P: Uh No, that's it. Thank you so much.

D: Great.


D: What brings you in?

P: Yeah, so I just came in today uh a bit concerned. Uh I've been just having this nasty cough for like the last week and then today morning uh, like I thought the cough would just go away, but today morning I also noticed I'm coughing up some blood.

D: Oh, OK.

P: Yeah.

D: So when did you first start coughing?

P: Um, so let me think uh I just returned from a mission trip uh to the Philippines 2 weeks ago. This cough started uh just last week, so I would say around six to seven days.

D: OK. And that and the blood in your cough, um that was about yesterday, you said? Or?

P: Yeah today, uh.

D: Today, OK. OK. Um are you bringing up any phlegm at all, besides the blood?

P: Uh no it's just uh like I saw it on my hand, like there wasn't anything, like my cough is like pretty dry.

D: OK, are you short of breath at all?

P: No, I'm not short of breath. Um just, it's just the cough.

D: OK, and are you having any wheeziness?

P: Uh no wheeziness.

D: OK. Um any runny nose or stuffy nose?

P: No, no uh runny or stuffy nose.

D: Changes in vision, hearing, smell, or taste?

P: Nope.

D: Uh weight loss?

P: Um I have noticed uh weight loss over the last uh, I would say few months. So I've been I've been doing like like I I came back from Philippines last week, but um, I had gone earlier, like during this year or two and I've kind of noticed this weight change, probably lost around 15 pounds within the last few months.

D: 15 pounds OK. Wow, that's a lot, yeah. Um any night sweats?

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

D: Any fevers or chills?

P: I did have a, I did have some chills over the last week, um but I didn't really think too much of it.

D: OK, we'll take your temperature today just to make sure. Um any rashes?

P: No.

D: Any chest pain?

P: No chest pain.

D: Uh swelling in your limbs?

P: No.

D: Fainting spells or dizziness?

P: No, nothing like that.

D: Confusion or memory loss?

P: No.

D: Headaches?

P: No headaches.

D: Uh, joint pain?

P: No.

D: Fatigue?

P: Uh, no.

D: Um, changes in your bowel movements?

P: Uh, no. Not at all.

D: No, changes in your urine?

P: Nope.

D: Uh, nausea or vomiting?

P: No nausea or vomiting.

D: OK, how about abdominal pain?

P: No, nothing like that.

D: OK, are you otherwise healthy? Do you have any longstanding medical conditions?

P: Yeah no, I'm otherwise I um I don't, I'm really healthy. I don't take any medications so this was something that happened out of the blue.

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

P: No.

D: No, um medications, are you on any?

P: No, I haven't um tried any medications.

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

P: Uh I I've been yeah, pretty up to date with all my immunizations.

D: OK, uh, allergies, do you have any?

P: No.

D: Sorry, forgot to ask, immunizations. Did you get the flu shot this year?

P: Yeah I did.

D: OK, good. Any family history of lung conditions?

P: No, not at all.

D: No, any lung cancers?

P: No.

D: No, OK. Do you smoke?

P: No, I have never smoked a day in my life.

D: OK, recreational drugs?

P: No I would never take drugs.

D: OK. Do you drink alcohol?

P: No, no, not at all.

D: OK. Um where do you live right now?

P: So I I just live in a small apartment by myself, uh just been moving around a lot.

D: OK, for sure. Um any like asbestos, mold, or like old carpets, dust, anything like that at your apartment?

P: No, I don't think so.

D: No, any sick contacts recently?

P: Um not uh, I don't think so like we um, maybe in the Philippines, we do provide a, so I go on like these mission trips with the Church and um we do sometimes go to the hospital as well.

D: OK.

P: Sometimes yeah, we we do see some sick people.

D: Mhmm, OK.

P: But other than that, not since I've been here, no.

D: Any travel outside the Philippines recently?

P: Uhm, so I think. So this year has just been the Philippines, before I used to go to India as well. Um but recently nothing outside of the Philippines.

D: OK. OK, um those were all the questions that I had for you. Do you have any questions for me?

P: Yeah, I I was very worried um uh about the blood. I was just reading some things up and uh, about tuberculosis, so I was really stressed out today.

D: Yeah so um, that's definitely high on our differential. So, we'll do a couple of things. We'll do a Covid swab on you um just to rule that in or out, you should hear back for, about those results, in 24 to 48 hours. While you're here in the hospital, we're also going to do a chest X-Ray and or like an AFB smear to see if you have active TB or latent TB. If those come back positive um we will require you to isolate because this uh, because TB is highly infectious and it's airborne. Um so we have a couple of uh, we have like a regimen that we'd put you on. It's called the RIPE medications that we keep you on for two months and then we continue a couple of those for another four months. Um but we will uh keep you here until we have more answers on um like from this TB standpoint. How does that sound?

P: Yeah, that sounds good. Um yeah I'm really worried, but hopefully it's not TB.

D: Yeah, hopefully it's not, um but if it is, it's it's OK, like um we'll get infectious disease involved. Uh we'll get the isolation going and we'll get you on the correct treatment.

P: OK, thank you so much.

D: Yeah, no problem.


D: So I understand you're having some chest tightness?

P: Yeah, it's uh, for the last maybe three days, um it's not really pain, not in any specific spot, it just feels a bit tight in my chest area when I breathe in especially, and it just gets a bit harder to breathe and it feels more tight like especially when I go for my walks, which I do everyday, uh I try to walk my dog. So I was just, you know, worried that it could be something serious and I wanted to come and get checked out.

D: OK, for sure. So you said it started about 3 days ago. Have you noticed it's been getting better, worse or about staying the same?

P: I think it's staying the same.

D: OK, was there anything that happened 3 days ago that you can recall where you first noticed it?

P: No, nothing in particular um yeah, it just kind of came on and now it's been pretty steady.

D: OK and when it came on three days ago, what were you doing?

P: Uh I think I first noticed it when I was gone for my walk.

D: OK, now when you're walking, you say you have some chest tightness, do you have any chest pain?

P: No, there's not there's not pain, it just feels like, when I breathe in it feels tight.

D: OK, did you feel anxious or sweaty or the feeling of impending doom at all?

P: Uh, no I can't say that I did.

D: Nothing like that, OK, and did you feel yourself becoming out of breath at all?

P: Uh I I feel like it was kind of harder to get a whole breath, um so yeah, yeah, I guess.

D: OK, and was this tightness all across your chest or was it in one particular area?

P: Kind of just all over.

D: OK. And since then, that happened when you were out for a walk, how many times does it happen a day would you say?

P: Well, I feel like it's kind of always there, but it gets worse when I go for my walk. Um and well sometimes I go for more than one walk, right, 'cause I walk my dog. It's always kind of there, and especially when I'm like getting up out of the chair, I can feel it more, or when I take a big like a big breath in, as I said.

D: OK, so it's been there pretty constantly for the past three days, but it's more noticeable, if not worse, when you're going for a walk?

P: Exactly.

D: OK. Have you had any cough at all in the last little while?

P: Uh no like I feel a little more hoarse and like there's maybe some more phlegm, like I'm clearing my throat more, but I haven't actually been coughing.

D: OK, any fevers?

P: No, can't say that, no.

D: OK, any night sweats, so waking up and the sheets are soaked?

P: No.

D: Any chills?

P: No.

D: Any unexplained weight loss at all?

P: Nope.

D: OK, and have you ever had anything like this happen to you before?

P: Uhm, I mean I have asthma um so I've had some trouble breathing before, it, this feels feels uh different than other times. I I guess it could be related, but uh I don't know, this this feels a bit different, that's why I wanted to come in and get it checked out.

D: OK, so you have asthma, do you use any puffers at the moment?

P: Yeah, I just use the one that um I take every day. I don't really use the uhm, the one thats as needed because I just haven't had to in a really long time so I didn't refill my last one.

D: OK, so you don't have any anymore of the as needed, but you have used it in the past?

P: Yeah, exactly like it's been a couple of years since I needed that, but I still I still take the daily one.

D: OK. And you haven't stopped taking the daily one in last three days either?

P: No, I always take it um so I'm supposed to actually take it morning and night, um for a while though sometimes I was skipping the night one because I didn't feel that I was needing it. Um so so lately I've been taking it everyday, but I've just been taking it in the morning.

D: OK, uh, what makes you say you haven't really needed the one at night? Have you just been doing well without it?

P: Exactly, like I haven't needed the rescue one in a few years and even when I was just taking it in the morning, I I haven't had any problems.

D: OK, understood. And then have you had, I should have asked, do you work currently?

P: Uh I I, I'm a financial advisor, I'm like semi retired so I do some stuff from home.

D: OK, got it. I suppose just, has this kind of chest tightness stopped you from doing activities that you normally would do, any missed time from work?

P: I haven't missed any work, but I'm not I'm not doing a ton of work right now. I don't think it would stop me, it just would make me uncomfortable um during work and it keeps me, maybe this, the last few days, it's kept me from, I usually go on a couple of walks a day, the last couple days I've just gone on one usually so yeah, it's a little bit, yeah.

D: So it's really not stopping too much of your day to day functioning, but it's noticeable?

P: Exactly, yeah.

D: OK. Now, is there any other issue that you see your doctor regularly for aside from the asthma?

P: Uhm, I have uh high blood pressure, I don't really see my doctor very much, I just am on um medication.

D: OK, how about we just talk about your medications a little bit? What are you taking currently?

P: Uh I take the, uh, salbutamol.

D: Yeah.

P: That we talked about, and I take um Ramipril.

D: Yep.

P: And, uh, sometimes a Tylenol if you know, if I have a headache or something, but not very often.

D: OK understood, so aside from the high blood pressure you're really not taking medications for much else?

P: No, no.

D: OK. Do you have any other lung issues or any trouble with your lungs in the past?

P: No, nothing major, just the asthma. But you know, like I said, it's been a few years since it has bothered me.

D: OK, got it, and just in terms of your life itself, so do you smoke at all?

P: No, never.

D: OK, so no smoking, any other recreational substances, drugs?

P: Oh no, no. I mean I I have um you know a few beers on the weekend, but I don't do very, I don't do any drugs and I don't drink much other than that.

D: OK, got it. Any allergies that you have?

P: Uhm no, no, like I, uh, when I was younger I got some seasonal allergies sometimes in the springtime, but other than that, I I like I, it's really been uh many years since I've noticed that.

D: OK, and so nothing new in the environment? You haven't changed where you've been living or you haven't introduced a new pet or a new dog?

P: Exactly.

D: OK, so sounds like you're pretty much staying the course last little while, just kind of a new onset of this new chest tightness, and aside from that, seems that it comes on mainly on walks outdoors, but you've kind of been limiting the, some of the medication you're taking for asthma the last couple of years because you haven't really felt that you needed it as much.

P: Yeah, like just the morning was, it was enough.

D: OK. Alright John, I think I've got most of the information I need just to go talk to the doc and talk about your story. Next of course we're going to do a quick physical exam, going to take a listen to your lungs and see what else we might want to do in terms of investigations. I have a feeling that this actually might be your asthma reoccurring in some capacity or that would be on the top of the differential for now, barring any other new findings. So I think maybe what we would like to do is, we'd like to try having those rescue puffers available to see if that helps at all when you are on walks, and if they don't help, then we'll come back to the table and see what other possible directions we could head in in order to help you next. Does that sound good John?

P: Sounds great, I'm just, you know, glad to know that it's probably not my heart.

D: No, it sounds well, I suppose you said that you didn't really get out of breath with exercise, more sounds like a chest tightness, and you haven't had any pain associated with it, so that puts more cardiac ischemic pictures kind of lower on the differential. But of course we're going to try one thing at a time, and then we'll come back to the table um depending on how you're feeling after that, OK?

P: Sounds great, thank you.

D: No problem. OK, I'll go talk to the doctor, I'll be back with you in a moment.

P: Thank you.


D: What brought you in today?

P: Yeah absolutely. I have had this awful, awful headache for the past, two days I wanna say, its horrible.

D: OK, has the headache, uhm, stayed the same, gotten worse, gotten any better?

P: It's only gotten worse over the past two days.

D: OK, and when the headache started, was it like a thunder clap, kind of worst headache of your life when it came on?

P: No, no.

D: OK. Was there anything going on two days ago around the time of the headache, like did you hit your head or anything like that?

P: No, I just, uhm, I just went out for dinner, the night before and I know that there are certain foods that can trigger my migraines, but this really feels different. It doesn't feel like my migraine.

D: OK. Uhm, and have you had any other associated symptoms, with the headache.

P: I've been feeling really tired. I took the day off yesterday and today, I'm working from home, but I still decided not to get any work done today or yesterday.

D: OK. Uhm, and the fatigue, when did that start?

P: I think that started yesterday morning.

D: OK. And sorry, back to the headache. Have you tried anything for it?

P: I took Tylenol and Advil, but, I guess it did get better for about an hour a little bit, but it was back on again.

D: OK. And could you describe like where you feel the headache?

P: Sure, yeah, so it's like right in the front. Just kind of feels like a band, just like this pressure in the front of my head.

D: OK, and has there been anything that's made the headache worse, like lights or, or sounds?

P: No, no, like I said it's like nothing like my usual migraine headaches.

D: OK. And, I mean, the Advil or Tylenol, It helps the symptoms for a brief period, but has there been anything else that's helped your headache?

P: No, not really.

D: OK. And is there any particular time of the day that the headache's worse, like, is, in the morning time when you're first waking up or later in the day?

P: I don't think so.

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

P: No.

D: OK. And have you had any, like visual changes?

P: No.

D: OK. Uhm, and have you had a runny nose or a sore throat?

P: Uhm, I've had a bit of a sore throat.

D: OK, have you, have you had a cough?

P: Yeah, but honestly the headache's been bothering me the most.

D: OK, and when did the cough start?

P: About the same time.

D: OK.

P: Maybe two days ago.

D: OK, and have you had any neck stiffness? Does it hurt if you, if you move your neck around?

P: No, nothing like that.

D: OK, uh and with the, with the cough, have you had any difficulties breathing or shortness of breath?

P: Maybe a little bit.

D: OK, how about any wheezing?

P: No.

D: OK. Have you been bringing up any sputum with the cough?

P: No.

D: OK, how about, any, any blood?

P: No.

D: OK. And have you had any changes to your sense of smell?

P: No.

D: Any changes to your sense of taste?

P: No.

D: OK. Uh, and have you had any changes to your weight recently over the last several months?

P: I don't think so.

D: Alright, and how is your appetite been?

P: Uhm, it's fine.

D: Any chest pain?

P: No.

D: OK. Uhm any lightheadedness or, or feeling dizzy?

P: No, no.

D: Alright. Any nausea or vomiting?

P: No.

D: Any diarrhea?

P: No.

D: Any urinary problems?

P: No

D: How about , uh, have you had any muscle aches or joint pains?

P: A little bit.

D: OK. And any rashes anywhere?

P: No, no, no.

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

P: Uhm, I have, uh, I have migraines and uh, I also have Polymyalgia rheumatica.

D: OK. Are you taking any medications currently, for either of those?

P: No.

D: OK. And have you had any hospitalizations?

P: No.

D: OK, any surgeries?

P: No.

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

P: no.

D: Drink alcohol?

P: No.

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

P: No.

D: OK. And any family history of similar symptoms like, like, unusual headaches or anything like that?

P: Well, migraines kinda run in the family.

D: Migraines, OK.

P: Yeah.

D: And any heart conditions or cancers or anything like that in the family?

P: No no no.

D: OK. And have you been around anybody who's been sick, recently? You went out for dinner a couple days ago.

P: Yeah, uhm, I don't think anyone was sick.

D: OK. And you didn't feel that you had any triggers to your migraines at that time?

P: No, I didn't. I did yes, I, I did meet up with my friends and we went out for dinner. I know we're not supposed to, but it's been such a long time.

D: Yeah.

P: I don't think they were sick at the time, but I haven't really talked to them after.

D: OK. Have you traveled anywhere?

P: No.

D: Alright. And so I don't think I asked, did you have a fever or chills?

P: No, not really.

D: Oh OK. Uhm, so the symptoms you've been experiencing, you've had a headache that's been the most bothersome these, these last couple of days, which feels different than your migraines but you've also had a sore throat, a cough, shortness of breath as well as a little bit of muscle aches and fatigue over these last couple of days.

P: Yeah that sounds right.

D: Is there anything else?

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

D: OK, umm so, I'm going to get the attending and we'll go through a physical exam and get some investigations ordered so that we can try to figure out what's going on, ok.

P: OK, thank you.

D: You're welcome.


D: How may I help you?

P: Hi there, I brought in my here because he's been barking, well not barking, he's had this cough that sounds like a barking cough and he's having a really hard time taking in a deep breath and money does it sounds, it sounds harsh.

D: OK, and when did the cough start?

P: It started about two days ago.

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

P: It sounds pretty dry, yeah.

D: Alright, so so there's been no sputum and no no hemoptysis?

P: No.

D: OK. And it it does, the cough happen at any particular time of day?

P: Uhm, I mean no, well, actually mostly at night, but also it happens throughout the day. Umm, but yeah, more so at night.

D: OK. And, uh, has there been any shortness of breath or difficulty breathing?

P: Uh, no shortness of breath or difficulty breathing. It just sounds harsh when he does take a deep breath in.

D: OK. Uh, and any changes to, uh, to the voice or, uhm, yeah, like this is saying does he sound any different like a hot potato voice?

P: Uhm, no. It doesn't sound like that.

D: OK. And uh, uhm, that you mentioned umm, oh sorry, has he had any changes to the sound of his breathing?

P: The sound of his breathing. It sounds like it sounds harsh when he takes a deep breath in.

D: OK. So that sounds like he's having some stridor. Has he been having any wheezing?

P: You mean like when he exhales?

D: Uh, yeah.

P: Uh, it's more when he inhales that I hear it.

D: OK. OK. And has he had any eye redness or any eye discharge?

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

D: Is the other a runny nose?

P: No.

D: OK, has he had a sore throat?

P: No sore throat.

D: OK, and have you had a chance to look in his mouth, has he had any, like any redness or any swelling in the back of his mouth?

P: I took a look. It doesn't look swollen.

D: OK. And, uh, no shortness of breath I think you said?

P: Yeah, no shortness of breath.

D: OK. And has he had a sore throat?

P: No.

D: OK, and any changes to his sense of smell or sense of taste?

P: Uhm, not that I've noticed.

D: OK. And how has his appetite been?

P: Not as great as it usually is, but he's still eating.

D: OK. How is his like mood and behaviour been?

P: Uhm, he's been a little bit more fussy than usual.

D: OK. And eating less as well?

P: He's been eating less, but not like much less. I still try to get something in him.

D: OK, well, that's good. And has he had any chest pain?

P: Uhm, no, I don't think so. He hasn't complained of it or anything to make me think that he has any chest pain.

D: OK. And has he had any fainting, or mentioned that he's dizzy at all?

P: No.

D: OK, does he have any headaches?

P: I don't think so. He hasn't complained of that.

D: OK. Any ear pain or or ear discharge?

P. Uh, no.

D: OK. Does he have any abdominal pain?

P: No.

D: Does he have any diarrhea or constipation?

P: No.

D: OK, any blood in the stool?

P: No.

D: OK, and any skin rashes?

P: No, not that I've noticed.

D: OK, has he mentioned anything about muscle aches or joint pains?

P: Ah no, he hasn't.

D: OK. And is he had any nausea or vomiting?

P: No.

D: OK. And has he been diagnosed with any medical conditions in the past?

P: Uh, no, he's been a pretty healthy child.

D: OK. And sorry, just to go back and just summarize the symptoms overall, so he's had a "barky" cough that started two days ago, as well as some stridor or some noise on inhalation. And, and this reminds me, has he had any fevers or chills?

P: Uh, he has had a fever. Actually it was 38.7 yesterday.

D: OK, and any night sweats?

P: No, hasn't seemed sweaty at night, no.

D: OK. And has he had any weight loss in the last, several months?

P: Uh, no.

D: OK. And you said he hasn't been diagnosed with any medical conditions before, but so, has he had any reasons to be hospitalized or or any surgeries?

P: No, it's been a pretty healthy child.

D: OK, that's great, and any allergies that you're aware of?

P: Uh, I think he's allergic to penicillin.

D: Alright, what's the reaction?

P: Uh, he just gets a rash.

D: OK. And  are his immunizations up to date?

P: Yes.

D: Alright, and currently who is he living with?

P: Ah, he lives with his, both his parents and his older sister.

D: OK, and has anybody in the family been sick, or is he been around anybody who's been sick?

P: No, everyone's been pretty healthy.

D: OK. Has there been any travel recently?

P: No, no ones traveled recently.

D: OK, and anybody smoke in the home?

P: Uh, no.

D: Alright, then any concerns for him being exposed to any forms of physical or emotional or verbal abuse or any violence in the home?

P: Oh no, no.

D: OK. And is he like going to daycare or who is the primary caregiver at home?

P: Uhm, it's usually his, his mom, yeah.

D: OK. And were there any complications throughout pregnancy, such as gestational diabetes or high blood pressure?

P: No.

D: Alright, and any complications with delivery and was it vaginal or C-section?

P: It was vaginal and no, no no complications.

D: Alright, and up to this point, as you better meeting is milestones for like talking, walking and and things like that?

P: Yeah, that's right.

D: OK, and uh, any concerns for his vision or hearing?

P: No.

D: OK, and has he been growing normally?

P: Yeah, he's had all his milestones.

D: Excellent, OK. And are there any conditions in the family such as heart or lung disease?

P: Oh, no.

D: OK. How about ah, asthma or things like allergic rhinitis and allergies?

P: No, nothing like that.

D: OK. Uhm, so I I think that was all the questions that I wanted to ask today on history. Was there anything else that I maybe forgot to ask about or or that you wanted to mention?

P: Uh, no, that was kind of it. What should I do for him?

D: Uhm, so it's it sounds like the most likely diagnosis now is something called Croup or laryngeal tracheal bronchitis, which is basically a viral infection of the upper respiratory tract areas, and so it can cause had a barky cough and stridor and fever. And so, if so, it's really supportive care and unless he decompensate's and becomes really short of breath and worse, in which case we could, the treatment would be steroids and uhm, possibly utilizing other other things as well, depending on his symptoms, but usually it will be steroids and maybe some oxygen as well. But if he stays relatively stable, then it's mostly supportive care, just making sure he's hydrated as much as possible, you could use like humidified air. Sometimes like a hot shower. That sort of thing can maybe help relieve the cough at night.

P: OK.

D: But umm, that's about it.

P: OK.

D: We'll, so, we'll so we'll just observe for now.

P: OK, that sounds good. Thank you.


D: What brings you in?

P: I've just come in today because I've been having some issues with my hips as well as my knees. Just over the last probably a month or two, I've been just getting, this stiffness and pain especially, uh, throughout the day as the day goes along, and I also experience some stiffness when I wake up in the morning, uh, in my hips and knees, so I just wanted to come and check out what that might be.

D: OK, and you said it started in the past month?

P: Yeah, maybe up to two months actually. Yeah, I would say two months.

D: OK, and is the pain and stiffness always there or does it come and go?

P: It's, it comes and goes. It's worse in the, so it's stiff, more stiff in the morning first, but like as the day goes on, probably near the afternoon it gets worse. So I've had to stop some of my activities like gardening and being outdoors and things like that.

D: OK. And you said it's, it gets worse with activity. Is there anything else that makes it better or worse?

P: Uhm, it probably, yeah, if I'm just exerting myself too much. Uh, in terms of better, I I think I've taken some Advil that does help with the pain.

D: OK, OK. And then if you were to describe the quality of this pain, would you say it's achy, throbbing, dull, or sharp?

P: It's kind of like this uh, achy pain, kind of deep within the joints themselves.

D: OK.

P: Yeah, it just gets worse. I, as I walk more and do more activities.

D: OK, and does the pain radiate also or does it, or is it pretty localized to your hips and knees?

P: It's mainly in those areas.

D: OK. And severity wise, one to 10, 10 being the worst pain you've ever felt, how bad is this pain?

P: Probably like a 7.

D: Seven, OK. And have you ever experienced this type of pain before?

P: Uh, no, not really.

D: And do you think your pain is getting worse?

P: Uhm, I think so. Like over the last two months, I feel like my pain, there's more stiffness, there's more pain throughout the day.

D: OK, OK. And yeah, so do you, are you experiencing any sort of numbness or tingling in the areas?

P: No, not really.

D: No, OK. Any muscle weakness?

P: Nope.

D: No. Are you still able to walk and do the things that you used to enjoy doing? I know you said gardening was hard for you. How about like other activities of like daily living like, uhm, cooking, using the washroom, things like that?

P: Yeah, those things I don't really have too much trouble with.

D: OK, OK, that's good at least. And any dizziness or fainting spells?

P: No.

D: No, OK. How about memory loss or confusion?

P: No, nothing like that.

D: Any headaches?

P: No.

D: No, OK. How about joint pains or muscle aches elsewhere?

P: Uhm, no, I haven't really felt any other pain in any other joint so far.

D: OK. And any weight loss recently?

P: No.

D: No, OK. How about and fevers or chills?

P: Uh, no fevers or chills.

D: No fevers or chills, OK. How about rashes?

P: No.

D: And changes in your vision, hearing, smell or taste?

P: Nope.

D: Uhm how about coughing, wheezing or shortness of breath?

P: Nope.

D: Uhm, chest pain, heart palpitations or fainting?

P: No.

D: Changes in your bowel movements?

P: Nope.

D: Uh, changes in your urinating?

P: Uh, no.

D: OK. And then are you otherwise healthy or do you have any past medical conditions?

P: Uhm, so I do have a prior history of hypertension as well as high cholesterol, diabetes, type 2 diabetes and also a bit more on the overweight side.

D: OK, uhm, are you taking any medications for all of this?

P: Yeah, so blood pressure, I'm taking this medication called Telmisartan. And then for blood pressure, I'm taking uh, metformin. Sorry, not blood pressure, for diabetes I'm taking metformin.

D: OK.

P: And then for the cholesterol I'm taking, and this medication, called Atorvastatin.

D: OK. Alright, and do you have any allergies?

P: No allergies.

D: No allergies. And how about immunizations? Are you up to date with them?

P: Yeah, as far as I know.

D: OK, that's good. How about family history of musculoskeletal issues?

P: Not that I know of, no.

D: No, OK. Then how about uhm, lung or heart conditions?

P: No. I I think my father, maybe he had some heart issues. He did have a heart attack in his, let's see, like in the 70s.

D: In his 70s, OK. OK, and then alright, and how about autoimmune conditions?

P: Uhm, I don't think so. Uh, I can't, I can't recall any autoimmune condition.

D: OK, an and do you smoke?

P: Yeah, I used to smoke a probably up until when I was like 65 or something. So, probably for 40 years of my life.

D: OK, how much did you used to smoke?

P: Probably a pack a day pack a day.

D: OK, uhm well, congrats for quitting. I'm sure that wasn't hard. I mean sorry, I'm sure that was hard. Uhm, yeah, so that's good. And have you, do you consume marijuana?

P: No.

D: Go to other recreational drugs?

P: No. No other recreational drugs.

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

P: Uh, nope, not anymore. I used to probably drink some wine here and there, but I've stopped drinking alcohol too.

D: OK. And who do you live with right now? And where do you live?

P: Right now, I live with my wife and we live in a small condominium.

D: OK. Uhm, alright, and then any recent sick contacts?

P: No.

D: No, OK, how about uhm, uh travel anywhere?

P: No.

D: No, OK, that's good. And now I'm just going to get you to do the physical exam part of this interview with me, is that OK?

P: Yeah.

D: OK, so we'll take a look at, if you can, if you have a mirror, we'll take a look at both hips first. Do you notice any redness or swelling on those hips?

P: No, not really.

D: No, OK. How about any atrophy, deformities, or skin changes?

P: No.

D: No, OK. And then how about on your knees? Do you see any redness or swelling there?

P: Not really, no.

D: No. Any atrophy, deformity, or skin changes there?

P: Uh, no.

D: No, OK. I'm gonna get you to palpate your hipbones. Does that hurt?

P: No, not really.

D: OK, how about when you do that to your knees?

P: Uh, the knee I can feel a little bit of I would say it's more of a discomfort then tenderness.

D: OK, so some discomfort on the patella palpation. Uhm, alright and then when you palpate those areas, do you feel like there is a grading sensation? How, does it feel warm?

P: No.

D: No, OK. And then I'm gonna get you to, can you flex your hips all the way so bend so from a sitting position stand up first? Does it hurt when you extend your hips like that?

P: Not right now. I think, I'm pretty sure my hips are pretty well rested right now, but there is still a little bit of stiffness.

D: OK. OK, so some stiffness on hip extension. How about when you bend your hips all the way?

P: Yeah, that's a I can't really go down that far. But yeah, even bending, as much as I can, there is some discomfort there.

D: OK, so some discomfort and some pain on hip flexion as well as limited range of motion.

P: Mhmm.

D: OK. Alright, and when you do both of those, do you hear any like what's called a crepitus or like a grating sensation where you feel like bone maybe hitting bone?

P: No, not really.

D: No, OK. Alright, and I'm going to get you to, uh, extend your knee, so straighten it out. Yeah, does that hurt?

P: Uhm, yeah, a little stiffness in my knees. I feel like I feel more of the grating sound in my knees.

D: OK, OK. And then how about when you bend your knees all the way backwards? You can do one at a time.

P: Uh, yeah I, yeah I definitely feel some discomfort there as well.

D: Yeah, OK. Alright, and how about when you point your toes to the ceiling?

P: No, that's fine. I can do that.

D: And then how about when you point your toes to the ground?

P: Yeah no issues.

D: OK, so no pain or limited range of motion with plantar flexion or dorsiflexion. OK, so those were all the test that I want to do with you today. Did you have any questions or concerns?

P: Uh, no, not really.

D: No, OK, uhm, so it sounds like what you may have is something called arthritis, which basically happens, uhm, when the cushions at the ends of your bones and your joints kind of degenerate over the years, and so bone can eventually rub on bone, which causes like the grading sensation and causes the pain. Uhm, and it's it happens in old age, it happens with wear and tear so to diagnose it, we we'll, yeah, we did the physical exam. We can also get an x-ray of your hips and knees which can have some findings that align with osteoarthritis and basically for now we'll try to manage it conservatively so you can take and sets like ibuprofen for the pain or acetaminophen for the pain. We'll also refer you to physiotherapy to strengthen those muscles around your joint and to increase flexibility and reduce that pain. Uhm, and another thing that may be worth considering is occupational therapy because they can help you find ways to do everyday tasks without putting too much stress on an already painful joint. And if these things don't work in the future, we can also discuss things like steroid injections or joint replacement. Does that sound like a good plan?

P:: Yeah, that sounds great, thank you so much.

D: OK yeah, no worries.


D: How may I help you?

P: I'm I am here because I've had this intense pain in my right foot for the past six hours or so or so, and I thought it was important to come get it checked out by you guys.

D: OK, so you say it started six hours ago has the pain been getting better or getting worse?

P: Uhm, it's been it's been the same since it started.

D: OK, and was there any trauma to the foot or anything happen within the last day, or in the last six hours?

P: No, not no trauma.

D: OK and, where is the pain located if you had to try to pinpoint it with one finger?

P: It's just below my big toe, kind of like on the medial side.

D: OK. Do you feel the pain radiating anywhere else, or you just feeling it at that one spot?

P: I'm feeling it just in that one spot.

D: OK. And how would you describe the pain?

P: It's intense, it's sharp.

D: OK, and and has there been anything that you've tried that's made the pain better?

P: Um no I haven't really tried anything. I've I can't seem to move it so every time I move it, it hurts. I'm trying to keep it pretty still and stationary. I took an ibuprofen, that's not, that doesn't seem to help.

D: OK. And so like any movement makes it it worse, is there anything else that makes it worse, like putting socks on or even having I don't know clothing touch it or your shoes touch it?

P: Yeah, I guess yeah, my shoes, my shoes touching it hurts.

D: OK, and are you able to walk?

P: I'm able to walk on it, it's just very painful and I can't you know, I can't bend that toe. I can't flex it or extend it, but my other toes are OK.

D: Alright, and how would you describe the severity of this pain. One being the least pain and 10 being the worst pain you've ever felt.

P: I say it's like an 8.

D: OK, and have you ever had a pain like this before and in your toes or or any of your other joints?

P: No, never.

D: OK. And have you had any neurological symptoms such as like numbness or tingling or sensory loss?

P: No.

D: OK, how about any muscle weakness?

P: No, nothing like that.

D: Alright, and have you had any any headaches?

P: No, no headaches.

D: Have you had any memory loss or or or confusion?

P: No.

D: OK. Have you had any fevers or chills?

P: No.

D: Have you had any unexpected weight loss?

P: No.

D: And have you had any any night sweats?

P: No.

D: OK, and how about any sensory changes like changes to your vision, hearing, sense of smell or sense of taste?

P: No changes there.

D: Alright and have you had a sore throat or runny nose?

P: No.

D: And how about having a cough or shortness of breath?

P: No, nothing like that.

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

P: No.

D: And how about any heart palpitations or feeling like your heart is racing.

P: No.

D: OK. And have you had any lightheadedness or dizziness?

P: No.

D: OK. And how about any nausea or vomiting?

P: No.

D: Alright, have any abdominal pain?

P: Nope.

D: Any changes to your bowel habits like diarrhea or constipation?

P: No, I don't think so.

D: OK, and have you had any changes to urinary patterns like pain frequency or incontinence?

P: No.

D: OK. And have you had any skin changes like rashes or any changes to your nails or hair?

P: No.

D: OK, and how about your energy, have you had a fatigue or malaise recently?

P: Uh no, nothing like that.

D: Alright, and any muscle aches or body pains or or any joint pains anywhere else?

P: No.

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

P: Um no, I am. Actually sorry I have um high blood pressure as well as diabetes and I am a little overweight. But other than that, nothing else.

D: OK, do you take medications for any of those things?

P: Um I take ramipril for high blood pressure and I'm on insulin for the diabetes.

D: OK, have you had any medication changes recently?

P: Um no, no medication changes.

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

P: I was recently hospitalised for kidney stones. But that since has resolved.

D: OK.  Have you had any any surgeries?

P: No surgeries, just the lithotripsy for the kidney stone.

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

P: Yep they are.

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

P: No, I don't.

D: How about marijuana or using other cannabis products?

P: No.

D: OK and do you use any recreational drugs?

P: Uh no.

D: OK, and how about alcohol, how many drinks per week would you have usually?

P: Um alcohol have about. I usually have about 2 glasses of wine a day.

D: OK, and has that changed recently for you.

P: No, not really. I've just been I've also been start drinking like a beer every day as well recently.

D: OK. Alright, and alright could you tell me a little bit about your living situation right now who you're living with and and where?

P: I live with my son in a house.

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

P: No.

D: Alright, and have you traveled anywhere recently?

P: Um no no travel recently.

D: OK, and and can you tell me a little bit about your diet an and like do you eat a lot of red meat and or a lot of seafood like like shell shellfish?

P: I eat a lot of red meats. But not a lot of um seafood.

D: OK. And. OK, and anybody in the family have a history of musculoskeletal or or neurological conditions?

P: Um so. Who OK, so my my father had like arthritis and I don't remember what kind of arthritis he had but he had severe arthritis. He also had high blood pressure and diabetes, and on my mother's side. Um there is some arthritis there as well and as well as gout and kidney stones.

D: OK.  So that that was everything I wanted to ask all the history. And so, uh, next to ask you to have a look at your feet. And are you seeing any swelling, redness, or discolouration?

P: I see some redness and uh, some swelling in that area.

D: OK, and are you feeling any temperature changes?

P: Yes, and the right one is definitely warmer than the left.

D: OK, then how about any muscle atrophy in the foot or or lower leg or any joint malalignment or deformities?

P: Uh, so in terms of deformity is like it just looks swollen and so there's like a big bump on the right side of my foot, whereas it's completely straight on my left, but other than that, no deformities.

D: OK, and if you were to a palpate or press on areas of your foot or joints of your toes, are you feeling any any pains along the top of your foot or or in any of your other toes?

P: None of my other toes.

D: OK, and how about any pains at the ankle?

P: Um no pain at the ankle.

D: OK, so the metatarsals are not having any pain and then the joints of the 2nd 5th digits are pain free along with the ankle as well. Um and when it comes to range of motion, are you able to flex your toes downwards and extend them upwards towards your nose?

P: Yes, I can do that.

D: OK, and how about your ankle, are you able to um move your ankle on a full range of motion.

P: I can.

D: OK, and are you having a limping with, walking or otherwise called an antalgic gait?

P: Somewhat because I'm trying not to put too much weight on my right big toe.

D: OK. Alright, and so I think that was everything that I wanted to ask and check today. So did you have any other questions or anything that I maybe forgot to ask about you wanted to mention today?

P: Um no just what can I do for my foot how do I make the swelling go down?

D: Yeah, for sure it's so right now with having a like a red, warm and swollen joint that that's extremely tender and has limited range of motion. It's important to rule out a septic arthritis, however. Based on several of the risk factors such as diabetes, and obesity, as well as your family history of arthritis and gout. Taking the most likely thing is that this is a gout flare, and in particular in the toe like that it could be called podagra and so we will need to get a aspiration of the joint fluid just to send it off and make sure that it's not not an infection and that we're treating the right thing. If this is, gout and it comes back that this way it's treated with that high dose, high doses of anti inflammatories. I will start with medication called colchicine to help with this flare, and in the meantime, important things for preventing this in the future are diet and kind of lifestyle related with reducing things like red meats, alcohol, weight loss and um just trying to improve the diabetes management as well.

P: OK, that sounds great. Thank you.

D: Alright, thank you, we will get that started.


D: I was wondering if you could tell me what brought you in.

P: Sure, um, I have been coughing a lot. I've been feeling short of breath and I just feel really wheezy, so I thought I should come check it out.

D: OK, when did the cough start?

P: I've always had a cough. Well, I guess I've had a cough for the past five years, but over the past three days it's gotten a lot worse.

D: OK, did anything happen 3 days ago that has brought the cough on?

P: Uhm, no, I was, I did groceries, I came home and then I started coughing a little bit more and I haven't been able to stop since.

D: OK, is there any particular time of day that the cough is worse, like morning, night?

P: Uhm, it seems to be worse in the morning.

D: OK, and are you bringing up any sputum?

P: I am. Umm, and it looks yellow and sometimes even green.

D: OK. With your cough prior to three days ago were you bringing up sputum with that?

P: I guess some, but it was clear.

D: OK, and are you bringing up more sputum now, the same or less?

P: Um, more sputum, and sputum just looks different.

D: OK, have you noticed any blood?

P: No blood.

D: OK, and you mentioned you've been you've had a wheeze, when you do you notice that?

P: Uhm, I also, I guess I notice that mostly last night, yeah.

D: OK, um and what types of activities have you had shortness of breath?

P: Uhm, I guess walking, doing day to day things has made me feel a little bit more short of breath than I used to feel.

D: OK. And have you been experiencing any other symptoms besides the cough, wheeze and shortness of breath?

P: Um, I feel a little bit more tired, but other than that, no.

D: OK. So a bit more tired. How has your sleep been?

P: My sleep has been, um, pretty normal. It's been, yeah, it's been the same. I guess it's the coughing that's making me tired.

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

P: Ear pain, or eye pain? No.

D: Any discharge from either, either your ears or eyes?

P: No.

D: OK. Have you had a runny nose?

P: No.

D: Or felt congested?

P: No.

D: OK, have you had a sore throat?

P: Uh, no.

D: Or any difficulty swallowing?

P: Uhm, no.

D: Changes to your sense of smell or taste?

P: No.

D: OK, have you had any changes in appetite?

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

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

P: Weight loss, no.

D: OK. How about have you had any fevers or chills?

P: Fevers or chills ah, no. No, nothing like that.

D: Nights, how about night sweats?

P: No.

D: Have you had any chest pain?

P: Ah no, no chest. Well my chest feels, I guess sometimes I, it feels painful because I'm coughing so much, but nothing more than that.

D: OK, do you get chest pain when you exert yourself physically?

P: Uhm, no.

D: OK, so it's just after the coughing?

P: Yeah.

D: OK and how would you describe the character of the chest pain? Some people will say sharp, dull, achy.

P: Um, I would say dull.

D: OK, and have you had any like heart palpitations, feeling like your heart's racing?

P: No.

D: And how about any episodes where you felt like you were going to faint or, yeah, pass out?

P: No.

D: OK. Uhm and have you had any swelling in your feet, ankles, hands?

P: No, nothing like that.

D: OK. And then have you had any urinary problems?

P: Um, no.

D: Any bowel problems?

P: No.

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

P: No, nothing like that.

D: And how about any rashes anywhere?

P: No.

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

P: Uh, no.

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

P: Uhm, I have high blood pressure and diabetes.

D: I see. Are you on any medications for those?

P: Um, for the blood pressure, the high blood pressure, I'm on a beta blocker and then for my diabetes I'm on metformin.

D: OK, uh, do you, are you taking any other medications?

P: Um, just some calcium and vitamin D.

D: Any surgeries in the past?

P: Nope.

D: Any allergies to medications?

P: No.

D: OK. Are your immunizations up to date?

P: I believe so, but I recently learned that I should get something called the pneumococcal vaccine. I haven't gotten that yet.

D: Yeah, you're you're right. So for um, in Canada or anybody or in Ontario, at least, anybody who's older than 65, it's recommended to get this vaccine to protect against certain types of bacterial infections type which can cause pneumonia. So it would be good something that you can set up with your family doctor.

P: OK.

D: Yeah, and so are you, so do you smoke cigarettes?

P: I used to.

D: OK, and how much do you smoke or how much did you use to smoke?

P: Um, I smoked a pack a day and I smoked for 45 years, but I stopped two years ago.

D: OK, that's great that you were able to stop. Do you drink alcohol?

P: Uhm, occasionally like once every two weeks.

D: OK, and any triggers that you can think of you were exposed to either at work or home like chemicals or things that you were exposed to that you had to breathe, that you breathe in?

P: No, nothing like that.

D: OK, have you traveled anywhere?

P: No.

D: Alright, and have you been near anybody who's been sick or has similar symptoms?

P: Uhm, no.

D: Alright, and anybody in the family have a heart or lung condition?

P: Um, no.

D: Any cancers in the family?

P: Um, there was a liver cancer.

D: OK, and, I think that.. OK, and that was all I wanted to ask on history. Was there anything else that you wanted to tell me today?

P: Um, no, just um, what do you think the problem is? I've never felt this bad with my shortness of breath before.

D: Yeah, certainly so umm, it, it sounds like it could be maybe a viral infection that I brought on this cough and worsen the sputum. This could be a bacterial infection, it could be a COPD exacerbation and also one of the other things that we would have to consider right now is Covid as well and so we will do a PCR nasal swab for Covid and a chest Xx-ray and some other investigations as well and uhm, we will try to get to the bottom of what's causing your your shortness of breath.

P: OK, that sounds good, thank you.


D: How may I help you?

P: Hi I um I just developed uh or I guess I just started having difficulties with uh breathing starting this morning. It was just very odd, I was fine yesterday night and then just this morning, I've had a really hard time breathing um and yeah, I thought I should come in and get it checked out. I don't know what's going on.

D: Yeah, certainly, and so uh like did this shortness of breath wake you uh like did you wake up, um like just like uh to kind of sit up to catch your breath, um or when did the shortness of breath start?

P: Um it was kind of after I woke up and I was sort of, um just walking around that I I noticed that I was feeling short of breath just walking around, which was so weird. You know that that doesn't really happen to me.

D: OK. Um and with this, with the shortness of breath, have you had had a cough?

P: No.

D: OK, and um have you had any wheeze?

P: Um no.

D: OK, and have you been having any uh any chest pain?

P: Yeah, I kind of, I guess it just hurts a little bit when I take a, when I breathe in.

D: OK is is this pain when you take a deep breath in?

P: Yeah, I guess so, yeah.

D: And where do you feel the pain?

P: Um it's kind of on my um right side.

D: OK, does the pain uh like radiate anywhere or do you feel it just in that one spot?

P: It's just uh it's just in that one spot. It's just this sudden and like like this stabbing sensation um when I'm like taking a breath in. Uhm, actually now that I think about it, it's it's kind of there even when I'm like breathing normal, but it's not as bad. When I take a deep breath it's like really, really bad or when I um yeah, when I like cough or like I'm laughing or something, it just gets really bad.

D: And when did you first notice this pain?

P: Kind of um late this morning.

D: OK uh have you tried anything for a for the pain?

P: Uh I don't know, it's just I just try not to take deep breaths, I'm just trying to just take a normal breath and try not to talk too much. And yeah, just like not doing anything that worsens the pain.

D: OK, I see and um did you have any trauma to that to that area recently like a car accident or I don't know, getting hit in the ribs, or anything like that?

P: No, no I didn't.

D: OK. Um and have you had any episodes where um or actually rather like, do you have any issues with lying flat and having shortness of breath?

P: No.

D: OK, and um have you had any headaches?

P: Uhm, no.

D: Have you had any uh fevers or chills?

P: No. I don't think so.

D: OK, and have you had any night sweats?

P: No.

D: Have you had any changes to your weight recently? I mean, like over the last several months.

P: Uh no.

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

P: No.

D: How about any changes to your sense of uh taste or your sense of smell?

P: No, those are OK.

D: Alright, and have you had uh a runny nose or a sore throat?

P: No.

D: Alright. Um and have you had any diarrhea?

P: No.

D: How about any urinary problems?

P: No.

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

P: No.

D: OK. Um and how about any uh muscle aches or body pains?

P: Um yeah, I kind of have uh, it's just my left leg hurts a little bit. I'm not quite sure why. But yeah, nothing else.

D: OK, whereabouts, uh where does it hurt um on your left leg?

P: Um kind of in the calf area.

D: OK is it is it swollen or have you noticed any redness of the skin there?

P: Yeah it is. It is swollen actually, compared to my right leg. It's a little bit warm too.

D: OK, um have you had any uh like periods of time where you were bedridden over the last several days or or last several weeks?

P: No.

D: OK, any surgeries recently?

P: No.

D: Alright, and have you traveled anywhere over any long distances recently?

P: Oh yeah, yeah, I came back um two days ago. Um I went to um I went to India to visit my family, there was a death so had to to go. I came back yeah, two days ago.

D: OK, yeah, that's quite a long flight and I'm sorry to hear about um the loss of the family. Um OK, um oh and that reminds me, have you coughed up uh any blood at all?

P: Uh no.

D: OK. Um and um I just wanted to switch gears a little bit and ask about your past health. Have you been diagnosed with any medical conditions?

P: Uhm I I've had um anxiety. And uh yeah, that's that's about it. I had asthma as a child, but nothing since then.

D: I see, and do you uh take any medications for anxiety or have you?

P: Uh no, I'm just trying to um, just trying to reduce my stress and and trying other other ways to sort of handle my anxiety before I, I'm just trying to avoid builds actually.

D: I see, OK. So do you take any medications like either prescribed or over the counter?

P: Uh no.

D: Do you have any allergies to um to medications or or environmental?

P: No.

D: Alright, and um have you had any surgeries in the past or any hospitalizations?

P: Uh I had my appendix removed when I was uh 30 years old.

D: OK, um and any complications with that?

P: No.

D: Alright, and currently uh whereabouts are you living and uh who are you living with?

P: Um I'm just living with my sister. And uh yeah, we we live in an apartment together.

D: OK, and has she been sick or have you been any, around anybody who's been sick?

P: No.

D: OK, um and uh any potential exposures to uh TB, uh either in your on your travels or or anybody that you that you know of?

P: I don't think so, no.

D: OK. Um and do you smoke cigarettes?

P: No.

D: And do you drink alcohol?

P: No.

D: Uh how about the use of any uh recreational drugs?

P: No.

D: OK, um and in the family is there a history of any bleeding disorders or any uh clotting disorders?

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

D: OK, um and any heart conditions, lung conditions?

P: Um just a heart attack. Uhm both my grandparents on my dad's side uh had a heart attack and uh diabetes as well. Um I think both my parents have diabetes.

D: OK. Have you been tested for uh diabetes as well?

P: Uh yeah, yeah yeah I go to see my family doctor and my uh, he said my sugars were good.

D: OK, great. Um alright, so um you've been experiencing uh so this this chest pain when you breathe in deeply since this morning um as well as some more difficulty breathing, and some left pain uh left leg pain with with some swelling. Uh have you been, after travels as well, have you had any other symptoms?

P: No. I don't think so.

D: OK, so that was all I wanted to ask today on on history and before I went on to uh the physical exam, we want to check uh vital signs and have a listen to your heart and lungs and um measure the diameter of your of your shins as well. Um but um it'll be important to get uh some imaging of your of your lungs um to assess whether or not there's a pulmonary embolism um uh because that would be one of the more um life threatening, or potentially um complicating uh causes of what's going on right now.

P: Sure.


D: What brings you in?

P: I've just had a real like a real bad cough. Umm, it's been going on for 4 or 5 days now umm, and I'm just, I'm having some trouble breathing. I'm coughing up like gunky green stuff. Uhm, yeah, it's just really bad. I haven't had anything like this before.

D: OK, so when did the cough start?

P: About four or five days ago.

D: Four or five days ago. OK, and, uhm OK. So for 5 days, did you do have any shortness of breath with that?

P: Yeah, it's uh, I'm just I feel like I can't, can't quite like breathe fully.

D: OK, uhm you can't quite breathe fully, so like when you take a deep breath in, you can't expand your lungs fully. Is that what you mean?

P: Yeah, yeah, I just overall I just feel like yeah, I'm I'm short of breath. I guess that's the best way to put it.

D: OK, so you're short of breath. And how about wheezing? Do you have any of that?

P: I don't think so.

D: OK. So when did this start again? You said if a couple days ago or a few weeks ago.

P: I think it was four days ago.

D: Four days ago, OK, and did you have like a runny nose or stuffy nose at that point?

P: Maybe a little bit. I wasn't really thinking about it too much.

D: OK, uhm sore throat?

P: No, not a sore throat.

D: Not a sore throat, OK. Uhm, how about changes in your taste or smell?

P: No, none of those.

D: OK. How about changes in your vision or hearing?

P: Uh, no.

D: Fever, weight loss?

P: I feel like I've I've probably had a fever the last couple nights. I've just been really hot in the evenings.

D: OK.

P: Yeah, I feel like I've had a fever. I don't know bout my weight. I don't weigh myself all the time.

D: Mhmm.

P: But nothing like major.

D: Any chest pain?

P: Feels a little like it hurts a little bit, like when I when I breathe in.

D: OK. Uhm, do you ever feel like your heart's racing?

P: No, I don't think so.

D: Alright, And any changes in your bowel movements?

P: No, no, that's all the same.

D: No bellyaches?

P: Nope.

D: No bellyaches?

P: Nope.

D: OK, how about changes to your urine?

P: Uh, no.

D: No, any dizziness or confusion?

P: No, uh no, not dizziness or confusion, but I have just been feeling very weak and tired.

D: When you say weak, have you like lost any of your like motor movements like your arms, legs?

P: No, no, not like that kind of weak. I just have felt like very rundown.

D: OK.

P: Just like just fatigued like more than usual, yeah.

D: OK. Are you otherwise healthy or do you have any longstanding medical conditions?

P: Uhm, I don't I don't have too much luckily, knock on wood. Uhm, I, I take a medication for my reflux.

D: Mhmm.

P: And I did, I did have a knee replacement, five years ago.

D: OK.

P: Other than that, like I don't, I haven't really been to the doctor for much.

D: OK. Uhm alright. Do you have something called COPD?

P: No.

D: No, OK. Uhm, are you on any medications?

P: Just that one for the reflux its uhm oh, it starts with an R. Uhm, Rabeprazole?

D: OK.

P: Yeah.

D: Alright and are you up to date with all your immunizations?

P: Uh, yeah.

D: Including like the pneumovax vaccine and the shingrix?

P: I had the shingrix the pneumo I think the doctor said we were going to look at that the next time I came in.

D: OK, sure.

P: So I I'm not sure I I know that I always say yes to these things, but I'm not sure because of Covid and stuff if I've been getting everything exactly on time.

D: Mhmm. OK, and how about uh, how about allergies? Do you have any allergies?

P: Oh, like uh, just seasonal. Not to any medications or anything.

D: OK. Uhm, have you been in touch with anyone sick recently around you?

P: No, like the only person I see is my husband. I guess him, and so he has a PSW that comes in to take care of him. He has a couple more problems than I do. So basically, we see I see him and her and we see we see our kids, but just like outside.

D: OK. OK and alright and then, uhm, have you traveled anywhere recently?

P: No, no

D: No, OK. Dietary wise, are you like eating healthy?

P: Yeah, yeah, I think so. I try to, you know, cook, you know, whole foods for us like lots of veggies and you know fish and good meat. Although in the past you know few days, I just 'cause I felt really rundown and fatigued, I haven't been eating as much as I normally do.

D: OK.

P: Otherwise, I think we pretty healthy I try to, you know, follow healthy recipes and find them online.

D: Yeah, for sure. Yeah, that's good. Do you, do you smoke?

P: No, no.

D: No, OK, and any other recreational drugs?

P: No, never.

D: OK. Do you drink alcohol?

P: I'll have the occasional glass of wine on a special occasion, but not frequently and not, not heavily.

D: OK. And where do you live and who do you live with right now?

P: Uh, just me and my husband. We live outside of town. We live in the country on a little farm.

D: OK. Any old carpets or dust or mold or asbestos in the, in the home?

P: No, no we renovated probably 15 years ago, and there's no no more carpet, and there were never any asbestos problems or anything.

D: OK. OK, well I think those are all the questions that I had. Did you have any questions for myself?

P: I don't think so. I just I hope you know we can get this figured out.

D: Yeah, for sure. So we'll start with doing a Covid swab because you have some symptoms that overlap with it, so you should hear back in about 24 to 48 hours with those results. But it does sound like what you're telling me with the wet cough and you know a little bit of shortness of breath, I think it's worthwhile to get a chest x-ray to see if you might possibly have a pneumonia, and if you do, if there is some consolidation we'll probably prescribe some antibiotics for that. Umm, how does that sound to you?

P: Sounds great to me. Yeah, I just you know, hope there's nothing serious going on.

D: Yeah, yeah, and it shouldn't be. It's probably 1 something that's been going around in the community and you haven't had any recent hospitalizations or surgery, so I wouldn't worry about like any of those atypical bugs just yet.

P: OK, OK, that's good to hear.

D: Yeah, for sure. Well, uhm, thank you.

P: OK, thank you.


D: What brings you in today?

P: So two days ago I started to have this cough. Came out of nowhere. I haven't had a cough before and I, just today I've noticed the fever as well and and I've had a headache the last few days.

D: Can you tell me a little bit more about your cough? Has it gotten better or worse over the past two days?

P: So it, it's a it's been about.. well, it got worse at first and then it's been about the same since then.

D: Okay, and is it dry cough or wet cough?

P: It's dry.

D: Okay. Uhm? And does it ever wake you up at night?

P: No. Well, it kind of happens all throughout the day. Yeah, no, no, it hasn't woken me up at night.

D: OK, is there any, are there any triggers? Anything that makes your cough worse?

P: I can't think of anything really. It just kinda comes on like throughout the day on it spontaneously.

D: How do you take any medications to help with your symptoms?

P: Yeah, some over the counter cold medicines. I tried some to take Tylenol cold and sinus or something like that anyway and it did help me sleep a little bit with that the headache and just haven't been feeling very good, to help with that.

D: And tell me about your fever. Did you check it check it, check your temperature?

P: I did yeah today I checked it and it was, like just over 38 I think like 38.1 or two.

D: OK, what about your headache? Where exactly is it?

P: I kind of feel it all over. It's like a band night feels like it's just around my head and squeezing.

D: And, how like if you had to give it a number from one to 10? What number would you give it? With 10 being the worst headache ever?

P: I would say maybe a 5.

D: OK, and you mentioned that the Tylenol helped.

P: It did, yeah, probably took it down to a two or three. The headache didn't go away entirely. It was sort of still there, but did help.

D: Have you had any other symptoms?  Have you had a confusion or is it any fuzziness? Or any flu like symptoms?

P: Uh, I have felt just tired and, over these last couple of days. That and I have had a sore throat as well.

D: Oh, you get OK. OK, what about a runny nose or stuffy nose?

P: Uh, no, nothing like that.

D: Any difficulties breathing?

P: No.

D: Any difficulty swallowing with a sore throat?

P: Ah is a little bit painful, but I've been able to to eat and drink okay, just really takes a little longer.

D: Any dizziness or fainting in the past couple of days?

P: No, nothing like that.

D: OK, any rashes or changes in their nails?

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

D: Any changes in your? I guess have had any chest pain?

P: No, haven't had any chest pain, haven't had anything like that before.

D: Any belly pain?

P: No.

D: any changes in your bowel movement, any diarrhea?

P: No, no, I haven't had ah, any diarrhea.

D: OK, uhm any changes in your urination, any difficulties or any pain or any increase in frequency?

P: No, I've had a urinary track infections before so I know what that's like. I haven't had any of those symptoms.

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

P: Uhm? No, I haven't. I had surgery on my knee when I was a teenager. I uh tore my ACL but it's been good since then.

D: Any hospitalizations?

P: No.

D: OK, any medications that you're taking, including over the counter meds?

P: Yeah, I just say I'm on birth control right now. I've been taking it for the last like five years.

D: OK, any allergies?

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

D: OK, good. And do you have any medical conditions that run in the family? Including any heart or lung conditions or cancers.

P: Yeah, my, my aunt had had breast cancer. But ah, and my dad has high blood pressure.

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

P: No, I don't.

D: Do you ever smoke in the past?

P: No, I I I I I've stayed away from that.

D: Good. Any marijuana or recreational drugs?

P: Yeah, sometimes, well, we'll smoke with like friends at a party I guess, but I haven't had any. I haven't done that in awhile.

D: Alright. Any alcohol?

P: Similar like sometimes at a party, but I mean yeah, it's been awhile for something like that, so I haven't really had any alcohol on in months.

D: And are you currently working, or?

P: I am yeah. So it's uh, yeah I work for this tech company so I've been able to do a lot of my stuff at at home.

D: OK, uhm. Have you had any exposures to anyone who could potentially be sick?

P: I will without, well, yeah I there a couple or last weekend. Actually there was a family party that we went to. It was outside, but uh, it, yeah, there's people around. There was nobody that was sick that I'm aware of.

D: OK. And and have you traveled anywhere outside the province?

P: No been besides that, the family party last weekend, but I mean that was just here in town so. It was close by.

D: OK, I guess I forgot to ask about a symptom. Have you felt that you've lost your sense of smell or sense of taste? Has it just been different?

P: Yeah, I said some actually now that you mention it right sense of smell has been different, which is kind of weird, 'cause I I don't have, everybody knows or I don't feel congested or anything. So yeah, but my taste has been OK.

D: Good. Well, that's all the questions I had for you. Given that your symptoms sort of sound like you may have a viral or bacterial infection and seeing that you were, you had some exposure to to other people even though they weren't sick, it could, it could be that they, they had some sort of an illness that they could transmit that they weren't just showing symptoms at the time. We will get a covid swab done just to make sure that that's not what's happening. It could be that. And I'll recommend that you continue to, you know, take Tylenol and rest and take care of yourself and if your symptoms worsen or stay the same for long period of time, definitely come back or call public health to get some guidance and try to stay away from others and self isolate for the next couple of days or at least clear covid swabs back or your symptoms improve. Or the next 14 days. So that's all I have for you today. Do you have any questions for me?

P: No, that sounds really good, thank you.


D: What brings you in?

P: I've um I've been having this numbness and tingling and I guess kind of burning sensation that well uh it's been happening more often in my uh left hand.

D: On your left hand, OK. And sorry when did you say this started?

P: Uh it's been going on for probably four or five months um.

D: OK.

P: Yeah, it first uh it would only bug me for a couple of minutes at a time and I could kind of shake my hand out, like flick like flick my wrist and um and it would go away after a few minutes. But now I'm starting to get uh like symptoms at night sometimes as well.

D: OK, so um it's gotten worse then, you said over the past few weeks?

P: Yeah it has.

D: OK um and is it always there? Is it persistent or does it come and go?

P: It comes and goes.

D: OK and what makes it better or worse?

P: Uh better uh I've tried some um Advil um and Tylenol and it's kind of the, hasn't done much um for the pain really, uh I think only the thing that kind of helps it is just not using it as much, um yeah.

D: Yeah, alright, um have you tried any like cold compresses, um topical creams? Anything like that?

P: No.

D: No, OK. And uhm if you were to describe the quality of how it feels like, does it does it, is it painful, is it tender, or is it just numb and tingling, kind of like when your foot goes to sleep?

P: Uh I guess I have, it is a bit painful as well, yeah. I have um like a burning kind of pain.

D: OK and 1 to 10, 10 being the worst pain ever, how bad is this pain?

P: Uh when it gets to its worst, I would say about a 6.

D: OK, OK. Um and have you ever experienced this before or is this kind of like the first time you're experiencing this?

P: Yeah, this is the first uh really like over these last three months, the first time I've been experiencing it, I think uh the first time that it started it started to wake me up at night though has been like about a couple of weeks ago.

D: Oh I see, OK. Um alright and do you feel like your symptoms are getting worse over the past few weeks or is it kind of the same?

P: Uh over these past couple of weeks, about the same. It's woken me up uh like two or three times at night.

D: OK, alright and do you have any numbness or tingling elsewhere on your body?

P: No, it's just um just kind of the the outside of my hand here, it's really only the first like 3 fingers.

D: OK, first three fingers so your um thumb, index finger and uh middle finger? Or your pinky to middle finger?

P: Yeah, it's just the uh my thumb index finger and ring finger.

D: And ring finger, OK.

P: And maybe just like a little bit of the um like of the ring finger too, but not all of it.

D: OK, um alright, so um any weakness in your arms or do you feel like you can still use your arms OK?

P: Uh yeah I haven't had any, uh, any muscle um weakness, I guess I may be a bit more clumsy um with uh with my left hand like I've dropped a few things, I've had it, a little bit more difficult time like opening jars or like car doors and stuff like that.

D: OK, OK, and any confusion or memory loss?

P: No.

D: Headaches?

P: No.

D: OK, um how about weight loss?

P: No, I haven't had any weight loss.

D: Uh fevers or chills?

P: No.

D: Uh rashes?

P: No rashes.

D: Changes in your vision, hearing, smell or taste?

P: No, that's been normal.

D: OK, how about um a cough?

P: Uh no, I haven't had a cough.

D: OK, um wheezing or shortness of breath?

P: Nope, neither of those.

D: OK. Chest pain or heart palpitations?

P: Um nope, I haven't had that.

D: OK, how about um changes in your bowel movements?

P: Uh nope, I haven't had any diarrhea and no no constipation and no blood either.

D: OK, good. Any nausea or vomiting?

P: No I haven't had any of that.

D: OK, any changes in your voiding?

P: Uh, no I I um haven't had any problems with urination.

D: OK, um are you otherwise healthy? Do you have any longstanding medical conditions?

P: Um I have hypothyroidism, so I take um like uh thyroxine for that and um I am overweight as well, or in obesity class one I think.

D: OK, and um do you take any medications for the hypothyroid?

P: Yeah I do, I take um I take uh Synthroid, I think.

D: OK, alright, and are you on any weight loss medications?

P: No, I've just been trying to uh change diet around when I can and um and trying to um exercise a bit more, but uh it's been it's been tough, especially now with my wrist or my hand bugging me.

D: Yeah, for sure. Um alright, and then are you up to date with your immunizations?

P: I am, yeah and I get the flu shot every year.

D: OK, that's good. Um and have you had any hospitalizations or surgeries in the past?

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

D: No, OK. Um any allergies?

P: Uh no allergies.

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

P: Um my grandfather had a stroke when he was in his uh 70s, um and my dad has high cholesterol.

D: Have you been worked up for all of that? Like high blood pressure, diabetes, cholesterol?

P: Uh yeah, I think my family doctor checked a few years ago, but I've been healthy besides this um uh this this pain um so maybe that, yeah maybe that could be investigated as well.

D: OK, um any neural, neurological, or musculoskeletal issues in the family?

P: Um I think osteoarthritis, a few few people have that.

D: OK, um how about autoimmune conditions?

P: Uh no, I think I'm the only one with the thyroid.

D: OK, um how about cancers?

P: Uh no cancer.

D: No cancers, OK. Um alright and then, do you smoke?

P: I do, yeah, I smoke about um 5 to 10 cigarettes per day.

D: OK, and um for how long have you been doing that?

P: Uh probably yeah about the last 10 years, it was kind of around when I started working um in the warehouse here, um yeah.

D: OK, and have you ever thought about quitting?

P: I have, yeah I've tried, it's just such uh I mean people just go out and I mean have their coffee and cigarettes and it's sort of a social thing while at work, it it's kind of what people do so, I have been trying to cut down though.

D: OK, OK, that's good. If you need any resources, we have some that we can refer you to. Um and do you consume marijuana in any form?

P: Um no, I don't.

D: No, OK. Any recreational drugs.

P: Um nope, I don't use anything like that.

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

P: Um I'll have wine every once in awhile on the weekends, maybe maybe a drink per week, something like that.

D: OK, um and have you been in contact with anyone sick recently?

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

D: OK, how about travel?

P: No, I've been I've been at home and and just going to work.

D: OK. Um and and where do you live and who do you live with?

P: So I live with my husband and our two daughters and we live and we live in a house.

D: OK, um any concerns for STI's?

P: No, I'm just um, I've been monogamous with my partner now for uh over 10 years and um no concerns for uh an STI at this time.

D: OK, alright good, um so now we're just going to move on to the physical exam part um of this interview. Um so I'm going to get you to look at both your arms, hands, and wrists, um side by side. Does your left one seem at all more red, swollen, uh or hot.

P: No, no symptoms like that.

D: No, OK. And um do you, does that one seem to be more atrophied or are there any deformities or skin changes on that one?

P: Um maybe uh a little less muscle bulk on the, like where my thumb is.

D: OK, OK. Um and then I'm gonna get you to palpate certain areas of that arm. So let's start um at the top, when you when you press down on your shoulder blades or just at the very top of your um arm where your, or at the very top where your arm connects to your shoulder, does it hurt over there?

P: No, no pain there.

D: OK. So no pain on the acromion process or the scapula. Um any pain where your biceps are?

P: No.

D: No, OK. How about at your elbows?

P: Uh no pain at the elbows and full, I can move my elbows and shoulders, uh no problem either. And my neck doesn't hurt at all either, I can move my neck around.

D: How about when you um palpate your wrists, both sides, medial and lateral?

P: Uh, yeah no, no pain if I'm just pressing or palpating the wrist.

D: OK. Um and I'm going to get you to um straighten out your arm and flex at your shoulder and extend at your shoulder, does that hurt?

P: No.

D: How about when you flex your elbow and extend your elbow?

P: No.

D: Um how about when you flex your wrist and extend your wrist?

P: No.

D: OK, so I'm going to do a special test for something called carpal tunnel syndrome. Um so um I'm gonna get you to straighten out your left arm again um and right where um alright, how do we do this? OK, so with your right hand or with your yeah, with your right index finger and middle finger, you're going to tap um just below uh where the bulk of your thumb muscles are um connecting to your wrist. I'm just going to get you to tap that area. Do you feel tingling like an electric shock sensation in your hand or anything like that.

P: I do, yeah.

D: You do, OK, so that's a positive Tinel's sign. Um and then we're going to do one more test, so I'm going to, OK so make like a prayer motion with your hands like um putting your 2 palms together and then um and then instead invert your hand so that the outer parts are touching and your fingers are pointing towards the ground.

P: OK.

D: So kind of like upside down but with your outer parts of your hands touching. Um and then I'm going to get you to uh just hold your arms like that um for about 60 seconds. Do you feel any tingling, numbness, or pain in those fingers?

P: Yeah, I get a bit of uh numbness and tingling when when I do that.

D: OK, so that's a positive Phalen's sign test. Um alright, so that brings me to the end of um this interview, did you have any questions or concerns, anything that you wanted to bring up?

P: Uh just wondering about um what this could be.

D: Oh yeah, so um it seems like you have something called carpal tunnel syndrome. Um and that is, it's pretty common um so it can be caused by um a lot of things, but basically your median nerve runs through your forearm into your wrist, and anything that squeezes or irritates that median nerve can lead to carpal tunnel syndrome, um and some things include um like repetitive movements at work, um obesity, um any nerve damaging conditions like diabetes, um inflammatory conditions, but mostly just like workplace factors can can do it, um especially if you're working with like vibrating tools or on an assembly line that requires like repetitive and prolonged flexing of the wrist. Um so uh diagnosis, we just do that through like symptoms, physical exam, um we don't really need to do any imaging at this at this point. And to treat it um basically work modification, so taking frequent breaks, uh not doing those repetitive movements um as often um and then you can do things at home, like apply cold packs. Um and then we also have some like non-surgical treatments where we can uh splint, we can put like a wrist splint um while you sleep to relieve those nighttime symptoms. Uh you can take some NSAIDs to relieve pain, um and if those don't work, we can try corticosteroids, um and if that doesn't work, then we can also discuss surgery sometime down the line. Does that sound OK?

P: It does, yeah, thank you.

D: Yeah no problem.