D: How may I help you?

P: So, I just came in here because for the last day I've been just getting shortness of breath. I recently, yesterday actually, was just busy at home, cleaning out my basement. And, like that was yesterday afternoon, I did that for a couple hours and then at night I just started to get the shortness of breath. It's continued until today. I'm also getting some wheezing and tightness in my chest as well as some cough. So yeah, that's all just been happening over the last day.

D: OK, and uh, is the shortness of breath here now? is it, is at rest? Or are you having that when you're exerting yourself?

p: More so when I'm like exerting myself, if I'm sitting down it's better, but I still have, I would say, like my breathing is not normal right now, like it's, I still have to take deeper breaths. And I do have that chest tightness when I take those deep breaths.

D: OK, do you have any chest pain?

P: No, it's more so just the tightness. I wouldn't call it pain, but I do still have a little bit of wheezing.

D: OK.

P: So yeah, that's, that's that.

D: And you mentioned a cough as well. With the cough is it, has it been dry, or have you been bringing up sputum?

P: Uhm, it was, it was mainly dry yesterday, like, like the cough has kind of gone away, but yesterday night I was coughing a lot and it was mostly dry.

D: OK, have you brought up any blood?

P: No.

D: OK, and have you had any infectious symptoms like, eye tearing or red eyes, maybe a runny nose or sore throat?

P: Uhm, not a sore throat, but it does feel like it, it's kind of like just constricted in there like, uhm, I don't know if it's relevant, but I, I do have asthma. Uh, like I was diagnosed ten years ago, but it's been pretty stable, like it's, like just right now. I haven't had shortness of breath for a pretty long time.

D: OK, uh, and, uh, we'll get back to the past medical history shortly, I just wanted to ask a few more symptoms, but certainly could be relevant today. Uhm, so uhm, so you mentioned that you have had some throat tightness. Have you had any loss of smell or, or loss of taste?

P: No, nothing like that.

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

P: No.

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

P: No, no nausea or vomitting.

D: How about, any diarrhea or Constipation?

P: No.

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

P: No.

D: OK and have you had any night sweats over the last several weeks to months?

P: No, nothing like that.

D: And, uhm, have you had any weight changes over the last little while?

P: No.

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

P: Uh, no, I, I do have just like the general, like, eczema, that I use a cream for, but that's just normal for me.

D: OK. And any muscle aches or, or joint pains?

P: No.

D: Have you had any fatigue?

P: No.

D: OK, alright you mentioned asthma as part of your past medical history. Have you been diagnosed with any other conditions?

P: No, it's just asthma and it was diagnosed, I think when I was like, probably 11 or 12 years old.

D: OK, and do you use inhalers for that?

P: Yeah, I have two inhalers, uh, like one, one is like a blue one, one is like an, like an orange one, uh, it's, so I think it's one of them is just like, I take whenever I really need to and the other one I take every day. Uhm, and I haven't been taking the one, uh, I think it's called Ventolin. But I took it like, uh, had to take it like three or four times last night and like, throughout the day yesterday. And it, it did help, but it didn't really relieve some of my symptoms.

D: OK, and prior to that, how often have you been using, uhm, the blue one.

P: The blue one before yesterday, probably the last time I used it was probably like a month ago.

D: OK, so you don't need it that that often then?

P: No.

D: Do you have any triggers for asthma that you're aware of, like exercising or going out into the cold or even like allergies like dust or, or, or pollen?

P: Uhm, I do have allergies in the spring. I think it's to pollen and in the winter, it does, like my symptoms do get a bit worse and I have to use the ventil more. But recently for the last few months at least, it's been pretty stable. I haven't really had to use, use it too much.

D: OK, and, and do you use any other medications?

P: Uh, just when I have allergies. I, I just use over the counter allergy meds.

D: OK, and you use a cream for, for your skin too like, yeah?

P: Yeah, I use, like it's, it's, I think it's like a mixture of like a steroid cream.

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

P: Not that I know of.

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

P: Yeah.

D: Alright, and right now, who are you living with, and whereabouts are you living?

P: Yeah, so I'm just living with a couple roommates. I just go to college and I'm living with three other roommates.

D: OK, and has anybody been sick?

p: No, everyone's been fine.

D: And have you traveled anywhere?

P: Uhm, I decided, like, I, yesterday I went home like, to my parents house and helped my dad, that's where I was cleaning the basement. But besides that, that was, that was uh, that was it?

D: OK, and  sorry, just had to backtrack a little bit. Have you had any hospitalizations, either due to asthma or for any other reason?

P: Uhm, I think when I was 15, I, I had to go to the emergency department, but I, I wasn't hospitalized.

D: OK, and was this, uh, did you have similar symptoms at that time?

P: Yeah, it was, uh, it was for asthma and like, uh, that time it was definitely much much worse and I remember like I was breathing a lot, uh, the shortness of breath was really bad and the ventolin like puffers weren't even helping me at that time.

D: OK yeah, OK, and have you had any surgeries before?

P: No.

D: Alright, so yeah, you mentioned that you're, you're cleaning up the basement yesterday? Was there a lot of dust down there or anything like that, that might have triggered it?

P: Yeah, we were like just moving boxes. There were books here and there that definitely there would have been dust. I should have been more careful, like wore a mask, but I didn't think about it at that time.

D: OK yeah for sure, uh, and do you smoke cigarettes?

P: No, like I can't even stand cigarette smoke.

D: OK, that's good. And do you smoke marijuana or use any cannabis products?

P: Uh, no if I, if I really want marijuana, I would have to go with edibles, I, I can't take the smoke.

D: OK, I see and, do you drink alcohol?

P: Uh just, I would say probably on the weekends I might have four or five beers.

D: OK, and, anybody else in the family have asthma or skin irritation like, like you have?

P: Yeah so my, my older sister actually also was diagnosed with asthma. She also has the eczema that I have and my mom was also diagnosed with asthma when she was a child, but she's been completely fine since then.

D: OK, well that's good that, that she's been OK. Does anybody in the family have any heart or, or lung conditions or any cancers that run in the family?

P: My grandfather died of lung cancer, but he was just, just smoked all throughout his life.

D: OK, uhm, alright, so that was all of the questions that I wanted to ask today. So the next part we'll go on to do a physical exam, but did you have any thing else that maybe I forgot to ask about today?

P: Uh, no, I, I, I think I know what this was caused by, but yeah, let's, let's see. Thanks for your help.

D: Oh you're welcome, so yeah, we'll, we'll, uhm,trial some more puffers and see what we could do, cause certainly it's sounding like an asthma exacerbation, and so definitely let somebody know if your, your breathing is getting more difficult.

P: Yep, sounds good.


D: How may I help you?

P: I've just been experiencing a, some pain and numbness and tingling in in just my wrist area and thumb, middle finger, and index finger.

D: OK, and when did this pain start and is it the right hand or or left hand?

P: Hum, it's the right. It's a the right hand, but I also find it so starting to happen in the left hand as well, but more so on the right hand. I feel this kind of sensation over my palms and fingers it started I would say probably 2 weeks ago. And it's been, I think it's gradually been getting worse. I'm having more difficulty at nighttime, especially. It's also waking me up from sleep, and it's yeah just affecting my daily routine, my work. So yeah, I just wanted to understand what was going on.

D: OK, I see and did you have any trauma to the wrist or or any injury, or have you had an injury in the past?

P: No, I haven't had any falls, no accidents, nothing like that.

D: OK. And are you right or left handed?

P: I'm right handed.

D: OK yeah, and you mentioned it was the right hand that started to hurt first and then the left one has started since then?

P: Yeah, yeah, and I don't know if it's just 'cause I use my right hand more that I feel more pain and the symptoms. But yeah, I definitely would say it's worse.

D: OK, and where are you finding that the pain is specifically located?

P: So the pain I feel like it's more like a discomfort. Just over the like palm, like near the wrist and the lower palm area is where the discomfort is and then the numbness and tingling is just like in thumb an the 1st 2 digits.

D: OK, and how would you describe the character of this sensation, is it burning, is it sharp, achy or or stabby?

P: Um I would say it's more of kind of like an aching, aching pain. Um it does sometimes turn into kind of like a burning sensation with the tingling, but yeah, more so on the palmer like on the palm side of things, it's more like an aching pain.

D: OK. And you have some burning as well?

P: Yeah.

D: OK. And is the does it radiate anywhere, are you feeling this in in your neck, shoulder, or down your arm at all?

P: It kind of goes from the palm, along, so it goes from the palm it goes upwards like to my fingers, but also backwards like into my lower arm as well. Like my forearm.

D: OK, and do you have any pain in the neck?

P: In my neck?

D: Yeah.

P: No.

D: OK, an anything that you've done that makes the pain worse?

P: Uh. I I just have to like I work as an accountant. There's a lot of work I do on the computer with a keyboard mouse, so I feel like it's hard to really do that all day right now. So I think if I do that, I'll make it worse. But if I take a rest and kind of just shake my hands a little bit, then it gets better.

D: OK, um so kind of like flicking your wrist sort of thing, so kind of shake out the?

P: Yeah.

D: OK, um an anything that you do that makes it better besides those moves like have you taken any medications or tried any like wrist splints or anything like that?

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

D: OK, and what is the severity of the pain on a scale of 1 to 10, 10 being the worst you've ever felt and do you feel this pain at any particular time of day more than than others?

P: The pain is probably like a, a 5,  and I feel it more during the night as well as like when I'm working, I feel it's definitely more as I continue to do more work.

D: I see OK. And. Have you had any like numbness and and that tingling in the hand or anywhere else?

P: No, just in the areas that I described nowhere else.

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

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

D: OK, and how about any issues with like gripping objects, dropping objects or like opening jars?

P: Yeah, I I do I do have like when I'm lifting things and opening jars opening lids like I do have the similar discomfort, pain as well as the numbness and tingling.

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

P: No.

D: Have you had any night sweats?

P: No.

D: Have you had any unexpected weight loss?

P: No.

D: OK. Have you had any headaches?

P: No.

D: How about any like sensory changes such as changes to your vision or hearing?

P: No, no, nothing like that.

D: How about a loss of your sense of taste or sense of smell?

P: No.

D: Have you had any runny nose or feeling congested?

P: No, nothing like that.

D: How about a sore throat or a cough?

P: No, OK.

D: Have you had any shortness of breath or wheezing?

P: Uhm no, nothing like that.

D: Have you had any chest pain or feeling as though your heart's racing?

P: No.

D: OK, have you had any dizziness or or lightheadedness?

P: No.

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

P: No.

D: And any abdominal pain?

P: No.

D: OK. Have you had any diarrhea or constipation or blood in the stool?

P: No.

D: Alright, have you had any urinary problems like pain or frequency?

P: No.

D: Alright, have you noticed any skin changes or like rashes or anything like that?

P: No.

D: OK, and. Have you had any like muscle aches or or body pains?

P: No.

D: OK, and any confusion or memory loss?

P: No.

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

P: No, I've been fairly healthy.

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

P: No, I I've been pretty healthy. Sometimes I take some Advil for headaches and stuff or Tylenol, but that's it.

D: OK. Uhm and do you have any allergies?

P: Uhm, nope.

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

P: No, I haven't.

D: Alright, and can you tell me a little bit about where you're living and and who you're living with?

P: I'm living with my husband and two kids in a small townhouse.

D: I see and you mentioned you're an accountant. Are you working right now?

P: Yeah, I. I am in, I'm an accounting, time off and just taking a little bit easy before I find out like what this is and how this will really impact my work.

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

P: No.

D: Have you traveled anywhere?

P: No.

D: Do you smoke cigarettes.

P: No.

D: OK, and how about smoking marijuana?

P: No no, no drugs.

D: OK, so no recreational drugs?

P: No.

D: OK, and are you currently sexually active?

P: Yes, just just with my husband.

D: OK, uh, and any concern for sexually transmitted infection?

P: No.

D: OK, um and do you drink alcohol?

P: Uh, just maybe some wine every other day.

D: OK, um and in the family are there any musculoskeletal or like neurological conditions?

P: No.

D: OK, and how about autoimmune conditions like rheumatoid arthritis or like hypothyroidism or type one diabetes?

P: In my family history? I think there is.

D: Yeah.

P: Some, there's definitely some diabetes on my father's side. But other than that, I think one of my aunts on my mother side had um a hysterectomy for cancer.

D: OK, alright and was it endometrial cancer?

P: Not sure actually, but she I just know that she had her uterus removed.

D: I see alright and um so next I wanted to just move to the physical exam portion and so just first inspecting the hand and wrist do you see any swelling or redness?

P: No.

D: How about any changes to temperature, do any of the joints feel warm?

P: No.

D: And are you seeing any muscle atrophy or any deformities of any of the joints in the hand?

P: Uhm, maybe like just a little bit like I feel like I've lost some of like the fat pad just right near my thumb.

D: I see OK. And is there any areas of your hands over like any of the joints or over the rest that if you press you feel pain?

P: Um no.

D: OK and are you able to to move your wrist or the full range of motion?

P: Yeah, I can move it.

D: OK, uh. And is there any, uh, so that then the next test I'll just ask you to just tap on the the kind of base of your palm there with your index finger and middle finger of your left hand, and when you do that, do you feel any burning or tingling?

P: Yeah yeah. I definitely do.

D: OK, so that would be, yeah, positive Tinel sign and do you get any, so if you flex both of your wrists so that the back of your hands are pressing against each other. And if you hold that position, do you start to get symptoms of the burning and tingling?

P: Um yeah, I do feel it as well there.

D: OK, alright so that was everything I wanted to ask about and check today um did you have any questions?

P: No, I just wanted to know how I can fix this.

D: Yeah, certainly so it's sounding like a carpal tunnel syndrome which that the differential would be something like radiculopathy coming up up from the neck, which you're not having any neck symptoms and the positive Tenel sign and positive Phalen sign are highly suggestive of carpal tunnel syndrome, along with the nighttime symptoms and the burning and tingling sensation you're experiencing. And so to help with this one of the first things that that can be done is trying to use like wrist splints at night to try to keep your hand in a neutral position, but also, uh depending on like if there is inflammation there NSAIDs might help a little bit like ibuprofen or or things like that. But the majority of the therapy will be kind of an activity modification, and if symptoms don't improve over a period of time, then surgery could be a potential option as well.

P: OK, sounds good.

D: OK.


D: So what brings you here today?

P: Yeah I have my 2 year old daughter here with me. I don't know what's happening with her, but she seems to be getting really sick. So I'll give you that kind of timeline. So two days ago she was feeling hot and her fever hasn't broken. We've been giving her Tylenol, but she still seems to have a fever. The last time I checked her temperature was 38.5 and she seems to have issues swallowing food. She's drooling and she seems short of breath.

D: OK, and when did she start getting short of breath?

P: That started yesterday.

D: Has her fever been getting worse or has it stayed around the same?

P: So I just checked the first day. It was like 38, 38.5.

D: OK, and when did the trouble swallowing start?

P: That started yesterday as well.

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

P: I think so. Now she's barely even drinking fluids.

D: OK, so it's both solids and fluids. OK, have you noticed any swelling in her neck area or redness or swelling in her throat?

P: Yeah, I've noticed some of that.

D: OK, you see a lot of redness in there?

P: I see, yeah, I see quite a bit of redness in there.

D: And has she been drooling at all?

P: Yeah, a little bit today.

D: OK. Alright, any coughing?

P: Not hat I noticed.

D: No coughing. OK, and do you notice that she's increasingly fatigued, or just not herself? Or is she irritable?

P: Yeah, she's very irritable.

D: OK, do you notice any kind of paleness or blueness in her skin? Anything like that?

P: She's not blue. She's looking a little pale though.

D: OK, and sorry, when did the shortness of breath start? Is it getting worse at all?

P: Shortness of breath started yesterday as well, moreso today which is why I brought her in.

D: OK, any other symptoms like nausea or vomiting or diarrhea or constipation?

P: Um, no nothing like that.

D: OK, and how's her appetite and sleep?

P: It's been, it's been not great. She's not eating well, I guess because she's in a lo of pain and she didn't sleep well for the past two nights either.

D: OK uhm, has she had any recent infections at all, like a cold or anything like that?

P: She did have a cough 2 weeks ago, yeah.

D: OK, and did it just go away on it's own or did she need any antibiotics or any other medications?

P: I think no, she didn't need any antibiotics. It kind of went away on its own.

D: OK, any sick contacts within the last week or two weeks?

P: I mean, she goes to daycare so she might have picked something up from there. Yeah, last I checked, no one at daycare was sick like right now. But three weeks ago there was someone who was sick.

D: OK, any past medical history?

P: Um, no, she's been pretty healthy otherwis.

D: Any issues during pregnancy or after birth at all?

P: No.

D: Are her immunizations are up to date?

P: Um, yes, she didn't get the H. flu vaccine though.

D: OK, OK, any hospitalizations or anything like that in the past?

P: Um, no.

D: OK, and any family history of any medical conditions?

P: Um, no.

D: And currently, who does she live with at home?

P: I'm she lives with myself as well as her older brother.

D: OK, alright, so yeah those are all the questions that I have.

P: Do you think this is like an urgent matter?

D: Because she has not been vaccinated with the H.flu vaccine and some of the symptoms that she's displaying like the drooling and trouble swallowing and now especially the shortness of breath are very concerning, I really think we should go to the Emergency Department. I'll give them a call to le them know that you're coming. Yeah, and what they will most likely do there is get a test done to see if she has H. flu and also they might do perhaps like a COVID swab as well. They might get an X Ray of her neck as well to see it. So what I think might be going on is with H. flu you can get swelling of your epiglottis and it can kind of obstruct your throat. It's very urgent matter, so that's why we will make sure you get to the ER and, uh, you know, we'll go from there. Does that sound? I know it may be very worrying right now. Do you have any questions at all?

P: Yeah, do you know how long will she have to be in the hospital?

D: So right now we just need to make sure that she's stable, like all her vitals. You know when she gets to the ER, they can give her the appropriate antibiotics as well. And based on that, we need to make sure her breathing get stabilized, so she might be in the ER for one day. If they think she needs to be on IV antibiotics in the hospital, she might be in the hospital for a few more days or even a week. So it's really hard to say right now, but our priority right now is to make sure she's stabilized in the ER.

P: OK. OK yeah, that sounds good.

D: So I'll give them a call right now, and, uh, you can head over to the ER. Or if you need a ride, we can arrange to do that for you too.

P: OK, great, that sounds great.

D: Thank you.

P: You too.


D: So what brings you in?

P: OK, I'm so I have been coughing a lot over the past week or so. And it's been pretty dry, but I've been coughing like almost nonstop throughout the day, and I'm feeling very short of breath, and my bronchodilator helps, but I found I'm using it a lot now.

D: OK, how long have you know that you have asthma for?

P: I was diagnosed when I was eight.

D: You're 10 now.

P: That's right.

D: So you're using your bronchodilator more. This is the one that you use, kind of as needed?

P: Yeah.

D: OK and then do you have one that you take every day no matter what?

P: Uhm? No, I don't have that one.

D: OK. You just have the one that you take is needed. Do you take any other medications?

P: Uh no I don't take anything else.

D: Just the one is it a it's a puffer?

P: Yes.

D: OK, and you're using it more than normal, so how often were you normally using it?

P: Um I was only using it like I don't know. Maybe once every two weeks or so. Not very often. But now I'm using it like almost everyday like five six times a week.

D: OK, any are you? Does it usually turned out that you need it like during certain times like say when you're exercising or when it's cold?

P: Um I find I use it more, both like when it when it's right after I like, run around after gym during recess. Um and yeah, the cold also makes it worse.

D: OK, any other triggers that you can think of?

P: No, no other triggers.

D: Normally get more in certain seasons?

P: I. I guess no, no big changes there. I find the cold air makes it worse like winter makes it worse or like. Yeah, maybe also the spring spring with like pollen and stuff like that.

D: OK, so you have allergies too?

P: I think, so I haven't ever been like formally diagnosed.

D: OK, I see I see. Yeah, that would make sense. No. OK, uh, so you say you've had more coughing lately, is that right? You said the last two weeks.
Or the last week

P: Last two weeks.

D: Last two weeks. Is your cough and a dry cough?

P: Yeah.

D: Have you been bringing up gunk OK. Dry cough? Have you noticed any wheezing?

P: Oh yeah, I've been wheezing a lot, actually.

D: OK, uh and that's uh. Do you use your bronchodilator every time that you're wheezing?

P: When it gets really bad, like when I get so easy that I find it hard to breathe.

D: OK, so you're getting Wheezy even more times than then you're having to use your bronchodilator.

P: Yes, that's right.

D: OK. Are you having any symptoms at night time?

P: Yeah, how they don't happen as much as my daytime symptoms, but I been having it maybe like every other day or like you know, every two days or so.

D: OK. And when you have these so when you have these episodes, you're copping your wheezy. Do you feel like you're having a hard time breathing?

P: Yep, that's right.

D: Do you feel it gets tight in your chest?

P: Yes.

D: OK. OK, have you had any any colds lately? Or any infections? .

P: Um no, no, nothing like that.

D: K, does anyone that lives with you or anyone that you're around often, has anyone been sick?

P: No.

D: OK. Could you have been in contact with anyone that sick even outside of your house?

P: No.

D: OK, have you traveled anywhere?

P: Uh no.

D: Have you lost any of your sense of taste or smell?

P: No.

D: Have you had any fevers?

P: Uh no.

D: OK. Any any? Nausea or vomiting?

P: No.

D: Any belly pain?

P: No.

D: We just ask those questions because sometimes these things can happen with an infection or after an infection and we just want to make sure that that's not, you know what's happening right now. We probably will do a covid swab just because of the times that we're living in right now, but I just want to ask you a few more questions before I go talk to the doctor. So do you have besides your asthma, do you have any health problems?

P: Oh no, no no.

D: OK. And you said, besides the bronchodilator, you're not taking any medications.

P: No.

D: And you think you might have allergies in the spring? Do you have allergies to anything else that you know?

P: Uh no, not that I know of.

D: OK, does anyone else in your family have asthma?

P: I think my sister has asthma too.

D: Anyone in your family have any other breathing problems?

P: No.

D: Anyone else in the family have any allergies?

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

D: OK. OK, sounds good and you live at home did you say live with your parents and your sister?

P: Yep, that's right.

D: Cool. Are you currently going to school online or in person?

P: Uh both We do half days.

D: OK. How are you finding that?

P: Yeah, it's been OK. It's it's different, but it's been working out OK so far.

D: Cool not to have to get out of your PJS some days.

P: Yes, that's true.

D: OK, did do you guys have any pets in the home?

P: No pets, we have just like well I guess we have goldfish.

D: Oh, OK. Those are cool pets. Does anyone in the house smoke?

P: No.

D: OK. OK, I think that's all my questions that I had for you today. What do you like to do for fun?

P: Oh I'm I like playing games online with my friends and and before covid we used to get together and have movie nights and play sports together.

D: It sounds really cool. Hopefully we can get this figured out for you so you don't have any, you don't have to use your your medications every time you play sports 'cause that's no fun. And

P: No.

D: You should be able to enjoy that. So, so we're going to try to get this sorted out for you. I'm gonna go talk to the doctor and tell him everything or her everything that you said and yeah we’ll come back and see you shortly, hopefully maybe all you need is a little change to your medications and maybe it will be better be able to better control your asthma.

P: Yeah, that sounds great. Thank you.

D: Thanks talking with me and we'll see you soon.

P: OK, great thanks.


D: What brings you in here today?

P: Yeah, hi, I'm so I have been very wheezy for the past week um and I'm also like consistently coughing all the time and it's not getting any better. Um I do have asthma and I think it's it's acting up.

D: OK, and how long have you had asthma for?

P: Since I was like 5.

D: OK, and are you using any puffers?

P: Yes, so I am on a short acting. As well as an inhaled cortico steroid. And I only take the short acting like when I have the symptoms

D: OK. And so how how long have you been symptoms worsening for?

P: For the past week I would say.

D: OK, and how how often have you used the ventilin?

P: The ventilin that I use is almost every day like a couple times a day.

D: OK, so would you say more than 10 times?

P: Yes.

D: OK. And have you had to do you have y to miss any school or anything like that over the past week?

P: I missed two days.

D: Two days, OK. And are you just getting daytime symptoms or are you waking up from sleep or not being able to sleep because of your symptoms?

P: I woke up twice last week.

D: OK. OK, so yeah, definitely seems like your symptoms are really acting upon and so you're getting some wheezing and you say you're also getting a cough.

P: Yes, that's right,

D: OK. And what kind of things would you be doing that you get these symptoms? Is it mostly exertion or is it exposure to dust or any other environmental factors?

P: Uh, but, it's mostly exertion, but things like cold air can trigger it too.

D: OK, I see. OK, any have you been exposed to any new environments where there is, you know, dusty carpets, mold, new animals, anything like that?

P: Uh no nothing like that.

D: OK, OK, and how would you describe the cough? Is it wet or dry?

P: It's dry.

D: OK, and. And how about the wheezing? Are you getting it like frequently every time you have an episode, or just sometimes?

P: I I'm getting an on and off, but basically every time I cough after that I'll be wheezy for a little bit.

D: OK. OK, and are you having any other symptoms like sore throat, runny nose, shortness of breath, anything like that?

P: No, nothing like that.

D: OK, and any blood in your sputum at all?

P: No, no blood.

D: OK, OK and has the ventilin been helping at all? Or do you find that it's less effective?

P: Ventilin um it's been helping temporarily, but it definitely doesn't help as much as it used to.

D: OK, um. And have you traveled at all recently or been in touch with anyone who's been sick?

P: Uhm, no, nothing like that.

D: OK. And, and any headaches? Nausea or vomiting?

P: He no, nothing like that.

D: Nothing like that OK, any dizziness or fainting?

P: No.

D: No OK, any fevers or chills?

P: No.

D: No. Any fatigue?

P: Um a little bit because I haven't been sleeping too well.

D: OK, any? Sensation of chest pain or racing of your heart?

P: No.

D: No. OK. Any changes in your bowel movements?

P: Uh no.

D: Any changes in your appetite or weight?

P: No.

D: No, any changes in your sense of smell or taste?

P: No

D: OK, OK. An other than asthma since you were five an do you have any other medical conditions at all?

D: OK, do you take so you take the ventilin and then do you take the inhaled cortico steroid puffer as well?

P: I do.

D: OK and you take that daily?

P: Um yes.

D: Any other medications that you take?

P: No, just some multi vitamins. That's about it.

D: OK, any allergies to any medications that you know?

P: Not to medication I’m allergic to like strawberries and Kiwis.

D: OK, and what kind of reaction do you get?

P: I just break out in hives.

D: OK, and have you been previously hospitalized for any reason?

P: No.

D: OK, any past surgeries?

P: Ah nope.

D: OK and currently like who do you live with?

P: I love with both my parents and two of my siblings.

D: OK, and are any of them sick at all?

P: No everyones pretty healthy.

D: OK. And. So currently right now you're 16. This is an age where sometimes your peers or yourself might experiment with alcohol, smoking or recreational drugs. Have you have you tried anything at all?

P: No, I haven’t.

D: OK. Do you have any friends or peers that have tried alcohol or recreational drugs?

P: I don't think so.

D: OK, and in terms of just your home environment school. Do you feel safe or do you find yourself feeling unsafe or having been bullied at all?

P: Oh, I'm pretty, I feel pretty safe.

D: OK, that's good. And any family history of any heart or lung conditions at all ?

P: No.

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

P: Yeah, So what can I do about These these symptoms? Should I continue taking my puffers?

D: Yeah, So what we'll have to do is re assess. So right now we will need to alleviate some of your symptoms so we will get you get you some ventilin and you mate will do like a full physical examination and get your oxygen saturation and everything an you might need some cortico  steroids as well and then we'll talk about changing your regiment for your puffers as well and whether or not we need to add something else into your therapy, so we'll do a full physical examination and then go on from there. Does that sound good?

P: Yeah, that sounds great. Thank you.

D: You're welcome.


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

P: Sure, you know I've been feeling kinda hot for the past couple of days and I have this terrible, terrible headache. And just my brain feels foggy. So I thought I should come get it checked out.

D: OK, I see when uh did these symptoms start exactly?

P: So they started about 3 days ago. But it's getting worse.

D: OK. Uh, and uh, in terms of the headache, uh, does your head hurt in any particular location?

P: I would say mostly the sides of my head.

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

P: Uh the same amount of time, so like the past three days.

D: OK, and um, how would you describe the headache? Is it like sharp, is it like a vice grip? Is it pulsating, pressure like sensation or none of those?

P: It you know it feels crampy.

D: OK. Um, and has there been anything that triggered the headache or or made it worse?

P: I don't think so. Nothing is helping, sleeping is not helping, moving around is not helping. It's just always there.

D: OK, does the headache get worse with lying flat?

P: Uh, no, I wouldn't say so, no.

D: OK, and are you feeling any pain down into your neck or into your shoulders or back?

P: No, no.

D: OK. And, would you say that this headache, which is was like worst headache of your life or thunder clap kind of sensation?

P: Uh, no, no.

D: OK, have you had headaches like this before in the past?

P: No, never.

D: OK. And, how would you rate it in terms of severity, with 10 being the most severe that you could possibly have and one being not painful at all? How would you rate it?

P: I would say I would give it around a 6 or seven.

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

P: No.

D: OK, and how about any sensitivity to light when you're you're seeing it or sensitivity to sound?

P: No.

D: OK, and have you had any eye symptoms such as discharge, tearing or or itchiness?

P: No, nothing like that.

D: OK, um, and so you you mentioned that you had you had a fever as well. Did you check your temperature?

P: I didn't actually, no I didn't check my temperature, I just feel hot.

D: OK, we'll be sure to check that today in clinic. And have you been experiencing any other symptoms?

P: Um, just like the brain fog that I was speaking of, you know. I just don't remember, I remember things, but it's it's like I'm doing everything underwater.

D: Oh OK. Have you been uh confused or concerns with your memory?

P: Um, no, I haven't forgotten things. It just feels like I'm really slow at doing things.

D: I see, OK, and how has your energy been? Have you had uh significant fatigue?

P: Yes, I would say I am significantly more tired than I used to be.

D: OK, um, how has your sleep been?

P: My sleep has been pretty normal. I go to bed around the same time, wake up around the same time. Yeah, I'd say that there's no issue there.

D: OK, with this fatigue, have you had any aches and pains?

P: Some muscle aches, I would say mostly in my arms and just my legs, yeah.

D: OK, and have you had a cough?

P: No cough, no.

D: Alright, how about shortness of breath?

P: No shortness of breath either.

D: OK, have you experienced any chest pain?

P: No.

D: OK, how about any period where you felt as though your heart was racing?

P: No.

D: OK, and have you have any wheezing?

P: Um no no wheezing.

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

P: Um, no.

D: OK, alright have you noticed any rashes?

P: No rashes either.

D: Alright. And have you had any abdominal pain?

P: No no.

D: OK, have you had any diarrhea?

P: Um no, no diarrhea.

D: OK, um and any constipation?

P: No.

D: Alright, and then how about any urinary problems such as painful urination or going frequently?

P: No, no changes.

D: OK. And are you currently sexually active?

P: I am.

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

P: Sure, I I just my husband, um we we don't use protection. But I'm on the birth control pill.

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

P: No.

D: OK, and any I guess like vaginal discharge or vaginal discomfort?

P: No.

D: OK. And, so next just wanted to ask a few questions about your past health. Have you been diagnosed with any medical conditions in the past?

P: No.

D: OK, so no diabetes, high blood pressure, anything like that?

P: No.

D: Alright, and do you take any medications regularly like prescription or over the counter?

P: I don't.

D: Alright, so it's just the birth control?

P: Oh sorry, yes. Just the birth control pills.

D: Yeah OK, no worries, and any allergies?

P: Just seasonal allergies.

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

P: Yep, they are.

D: Alright, and in in the home, is there anybody who's sick right now?

P: No, no one is sick.

D: Ok, how about at work?

P: I'm I'm a teacher. Um, so I work with a lot of children, but no one that I no one I know of has been sick.

D: OK, um and so have you traveled anywhere recently?

P: No.

D: Alright. And do you smoke cigarettes?

P: I don't.

D: OK. Do you smoke marijuana?

P: I don't.

D: Alright. Did you use any recreational drugs?

P: I sometimes take some marijuana edibles, but that's about it.

D: OK, and, do you purchase those at a dispensary?

P: I do.

D: OK, so for one of the Ontario stores?

P: Yes.

D: OK great yeah 'cause you could never be sure where else, what the dosing is, so it's good to get it from the appropriate stores for sure.

P: Right.

D: Do you drink alcohol?

P: I do, I'll have a glass of wine with dinner.

D: OK is this daily?

P: Um most days I would say, maybe like four or five days of the seven days of the week.

D: OK, I see. And has anybody in your family had similar symptoms in the past to what you're having or had any lung conditions in the past?

P: No, nothing like that.

D: OK, how about any heart conditions?

P: Um, my father passed away at 75 from a heart attack.

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

P: None that I know of.

D: OK. So I think that was, uh, all of the questions that I wanted to ask on history today. Was there anything else that you thought I was missing or that you wanted to tell me about?

P: No, I don't think so. But, uh, what do you think I have?

D: So with the acuity of your symptoms, starting with the last few days and getting worse, especially with a fever which we now have documented of 38.8 and a kind of feeling, uh, tired with aches and pains and the headache, I am concerned that you have possibly a viral infection, and one of those possibilities could be COVID-19, but also it could be the influenza. It could be something like the common cold, such as adenovirus. So certainly we will do a PCR COVID swab as well as order some general lab work to look for signs of infection, such as a CBC and a white blood cell count. But um, for now we will get those tests ordered. Did you have any questions?

P: OK yeah that sounds great. Do you think I could also have you know, meningitis or something? 'Cause I was reading online on Google and that's the first thing that came up.

D: Oh yeah, you're you're absolutely right, so, um sorry, I we will go ahead and investigate that as well and we might need to do a lumbar puncture or some blood work to look for signs of infection that might be needed to be treated with antibiotics.

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


D: How may I help you?

P: Hi, umm, so I've had a sore throat for the past three days and it doesn't seem to be getting any better, and I've also had a fever. So, I thought I should get it checked out by you.

D: Yeah, for sure. So you said that the sore throat started three days ago. Has it been getting any better or any worse?

P: Neither, it's been the same.

D: OK, is it painful to swallow food or liquids?

P: It's painful to swallow solids, yeah.

D: OK, uh, and how is your, umm, have you had any voice changes like a hot potato voice or sound like muffled or any voice changes at all?

P: No, not really. No.

D: OK. And have you noticed any like neck swelling?

P: No.

D: OK. And how about your appetite? Has that changed?

P: Uhm, I'm still hungry, I just don't eat as much 'cause my throat is sore.

D: Right, OK, that makes sense. And so you mentioned that you also had a fever. When did that start?

P: That started two days ago.

D: OK, OK and did, did you check it?

P: It was 38.8.

D: OK. Alright, so yeah, certainly a fever. OK, and have you had any, uh, like any runny nose?

P: No, not that I've noticed.

D: How about any red eyes or itchy eyes or eye discharge?

P: No.

D: OK, how about any loss or changes to your sense of smell or taste?

P: No.

D: OK. Have you had any any headaches?

P: Um, no headaches, no.

D: OK. How about any cough?

P: No cough.

D: No coughing, OK. And how about any shortness of breath?

P: No.

D: OK, have you had any wheezing?

P: No.

D: How about any chest pain?

P: No chest pain.

D: Any fainting or dizziness?

P: No.

D: OK, and have you had any heart palpitations?

P: Uh, no.

D: OK. And so you don't you haven't had any cough, but have you had any instances of bringing up any sputum or or any blood?

P: No.

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

P: No.

D: Have you had any abdominal pain?

P: No.

D: You had any diarrhea or, or constipation?

P: Uh, no.

D: OK. How about any urinary problems?

P: Um, no, nothing like that.

D: I see, OK. And any skin changes or rashes?

P: No.

D: Alright, any muscle aches or body pains?

P: No.

D: And any, and how's your energy been? Have you had fatigue?

P: I have been, yeah, I've been tired.

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

P: Um, I have type one diabetes.

D: OK, and uh, insulin wise, do you use a pump or is it like, how do you manage diabetes?

P: I use an insulin pump, yeah.

D: OK, excellent, and do you see an endocrinologist for that?

P: I do.

D: OK. Well that's good and have you had any complications or have things been stable?

P: Things have been pretty stable. I had, when I was younger, I had a few episodes of like hypoglycemia. But now things are pretty stable.

D: OK, and you can recognize those signs like feeling jittery and sweaty might, maybe a little anxious when that comes on?

P: Yes, I'm an expert now.

D: OK, that's great that you can recognize that those signs. It's important. And have you had any allergies?

P: Uhm, no allergies.

D: Any, and all your immunizations up to date?

P: Ah, yes.

D: OK. Uhm, and any hospitalizations or surgeries before?

P: No.

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

P: I'm in school. I'm in Grade 10 and we're doing half days now.

D: OK. Err, half days like in person?

P: Yeah half in person and half online.

D: OK. Have you been around anybody who's been sick?

P: No, no one at schools been sick actually.

D: OK. Uhm and have you traveled anywhere?

P: Ah, nope, not not since COVID.

D: OK, I see an are you ah, who are you living with?

P: I live with both my parents and three of my siblings.

D: OK, and anybody at home have any sore throat or cough, or or anything like that?

P: Uhm, so my younger sister had a sore throat like a week back, but that's all she had. She never had a fever and her sore throat went away in like 2 days.

D: OK. Uh, OK and does she need any treatment?

P: No.

D: OK. Uh, and uh, and I I know people around your age might experiment with drugs or alcohol. Have you used anything like that or your friends?

P: Oh no, no, nothing like that.

D: OK. And do you smoke cigarettes or have you tried?

P: Uhm, I tried once but I don't ever do it regularly.

D: OK. And uh, and do you smoke cannabis or use cannabis products?

P: Um, no, I never have tried.

D: OK. And and is there a family history of any heart or or lung conditions?

P: Uhm, I know my grandfather had lung cancer, but he used to smoke.

D: OK, I see. How old was he? Roughly?

P: Uhm, he was in his late 60s.

D: OK, I'm sorry to hear that, and thank you and oh sorry, I forgot to ask her are you currently sexually active?

P: No.

D: OK. Have you been sexually active before?

P: Uh, no.

D: OK, so umm, OK. Uhm, so that was all the questions that, uhm that, that I wanted to ask, was there anything else that you wanted to umm, mention today?

P: Uh no, I don't think so. Is it, when you asked me if my neck was swollen, my necks not swollen but I feel like inside the back of my throat, my tonsils feel a little bit swollen.

D: OK. And have you looked? Does it look like you have like redness in the back of your, back of your mouth?

P: Yeah, it looks pretty red and angry.

D: OK, and it's sore?

P: Yeah.

D: OK, so it's just to kind of summarize, this happens like this sometimes you been having so the sore throat, like the redness and swelling of the tonsils in the back of your mouth, as well as a fever and being pretty tired over these last few days.

P: Yes.

D: OK, yeah. Um alright, so it's sounding like most likely this would be strep throat or, or Group A strep pharyngitis with, because you have no cough, and with a high fever and swelling that you've been redness that you notice in the back of your mouth. And so we'll do a rapid strep antigen test and it will require just a throat swab. To see, to to detect for that, however with a, uh, umm, yeah, I guess that's it. That's what I yeah, well, we'll start with with that now and it could potentially be something like uhm, a viral illness, but that's lower on the on the differential then the bacterial infection is right now. And because of COVID it will be, we'll do a swab as well because people can get fever and sore throat with with COVID as well.

P: Ok.

D: So just to make sure that we're being comprehensive.

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

D: Thank you.


D: What brings you all in today?

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

D: Oh OK.

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

D: Yeah for sure. Um, OK, so just to clarify, he's had this cough and fever for the past five 5 days.

P: Mhmm.

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

P: Sorry, it's been more like 3 three days like Wednesday is when he came home and then, and then today's Friday, so yeah, sorry.

D: Today is Friday, OK. Um, OK, yeah sure. So, is this cough a productive cough, or is it kind of a dry cough?

P: Ah I think it's dry. I haven't noticed him like spitting up anything. Umm, yeah, he yeah, it's just been like little coughs.

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

P: No.

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

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

D: OK, how about short of breath?

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

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

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

D: OK um. And does it, how does it sound? Does this sound like a barky cough? Does it sound? Um, like harsh, what is, what would you say the quality of it, of the sound of the cough is?

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

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

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

D: OK. And are his symptoms getting worse?

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

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

P: No, I don't think so.

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

P: I don't think so.

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

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

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

P: Maybe a bit of like a runny nose.

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

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

D: OK, how about vision or hearing?

P: I think those are fine.

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

P: No.

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

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

D: OK, any changes in his bowel movements?

P: Uh, no.

D: Pardon?

P: I'm sorry, no changes.

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

P: No.

D: OK, any nausea or vomiting?

P: No.

D: OK, any changes in his urine?

P: Really been looking, but I don't think so.

D: Any dizziness or fainting spells?

P: No, just like fatigue.

D: OK, any confusion or memory loss?

P: No.

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

P: Yeah, absolutely, he hasn't like decide to like vaccines, he hasn't had to go to the doctor like ever. I mean, he broke his arm once but that was it.

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

P: Exactly, like nothing.

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

P: Yeah totally

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

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

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

P: Yeah totally

D: OK. And does he have any allergies?

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

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

P: Yep.

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

P: Uh, no, everyone is really healthy.

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

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

D: OK, and is she healthy?

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

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

P: No.

D: No OK, um has he been around any sick contacts recently?

P: Not not like outside of school. I like we know for sure, not outside of school but he goes to school right now so kind of hard to say. They haven't like contacted us about anything.

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

P: No.

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

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

D: Mhmm.

P: So yeah yeah, like. Sorry, go ahead.

D: No go ahead.

P: So I just wanted to basically see if it was that and I mean he does receive you're so scared. That's kind of what made me come in, like it's scaring me a little bit.

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

P: Yeah, sounds good.

D: OK great.

P: Thank you.

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

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

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

P: You too, thanks.


D: What brings you in today?

P: I I've been having uh, this fever, the last couple of days and I've had a cough as well and my nose is, keeps running.

D: OK. And when did the fevers start?

P: I think the fever started two days ago.

D: How, did you measure your magic temperature?

P: Yeah, it was 38 point .5 when I when I checked it.

D: And have you been checking it out past days? Has it gotten better or worse?

P: It's been about the same both both days.

D: And your cough, when did that start?

P: Cough started four days ago.

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

P: It's been dry.

D: I've been bringing up any blood or any mucus or anything like that.

P: No, and I haven't had a cough before either. This is new.

D: OK, and the runny nose, what kind of discharge, or what like what's coming out of your nose?

P: It's pretty pretty watery and clear.

D: OK, alright, and when did that start?

P: Yeah, yeah, sorry that started about four days ago as well, so about the same time as the cough.

D: Have you had any other symptoms, such as having a stuffy nose that have congestion in your sinuses, sore throat? Umm, red eyes? Watery, teary eyes? Sneezing, any of those symptoms.

P: Um, no nothing like that.

D: Any difficulties breathing?

P: No.

D: Any pain in your chest?

P: No.

D: OK, any headaches?

P: Uh yeah I have had a bit of a headache, actually. Well, just just this morning.

D: How how bad is it?

P: It's pretty mild. Something pretty simple like it, so I've had headaches like like this before. It's not, it's not a big deal.

D: And do you have any fatigue or muscle aches?

P: No muscle aches, but yeah, I have been fatigued last a couple of days. Two or three days.

D: Any changes in your sense of smell?

P: No.

D: Changes in your sense of taste?

P: No.

D: Any pain in your belly or any diarrhea?

P: Nothing like that.

D: OK? Alright um, any medical conditions that you've been diagnosed with?

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

D: OK, any surgeries or hospitalizations?

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

D: OK. And do you take any medications?

P: No, I'm not.

D: OK, and allergies to food or medications, or environmental allergies?

P: I think I have an allergy to penicillin. I got it, I had a rash when I was I younger when I had that.

D: OK, and do you currently? Would you currently let that?

P: Yeah, so I I just live with my with my mom.

D: OK, do you have any pets at home?

P: No, it's just us two, uh, we live in a in a townhouse in in the city.

D: Nice, OK. And do you do you or your mom go out for school or for work?

P: Uh yeah, I've been going been going to school. I know with the some of the lockdowns and what not the schools been open so we've been going. They've been pretty cautious with the covid protocols. And but my mom's been working from home.

D: OK, good. Do you feel like you or your mom may have had contact with anyone who could have potentially been sick?

P: Uhm, I mean, maybe at the school or something like that, but I can't think of anybody who who's been sick.

D: OK, alright, have you traveled anywhere outside the province?

P: No.

D: OK, uhm. And, uh, do you I guess a couple of other more general questions. Do you feel safe at home?

P: I do, yeah. We have a good a good relationship.

D: I'm glad, I'm glad, and an anything that we discuss will see confidential between you and me, unless there's something that you could be talk about that could harm you or harm anyone else. Do you feel safe at school?

P: Yes, I do. I enjoy school. It's been fun.

D: That's good, that's good. And have you can have been consuming the drug? Tried anything?

P: No, I've heard of other people. I mean in high school doing stuff like that, but I haven't been around anything like that.

D: OK, alright. Any alcohol?

P: No.

D: OK, are you sexually active?

P: No.

D: Alright. And uh, let's see so.. uh, you've had a fever, a cough, and a runny nose for the past few days. And have you been going to school? In the past couple of days or no?

P: I know I've taken the last couple of days off, just been so tired and not feeling good so, yeah well.

D: OK, OK. So yeah, it sounds like you might have some sort of viral infection which could potentially be covid, but could also be another sort of another viral illness, just like the common cold or the flu. Um, so I'll request that we get a covid swab done and the results should come back in 24 to 48 hours and um, just try to self isolate as much as possible. Don't go to school, don't meet other people. Try to stay away from your mom as well. And based on the results, you'll get more guidance from public health nurses, and you should just continue to sort of rest and drink lots of water. Maybe take Tylenol or Advil if that's making you feel better and hopefully your symptoms will get better. If not, if you feel like your symptoms are persisting for days or week or so, or you're having worsening symptoms, definitely come back or give us a call.

P: OK, thank you.


D: How may I help you today?

P: Hi, um so for the past week or so I've um I've had this cough um and some shortness of breath. I feel hot and I just feel kind of uh fuzzy like I just I can't concentrate on things very well. I get confused sometimes so I thought I'll come to you to get it checked out.

D: Yeah, yeah it's it's that was a really good idea to come in to get checked out. Um so can you uh, I'll talk I'll ask about each symptom a little bit. So starting with the shortness of breath can you um tell me how uh bad the shortness of breath has been?

P: Uh it's been sometimes it's not so bad, some other times it's really bad. Um at first it wasn't that bad, but now like I'm having a hard time taking a deep breath in. Um it hurts and I just feel like I can't walk like 2 blocks even before getting short of breath.

D: And uh before this week how much did, did you ever feel short of breath before this?

P: No, nothing like this before.

D: No, OK. Um do you feel that the shortness of breath has gotten kind of worse over time?

P: Yeah, I think so.

D: And what about the cough? Did that start at the same time as the as the difficulty with breathing?

P: Um it started before the difficulty with breathing.

D: Can you, uh is it a dry cough or a wet cough?

P: Um it was it was a dry cough at first, but now I'm seeing some phlegm um and it looks kind of yellow.

D: Have you seen any blood in the phlegm?

P: No.

D: Uhm and, uh, are you hearing any wheezing sounds?

P: Yeah, a little bit.

D: OK. Um how uh, has the cough sort of improved or gotten worse over time?

P: Um it's it's gotten worse.

D: OK. And you mentioned you also you also have a fever. Did you check your temperature?

P: Um I did I it was like 38.5 this morning.

D: And have you been checking your fever this past week, or was that the first time you, um, checked it?

P: It's the first time I checked it. I I've felt hot though in the past and I've felt like I had chills.

D: Yeah. You're also feeling a little bit fuzzy. When did that start, and can you explain that a little bit?

P: That started about um, I think like yesterday morning. Um I just feel fuzzy like I can't concentrate on things as much as I used to be able to. And the other day I uh was cooking something and then I forgot I was cooking it. Um yeah, just a little bit confused.

D: Did you leave the stove on?

P: No, no, I had turned it off. I just forgot I left like the pot on the stove and made dinner.

D: OK, OK and you feel like this is very new, that this has not been going on for weeks or months where you forget things or having difficulties with concentration?

P: No this has never happened before.

D: Uh OK. I'm gonna ask you about a couple of other uh symptoms just to make sure that you don't have any other um, just to get a full picture. So do you have a headache at all?

P: Um no, no headache.

D: OK, any changes in your vision or your uh hearing that has that has uh been very sudden or that has happened over the past week?

P: No.

D: Nothing like that, OK. Um any change in your taste, change uh, sense of smell?

P: No.

D: Sense of taste?

P: No.

D: OK uhm and uh any runny nose or congestion?

P: Um a little bit of a runny nose, yeah.

D: And what's that discharge like? What colour?

P: It's also yellow.

D: Um any uh sore throat?

P: Uhm no, no sore throat.

D: OK. And um any chest pain?

P: Yeah, it hurt hurts when I try to take a deep breath in.

D: When did that start?

P: That started about the same time as my shortness of breath.

D: OK, uhm and uh any uh do you feel like your heart is racing?

P: Um no, not really no

D: OK. Do you get any chest pain otherwise um in this week when you're not trying to take a deep breath?

P: No, there's no chest pain at rest.

D: Where is your chest pain?

P: It kind of feels like central to my chest um uh yeah, just in the chest area, it doesn't radiate to anywhere else.

D: OK OK. Does it get better right away after you um sort of stop taking that deep, stop doing deep breathing?

P: Uh no otherwise it doesn't hurt.

D: It doesn't hurt, OK good. Um alright, and any uh belly pain?

P: Uh no.

D: Any nausea or vomiting?

P: No.

D: Uh any changes in your bowel movements like diarrhea or constipation that is new in the past week or two weeks or so?

P: No.

D: OK. Um any um difficulties with uh peeing? Do you have uh any pain or any increase in how often you're going to the bathroom, or how um urgently you need to get to the bathroom? Anything like that?

P: No.

D: No, OK. Any pains in your joints or muscles?

P: Uh no.

D: Any fatigue uh in the past week?

P: Yeah, I've been feeling tired.

D: Um any um any weight loss recently?

P: Uh no.

D: OK, any um night sweats? Do you feel like you're drenched in sweat at night?

P: Um no, no night sweats, but I do feel chills.

D: Yeah, um and any swelling in your your belly or your um in your feet, in your legs?

P: No.

D: No, OK. OK uhm can you tell me about any uh medical conditions that you might have?

P: Um sure I had a DVT uh two years ago. I have diabetes, for which I am on insulin. And I have hypothyroid.

D: OK. I've got to say it's quite impressive that you know uh the word DVT, most patients don't know that.

P: I've had a blood clot.

D: Any um, so are you on any medications uh other than the insulin?

P: Um yeah, so I'm on insulin and I'm on Synthroid. I'm on aspirin as well, like baby aspirin.

D: Have you ever had any um COPD?

P: No.

D: Ever been diagnosed with asthma?

P: No

D: Heart attack or any heart related problems?

P: No.

D: OK, OK. Um has, have you had any hospitalizations in the past?

P: Um no. Actually sorry, I have, for the DVT.

D: Yeah, yeah, yeah, I see. Any surgeries?

P: Uh no, no surgeries.

D: OK. Um what what caused your DVT? Do you remember or do you know?

P: Uh I was, I was flying somewhere. I was well, I was flying back from somewhere and I got off the plane and um I guess they found uh blood clots.

D: I see, I see. OK. Any allergies to medications, environmental allergies, food allergies, anything?

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

D: OK. And I forgot to ask in terms of medications, are you taking anything over the counter? Any herbal pills, any vitamins, etc.

P: Just some um calcium, vitamin D.

D: Well, that's great.

P: Yeah.

D: That's great. Uh yeah, that's very important that you know for women um um above the age of 65, I think, 50. Um uh OK, so in terms of your living situation, are you living with someone? Are you living alone?

P: Um I live with my husband.

D: OK, and are you, um, is there anybody else in the house? Any pets, animals?

P: Uh no, we don't have any pets or animals.

D: And uh are you able to take care of things like uh dressing, uh changing, going to the bathroom on your own? Do you need help?

P: Uh no, I am pretty independent.

D: What about things like groceries or taking care of finances?

P: Uh no, I'm pretty independent in in that aspect as well.

D: OK, that's wonderful. Um have you had any recent travels?

P: No, I've been trying to stay at home because of Covid.

D: That's good. Um and any, do you think any exposures to anyone who could possibly be sick? For you or your husband?

P: Um I mean we we do laundry at a laundromat. Um but other than that, no.

D: OK. Um OK. Uh alright, well I think I have all the information I need today. Um let me go talk to my my preceptor and we'll come and do physical exams and listen to your chest and uh do a few uh lab tests to draw your blood and do a chest X Ray likely and then um uh go from there. You, it sounds like um sounds like with the with the fuzzy feeling, the fevers, the difficulties breathing, I think it would be a good idea for you to stay here for a couple of days maybe, but we'll um we'll let you know what happens and what the results show. I'm really glad that you decided to come in today. Do you have any questions for me?

P: Um no, thank you so much.

D: Welcome. Um so the likely diagnosis is um a pneumonia, either bacterial or viral, but given yeah, yeah could be either, OK.

P: Do I still need to isolate in this case?

D: Oh that's very true. Yep, Yep uh so.

P: OK.

D: Well, you will be in the hospital, so yes you do. We will be we will be doing a Covid test, but that's a really good point um uh because your symptoms do overlap with Covid symptoms um we will also uh have you in an isolated room away from other patients until your Covid swabs are back and we know whether um, yeah, we'll follow the guidelines um put forth by the public health.

P: OK, sure.


P: I've been having this cough for around, I would say half a year now and I just can't seem to get rid of it.

D: OK. And does this cough have any phlegm that you bring up?

P: No, it's completely dry. I can't bring anything up.

D: OK, and since the cough started, has it been getting getting worse, staying the same, getting any better?

P: It was pretty much the same for I would say like three or four months, but then I've noticed it getting more frequent over the last couple of months.

D: OK, and six months ago, can you think of anything that that changed? Including like, traveling anywhere or changing in in your work or or living environment?

P: Uh, not really, uh, I'm like almost 75 years old now, so I just thought it was probably just due to my age.

D: OK. Uh, have you been have you brought up any blood with the cough?

P: No, I've never brought up any blood.

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

P: Not that I've noticed, but I do find that I get a little bit more tired with exercise than I used to, but not really any shortness of breath.

D: OK. Um, and have you been experiencing any other symptoms?

P: I don't know if this is just due to old age, but like I've noticed some joint pain as well, like in my hands and feet. I just assumed that was 'cause I'm getting old.

D: OK um, and has there been anything that's made the cough worse?

P: Sometimes when, I'm exercising a lot more but not not too much, it's kind of just always been there, hasn't really changed too much, but it's gotten more frequent over the last couple of months.

D: OK, and anything that's made the cough better that you've tried?

P: No, nothing I've tried like everything. I've tried Tylenol cold, I've tried other home remedies but like like steaming and everything like that but nothing has really helped.

D: OK, and is the cough worse in the morning, throughout the day or or at night?

P: It's pretty much always there. It doesn't really change with any time of the day.

D: OK, and is the cough interfering with sleep?

P: Yeah, I sometimes I I do have coughing fits at night that wake me up. I do have
disrupted sleep over the last few months.

D: OK. Um and, you mentioned some joint pains as well and then when did that those start?

P: I would say over the last year is when I started noticing it a lot more than before.

D: OK, have you been having joint stiffness or or muscle stiffness early in the morning?

P: It does get a little bit more stiff in the morning, but it's kind of just there throughout the day.

D: OK, have you noticed any red hot or or kind of swollen joints?

P: No, nothing like that.

D: OK, any injuries to any of your limbs or or joints that could explain some of the pains
there?

P: No, not that I know of, nope.

D: OK, um, and how has your energy been? Have you been experiencing a lot of fatigue?

P: Yeah, I definitely have been more tired. I can't really even go outside for a walk sometimes or I get really tired working in the garden. So it's been tough.

D: OK, and when did that when did you notice that change and and how were you different before?

P: Like before, like before six months ago, I remember I used to be able to go for long walks around the block, then when I was gardening I can go on for hours, but now I'm pretty it's pretty limited to like maybe 15-20 minutes and then I have to go back into the house.

D: I see OK, so pretty big difference over the last six months to a year for you.

P: Yeah.

D: Have you been experiencing any fevers or chills?

P: Not really. Not that I know of.

D: OK, how about, uh, excessive sweating at night?

P: Nope.

D: Alright and, how has your appetite been?

P: My appetite has been around the same, no changes there.

D: OK, have you experienced any weight loss?

P: I've actually, I think, lost a couple pounds but not not too much.

D: OK, would that be over the last six months or so?

P: Yeah, around the last I would say three to four months.

D: OK, uh, have you noticed any swollen glands anywhere like in your neck or anything like that you might feel like a lump?

P: No, not really.

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

P: No, I haven't had a cold for more than two or three years I think.

D: OK, about a loss of smell?

P: No.

D: Loss of taste?

P: No.

D: Alright, have you been experiencing any chest pains?

P: When the coughing gets pretty bad like I get some strain in my chest but nothing other than that.

D: Alright, and any heart racing?

P: Nope.

D: Alright, and how about wheezing?

P: No, not really.

D: OK, and have you noticed any swelling in your limbs, like in your hands and your feet or ankles?

P: No, not really.

D: Alright at night, have you had any periods where you woke up extremely short of breath and you had to sit on the edge of the bed with your feet over?

P: No, not that I remember.

D: OK, and how many pillows do you sleep with?

P: Just one, same as before.

D: OK, um and any abdominal pain?

P: No, no pain is just in my joints and sometimes in my muscles, but other than that, no.

D: OK, any urinary problems like pain or or going really often?

P: Nope.

D: Alright and then any changes to bowel habits like diarrhea or constipation?

P: No, not that I know of.

D: OK, and have you noticed any skin rashes?

P: Uh, nope.

D: OK, and, uh, are there any joints in particular that are most affected?

P: I would say like my legs and arms. It's it's pretty much  lot of the joints, not really affecting my hip, but like everything else seems a bit sore.

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

P: No, never. I've been pretty fortunate.

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

P: No, just vitamins but nothing else.

D: Alright, do you have any allergies?

P: No, not that I know of.

D: Have you been so you said you've been pretty healthy, but have you been in the hospital for any reason recently?

P: No.

D: OK. Um and are your immunizations up to date?

P: Yeah, I I got a shingles vaccine, the one for pneumonia as well.

D: OK, and have you traveled anywhere recently?

P: No I've been at home.

D: OK um and in the family, have you heard of anything like this happening in the family sort of way, onset of this kind of shortness of breath and cough that you've been experiencing?

P: Not really, I I don't really have shortness of breath like it's it's like a dry cough. Sometimes I do find myself breathing more shallow. Yeah, mostly it's just a dry cough that's been going on.

D: OK, and more of the fatigue.

P: Yeah.

D: OK. And anybody in the family have like autoimmune diseases like rheumatoid arthritis or or lupus?

P: Uh I don't really, I can't really think of nothing my mom and dad were completely healthy. So I know and I don't have any siblings, so yeah, not nothing that I know of.

D: OK, uh, any cancers in the family like colon cancer or anything like that?

P: No, no cancers.

D: OK. Um, and could you tell me a little bit about your living situation?

P: Yeah, so right now I live alone in a small townhouse and yeah, that's I have a pet dog, but that's that's about it.

D: OK, um, and how do you support yourself financially?

P: So, I'm retired, but getting a pretty good pension as well as for my a husband's pension as well, but he unfortunately passed away a couple years ago.

D: I'm sorry to hear that. What did you say you retired, what did you do for work previously? Did you have any exposures to chemicals or asbestos products while while at work?

P: Not that I remember, no it was it was a pretty, pretty much like a desk job I would say.

D: OK um, so no reasons that you were visiting farms and like being around birds or anything like that?

P: Um, not really, but I I do think like the old building that we lived in might have had asbestos. Does that does that like count at all?

D: Like a it could be important, uh, because, uh, well how long, how long did you live there for?

P: I would say almost 20 years.

D: OK, so um, yes, that definitely would be is is important for the history today because, unfortunately, long term exposure to asbestos when breathing it in can cause some of the symptoms that you've been describing along with cough and uh, respiratory symptoms. So it'll be something that we'll be sure to investigate today, OK? But I just had a couple more questions. First, do you smoke cigarettes?

P: I quit long time ago, more than like 10 years ago, but I used to smoke like 5 to 10 cigarettes for around 20 years.

D: OK, and do you smoke cannabis?

P: No.

D: Alright, do you drink alcohol?

P: No, not anymore.

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

P: No.

D: Alright, and are you currently sexually active?

P: No.

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

P: No.

D: OK, so those are the questions that I wanted to go over to make sure I asked on history. Was there anything that else you wanted to tell me?

P: No, I think that's all.

D: OK, so next we'll do your physical exam and order some investigations. But currently thinking that it could be related to asbestos exposure as well as um, something called, well, it could cause pulmonary fibrosis and then also the joint pains that you've been experiencing might be another symptom that is suggestive of a connective tissue disease, and it doesn't sound like you have a family history of those, but we will do some lab work and investigations for for those including a chest X-Ray and a chest CT.

P: Sounds good.


D: What brings you in today?

P: So I've been having just a worsening breathlessness. I've been also having a cough, and I think I might have also had a fever in the last couple weeks.

D: OK, um so the breathlessness started six weeks ago, correct?

P: Yeah.

D: OK and then when did the cough start?

P: I'd say around the same time the breathlessness started, so around six weeks.

D: OK. And then the fever?

P: The fever I've kind of had on and off in the last couple weeks. I would say two to three weeks.

D: OK, OK um and do you, how often are you having this breathlessness?

P: Um I would say it's pretty much there most of the time. It sometimes gets worse when I'm exerting myself, but I think just baseline, I feel like I've been able to breathe less heavily than before.

D: OK, so alright, and how long does it last when you do get it? Or is it just always there?

P: Uh, it's kind of just there, but then when it's getting worse like it lasts a couple minutes to, I would say like 10 to 15 minutes and then it goes back to like just the normal breathlessness.

D: OK, and if you were to describe the quality of your breathlessness, would you say that it feels like a kind of like a burning feeling, like you're having a hard time catching your breath or does it feel like you're breathing too fast?

P: I think it's more I just can't seem to take like deep breaths. And then when I get breathless, I I really try to take a deep breath but I just can't find myself catching my breath at that time. So it's just more not being able to catch my breath.

D: OK, sure. And are there things that make make it better or worse?

P: Uh, not really, I think it's sometimes moving around too much, but like nothing, nothing really causes it.

D: OK, um, and was there any sort of trigger six weeks ago that you think may have like caused all of your symptoms?

P: Oh I'm not sure I I don't think there was any triggers.

D: OK, has anyone around you been sick?

P: So there there are some people living in my house that have a bad cough over the last few weeks.

D: OK.

P: So yeah.

D: So they have similar symptoms to you as well then?

P: Yeah, some of them like don't really have the shortness of breath and it's just like a cough.

D: OK.

P: But yeah, there are some of them also have some shortness of breath.

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

P: So I actually came to Canada one year ago. I'm originally from India and I I'm I came here to study.

D: OK. OK, um alright. If you were to rate your breathlessness from one to 10, 10 being the worst, how bad is your breathlessness?

P: It can get pretty bad. Like I I would say up to an 8 sometimes, maybe a couple times a week.

D: OK, and have you ever experienced this before?

P: No, this is like the first time I'm having this issue.

D: OK, and do you feel like it's getting worse, better, has it changed since you started having these symptoms?

P: I think it's getting worse and that's why I was getting a bit scared and I came here.

D: OK. Yeah, that was a good call and have you had any changes to your smell recently?

P: No, no changes to smell.

D: Any anything like a runny nose or stuffy nose?

P: Uh, no, not really, no.

D: No? OK, how about a sore throat?

P: No, no sore throat.

D: No sore throat, any changes to your taste?

P: Nope.

D: Any changes in hearing?

P: Nope.

D: Ear pain or discharge from your ears?

P: No, nothing like that.

D: OK, any eye pain?

P: No.

D: Changes in your vision?

P: Nope.

D: Any discharge from your eyes?

P: Nope.

D: OK, and you mentioned fever and some night sweats. How often are you getting these night sweats and do they feel like chills?

P: I think in the last two weeks I've been getting it more frequently, like I would say every other night I I feel, I would feel chilly at one point and then I'll break out into night sweats or have to take off my blanket. I think I measured it once or twice over the week and it did show like a fever of 102.

D: OK, OK. OK, and any changes to your skin like rashes?

P: No, nothing like that.

D: Any weight loss?

P: I would say I think I'm losing a little bit of weight over the last couple weeks. I haven't really weighed myself, but I feel that I have lost some weight.

D: OK yeah, and the coughing, are you coughing up any blood?

P: Uh, I don't think so. Sometimes, like when I cough up like sputum, there is like a little bit of pink, pink tinged sputum as well. Sometimes it's like brownish in color and sometimes it's green, but I haven't actually coughed up any blood.

D: OK, um and you said there's some sputum like pink tinged sputum. How much sputum would you say you cough up every time you cough?

P: Maybe like a like a spoonful I would say.

D: OK. And do you ever feel like you're wheezing?

P: Uh, no, I I don't think so. I I don't really notice any noises when I'm breathing.

D: OK. And, alright, so any chest pain?

P: No, no chest pain at all.

D: OK. How about swelling in your legs or in your limbs?

P: No, no swell leg swelling.

D: No leg swelling? OK, um how about do you feeling like your heart's racing?

P: No.

D: No OK. OK, and any nausea or vomiting?

P: No, no nausea or vomitting.

D: How about changes in your bowel movements?

P: No.

D: OK, how about changes in urinating?

P: No, it's been fine.

D: Alright any headaches?

P: No headaches.

D: Any dizziness or fainting spells?

P: No, nothing like that.

D: OK, no confusion or memory loss?

P: No.

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

P: Um I think when I was back in India a couple years ago, they did give me some antibiotics for like a chest infection, but I couldn't really afford the medications and didn't take them. I didn't finish the course, but other than that, nothing else.

D: OK, did they mention what type of chest infection it could've been?

P: No, I don't really remember. I think it was some kind of pneumonia.

D: OK, OK. Are you on any medications?

P: Just uh I take Tylenol sometimes, like it hasn't really been helping.

D: OK. And, are you allergic to anything?

P: No, not that I know.

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

P: Yeah, as far as I know.

D: OK. And and is there any family history of lung conditions or heart conditions?

P: Nope.

D: No OK, how about cancers?

P: No cancers that run in the family, no.

D: OK OK, so you mentioned you moved to Canada from India about a year back. Where do you live now?

P: So I live in it's, we have like a student house with some of the students who came from India as well, and there's six of us living together in in a house.

D: OK, OK, and are they sick as well or no?

P: Yeah, so three of them actually have like, two of them have a cough and one of them has some shortness of breath as well.

D: OK. And have they been to a doctor? Have they been investigated? Were they ever given a diagnosis?

P: No, not that I know of. I think I might be the first one who actually went to a doctor.

D: OK, OK. Um, do you smoke?

P: I smoke like I would say like 5 cigarettes a day.

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

P: Around 10 years.

D: OK, that's, it's been a while then. Um, and do you do you drink alcohol?

P: No, I I don't drink and I don't do any drugs either.

D: OK, OK. Are you sexually active?

P: Not currently, no.

D: No, OK. Have you ever had unprotected sex?

P: No.

D: No?, OK. OK, um, did you have any questions or concerns? Anything you wanted to discuss that I hadn't asked you about?

P: Um, so yeah, this is just like my first time visiting a doctor in this country and like I was just very scared that it might be something serious, so just wanted to know what it can be.

D: Yeah, for sure. So the first thing we want to rule out is TB. Because you have recently moved to Canada from a country where it is, I believe it is endemic, so and some of your most of your symptoms fit with TB and how it presents so we just want to make sure it's not that because it is highly infectious and and we don't want it to spread. So, we can do like a AFB smear or I think they have other diagnostic work up for that too. So we'll do that first. If not, we can check to see if it's like another, another typical pneumonia, we can do a chest X Ray for that as well. If both of those turn out to be negatives, then we'll have to work you up further for other things, like COPD, or lung cancer. How does that sound?

P: That sounds good. Thank you.


D: How may I help you?

P: I've been having difficulties breathing over these last few days.

D: When did it start?

P: It started about, like, three or four days ago.

D: OK, and since then, has it gotten any better or worse?

P: It has, maybe gotten a little bit worse, but not, maybe, a little worse.

D: And are there certain times when you feel that you're more short of breath than other times? Anything in particular that you're doing that makes it worse?

P: Uhm, not really, it's kind of, I just feel like, it's just more difficult to breathe, uh, most of the time.

D: And, has this happened to you before?

P: Uhm, not like, no, nothing like this has happened before.

D: OK, do you have a history of any lung problems?

P: No, I don't, I've been healthy.

D: So no COPD, no asthma, nothing like that,  right?

P: No, nothing like that.

D: OK, so you're just having difficulties breathing for the past three-four days. Do you have any, uh, do you have a cough?

P: I did have a, uh, yeah, I've had a cough as well, over these last few days.

D: And has it been a dry cough or wet cough?

P: I've been bringing up, some, like, uh, whitish sputum. It's like, yeah, whitish or clear.

D: And you haven't seen blood anytime right? In your sputum?

P: No.

D: OK, and has the cough gotten any worse overtime?

P: Uh, it's been about the same.

D: And have you had fevers or chills?

P: I have felt hot but no chills.

D: OK. What about, any redness in your eyes or any congestion in your nose?

P: Uh, I haven't noticed anything like that.

D: OK, have you had a sore throat?

P: Uh, it's felt a little itchy I guess but no pain with swallowing.

D: And do you have any chest pain or chest pressure?

P: Yeah, when I like, uh, take a deep breath or after after I cough I've been having some chest pain.

D: To give it a number from one to ten, what would you say in terms of how severe it is with ten being the worst pain ever.

P: I would say, maybe six. It feels pretty sharp when it happens and it goes away after a few minutes.

D: OK, and where exactly is it, is the pain?

P: Uh yeah, I kind of feel it, Yeah, just over on the right side of the sternum.

D: OK. Alright, and does it radiate anywhere? Does it go anywhere other than that one location?

P: No, I feel it just in the one spot.

D: OK, uhm, and has that pain gotten worse overtime?

P: No, that pain started, I guess like two days ago. More recent than the cough or shortness of breath.

D: I see, I see, OK. And so you said that coughing makes it worse and sometimes breathing in. So is it just normal breathing or when you're doing like, deep breathing?

P: Deep breathing.

D: Deep breathing hurts? OK. Alright, and you've never experienced this before, right?

P: No, I haven't had a pain like this before.

D: OK, when you sort of touch that area over your chest, does touching it make it worse?

P: Uhm, no, I haven't noticed that, touching it doesn't make it worse.

D: OK. Uhm, alright, have you had a headache?

P: Uh, no.

D: No, OK. What about fatigue or muscle aches?

P: I've been fatigued. No muscle aches.

D: OK, any pain in your belly?

P: No.

D: Any diarrhea?

P: No.

D: Constipation?

P: No.

D: Any changes in your, uh, any changes when you pee?

P: Uh, nothing there.

D: No. OK. Any rash that you've noticed on your skin?

P: No.

D: OK. Any changes in your sense of taste?

P: No.

D: Changes in your sense of smell?

P: No.

D: OK, alright. So sounds like for the past three-four days you've had difficulties breathing and a cough with this whitish sputum, whitish or clear sputum. You've also been feeling a little bit feverish. Have you checked your temperature?

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

D: Yeah, no problem and your throat's been a little bit itchy and then two days ago you also started having this pain in your chest. Is there any other symptom that I have not mentioned that you have been experiencing over the past couple of days?

P: No, that's everything.

D: Yeah, OK. And you mentioned that you don't have a history of asthma or COPD. Do you have any other medical conditions?

P: I have high blood pressure. And I take Amlodipine, for that.

D: OK any other over the counter medications or any other medication that you're on?

P: No.

D: Any allergies?

P: No allergies.

D: OK, and where do you currently live?

P: In a townhouse just outside of the city here.

D: I see, do you live alone?

P: No, I live with my wife and daughter.

D: And have your wife and daughter been sick recently or have either of you had contact with someone who's been sick?

P: I've been working from home, uhm, but my daughter has recently started going back to high school and she's had a runny nose recently and a sore throat, but that's about it.

D: And what about your wife?

P: She's been fine. Yeah, she's been healthy.

D: OK, good. Other than your daughter, have you been in contact with anyone else who might have, who might be sick or might have symptoms similar to what your daughter has?

P: I don't think so.

D: OK, alright, and do you, have you traveled anywhere recently?

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

D: OK, and do you smoke?

P: No.

D: Ever smoked in the past?

P: No, I've never smoked before.

D: Marijuana?

P: I mean, I'll have a joint sometimes with friends at a party or something, but that's maybe once a month?

D: Sure, and any street drugs?

P: Nope, nothing like that.

D: OK, and do you drink alcohol?

P: I have a beer a couple of times per week.

D: Alright, and you told me about your medical history, but do you have, have you ever had any surgeries or any hospitalizations in the past?

P: Uh, I've had a hernia repair, about seven years ago. I haven't had any issues since.

D: Alright, OK, uhm, and are there any medical conditions that run in your family?

P: Uhm, my grand-father had a heart attack, in his seventies. And, I think my dad has high blood pressure as well, but, I think that's it.

D: Alright, well, so, I think that's all that I wanted to know. I can see that you haven't been feeling well over the past couple of days and I'll go back to my attending and we will come back and chat with you little bit more and do a physical exam and go from there.

P: Sounds good, thank you.

D: You're welcome.