D: How may I help you?

P: I just came in here today, I've been having a lot of shoulder pain that's just kind of left me not doing any of my activities recently. Just in my left shoulder.

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

P: It started 5 days ago but it became pretty bad and I've been kind of having like a somewhat of a pain for the last couple weeks, but it got really bad just this week.

D: OK, did you have any trauma to the shoulder like any any injuries or triggers that could have caused the pain?

P: Uhm I have been just going to the gym more frequently over the last few months and lifting weights and things like that. But just this week I wasn't even really able to do that either.

D: OK, when you were lifting weights like a few days ago like was there an episode where there was an acute onset of the pain, where it got worse kind of like right away.

P: I think it was more progressive, but five days ago I do feel that there was like just. I was having some pain before that, but then I just noticed while working on I I started having more pain. But yeah I don't think there was anything like sudden that happened though.

D: Oh OK, but it yeah it was progressing and then it got acutely worse with the weight lifting. It sounds like.

P: Maybe like I did increase my weight like in the last two weeks. So I did feel like a little bit more pain with the increase last week.

D: OK, I see an in the left shoulder do you feel the pain at the front at the sides or or back?

P: It hurts, particularly like in the front part of the shoulder.

D: OK, do you feel that it's radiating anywhere else?

P: Just my whole left shoulder, nothing else really.

D: OK. And could you describe the character or the quality of the pain? Is it sharp, or is it a key?

P: It's more achy.

D: OK.

P: But but certain like some movements so it can get like kind of sharp.

D: OK, and has there been anything that has made the pain worse?

P: Uhm, if I just if I carry anything with my left arm or if I have to lift anything or place it on my shoulder like it really hurts.

D: OK, and have you done anything that's made it better?

P: I just like resting it, not carrying anything. And trying not to lie on my shoulder.

D: OK, so you're sleeping on the others on the right side then.

P: Yeah.

D: OK alright, how would what would you say the severity of the pain is on a scale of 1 to 10.

P: Uhm, if I'm not doing it, doing anything or not doing much, it's probably like a two or three, but if I try to carry anything it goes up to like probably like a 7.

D: OK, uh, and um. Do you do any repetitive kind of like overhead activities? Things like playing basketball or just lifting things like above your head at the gym?

P: Um not recently just just like normal weight exercise, maybe with the bands I do some overhead exercises, but in terms of sports I I play or I used to play a lot of tennis. I did have some issues with the same shoulder, which is why I kind of stopped playing tennis. My doctor said it, I might have overused that shoulder, but that's that was like a couple of years back so I thought it must have healed by now.

D: OK, so previous overuse injury of the left shoulder?

P: Mmmm

D: OK, and uh. I'm have you had any trauma to the shoulder?

P: Um no not that I know of.

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

P: No.

D: Have you had any night sweats?

P: No.

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

P: No.

D: OK so even over the area you haven't noticed any redness or like soft tissue swelling?

P: No.

D: OK. Have you had any chest pain?

P: Nope.

D: OK, how about any shortness of breath?

P: No, not that I've noticed.

D: OK, have you had pains and any other joints?

P: No, just my shoulder.

D: OK And. Um, Have you had any recent infections or or symptoms such as like a runny nose or sore throat or even a cough?

P: No, nothing like that.

D: OK, and how about any nausea or vomiting?

P: Um nope.

D: OK. And um. How has your sleep been these past couple of nights? So you mentioned you haven't been able to lay on your left side?

P: Yeah, it's been pretty painful like I kind of wake up every time I accidentally go on to my left side.

D: OK, so you're getting worse thing a pain at night?

P: Yup.

D: OK. Have you had any weakness? Do you feel like you have less strength in your arm?

P: Um I do you feel that there might be some less strength in my left arm, but it's I'm not really using it much so it's hard to tell.

D: OK,  And how about a range of motion. Do you feel as though you could lift your left arm up to like, scratch your head and back?

P: It does hurt like when I try to lift my arm up.

D: OK, so it sounds like a range of motion is decreased?

P: Mmm

D: OK, and have you had any altered sensation of your arms being like numbness or tingling?

P: No, I haven't felt any of that.

D: OK. Um and have you had any changes to your bowel habits like constipation or diarrhea?

P: Nope, nothing like that.

D: Have you had any abdominal pain?

P: Nope.

D: And have you had any urinary problems?

P: No.

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

P: Uh. No, I've been a pretty healthy actually just just that overuse injury like two years ago.

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

P: No.

D: OK, do you take any medications regularly?

P: Just recently I've been taking a lot more of the Advil, but that's about it.

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

P: No, no prior surgeries or hospitalizations.

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

P: Yeah, so I'm living with with my wife in a small condominium in downtown.

D: OK, and are you working currently?

P: Yeah, I'm working as a real estate agent.

D: OK, uh, and do you drink alcohol?

P: Rarely just on some occasions, but not regularly.

D: No. OK. How about smoking cigarettes or cannabis?

P: No, I've never smoked.

D: Do you use any recreational drugs or have you in the past?

P: Nope

D: OK. Um. And so so the next part, just for the physical exam. So do you have pain with shoulder AB duction.

P: Uhm yes. So just to yeah, I do have some pain. Especially from. Yeah yeah pain throughout AB duction.

D: OK, is there any like pain that's like parts of that that range of motion that are more painful for you?

P: yeah, so probably from 60 degrees to 120 degrees is more painful.

D: OK. And. If your arm is outstretched and your thumb pointing down so your arm is internally rotated does that give you pain?

P: Yeah, if yeah, not not just like that, but if you were to like press down on it it the internal rotation does cause a little bit of pain.

D: OK. OK, so it sounds like a positive jobes test and a positive Neer's test as well as a painful arc for your shoulder. And is there pain to palpation?

P: Uh. Just to, yeah, definitely just at the front of the shoulder there is some some pain over with palpation.

D: OK, that sensation is normal, reflexes are normal and strength is slightly reduced as well. OK, so that was everything that I wanted to ask on history and check on the physical exam as well. Was there anything else that you wanted to mention today that I maybe forgot?

P: No, I think that's it.

D: OK, um so based onI know that the symptoms today along with your age and prior history of an overuse injury of the left shoulder, it certainly raises concern of having a rotator cuff tear or um a rotator cuff impingement syndrome and where there is inflammation there not necessarily actually a full tear of the muscle that's causing the pain. So, uh, those would be the two most likely things. Yeah, their rotator cuff tear or subacromial impingement syndrome. And so we were going to get an ultrasound of the left shoulder to evaluate the structures and possibly some other imaging such as an X Ray or MRI to determine the extent of the injury in the left shoulder.

P: OK, sounds good. Thank you.


D: How can I help you today?

P: Hi, um I'm here because I've had this awful sore throat for the past four days. Doesn't seem to be getting any better and I think I'm developing a fever now.

D: Have you checked your temperature?

P: No, I haven't checked my temperature, I'm just really hot.

D: We'll check that here then. And, uh, do you, OK so you've had this sore throat for four days and a fever. Have you had any difficulty swallowing?

P: Yeah, um not, like I can drink OK, but it's really hard for me to eat solid foods right now.

D: Um why is that?

P: Oh it just hurts.

D: Yeah, OK, but it's not that you can't um, you can't sort of like, you don't feel like it's getting stuck?

P: No, no, nothing like that.

D: Um and have you noticed any changes in your voice? Do you find that your voice is more hoarse?

P: Um a little bit uh but I think that's just because I try not to talk as much since my throat is so sore.

D: OK, OK and uh have you had a runny nose?

P: No, no runny nose.

D: Uh a cough?

P: No.

D: OK. Have you had any difficulties breathing?

P: No.

D: Any chest pain?

P: No.

D: Any sort of um congestion, do you feel like your nose is stuffy or hurts your, uh, in your cheeks or your head when you bend down?

P: No.

D: No, OK. Um so all you have is a sore throat and this fever, OK um and um, OK. You have a headache?

P: Um no headaches.

D: Do you feel like you've been confused or just feeling not yourself?

P: No, nothing like that.

D: OK. Any uh changes in your hearing or your vision?

P: No.

D: OK, any um and do you feel like your heart's beating very fast?

P: Uh no.

D: Do you feel short of breath?

P: Nope.

D: Any uh belly pain?

P: No.

D: Any nausea or vomiting?

P: Uh no.

D: OK, any diarrhea or constipation?

P: No.

D: Any fatigue?

P: No.

D: Weight loss? Unintentional.

P: No weight loss, no.

D: Uh and uh do you have any medical conditions?

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

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

P: Uh yeah the only one that I haven't gotten is um that HPV vaccine.

D: OK OK, um OK, any uh, did you get the flu shot?

P: Oh, I didn't get that this year.

D: OK, well we recommend that you you get your vaccines and um also the uh HPV vaccine. Um it's it's best to get the HPV vaccine earlier on. It's a little bit less effective as you um go past a certain age, you are still obviously nowhere close to that, but it's,  I I don't believe it's covered after the age of 26 either, so it's best if you get it done earlier. And let's go back to your symptoms, then. Have you had any surgeries?

P: Uhm, I got my appendix removed when I was 13.

D: Anything else?

P: No.

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

P: No, I just take my multivitamins.

D: And uhm are you um are you currently living alone or do you live with someone?

P: I live with my parents and my two siblings.

D: And uh do you feel safe at home?

P: Yes.

D: OK. Are you um currently sexually active?

P: No.

D: OK. Um do you plan on being sexually active in the near future?

P: Uh no, not before I finish high school.

D: OK, alright. Um and um are you uh, do you uh drink alcohol?

P: No.

D: OK, do you smoke?

P: No.

D: Have you tried marijuana or any recreational drugs?

P: I haven't.

D: OK. Are things going well at, are you in school right now?

P: Um yep, I'm in grade 10.

D: OK. Are things going well?

P: Yes, I would say so.

D: Any bullying uh at school?

P: No.

D: OK, any um any any concerns about depression or anxiety?

P: No.

D: OK OK alright and uh you uh traveled anywhere recently?

P: No, I've been um just at school and home.

D: So it's not it's not virtual, it's in person?

P: So half the day is in person and the other half is virtual.

D: OK and are you maintaining social distancing at school, wearing a mask?

P: Yeah we do, except sometimes I guess like I don't know if you have to drink water or something, we take it off.

D: Yeah, sure, OK. Um and uhm, I suppose just um OK. What was I gonna ask? Um do you uh, so no travels, OK. Do you feel like you've been in contact with someone who might be sick or might have Covid?

P: Uh I don't think so.

D: No, OK alright. And have you looked at your throat? Does it look swollen or red?

P: Yeah, it looks pretty swollen and red.

D: Well, that's all the questions, oh one more question actually. Do you have um any medical conditions that run in the family?

P: Um no, I don't think so. Maybe like high blood pressure.

D: Uh all right, well um that's all the questions I had. We'll do a physical exam, have a look inside your throat. Um given uh the symptoms that you have, it sounds like you have um an an inflammation or swelling of your throat which could be caused by bacteria or viruses. It could be something like um mono, or it could be um strep throat. Um it could be other things as well. Um seeing that your symptoms are somewhat overlapping with the symptoms for covid, we would also like to do a Covid test. Um we'll do a rapid strep test here as well um just to rule it out and then uh we'll uh ask you to quarantine for the next 14 days um until or at least until your covid swabs are back or your symptoms improve um and we'll let you know about um the management based on the strep test result. Do you have any questions?

P: Um no, that sounds great, thank you.

D: OK sounds good.


D: What brings you in?

P: I brought my son in today because he had a fever that started two days ago and, and then since then he he's had a cough that started as well and it it he's been short of breath. It looks like he's like breathing faster and just having a harder time to breathe.

D: OK, uhm, before the fever, did you notice any other symptoms, like a runny nose or a stuffy nose?

P: No, nothing like that. Yeah, the fever kind of came on pretty, pretty suddenly it seemed like.

D: OK, and did you take his temperature at home?

P: I did, yeah. It was like 38.7 and then like two days ago and then it was high again, like yesterday and today.

D: OK, and you mentioned the coughing started soon after the fever, correct?

P: Yeah, yeah kind of like the day after e started having getting this cough.

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

P: It's, uh, yeah, he is bringing up a little bit of sputum, yeah he's doing it.

D: OK, what color is the sputum?

P: Uh, it's a maybe like like greenish, greenish, yellow?

D: Greenish yellow, OK. Any blood in there?

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

D: OK, and does he seem short of breath or wheezy?

P: No wheezing, but he does have some shortness of breath.

D: OK. And the service of bread started with a cough?

P: Ii did, yeah.

D: OK. Uhm, how much shortness of breath is he having? Is it just when he's exerting himself or is it at rest as well?

P: I'd say ah, even at rest now he's like breathing faster.

D: OK, umm, and it does anything help with that? So does sitting up help? Or, uh, you know, getting fresh air or anything like that?

P: No. But you'd say, like taking a smaller breaths helps because like if he if he takes a deep breath and he gets, he gets like chest pain.

D: OK, OK, and how about when he's laying down?

P: No, he hasn't said anything like, like that for laying down just I think when he's just taking a deep breath, he said.

D: OK, is it waking him up from sleep?

P: Uh, no.

D: No, OK. How about chest pain?

P: Yeah, so yeah he's had some pain when he, when he just really takes that deep breath in.

D: OK. Does he ever feel like his heart's racing?

P: Uhm, no.

D: No, OK. Uhm how about any dizziness or fainting spells?

P: No, he doesn't have anything like that.

D: OK, has he had a sore throat?

P: No, no.

D: Any changes in vision or hearing?

P: No.

D: Uh, smell or taste?

P: No.

D: No. Weight loss?

P: No, he's been gaining weight well.

D: OK, how about any rashes?

P: Nope, I haven't noticed any.

D: OK, uhm, and then any numbness or tingling?

P: No, he hasn't said anything like that.

D: OK, muscle aches or joint aches?

P: No.

D: OK. Confusion or memory loss?

P: No.

D: Changes in his bowel movements?

P: Nope, yeah, that's been been getting out, no diarrhea or anything like that.

D: OK. Changes in his voiding?

P: Nope, he hasn't had any urinary problems.

D: OK. And is he an otherwise healthy child? Umm, does he have any longstanding medical conditions?

P: No, he doesn't. That's uh, this was so surprising, he's been healthy.

D: OK. Has he, so he's never had any hospitalizations or surgeries?

P: No, he hasn't.

D: OK. How about his mother's pregnancy with him? Were there any complications at that point?

P: Nope, everything went went well. No complications and he was like a good birth weight and went home right away.

D: OK. OK, and how about the delivery itself? Any complications during that, that point?

P: Oh no, not it was a vaginal delivery and it was normal.

D: OK. And he didn't need to be hospitalized as a newborn for anything like jaundice or shortness of breath?

P: Uh, nope, he hasn't had any any reason to be hospitalized.

D: OK. Uhm alright. And has he been hitting all his developmental milestones as well as like his height, weight and head circumference milestones?

P: He has, yeah, he's been growing well and reaching the developments stones, milestones.

D: OK, is he on any medications?

P: Uh, no he's not on any medications.

D: OK. Any allergies?

P: No allergies.

D: Uhm, is he up to date with all his immunizations?

P: He is, yeah.

D: OK. Any family history of lung or heart conditions.

P: Uh, no, nothing like that.

D: OK. Have about cancers in the family?

P: No, no cancers luckily.

D: Can you think of anyone he's been in contact with who's also been sick?

P: Yeah, maybe, he has a younger sister that goes to daycare and she was sick last week with like she had a cough and stuff as well.

D: OK. OK, and does she have a fever as well?

P: She did, yeah, she got better. Right uh, last week we we had to take her to to see the doctor and she got antibiotics for that. Actually for, for a few days.

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

P: No, we've been at home.

D: OK. Does anyone at home smoke?

P: No.

D: No, OK. And who lives at home with him?

P: So it's me, his mom, and then his younger sister.

D: OK. Any old carpets, mold, dust, asbestos, anything that could exacerbate his condition?

P: No, I don't think so. It's a newer home.

D: OK, good. Umm, so those are all the questions that I had for you. Did you have any questions of your own?

P: Uhm, no, I, no that was everything I think. The only I I guess other thing that that I forgot to mention is that just he doesn't really like his appetite's been a little bit lower couple of days as well. But uh, he hasn't had any, like nausea or vomiting though.

D: OK, OK, yeah, that's good to know. Uhm, so because some of his symptoms overlap with those of Covid, we will do a swab on him and you should hear back in about 24 to 48 hours with those results and he should isolate for 14 days because of those symptoms. And it doesn't, it sounds more in keeping with the picture of community acquired pneumonia, so for that we will get a chest x-ray, we'll check his oxygen and his temperature and if the chest x-ray shows consolidation umm, or some sort of infiltrate, it is likely that he has pneumonia. So, we will start by giving him some amoxicillin populate or cefuroxime for five days, and just keep monitoring his symptoms. They should resolve in about 5 days when the course of antibiotics is complete. If his condition gets worse like he's getting neurological deficits like weakness or seizures, just take him to the ER. And if symptoms don't resolve in five to seven days, we can do further work up or things like fungal infections or TB, or things like that. How does that sound?

P: That sounds great. Thank you.

D: OK, yeah, no problem.


D: How may I help you?

P: Hi, so yeah I I'm really worried. I started coughing up blood this morning, and for the last two days I've been having some, like on my right calf, just a lot of swelling and tenderness. Uhm, I just actually got out of the hospital just last week. I had a knee replacement surgery on my right leg. So yeah, I was just really concerned about this blood that I'm coughing up.

D: Yeah, certainly. So when, so you had a knee surgery last week, were you like immobilized afterwards for periods of time?

P:Yeah, I've been just taking some rest, not really doing too much. And even in the hospital, like I was there for a day and was pretty immobilized.

D: OK, and have you had any pain in your calf, and if so, which which one?

P: It's just the right calf and it's it's pretty swollen right now and I was having a lot of pain over it for the last two days.

D: OK is it, can you feel the pain at rest, or or is it with uh like with movement? Or if you press on it?

P: It's yeah, it's pretty tender when I press on it. I haven't really been moving around, and it's still like painful right now, but it doesn't really hurt when I'm like, like I've been trying to keep myself rested just because of the surgery, but when I press on it, it is pretty tender.

D: OK, and is the is the swelling in kind of one spot of your leg, or is it most of the of the leg?

P: It's just the calf, I would say more like just the lower leg area.

D: OK. Have you noticed any skin changes, like redness or or or temperature like it feels hot to touch.

P: Maybe a little bit. I haven't really noticed it too much.

D: OK, and do you have a history of like varicose veins or anything like that?

P: No, nothing like that.

D: OK. So uhm when did the coughing up blood start?

P: Just this morning actually. So just uh, like I would say a couple hours ago.

D: OK, and how much blood are you coughing up?

P: Just some on like I just notice on the tissue like just some spots that I noticed every time that I'm, like, I would have to cough it up. Maybe like in the last couple hours, I've had three episodes of that where I've noticed blood on the tissue.

D: I see and did you ever cough prior to this?

P: No, not really.

D: OK, uhm, and have you been experiencing any infectious symptoms like red or runny eyes, runny nose, sore throat?

P: No, nothing like that.

D: Have you been having any chest pain or or shortness of breath?

P: No chest pain, but I do feel like I do have to take like a deeper breath. Like I've just been feeling it this morning a little bit. It's just kind of a bit of uneasy breathing.

D: OK, so it has been more difficult to breathe. And is that is that at rest as well, do you feel that kind of sensation?

P: Yeah, even right now, just a little bit, like it's it's not anything that I'm too worried about, but it is there.

D: OK, do you have any pain if you have if if you take a deep breath in.

P: Uh, no I don't, no I don't really have any pain.

D: OK, and do you feel like your your heart's racing or beating really fast.

P: I I do feel like my heart is beating like faster, especially today. But yeah, I don't know.

D: Alright, and how about your breathing? Do you feel like you're breathing faster.

P: No breathing, I feel like it's around the same.

D: OK, and have you had any lightheadedness, or dizziness, or or feeling like you're going to pass out?

P: No.

D: OK. And have you had any any wheezing?

P: No wheezing.

D: Alright, uh have you had any abdominal pain?

P: Uh no, no abdominal pain.

D: Any nausea or vomiting.

P: Nope.

D: Have you had any diarrhea?

P: No diarrhea, no.

D: How about any urinary problems, like pain or frequency.

P: No.

D: Have you had any skin changes or or rashes?

P: Uh, no.

D: OK, and how about any other like joint pains, muscle aches?

P: No, nothing like that.

D: Alright. Have you ever had a a DVT before?

P: No, I've never had anything like that.

D: OK, or yeah, like a deep vein thrombosis or have you had a pulmonary embolism before?

P: No, I've never had anything like that before.

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

P: I do have uh, so with my with my knee and then I do have high blood pressure, uh I have diabetes.

D: OK, then was it a knee replacement you had done?

P: Yeah.

D: OK, and do you take any medications for the blood pressure and diabetes?

P: Yeah, so for the blood pressure I'm taking medication called Ramipril, and then for diabetes I'm taking Metformin.

D: OK, have you needed like insulin for diabetes before?

P: No, I've never had to use insulin.

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

P: No, nothing else. I actually I do take some multivitamins, but besides that nothing.

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

P: Not that I know of.

D: OK, and any hospitalizations or surgeries in the past besides the the knee surgery last week?

P: No.

D: Alright, so you've been healthy otherwise. I I'm not sure I I ask this, I'm wondering if you had any fevers or chills.

P: No, not really.

D: OK, and uh how about any night sweats?

P: No.

D: Alright and uhm has your weight been stable over the last several months or have you had any changes?

P: Yeah, it's been pretty stable.

D: OK, thank you, just wanted to clarify a few things there. And uhm, currently, can you tell me about where you're living and who you're living with?

P: Yeah, so I'm living with my wife in a house. I do have two kids, but they're off to college right now so it's just us 2.

D: OK, and and what what do you do for uh for work?

P: Yes, so I actually work as a mechanic, and right now I'm kind of off of work with, I just need to recover and kind of get that physiotherapy done and then I can return, hopefully in a month or two.

D: OK, yeah we need to recover after the knee surgery. OK, and do you smoke cigarettes?

P: I used to, but I quit when I was in my thirties. I used to smoke like probably a pack a day between my 20s and 30s.

D: OK, but it sounds like yeah, you quit, about 20 years ago then?

P: Yeah.

D: OK, and do you drink alcohol?

P: Uh no.

D: OK, how about using any other recreational drugs?

P: No other drugs.

D: Ok, and in the family, are there any heart conditions or or lung conditions?

P: No, not that I know of.

D: OK, and anybody in the family have a bleeding disorder or or a clotting disorder?

P: No, not not that I'm aware of.

D: OK, have you heard of anybody in the family having, I know you said you haven't had had this before, but anybody in the family having a deep vein thrombosis or or PE.

P: Not that I know, not really.

D: OK. So that was everything that I wanted to ask about on history today. We'll do physical exam and I'll listen to your chest and have a look at your leg. We'll also order some imaging studies, with a CTPA it's called. Uh but before we go ahead with that, was there anything else that that you wanted to add?

P: No, I think that's that's all.

D: OK, so we'll get the lab work started, as well as the imaging ordered. It will look for, to see if there is any pulmonary embolism present, because with the surgery last week and being immobilized for a period of time, it is a risk factor for it, and leg swelling with uhm coughing up blood can be symptoms of this. So we'll wanna make sure to to do, to investigate for a pulmonary embolism.

P: OK. Sounds good, thank you so much.

D: Sounds good, thank you.


D: What brings you in?

P: Yeah, so I've been feeling just really down recently in the last week. I started off by having this sore throat which started around 5 days ago and then I also noticed I've been getting some chills over the last few day. And on top of all of that, within the last three to four days I've been getting muscle aches all over my body.

D: OK, alright so the sore throat started 5 days ago and then the fever started when?

P: So the fever. I think I haven't measured it, but I started having chills like 3 days ago.

D: Three days ago, OK, and the muscle aches started two days ago?

P: I would say 3 days ago as well.

D: Three days ago, OK. OK, are you having any trouble swallowing foods or fluids?

P: A little bit with solids with a sore throat but liquids, I'm doing OK right now.

D: OK. And is it hard for you to like, are you having issues vocalising at all?

P: No, I think my voice has been the same. It's just when I'm not talking, especially if I'm swallowing my own like spit, it still hurts sometimes, but mainly with solid food.

D: OK, OK and then, are you having any issues with taste or smell?

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

D: OK, how about hearing or vision?

P: No, no changes.

D: Any weight loss over the past few weeks?

P: No, I probably have gained weight.

D: OK, any fatigue or exhaustion?

P: Now that you mention it, I do feel pretty tired over the last few days, I don't know if it's just because of my muscles aching all the time, or I don't know. I have definitely felt very tired.

D: OK, how about changes in your hair, nails or skin like rashes?

P: No, nothing like that.

D: Do you have a cough at all?

P: No, I haven't really noticed the cough.

D: How about shortness of breath or wheezing?

P: No, no shortness of breath or wheezing.

D: OK chest pain or you feeling like your heart's racing?

P: No.

D: No, and how about dizziness or fainting spells?

P: Uh, no, I haven't had any of those.

D: OK, how about changes to your bowel movements?

P: No, I don't think so. I go regularly once a day and I haven't noticed any watery stool or diarrhea.

D: OK, that's good. Any changes in your appetite?

P: Yeah, with a sore throat I tend to like eat softer foods right now. I can't really, I don't really feel like eating.

D: Yeah, OK. How about nausea or vomiting?

P: No, no, nothing like that.

D: OK, OK, and any issues with joint pain? You said your muscle aches, but how about joints?

P: Um, no, I don't think it's specifically my joints. I think more so I would say like around in my thighs. Then I would say just my upper arms hurt a lot. And even, uh, my upper back area hurts a lot as well, so it's kind of just everywhere. But those are some areas that hurt the most.

D: OK, OK, are you otherwise healthy?

P: Um, yeah, I do have a couple of things on my list. I do have high blood pressure. I have diabetes and other than that, I also have like high cholesterol.

D: OK.

P: Yeah, that's just some of the things that I've been diagnosed with.

D: Yeah, OK, and do you take medication for any of these things?

P: Yeah, so I take for the blood pressure, I take this medication called the Ramipril.

D: OK yeah.

P: And then for diabetes I'm taking Metformin. And then for the cholesterol I'm taking this medication called Crestor, yeah. Yeah, but other than that, just like vitamin D and multi vitamins. Those are some of the medications that I'm taking.

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

P: Yup.

D: OK, do you know if you got a vaccine called Shingrix for shingles and Pneumovax for pneumococcal infections?

P: Yeah, I actually think I got them just this past season. Uh, with all this COVID going on, I just wanted to make sure I got all those vaccines as well. So yeah, I recently just got them.

D: OK, good. And and how about any allergies?

P: Uh, no, I don't have any allergies.

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

P: Uhm, no lung conditions and uhh heart conditions, both my mom and dad suffered from like high blood pressure. My dad also had a heart attack when in his 60s. Now there is some heart conditions that run in the family.

D: OK, OK. And then any cancers in the family?

P: Uhm, m son actually got diagnosed with colorectal cancer just a few years ago.

D: Oh, I'm sorry to hear that.

P: He's doing OK though. Like it was pretty scary at the time.

D: How old was he when he was diagnosed?

P: I think he was, yeah in his forties, 46.

D: OK, well he's yeah, that's young. Have you had a colonoscopy?

P: Yeah I had it done. Everything came back normal so yeah, I'm not sure where he got it from.

D: OK. Have you had any sick contacts recently?

P: No, no sick contacts that I know of. I've been mainly in my house. I do go outside for groceries and some things like that, but other than that I'm retired. I don't really go out too much.

D: Yeah, OK, and you said you're retired. Do you live alone? Do you live with anyone?

P: No, yeah, I live alone now. And I live in London in an apartment

D: OK, any old carpets? Mold, dust, asbestos?

P: No, nothing like that. It's a pretty safe building.

D: OK, good, and do you smoke?

P: I used to. I used to smoke, probably in my 20s to late 40s, but then I quit.

D: OK, good, good for you. How much did you smoke before you quit?

P: Probably one to two packs a day, I would say.

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

P: Uhm, I just stick to some red wine, maybe a couple times a week.

D: OK, couple times a week so two to three times?

P: Yeah, I would say two to three times and, uh, I probably go through maybe 1 bottle every two weeks.

D: OK, OK. And then any marijuana?

P: No, no, I've never had any marijuana or any recreational drugs, no, nothing else.

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

P: Yeah, uh, with all this COVID and the pandemic going on, I don't know, I like, I've been mainly at my house, but like I said I do go to do my own groceries. Of course I wear a mask, but I don't know if I might have caught COVID,  so that's something I was worried about.

D: Yeah, for sure. I think just because your symptoms do overlap with those of COVID, we will be doing a COVID swab today and you should hear back about your results in 24 to 48 hours. But you should still self-isolate for 14 days because you do have similar symptoms and if it's not COVID, it's probably another viral illness that's going around these days and for that you don't need any medication, like prescribed medications, but just keep an eye on that, on your symptoms. Stay hydrated, eat well. If you need to lower your feve, you can use Tylenol. And if your symptoms worsen or you start getting neurological symptoms like weakness or seizures or anything like that, you should seek help from the ER. How does that sound?

P: Sounds good. I just had another quick question. I did get the shingles and the pneumococcal vaccine back then but I didn't get the flu vaccine, like should I get it? Is it recommended?

D: Yes, it's definitely recommended. So we won't give you the vaccine right now because you have symptoms. But once you are healthy again, you should definitely get the get the flu vaccine and you should get it once a year.

P: OK, I just never took those vaccines, but I'll do that from now on.

D: Yeah, it's a good idea, and even if you get the flu, your symptoms won't be as severe if you have the vaccine, so it's definitely something to consider.

P: OK, alright sounds good.

D: Alright, take care.


D: What brings you in today?

P: I so I've just had this pain in my chest for just over a week now and it's caused me to have trouble breathing.

D: OK, um how old are you, Jen?

P: Um 52.

D: OK when did this pain start? You said a week back?

P: Uh, yeah, just about that I I think maybe 8 days ago.

D: OK, and is it a constant pain? Is it always there?

P: Ahh it it is, but it's definitely worse that um, it's the breathing that's been bothering me a lot more. When I take a deep breath that the pain is a lot worse.

D: OK, OK um. And when you do get that, get that pain. How long does it last?

P: Um I would say, uh. Around 15-20 minutes. It's it goes away over overtime.

D: OK, and the shortness of breath do you have that at rest as well?

P: Uh no if I if I take a break or sit down to rest then I can usually catch my breath. But if even if I'm doing a little bit of exertion like walking a few a few blocks or something like that I'm finding it, I'm I'm short of breath.

D: OK um do, did anything trigger this a week back? Any trauma to the chest area? Anything like that?

P: Uh, No, no one else has been sick. I I had a cough about a week ago so I thought it might be a
chest infection, but I'm not feverish, so I'm not sure.

D: OK, the cough is it still there?

P: Yeah, it's um. I still have a cough.

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

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

D: OK, how about sputum?

P: Um, no sputum.

D: No, OK. And do you feel like you're wheezing?

P: Oh no wheezing.

D: No wheezing, OK. Um, the shortness of breath 1 to 10, 10 being the worst, the most severe. How bad is your shortness of breath?

P: I would say when I'm exerting myself, it could get up to like a 7 or 8.

D: OK, and you mentioned how, how far can you walk before you need to rest.

P: I I would say maybe 100 meters. But before I was able to run uh like I was running a few days per week so. So this is not like me.

D: OK and the chest pain. Is it sharp or is a dull crampy? What does it feel like?

P: I say it's sharp.

D: OK, have you ever experienced this before?

P: No, nothing like like this before at all. I I have never had any, any problems like this before?

D: OK um, and has it changed since it started a week back or has have your symptoms been pretty much the same?

P: They've been pretty much the the the same.

D: OK, OK Um, do you have anything like COPD, Congestive heart failure, anything like that?

P: No, I've never had any heart problems, uh in the past. I've been healthy up to this point though, nothing I see a doctor regularly for.

D: OK, OK. This you mentioned, no fevers, no chills. And no night sweats too I guess?

P: Yeah, no night sweats.

D: OK, and how about weight loss? Any weight loss?

P: No weight loss

D: No, OK. Um, have you experienced any changes in your vision?

P: Yeah no, my visions been been, been fine.

D: OK hearing?

P: Hearing has been OK.

D: OK, how about smell?

P: No changes in smell.

D: No, um have you had a stuffy nose or runny nose in the past week or so.

P: No, it's just that the dry cough.

D: OK, dry cough. Any changes in your skin like rashes?

P: no rashes.

D: OK, and you mentioned some chest pain. Any palpitations like you feel like your hearts racing?

P: Uh, actually I did feel like that a little bit. Especially when I was moving a little bit more, I felt like my heart was racing.

D: OK, um, any calf pain.

P: Um yeah my left, my left leg's actually a little bit sore.

D: OK, any swelling in the area?

P: um uh nope, I don't see any swelling there.

D: OK, no?

P: Um, Yeah, we'll say that there is swelling.

D: Oh, OK. And, and you mentioned shortness some shortness of breath on exertion, how about when you're laying down?

P: Not when I'm laying down.

D: No OK, and not when you're OK, not when you're laying down, OK. Um alright and in terms of like
your stool, so bowel movements and urination. Like all of that's normal?

P: Yeah, all that's been normal.

D: OK, any headaches?

P: Um no headaches.

D: no, no confusion?

P: No confusion.

D: OK, how about dizziness or fainting spells?

P: Um, No fainting spells.

D: OK, OK, and have you already received any sort of imaging or pulmonary function tests or anything like that for this recently?

P: Oh no. I I I haven't.

D: OK and are you otherwise healthy? Do you have any past medical history of any conditions really?

P: No, like I've been um previously healthy, but I I guess I did have a hysterectomy a few weeks ago. I know it was, I I didn't bring it up before 'cause it's just a day procedure, but I was definitely
spending a lot more time um relaxing at home after that, a few weeks ago.

D: OK, OK, so you haven't been moving around as much. I guess since the hysterectomy?

P: yeah exactly it's starting to it was starting to get, the pain was starting to improve but it was keeping me on the couch a lot of days.

D: OK, yeah. Um, are you on any medications?

P: Um no I try, I've tried some Tylenol and Advil for the pain throughout this week, and it didn't really help much. But other than that, don't take any any medications, nothing for blood pressure or anything like that.

D: OK, and sorry. What was the hysterectomy for?

P: Um I I was having a lot of bleeding.

D: OK, so were they thinking it was like a cancer or something?

P: Um I think it was um. It was from Fibroids.

D: OK, OK and then,  So you mentioned no medications, any allergies?

P: Um no allergies to medications .

D: no. And are you up to date with any with all your immunizations?

P: Um, I am yeah.

D: you are OK. Any family history of lung conditions?

P: No lung conditions.

D: But how about heart?

P: Yeah, it's just my mom had a heart attack when she was 56.

D: OK, OK. I'm sorry to hear that. And. Any history of family history of something called pulmonary embolism or DVTS.

P: Uh, no, I haven't heard of a heard of pulmonary embolism before.

D: OK, so it's basically blood clots in your lung. And then DVT's are deep vein thrombosis. So also blood clots but in different parts of your body.

P: OK.

D: Yeah, anything like that that you know of?

P: Uh no, I I have might have heard of something like that happening in my mom actually, it might have been related to her heart attack, but I'm not specifically sure.

D: OK, sure. Um an then do you smoke?

P: Um I I smoke, I may be about half a pack of cigarettes per day. I've smoked ever since I was a teenager. I've tried to quit multiple times I I was smoking about a pack per day before, so I have
cut it down, but still something that I'm working on.

D: OK good, I'm glad you're trying to cut down. Um, we have resources available if you're interested
in some more help. And you smoke um marijuana?

P: No, I don't.

D: OK. Any use of other recreational drugs?

P: No, no.

D: OK. And how about alcohol? Do you drink alcohol?

P: Uh may be a glass of wine on the weekends, but other than that no.

D: OK. I mean, have you had any sick contacts recently? People around you? People you live with at work.

P: I can't think of any anybody who's been sick no.

D: OK, OK, and and what do you do for work Jenn?

P: I work as an administrator at at a bank.

D: OK, OK. I'm and I have you traveled anywhere recently?

P: Um, no I I can't remember the last vacation.

D: OK, alright, and so those are all the questions that I had for you. Did you have anything that you wanted to add? Anything that I hadn't touched on?

P: Um No, I think you covered everything. Thank you.

D: OK yeah, no worries. So I guess at this point we would do a physical exam. Just take a listen to your lungs and your chest. After that, so right now it sounds like it could be something vascular you know, like a pulmonary embolism like we talked about. That's kind of high on my list of things to
work up for. But also, we don't want to miss other things you know, like
cancer, infection, autoimmune things that could affect your lungs, so we'll just do a
work up for all of that. How does that sound?

P: Yeah, whatever, whatever you think we need to do.

D: OK sounds good. Thank you for your time.

P: Yeah, thanks.


D: How may I help you?

P: I'm I'm here because I, I've oddly been feeling really short of breath and have a fever or and a cough.

D: OK, when did the shortness of breath start and are you short of breath now?

P: It started about uh, I guess I could start yesterday. And a little bit, but it's getting better.

D: Started yesterday, OK, well I'm glad, it's getting better. When did the cough start?

P: It started around the same time.

D: OK, it is it. A dry cough or or wet cough?

P: It's a dry cough.

D: OK, is it? Is this cough new or if you had a cough before?

P: No, it's it's kind of new.

D: Alright, have you brought up any, I know you said its been but have you brought up any blood?

P: No.

D: OK, and have you had any wheezing?

P: No.

D: OK. And you mentioned a fever as well. Have you checked your your temperature today or yesterday?

P: Yeah, it was at 38 last night.

D: Are you feeling feverish today as well?

P: Yeah, a little bit.

D: OK, and uh. So have you had any any infectious symptoms, like runny or red eyes?

P: No.

D: How about a runny nose or feeling congested?

P: No, no, it's just a cough.

D: Cough? OK. And what what, were you around any triggers yesterday or like around any anything that was out of the normal for you?

P: I got a notice that this happens to me every time I go to my boyfriend's place, so I started dating, I started dating someone new about six months ago and every time I go to his place, a couple hours later I just like develop these symptoms, just kind of odd. I thought that I was just getting a cold. But now that it's happened like three times, I'm thinking maybe you have some sort of an allergy like maybe,  I don't know. Maybe it's like yeah, I'm just allergic to something. Maybe his plants or something. I don't know.

D: OK, and it does this happen each time that you go go to his house?

P: Um, yeah, yeah. Kind of almost yeah, that's like you haven't like. I haven't been to his place very often because of the pandemic. But yeah, every time I go kinda feel really crappy after.

D: I see OK and, uh, are there any other environments you can think of where this happens or have these symptoms happen at any other point?

P: No, I don't think so.

D: OK. And have you had a sore throat?

P: No.

D: How about any losses of smell or or taste?

P: No.

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

P: No, no. I haven't.

D: K, and have you had any nausea or vomiting

P: No.

D: Alright, and any abdominal pain or diarrhea?

P: No.

D: Any urinary problems like painful urination or frequency?

P: No.

D: Have you had any muscle aches or body pains?

P: Yeah, yeah. Just act different feeling achy and kinda tired these past well like 12 to 14 hours.

D: I see OK, so it has been kind of like all over or there are particular muscles sore or our body part?

P: No, it's it's like all over.

D: OK, and you've been fatigued as well?

P: Oh yeah.

D: OK. Have you had any headaches?

P: No.

D: Any skin changes or rashes?

P: Uh, no.

D: Alright. And then how about any night sweats or chills? I know you mentioned fevers.

P: No, I've just been feeling hot.

D: OK, I mean, how was your weight been over the last several months? Is it like have you lost weight or gaining weight or is up in the same?

P: Kind of in the same.

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

P: No, I'm pretty healthy.

D: OK, you see. Yeah, you haven't had asthma in the past or or anything like that?

P: No.

D: OK, any allergies to medications you're aware of or or environmental things like or dust or pollen?

P: No no. Which is why I was kind of surprised. I'm usually fine and I spend a lot of time outdoors so, I don't know. Yeah, I was surprised when this happened when I went to his place.

D: OK, did you ever get these kind of symptoms if you are like yeah or around smoke or or anything like that, you could maybe be inhaling or or even if you are outside in the cold?

P: No.

D: OK, and you get seasonal symptoms like throughout the year you get like itchy runny eyes or like. Like a runny nose?

P: No, no. That hasn't happened to me.

D: OK, and do you take any medications?

P: I just take a birth control pill.

D: And when, how long have you been on that for?

P: About three years.

D: OK. And any prior surgeries or hospitalizations?

P: Oh no.

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

P: I live alone, uh? I have an apartment next to the University.

D: OK, and any potential for being around anybody who's been sick like your boyfriend or his family or or anywhere else?

P: No, I've just been visiting him and I just go grocery shopping. I've just I've been doing schooling online. Yeah, I don't think so. I'm usually very careful, I'm not. Yeah, I'm not maintaining social distancing with my boyfriend. He's in my social circle, but yeah, other than that no one I think yeah.

D: Ok. And have you traveled anywhere?

P: No.

D: Alright then are you currently working or going to school?

P: I'm going to school.

D: OK, cool and uh. And are you currently sexually active?

P: Yep.

D: OK, and are you using birth control. Are you using condoms?

P: Yep. OK, any concern for any sexually transmitted infection at this time?

P: No. No, I'm very careful.

D: OK? And do you smoke cigarettes?

P: No.

D: Do you drink alcohol?

P: Sometimes if, like during like parties and stuff, but I haven't really been drinking much 'cause there's nothing going on.

D: OK yeah I see. And uh do use any recreational drugs?

P: No.

D: Alright, then umm in the family is there a history of any lung problems or any any heart problems?

P: Um just high blood pressure. My mom and dad have it.

D: OK. And so I wanted to ask about the boyfriend's house as well. Is there any pets in the home there?

P: Oh yeah. Yeah, he has this cute little parrot. And he also has a cat.

D: OK, and do you have any pets at your house?

P: No, no I don't.

D: Oh, OK. So that I think that was everything that I wanted to ask on on history today, was there anything else I forgot to mention or you wanted to to bring up?

P: I don't think so, no.

D: OK, so it sounds like there's potentially could be caused by an allergen such as which could be   from an animal like a parrot or a cat that is causing just a reaction and it's bringing these symptoms on like called hypersensitivity pneumonitis, but also we can't rule out asthma as well as being a trigger of kind of the cough and shortness of breath is being around allergens as well, so we'll order pulmonary function test, and maybe some, uh, uh, imaging and chest x-ray and we will go from there.

P: Great, thank you.


D: What brings you here today?

P: Um I'm here because my left hand, kind of just like at the base of my thumb, has been hurting for the past two days and it seems to be getting worse, um and I'm left handed so it's really hard for me to write or do anything um where I have to like, clench or grip things.

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

P: Uhm, so for the past two days, but it's got, it got bad yesterday.

D: OK, and have you had any, uh if you were to describe the pain, where is it located exactly?

P: It's just at the base of my thumb. Uh you know where the fleshy part of your hand is?

D: OK yeah yeah.

P: Yeah, so just just over there.

D: OK, and what kind of pain is it? Is it sharp or is it aching?

P: Uhm, it's it's like a um, at baseline it's an achy pain, but if I try to move it or um try to write or you know, use a computer or anything like that, it becomes sharp.

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

P: I'd say like a 6.

D: OK, and does this pain move anywhere else in your hand, or does it just stay where you described?

P: Um it just stays there.

D: OK, and what kind of motions uh cause the most pain?

P: I'd say like um you know, trying to touch my pinky with my thumb, that that hurts. Um just like trying to rotate it hurts.

D: OK, um have you tried anything for the pain that has helped?

P: Uhm, no, I haven't really tried too much. I've just I just tried not to use it as much.

D: I see. OK. And um, has this ever like, have you ever had any injuries to this hand? Any trauma either recently or in the past?

P: No, no, nothing like that.

D: OK. Alright, and is there any, do you do any kind of repetitive work that requires gripping or lifting um with that hand, anything repetitive?

P: So I do a lot of work at the computer. And um I guess I tend to type a lot with my left hand, so maybe that.

D: OK.

P: And sorry I also take lots of notes, like handwritten notes with my left hand.

D: OK, so are you left handed?

P: Yes.

D: OK. Alright. Have you been diagnosed with any medical conditions in the past?

P: No.

D: No, so you're healthy?

P: Yes.

D: Um do you take any medications on a regular basis?

P: Uh no, no.

D: No, OK. Any allergies to any medications?

P: Um no allergies.

D: OK, um any previous surgeries or hospitalizations?

P: No.

D: No, any family history of any medical conditions, whether it's musculoskeletal, rheumatological, any conditions?

P: Uh no, nothing like that.

D: OK, um any cancers in the family?

P: Um I know there's, yeah there's a lot of cancer in the family. There's colon cancer, breast cancer, ovarian cancer.

D: OK. And are they first degree relatives who had those cancers?

P: Uh no first degree relatives, just like aunts and uncles.

D: OK. Uh alright, and currently are you working right now or have you had any time off work or any modified duties?

P: Um so I'm still working online, I've just um haven't been taking notes by hand anymore.

D: I see, and does that help though?

P: Uh yeah it it has helped a little bit because I'm not moving my hand as much so it helps with the pain.

D: OK. Have you taken any uh Tylenol, Advil, anything for the pain?

P: No, I haven't.

D: OK. Alright. And currently right now, what is your living situation like?

P: Uh I live in an apartment by myself.

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

P: Um I smoke, I used to smoke like five years ago, and I only did that for like a year or two, um and it wasn't very much. But I don't smoke anymore.

D: OK, that's good. Um any alcohol?

P: Um I'll have like a beer on the weekend.

D: OK. Any recreational drugs like marijuana?

P: Um I will take an edible like once a month.

D: OK. Um and yeah, those were just some of the questions I had um and we're just going to do a few things for examining, examining uh that area. So are you able to make a fist?

P: Um I can, but it hurts.

D: OK, it hurts in that location that you mentioned?

P: Yes.

D: How about um if you make a fist without your thumb, does it still hurt or is it just when you are moving the thumb?

P: It's just when I'm moving the thumb.

D: OK. And if you were able to, are you able to uh rotate your wrist?

P: Uh yes, I can rotate my wrist.

D: Does that hurt at all?

P: No.

D: OK, um now I just want you to do this one test. It's called a Finkelstein test. OK so I want you to flex your thumb, press it up down against your palm.

P: OK.

D: And then hold your hand, sorry.

P: No, go ahead.

D: Yeah, and then after you do that, um, bring your fingers above your thumb, so just cover your thumb.

P: OK.

D: Kind of like a fist, but your thumb is on the inside of your fingers.

P: OK.

D: And then bring your uh arm out.

P: OK.

D: And with your other hand, can you, from above push your wrist downwards? So your uh pinky finger is uh pointing to the pointing to the ground.

P: OK, yep.

D: Yeah, and did that hurt at all? Like when you, so this is just called ulnar deviation or your um of your wrist. Does that hurt at all?

P: Yes, that is very painful.

D: That's very painful, OK. Alright, um and then you're also having pain with gripping and, OK, so those are kind of all the things I wanted to ask. Uh it seems that you may be having something called De Quervain's tenosynovitis. Um it's caused by some repetitive motions, uh it can be due to gripping. Sometimes it happens to new mothers who are lifting their children as well as daycare workers. It can also happen in other work environments, and so what we will first just need to do um is mainly to rule out something like osteoarthritis. You are fairly young um but if there was ever an injury in the past, it you can have early osteoarthritis in the area. So we just want to get an X-Ray. And other than that, the way we kind of deal with this issue is usually conservatively and with a splint.

P: OK.

D: And a sling for your thumb that uh helps relieve some of these symptoms, uh restricts some of your movements, reduces some of the swelling, and if it does get really bad and it's affecting your work and conservative management with pain and the splint don't work, and with physiotherapy, we do uh offer injecting corticosteroids into just right like in the area that you mentioned, right below the thumb.

P: OK.

D: Um and that often has some effect as well. Um but at first, yeah, let's just do some conservative management and see if that helps. It's only been a few days, so hopefully um what we try first helps. And then we can go on from there.

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

D: Welcome, take care.

P: You too.


D: What brings you in?

P: I've I I've had a, ah really runny nose and kind of feeling like like my nose has been obstructed. And I've kind of had this like sore throat as well over the last several days.

D: OK, so did the rhino start first or the nasal obstruction?

P: Yeah, they they kind of started it around the same time.

D: OK, and when was that?

P: About four days ago.

D: Four days ago. And then when did the sore throat start?

P: Uh, yeah, that started about two days ago.

D: Two days ago, OK. And and the, uh discharge is it is it clear? Or are you seeing colors?

P: It's pretty clear and watery.

D: So you're not seeing anything yellow, green or bloody?

P: No, not nothing like that. I haven't seen any yellow, green or or bloody.

D: OK and then your sore throat. Is it making it hard for you to swallow solids and fluids?

P: No pain with swallowing, just can kind of feel it there.

D: Yeah, any coughing?

P: Yeah, actually I started to have a bit of a cough. Uh, just this past day it's it's just started.

D: Is it a dry cough or is it a wet cough?

P: It's dry.

D: It's dry, OK. So you're not bringing up any sputum or blood?

P: No sputum or or blood.

D: OK good. And and then any shortness of breath?

P: No.

D: No, any wheezing?

P: No.

D: No wheezing, OK. Any chest pain?

P: No.

D: No, um, any fainting spells or dizziness?

P: No.

D: No, OK. And then any changes in your vision or hearing?

P: No.

D: Any changes to your smaller taste?

P: No.

D: OK. And any weight loss?

P: No, it's been stable.

D: OK, how about fevers?

P: No, I don't think I've had a fever.

D: No, OK. Uh, chills or night sweats?

P: No.

D: No, OK. Uhm, any rashes?

P: No.

D: No, OK. Uhm, and then any changes in your bowel movements?

P: No, I haven't had any diarrhea or, or constipation. Nothing like that.

D: OK and nausea or vomiting?

P: No.

D: No, OK. And then how about abdominal pain?

P: No abdominal pain.

D: OK, any changes in your urine?

P: No, no pain with urination.

D: OK, how about uhm gassiness or bloating?

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

D: OK, headaches?

P: Yeah, I have had a bit of a headache. I felt kind of like a a pressure of, well, I felt kind of like a pressure in my face and a headache.

D: OK. Uhm pressure in your face and a headache, OK. And do you normally get these?

P: Wait, no, I think I get headaches when I'm sick or I don't don't sleep well. And I mean I, I have been feeling pretty fatigued the last few days and, uh, yeah.

D: Yeah. Is it the worst headache you've ever had?

P: No, there, it's pretty mild, it's just kind of annoying 'cause it's still there.

D: Yeah, for sure. Uhm, alright. And then any muscle aches or joint pains?

P: No, nothing like that.

D: No, OK, good. And are you otherwise healthy or do you have any longstanding medical conditions?

P: I'm healthy, I haven't had any any conditions.

D: OK, that's good. Have you been hospitalized for anything? Have you ever needed surgeries?

P: No, I haven't.

D: OK, that's good. And are you on any medications?

P: No medications.

D: Alright, that's good, and then I'm are your immunizations up to date?

P: They are, yes.

D: OK, any allergies?

P: No allergies.

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

P: No. No. Everyone in the family is healthy.

D: OK, do you smoke?

P: Nope, I don't.

D: How about recreational drugs?

P: No. Well, I I use like I'll have a joint every once in awhile, like socially with friends, but uh, that's I mean, maybe a couple of times per month.

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

P: Yeah, I'll have uhm, like I don't know, a few beers on the weekend maybe so I don't know, maybe like four or five drinks per week.

D: OK. And then have you been in contact with anyone sick recently?

P: No, I am. I don't, I don't think so. I live, uh, in a student house, though, with that like four other people.

D: Oh, I see.

P: Yeah, just finishing up some school here in town.

D: OK, and had they been sick at all or had similar symptoms?

P: I think one of the guys last week had I had a little bit of a cough. And I don't know that yeah, said he wasn't wasn't feeling well.

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

P: No, been been just at home.

D: OK, Alright, no travel. And where do you live right now?

P: So I, I just live in a student house with a.

D: Oh yeah, sorry, you said that.

P: Oh, no problem.

D: I guess I'm trying to get at. Uh, are there any old carpets you know reasons for you to believe that there may be a lot of mold or asbestos or anything like that in the house that may be making your symptoms worse?

P: It's mostly like hardwood or like kind of ceramic flooring so there aren't many carpets and things like that, so I guess no.

D: No. OK, alright and those were kind of all the questions that I had. Did you have anything to add or anything you wanted to discuss today?

P: No, I was just I. wondering what might be going on. It's been a few days.

D: Yeah, for sure uhm so it sounds like you may have a viral infection, and because your symptoms overlap with those of Covid, we will do a Covid swab on you just to rule that out. Uhm, but from the sounds of what your symptoms are, it, it is most likely to be a common cold, in which case you can just manage it with a lot of hydration, nutrition, good sleep. But if your symptoms get worse or they're not going away after a couple of weeks, or you're having neurological deficits like weakness or seizures, you should get help from the ER. Does that sound OK?

P: Yeah, for sure I haven't had any any symptoms like that, so so far, so that's good.

D: Yeah for sure. Alright, take care.

P: Take care, thank you.


D: I was wondering if we could start by you telling me what brought you in today?

P: So I just came in today because I've been having a sore throat.

D: OK, could you tell me specifically where you're feeling the pain?

P: I would say it's mostly at the back of my throat.

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

P: I think it started last night.

D: OK. And how would you describe the pain? Is sharp, burning, stinging, dull?

P: I would describe it as like a burning pain.

D: OK, and uh, has anything, has the pain been getting any better any worse?

P: I think it's getting worse since last night.

D: OK, and any prior episodes like this where you had similar symptoms?

P: Nothing, nothing recently that I can recall, no.

D: OK, are you feeling the pain radiate anywhere else?

P: Uh, I think it's just staying at the back of my throat.

D: OK, and can you think of anything that triggered the the sore throat that you did just prior to the symptoms coming on?

P: Uh, no, not that I can think of. I haven't really changed what I drink or what I eat. Nothing really changed.

D: OK, and anything that's been making the pain worse?

P: Um, I would say when I, uh, especially when I'm eating when I'm swallowing, it hurts a lot, but that's about it.

D: OK. Anything that makes it better?

P: Uh, I I think when I drink like colder liquids or ice cream, it just soothes he pain a little bit.

D: OK. Any other symptoms that you been experiencing?

P: Um, so I I do find that like my mom told me, that I have my voice is kind of rough and like just a little bit hoarse. But other than that, besides the swallowing, um, nothing else really. I'm still able to swallow liquids but it's just the solids that causes some pain.

D: OK, have you had anything to eat today or when was the last time you had anything to eat?

P: I think I did have lunch today. I wasn't able to eat too too much just because of the pain. But yeah, just a couple hours ago I had I did have a lunch.

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

P: Sorry, what was that?

D: Have you noticed any changes to your like do you think your voice sounds different too?

P: Yeah, I definitely think um, like when I woke up this morning, my voice was definitely more like hoarse and more like raspy, almost. But yeah, I would say my voice has changed.

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

P: I definitely felt a bit chilly yesterday in the morning. I I didn't take any temperatures. I think you guys did take a temperature when I came in today. I I don't know what it was.

D: OK, yeah um you did have a fever today when coming in.

P: OK.

D: Uh, OK. Have you had any headaches?

P: No no headaches.

D: OK, how about any nausea or vomiting?

P: Sometimes I feel like with the pain and I think there's a lot of just swelling back back in my throat that when I talk too much, I almost feel like I'm about to gag, but I haven't really thrown up at all though.

D: OK, but you do feel like your throat is swollen?

P: Mhm.

D: Alright, and how has your energy been? Have you been experiencing any fatigue?

P: Yeah, I would say definitely the last few days, especially yesterday. I just felt exhausted, didn't really want to do anything.

D: OK, notice any skin rashes or or changes?

P: No, no skin skin rashes.

D: OK, and have you had a cough?

P: No, I haven't had any coffee.

D: How about any difficulty breathing or shortness of breath?

P: No, I think my breathing has been fine.

D: OK um, and how is your appetite?

P: Yeah, over the last few days, especially today, I just feel like with the pain I don't really feel like eating at all.

D: OK. And any recent changes to your weight?

P: No, I I I weigh around 150 and that hasn't really changed at all.

D: Alright, and uh, have you had any infections recently?

P: I think a couple of weeks ago I I did have a I would say like a bit of a runny nose. Maybe a little bit of soreness of my throat, but it just went away by itself.

D: OK, so you didn't have any treatment for that?

P: No, I didn't have any medications or anything. I didn't even go to the doctor then.

D: OK, and have you noticed any lumps in your in your neck or under your chin?

P: Uh no not that I know, I haven't really checked, but I haven't noticed anything like remarkable.

D: OK, um any changes to the smell of your breath?

P: I I don't know about a smell, but I do feel like I have like this gross taste in my mouth. Maybe I don't know. I think it might smell a little bit, but I definitely have that really gross taste.

D: OK, and uh, do you have any abdominal pain?

P: I do feel that like my stomach is a bit sore, especially today, but nothing I'm too worried about.

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

P: No. I've been fortunate. I'm completely healthy.

D: Any allergies?

P: No allergies.

D: Any medications?

P: Uh, no.

D: Any hospitalizations?

P: Nope. Never.

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

P: Uh, so just a couple of weeks ago, around the time when I had some cold symptoms, my girlfriend also had a sore throat and it lasted for around a week. Yeah, so I would say just my girlfriend.

D: OK, does your girlfriend have a sore throat now?

P: No it it started, I think around 2 weeks ago and it stopped last week.

D: OK, any surgeries before?

P: No, no surgeries.

D: Alright in the family, any history of cancer or cancer, early cardiovascular disease or chronic diseases?

P: Uh, I don't know about the rest, but I I, my dad does have type 2 diabetes, but no cancers or no like heart attacks or anything like that.

D: OK, and right now, how are you supporting yourself financially?

P: So I am currently not working. I'm going to college right now, majoring in the arts. Right now I'm living in dorm, I've been fortunate, my parents support me financially, so I'm currently not working, just a student.

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

P: Just just on the weekends when there's a like get togethers and parties. But throughout the week I I don't drink anything.

D: OK, and do you smoke cigarettes?

P: Uh no I've never tried cigarettes.

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

P: No, no. I try to stay away from all drugs because I I'm also an athlete so I need to make sure that my body is completely healthy.

D: OK, and are you currently sexually active?

P: Yes.

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

P: So I just have one partner for the last couple months, my girlfriend. Before that, throughout the year, I think I've had two other partners. But yeah currently right now, just my girlfriend.

D: OK and men or women or both?

P: Oh no, I'm I'm straight. Like I I've only been with women.

D: OK, and how many partners have have you been with over the last six months or the last year?

P: I would say for my girlfriend, two other girls, so three in total in the last year.

D: OK, and do you use a condom?

P: Uh I I always try to use a condom like the last thing my parents would probably kick me out if I ever got a girl pregnant. So yeah, I always always use a condom.

D: OK.


D: What brings you here today?

P: Hi I am having difficulties breathing and I've just had this cough and it's, It's been two months now.

D: Two months, so did the two months of the difficulty breathing or the cough?

P: Two months of difficulty breathing and the cough is gotten worse. I've had a cough for a couple years now. I'm a smoker.

D: OK and is is this cough different at all?

P: It's just, it just doesn't go away.

D: OK, and when did the shortness of breath start?

P: About two months ago.

D: OK, and is it getting worse?

P: oh yeah

D: OK. Are you bringing up any sputum at all with your cough?

P: Uhm? I sometimes uhm, yeah I do.

D: OK and is is there any color to it or is it clear?

P: it's pink in color

D: It's pink in color?

P: Hmm

D: Ok. Have you coughed up any blood at all?

P: Sometimes

D: sometimes?

P: Streaks of blood here and there.

D: Little streaks of blood? OK, and have you ever coughed up any just without without it being in the sputum, just onto a tissue or anything like that? Just coughing up any blood?

P: No.

D: OK. So an are your symptoms just constant over the last two months or do they come and go?

P: Shortness of breath just kind of stays.

D: OK, and is there anything that helps with your shortness of breath, like taking a rest or any positions in particular?

P: Yeah, sometimes resting does help. I find that it's worse when I'm moving around, I'm huffing and puffing more.

D: OK, and is it worse at all when you lay down?

P: No.

D: No? And do you find yourself ever having to wake up at night and gasp gasping for air?

P: No, it hasn't gotten that far but seeing how bad it's been over the past two months and how fast is progressing, I won't be surprised if I can't even sleep. It's been quite difficult I I don't even know why I waited so long. I should have come in earlier.

D: Well, I'm glad you came in today. We can definitely try and help you with what's going on. Do you at all use any kind of medications to help you with your symptoms?

P: I've just been using my inhalers a bit more but they don't always help.

D: OK, and what are you using the inhalers for?

P: Oh, I have COPD.

D: COPD? OK, and when were you diagnosed?

P: It's been 15 years now.

D: 15 years and do you know the how many puffers are you taking?

P: Uhm, I'm taking uhm, I'm taking two puffers.

D: OK, and do you have one that that you take when you when you absolutely need it?

P: Yeah, yeah I do. That's the one that I've been trying to use but

D: Has it been less effective at all recently?

P: Yeah, it hasn't been helping. The blue one I tried to keep taking the blue one and it's just, you know it's not helping.

D: Have you been sick at all recently with fever? Chills, like runny nose? Any cold like symptoms?

P: No.

D: No, nothing like that? Have you been in contact with anyone that's been sick?

P: Oh no. I've been staying at home. I've been very careful these days.

D: Yeah for sure. Any so this started two months ago? Are you having, so you have not traveled then I'm assuming?

P: No.

D: OK, are you having any kind of dizziness or fainting spells?

P: Oh no, no no.

D: No? OK, any kind of swelling in your legs or hands that you've notice?

P: No

D: OK. Any headaches at all?

P: No. Well, sometimes I do. But it's not been severe. It's been there for the past uhm always when I'm stressed out I get these headaches. It's nothing new.

D: OK, any nausea or vomiting?

P: No.

D: No? Any diarrhea or Constipation?

P: No.

D: No OK, any fevers or chills recently?

P: I have a mild fever. It just, it's been there.

D: When did you notice?

P: Uhm I was just checking my temperature about a month ago and noticed that I had a fever.

D: OK. This was a month ago?

P: Yeah.

D: Have you had it recently at all?

P: I haven't checked it recently, but I do feel a little hot.

D: OK, are you getting night sweats at all?

P: Sometimes.

D: Sometimes, OK. And are you getting any kind of significant weight loss?

P: No.

D: No, then your weight's been fine?

P: It's been the same. Although I have been eating quite a lot more now with the pandemic and being home, you know that might be still in the same.

D: And so are you having, do you feel like tired throughout the day or increased fatigue?

P: Oh my God. So tired I can, you know, with the difficulty breathing I feel like all my energy spent just trying to, trying to get to the bathroom.

D: OK, and how? Is there like? How much do you walk or move around that you get short of breath? Or are you short of breath at rest as well?

P: Uhm? I'm short of breath all the time. Yeah, it's just, It's it's worse when I am moving.

D: And so you've been diagnosed with COPD. Have you had to use oxygen at home at all?

P: No.

D: No OK, how about have you had any hospitalizations in the past for your COPD?

P: Yeah, I had a had a couple last year.

D: A couple of hospitalizations?

P: Yeah, yeah. About four hospitalizations last year.

D: Oh, I see. And and did you have to use any oxygen in the hospital?

P: Yeah yeah I did. I did.

D: They never sent you home with any like oxygen tank or anything like that? OK.

P: Although they told me my COPD was pretty bad. That I might need to get oxygen at some point.

D: I see. And have you, when you in hospital, did they give you antibiotics or when you went home?

P: Yeah. Yeah they did. they did.

D: Did they tell you you had pneumonia at all at any point?

P: I don't think so.

D: No. OK, OK any any changes or do you get any chest pain at all?

P: Uhm, sometimes when I breathe in very deep.

D: I see. Any any kind of sensation that your heart is racing?

P: No.

D: No. OK Any kind of issues with your sleep or appetite?

P: Umm. Well, no, not really. It's just the difficulty breathing sometimes it's been hard to sleep.

D: OK, any any exposure to any fumes or allergens in your household, any animals, pets?

P: No.

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

P: No, I'm pretty healthy otherwise.

D: OK, do you have any allergies at all to medications or environmental allergies?

P: I'm allergic to cats.

D: To cats, OK, do you have a cat?

P: No.

D: No OK. Have you been around any cats recently?

P: Nope

D: No OK, are you on any medications besides the puffers?

P: Nope

D: OK, and so you use the ventolin and then what's the other puffer that you use?

P: Uhm I don't remember the name.

D: Do you know the color at all?

P: It's orange

D: orange OK. So you've had four hospitalizations in the past year. Any surgeries in the past?

P: I had a knee replacement on my right side.

D: OK, and when was that?

P: 10 years ago

D: OK. Do you have any family history of any lung conditions, heart conditions, any cancers?

P: My dad had COPD as well.

D: OK. And any lung cancers in the family?

P: no.

D: No, so currently do you work at all?

P: I'm retired.

D: OK, and what did you do before you retired?

P: I was I was a mechanic at Chrysler's.

D: OK, and during your work, were you ever exposed to any chemicals or any kind of in your
 workplace or home exposed to any asbestos or anything like that?

P: Not that I'm aware of.

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

P: Oh yeah, I was a teenager when I started.

D: OK, and how much do you smoke on a on a daily basis?

P: I smoke, I smoke a pack a day

D: OK. Have you at all tried to quit before?

P: I can't quit. It's not gonna happen. A lot of people have told me try to quit but I I just can't live without it and I'm 75 now, you know. Like I'm not gonna live a lot longer anyway.

D: Yeah yeah but also even if you try to cut down some of your symptoms might get better. Like even though you're 75, you can definitely have improvement in some of your symptoms that you're having, like the shortness of breath and coughing. So if at all that you you want to consider cutting down and gradually. we can talk about that more as well.

P: Sure

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

P: No

D: Do you drink?

P: No

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

P: No, I just I guess I need to be admitted right? Just like those other COPD exacerbations? I'm thinking this is exactly that and I'll have to stay in the hospital, right? for a couple of days

D: Yeah, so we definitely before deciding on whether or not you should be admitted, since you said the Ventolin is not working for you, we will definitely give you some some ventilation and perhaps steroid for just to get rid of some of your symptoms right now, and we want to also make sure since you're having like cough as well as shortness of breath to do a covid swab on you, just in case. I know you've been like isolating and everything, but just in case I will do that and we'll get like a chest x ray on you as well, just to see if there's any kind of pneumonia going on. And then from there we'll also get your blood work, and then from there we'll see whether or not you will require another admission.

P: Sure.

D: OK, and there you might, I'm not 100% sure, but you might require home oxygen if like we take your vitals and everything and your oxygenation is very low. Have you have you been talked about that at all in the past?

P: Yeah, they talked about it last time I've been trying to avoid it, but if it has to happen, it has to happen.

D: Hmm yeah, and it might just sometimes just, you know you've had four admissions in the past and it might actually just help you stay at home if you are on oxygen. Anyways, yeah we can talk about that. We'll do like a full physical examination everything and go from there.

P: Sure.

D: Great, I'll be with you shortly.


D: What brings you in?

P: Hi, I've I've had this pain on the outside of my uh right elbow now it's it I first started knowing, noticing it several months ago, but recently it's just been more painful.

D: OK, so you said several months ago. Um did anything happen several months ago? Was there any sort of trigger, trauma, anything like that to that area?

P: No, there wasn't any any trauma or any triggers that that I noticed, I was just um feeling it, uh, a bit more at the end of of work. Um yeah, I was just having it uh, feeling the pain a bit more at the end of work.

D: OK, does uh anything make it better or worse, the pain?

P: Um yeah, if I, really if I'm just resting the elbow um it makes it better, and I've tried uh things like ibuprofen um which has helped with the pain, I'll I'll do that for um hoping I can get through work sometimes if the pain is bad enough.

D: Right, OK. Um and if you were to describe the quality of the pain, is it sharp, throbby, achy?

P: Uh it's um kind of uh, well, it's achy and then sometimes depending on the movement it can get, it can be sharp as well.

D: It can be sharp, OK. OK, um and what sorts of movements make it worse?

P: Um, so like, really it's mostly the movements at my wrist, if I'm bending my wrist down, uh I can I can feel it, or um if I'm having to pick things up or hold heavy objects at work, I do a lot of repetitive uh things at at work, I work on a line.

D: OK, OK. And 1 to 10, 10 being the worst pain you've ever felt, how bad is this pain?

P: It is about a four.

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

P: Uh, no I haven't.

D: No, OK, and do you feel like your pain is getting worse over the past several months, or is it the same, getting better?

P: Uh it's been getting worse.

D: It's been getting worse, OK. OK, um have you tried any like topical ointments or anything like that for it?

P: Uh I did, I yeah, I tried some um some stuff that you can get at the um drugstore and it did help take the edge off a little bit.

D: OK. Um alright and are you still able to move that arm, your right arm, um as well as your hand?

P: I am, yeah, I I have full range of motion of both the elbow and uh hand.

D: OK and it's not like preventing you from doing everyday tasks?

P: Uh, no. I I've been been able to manage so far at work, but um it is starting to become an issue um yeah, with my job.

D: OK. Um alright, and then do you have any sorts of aches or pains uh in any other joint or muscle groups?

P: No, it's just right there on the outside of my right elbow, and it's really annoying 'cause I'm right handed as well, so um yeah, it's causing problems there.

D: Right, um and is the pain radiating upwards or downwards?

P: Uh no, I kinda just feel it right over that that one spot.

D: OK, any numbness or tingling in that arm?

P: No, no, no numbness or tingling.

D: Yeah, um OK, and then how about um like your arm feeling like it's cold?

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

D: OK, alright, um and then otherwise do you have any other symptoms?

P: Um no I, it's just been the elbow pain.

D: OK, so no weight loss?

P: No, my weights been stable over these last few months.

D: OK, fevers or chills?

P: No, I haven't had any fevers or chills.

D: OK, any fatigue?

P: No, my energy's been good.

D: OK. How about um rashes?

P: Uh no rashes.

D: OK. Changes to your senses like vision, hearing, smell, smell or taste?

P: No changes there.

D: OK any coughing, shortness of breath, or wheezing?

P: No.

D: OK. Chest pain, any heart palpitations, or uh dizziness?

P: Nothing like that.

D: OK, changes to your bowel movements?

P: No.

D: No, no no nausea or vomiting?

P: No, I haven't had any nausea or vomiting.

D: OK. Changes to your urine?

P: No, I haven't had any urinary uh symptoms.

D: OK. Memory loss or confusion?

P: No.

D: OK, so if you look at that right elbow, um do you notice any redness or swelling?

P: Uh no, I don't.

D: No, OK. Does it seem misaligned or like asymmetrical compared to your other elbow?

P: No, it looks, it looks the same.

D: Looks the same, OK so no um skin changes or deformities there?

P: Uh no.

D: No, OK, alright and now I'm going to get you to um just palpate uh that lateral or yeah, the lateral aspect of that elbow and you let me know if you feel pain when you push, push on that.

P: Uh there is pain at the lateral uh lateral elbow.

D: How about the medial aspect?

P: No pain.

D: No pain, OK, and how about when you palpate your um forearm and your biceps?

P: Uh no no pain.

D: OK, alright and then do you feel like it's hot, that area?

P: No.

D: No, OK now I am going to get you to um extend your wrist.

P: OK.

D: And then keep your elbow in full extension as well. Does that hurt?

P: Uh it does, yeah.

D: Yeah, OK, how about when you flex your wrist with the elbow still in full extension?

P: Uh it does, yeah that hurts as well.

D: OK, how about when you flex your elbow?

P: Uh no, that that doesn't cause any pain.

D: OK. How about when you extend your shoulder all the way up?

P: No, nothing there, that feels fine.

D: OK, and then flexing your uh, or sorry abducting your shoulder?

P: That feels normal.

D: OK, alright, and then how about when you pronate and supinate your forearms?

P: Uh, pronation um?

D: So like twist your um arm inwards so that your palm is facing the floor.

P: No, that doesn't really cause any pain, pronation and supination.

D: OK, alright. Um alright, and then are you otherwise healthy or do you have any longstanding medical conditions?

P: Um I'm uh healthy.

D: You're healthy, OK. And then UM do you have, have you had any hospitalizations or surgeries in the past?

P: I had a surgery for um a C-section for uh my, my son, um but that's that's it.

D: OK. OK, and um how long ago was that?

P: That was about uh 17 years ago.

D: OK. And was that an emergency C-section?

P: Uh no, it was not.

D: OK um and then are you on any medications?

P: Um no, I've just been taking uh Tylenol and Advil um for the pain.

D: OK, alright um immunizations wise, are you up to date?

P: Uh I I am, yes.

D: OK. Do you have any allergies?

P: Uh no allergies.

D: OK, family history of any uh skeletal or muscular um issues?

P: Um no, nothing like that in the family.

D: OK, neurological issues in the family?

P: Um no neurological issues in the family.

D: OK, how about um autoimmune conditions?

P: Uh no, nothing like that.

D: OK and then um do you smoke?

P: Uh no, I haven't smoked before.

D: OK, uh do you do um marijuana.

P: No, I I don't use that.

D: OK. Um Alcohol?

P: Um uh yeah, I'll have a glass of wine every once in awhile, but maybe just one, one a week.

D: OK, and have you been around sick contacts recently?

P: Um no, I haven't been around anybody who's been sick.

D: OK. Any recent travel?

P: Uh nope, I've been at home.

D: OK. Um I think those are all the questions that I had for you, um did you have any questions of your own for myself?

P: Uh no, I was just wondering what this pain could be on my, in my elbow.

D: Yeah, so right now it seems like you may have a case of something called um lateral epicondylitis. So, it's also known as uh tennis elbow, um and there are a lot of things that could kind of predispose you to this, um so it could be like the repetitive strain at work, um and like continuous contraction of your wrist extensor muscle group there. Um so for this we basically recommend um a couple of things to manage the pain. Uh but first, like in terms of imaging, I don't think it is necessary because it doesn't seem like there was any trauma and I'm not too worried about any fractures. Um so to help you treat this, um we recommend some activity modifications, so um at work not doing things that are too repetitive, especially if it's using those um extensor forearm muscles. Um and then you can use some, use a compression sleeve as well, continue taking Tylenol or NSAIDs for the pain and uh really important is physical therapy um to increase mobility and strength in that arm. Uh and as well you can apply things like ice um to it for like the pain and swelling if you see any. Uh, yeah, so it should resolve in about six months to two years at most, uh but normally it does um go away in a couple of months with some physical therapy and the compression and splints if you choose to do that. How does that sound?

P: Yeah, that that sounds um good, thank you.

D: Yeah, no worries.


D: How may I help you?

P: Hi yes I'm just coming in, uh over the last week, I've been having um like a cough, runny nose and a lot of congestion as well. So I just wanted to come in here to make sure nothing's wrong.

D: I see, alright, and when did the uh cough start? Was it 7 days ago?

P: A bit less than that, I would say it's been probably like five or six days.

D: OK, um and has the cough been getting any better or any worse or staying the same?

P: Um it's kind of the same.

D: OK, and are you bringing up any uh sputum with the cough?

P: No, it's mainly like a dry cough, but I am getting like a lot of drainage and uh just congestion in my nose.

D: OK, so you're, you are, are you feeling um like mucus drain from your nose like into the back of your uh mouth?

P: Uh yeah, sometimes I feel like that over the last week.

D: OK. And you you haven't caught up any any sputum, but have you brought up any any blood?

P: Uh no, no blood.

D: OK, have you had any wheezing?

P: No, no wheezing.

D: OK, and how about um any chest pain?

P: Um no chest pain.

D: OK, and you've had a, and did you, have you had a cough before or is this a new cough?

P: Um no, this is like fairly new.

D: OK. And um could you, is your nose uh like, could you describe the discharge from your nose?

P: Yeah, it's more like kind of a clear to maybe whitish discharge.

D: And these symptoms start about a week ago as well or about five days ago?

P: Um yeah, around the same time.

D: I see, OK. And have you had any uh like facial pain like over your over your cheeks or or forehead?

P: Uh no, nothing like that.

D: OK, and have you felt like your nose um is obstructed, like you're not able to breathe in through either one of your nostrils?

P: Yeah, that happens and sometimes the nostrils keep switching.

D: OK, and have you had a loss or a change in your sense of smell?

P: Um just when I'm congested like I feel like I can't really smell.

D: I see, alright. Have you had a loss or a change in your sense of taste?

P: No.

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

P: Uh no.

D: OK, um and have you had any eye redness or um eye discharge?

P: No, I don't think so.

D: Alright, and how about a sore throat?

P: Uhm, maybe a little bit of a tickle in my throat, but not sore.

D: I see, OK, so have you had any pain with swallowing food or liquids?

P: No.

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

P: No.

D: Any fevers or chills?

P: No, nothing like that.

D: Any uh night sweats?

P: No.

D: And how was your weight been recently? Any changes?

P: No, no changes.

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

P: Uhm no, nothing like that.

D: Have you had any diarrhea?

P: Uh no, no diarrhea.

D: OK, and have you had any urinary problems like painful urination or or frequency?

P: Nope.

D: OK, and then any skin changes or or rashes?

P: Uh nope, nothing like that.

D: Alright, any muscle aches or body pains?

P: Uhm no, nothing like that.

D: Alright, and how has your energy been over this past week? Have you had fatigue?

P: Uh no, I've been, I haven't been tired or like, it's just been like these symptoms that don't seem to go away.

D: I see, OK. Um and uh, have you had any changes to your um to your voice?

P: No.

D: Or any any neck swelling?

P: No.

D: Alright, um so it sounds like over the past uh week you've been having this dry cough uh as well as some nasal discharge and some congestion with um a little bit of a scratchy throat. Um any other symptoms?

P: Uh no, that's pretty much it.

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

P: Uh no, I've been pretty healthy.

D: OK, that's good. And, uh, any uh prior hospitalizations or surgeries?

P: Uhm no, nothing like that.

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

P: Um I've just been taking like Tylenol cold, but it's not really been helping too much.

D: OK, um do you have any allergies?

P: Uh no.

D: OK, uhm and, uh currently are you, could you just tell me a little bit about your living situation, um like who you're living with and uh and whereabouts?

P: Um yeah, so I just live in an apartment with my boyfriend and uh live like just within the city.

D: OK, and are you going to school right now or are you working?

P: Yeah, I'm working uh currently um just at a grocery store.

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

P: Uh not that I know of, yeah, I haven't seen anyone like have symptoms or anything.

D: OK, have you traveled anywhere?

P: No, I've been in the province.

D: OK, um and you mentioned um that you have a boyfriend. Are you currently uh sexually active?

P: Yep.

D: And do you use condoms or any form of birth control?

P: Uh yeah, usually like just condoms.

D: I see, OK, and is there any chance that uh you could be pregnant currently?

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

D: OK, uh, and I just want um, are you currently smoking?

P: Uh no, I have haven't, haven't smoked ever.

D: OK, and that includes cigarettes and marijuana?

P: Uh Yeah, no no marijuana either.

D: OK, do you drink alcohol?

P: Uh just like once or twice in a week.

D: And is it like one or two drinks?

P: Yeah, so I would say, like it would usually be wine.

D: I see alright, and do you use any other uh recreational drugs?

P: Uh no, nothing else.

D: OK, um and in the family, um are there any history of heart or lung problems?

P: Um not that I know of, no.

D: Alright, and how about any uh any cancers?

P: No.

D: Alright, um so uhm that was everything I wanted to ask today on on history, was there anything else that maybe I forgot to ask about, you wanted to mention?

P: Uh no, I just yeah, I was just wondering if like I should be worried at all about Covid.

D: Yeah, certainly um something that we'll be testing for today with some of the symptoms that you're having like um cough and some nonspecific symptoms like that can show up in Covid, um for sure so it will be important to get a test for that today, which will require a nasal swab. Um that being said, it could be uhm another type of viral illness like the common cold, which is causing your your symptoms here today, um and so it will be just be important to be diligent and if your symptoms, diligent with the testing I mean, with the Covid, and if your symptoms get any worse we, it might be important to go to the hospital or or the emergency department.

P: Yep, sounds good. Thank you so much.