D: So can you tell me a little bit about what brought you in here today?

P: Yeah, I've noticed I've had this pretty bad cough for like the last couple of days. A little bit worried. Wanna talk to someone.

D: OK, so started two days ago.

P: No about what day is it today? Today is Wednesday. It started on Sunday, Sunday. I noticed it getting really bad.

D: OK, so it got really bad. Then it was it was it still present but not as bad before that?

P: Yeah I think I had like a bit of like a raspy cough on like Friday but Sunday it was when I started getting nervous about it.

D: OK so almost a week, it sounds like. And what exactly changed on Sunday that you made it worse in your opinion?

P: So Sunday I started bringing I noticed like little spots of red kind of the the gunk I was bringing up.

D: OK.

P: And I kind of ignored it, but the next day they were still there. I started getting fever just in I felt off, you know.

D: OK. OK, so that you first notice that on Sunday, were you bringing up sputum before that and it just didn't have these spots or did it, did that part just start on Sunday?

P: Sputum is kind of like the gunk up and bring it up? Yeah, it was. It's like this yellow custard, it’s got like well spots are red on it on Sunday.

D: OK, and before that did you have like the yellow custard without red? Or it all started at once all kind of started?

P: It all started at once to be honest.

D: Sorry, I know these are tricky questions, and you said that you've had some fevers. Can you tell me a little bit about that? When did that start?

P: So that started, the Monday really is when I first started. I never took my temperature. I just felt hot. You know that's been going on pretty much until today.

D: OK, did you ever feel like you were really shaky?

P: Yeah, I've been getting the chills, especially last two days.

D: OK. So over this time you've had this cough, have you felt like you've had difficulty breathing?

P: Not really, I feel a little bit winded doing things. I used to do like I take the stairs up to my apartment, but I have just happened really trying to exert myself that's been taking it easy so I haven't really noticed being out of breath.

D: OK, so probably if you were to get up and do a lot of physical activity you would feel worse.

P: Yeah, I could, probably I can still take the two stairs up to my apartment, but after that I started to feel pretty crummy.

D: OK. Is there anything else that you can think of that makes it feel worse?

P: No.

D: Has anything helped it to feel better at all?

P: Bringing up gunk makes it feel better for a little while.

D: So you kind of just clear it up and that feels a little bit better?

P: Yeah, I haven't taken some Tylenol at home and that helps a little bit.

D: OK, have you felt a sore throat at the same time?

P: After an awful lot of coughing, yeah, it starts to feel a little raw.

D: Have you had a runny nose?

P: Yeah, bit of 1 back in the day, maybe a week ago, but that kind of gone away by now.

D: Have you felt any chest pain?

P: Yeah. Yeah I got pain kinda on the right.

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

P: No never. Actually Doc, you're saying something that makes it feel worse? Taking a deep breath makes it feel pretty bad.

D: OK, and. I'm just going to circle back to this chest pain. You said you feel it on the right side. Is it always there or is it just when you take a deep breath or is it kind of on and off?

P: It's kind of always there. It gets a little bit worse with coughing and when I take a pretty big deep breath.

D: Yeah, OK, but if you were just laying down, not coughing, is that pain there?

P: Yeah yeah, specially notice over the last day,

D: OK.

P: Kind of dull.

D: OK. And have you had any weight loss recently?

P: No, not really.

D: K. Have you traveled anywhere recently?

P: Went to Sarnia. About a week back for work but.

D: OK, were you in contact with anyone that that was sick?

P: Nope, just been keeping to myself mostly.

D: OK, so in terms of your own medical history, do you have any chronic conditions that you see your family doctor for regularly?

P: Yeah, he’s given me a pill for a cholesterol.

D: OK. And do you know the names of any medications that you take?

P: Lipitor.

D: OK is that the only one?

P: Yeah

D: OK. Have you ever had any surgeries?

P: Uh, my wisdom teeth out as a as a kid. 15 or so I think.

D: OK. Do you have any allergies?

P: No.

D: I’m just going to ask you a few questions about your lifestyle and like do you live here in town?

P: Yeah, I live here in town, got a girlfriend living in apartment.

D: OK, you live with your girlfriend,

P: Yeah.

D: Do you have any pets?

P: Cat, yeah.

D: Do you do anything for work or are you retired?

P: Yeah, I still work a consultant for the chemical plant, so West. Mainly in Sarnia.

D: So have you had a lot of exposure to chemicals throughout your career?

P: Now they've always been pretty good for keeping us safe. I'm on the engineering side of things, so I don't really work too much in the plant directly. You know,

D: OK. Here, well, do you drink alcohol?

P: Once in a blue moon.

D: Do you smoke?

P: Yeah.

D: How much would you say that you smoke?

P: Got a pack a day.

D: Long is that been going on for?

P: Geez, must have picked it up when I was 15.

D: OK. Do you use any other substances?

P:  Like drugs?

D: Yeah, cannabis or any other recreational drugs.

P: Smoke the odd joint from time to time, but haven't in years now.

D: Do you have any family history of any respiratory illnesses?

P: Respiratory illness, like lungs?

D: Yeah, exactly.

P: Think my grandpa died of lung cancer, actually he was a pretty big smoker too though.

D: OK. OK, well thank you for sharing all of that with me, so I'm going to go over this with the physician I’m working with and we should be back shortly together to talk to you about the next steps.

P: Thank you kindly.

D: K, thanks.


D: What brings you in here today?

P: Yeah, I have this pain in my chest.

D: OK, and where is the pain exactly?

P: It's just right  over on the on the left side.

D: OK, and when did this pain start?

P: It started just 30 minutes ago.

D: OK, and did it just come on randomly or were you doing something strenuous?

P: I was just shovelling the driveway and it came on.

D: OK, and has that pain been getting worse at all over the last half an hour?

P: No, it just came on suddenly and it's uh, uh, I'm sorry. Yeah the pain has been there this whole time and it's gotten worse ever since it started.

D: OK, and how would you describe the pain? Is it kind of like an aching pain or is it a sharp or tight tightness kind of pain? How would you describe it?

P: It feels dull. I feel like there's a lot of pressure on my chest.

D: And how do you rate the pain right now on a scale of zero to 10, zero being the least amount of pain you felt in your life, 10 being the worst?

P: Uh, seven.

D: Seven, OK. Have you had ny similar episodes before?

P: No, I've never had any chest pain before.

D: OK, and is the pain just staying in the region of the left chest area that you mentioned or is it traveling to any other part of your body?

P: No, I'm kind of just feeling it right here. On the left side.

D: OK, uh, is there anything that you do that makes the pain either get worse or go away or like get better?

P: Uh. I think it's a bit bit worse if I'm moving around or when I was walking in here. I think it it made it a bit worse, but nothing has seemed to make it any better since it starting.

D: OK, and does it change at all from you changing positions like if you're standing up versus sitting down or laying down?

P: I think it's a little bit worse when I when I'm laying down.

D: OK, and other than the pain that you've been having, have you been having any other symptoms like a cough or difficulty breathing or any pain when you're breathing in or out?

P: Uh, I've felt a little bit uh short of breath or having difficulty breathing since yesterday when the sorry since the pain started, but uh just the difficulty breathing.

D: OK. And have you recently injured your chest or surrounding area at all? Like from a fall or anything like that?

P: I do I play rugby and was tackled by another player yesterday. But but my chest felt fine after that.

D: OK so but the pain just started half an hour ago?

P: Yeah.

D: OK, have you have you been traveling at all recently?

P: No, been at home.

D: OK, has anyone around you been sick at all?

P: No.

D: OK, have you been having any symptoms like nausea or vomiting or any fevers or chills?

P: No nausea or vomiting, but I do feel a little bit hot today.

D: OK, but have you measured your temperature at all?

P: Uh I did and it was 38 degrees.

D: OK, and have you been having any kind of swelling in your legs or feet?

P: Uh, no swelling in my legs.

D: OK. Have you been feeling tired at all, like increasingly fatigued?

P: No, my energy has been good.

D; Have you been having any kind of thumping or palpitations or feel like your heart has been racing at all?

P: It uhh it does feel like it's beating faster right now. It usually only feels like this when I'm playing sports.

D: OK. And have you noticed any changes in your skin at all? Any rashes?

P: No rashes.

D: OK, have you had any cough or runny nose or sore throat? Any kind of those symptoms and in the past month?

P: Uh few weeks ago I was a little runny, but that went away on its own. I haven't had any cough.

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

P: No dizziness and uh no I haven't fainted at all.

D: OK. Just a few more questions. Have you had any diagnosis made by any physician or any anything like diabetes or high blood pressure?

P: Yeah, I've been told I have high cholesterol and high blood pressure.

D: OK, and do you take any medications for the these things?

P: Um, I do take medications for both blood pressure and cholesterol, Rosuvastatin and um Lisinopril and I take a multi vitamin.

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

P: No allergies.

D: OK, have you at all in the past been hospitalized for any reason?

P: No hospitalizations.

D: Any previous surgeries?

P: No.

D: OK, and within your family, has anyone passed away from a heart attack or any cancers that run in the family?

P: No.

D: OK, and currently right now, do you live alone? Do you live with someone? And where do you live, like an apartment or house?

P: I I live in a house with um, my parents.

D: OK, and do you currently work?

P: Yeah, I I drive a bus for the city.

D: OK. And in your daily routine, would you say you get enough exercise throughout the week?

P: Uhh yeah, usually on Sundays I'll go for a run.

D: OK, and how about your diet? Well, how's your diet like, just regularly?

P: Uhh, usually I feel like it's fairly balanced overall, I might I eat out a little bit too often, but try to eat as many vegetables as I can.

D: OK. And do you smoke cigarettes at all?

P: I do yes. Been smoking for the last 20 years roughly.

D: OK, how much do you smoke on an average day?

P: About a half a pack to a pack a day.

D: OK. And do you drink?

P: No alcohol.

D: OK, and any recreational drugs like marijuana?

P: Um, no marijuana, but I have used crystal meth in the past.

D: OK, and when was the last time that you used crystal meth?

P: Um, six days ago.

D: Six days ago, OK, and how often do you use crystal meth?

P: Um, I would say a couple of times a month.

D: A couple of times a month, OK. Alright, and for how long have you been using crystal meth?

P: Uh for the last seven years.

D: Seven years, OK.


D: What brings in you here today?

P: Yes, I brought in my daughter. She's 8 years old. So recently she's been telling me she's having a lot of ear pain. And she's had a fever for the past two days as well. We checked her temperature at home. It was 38.8. And so we're just here to see if we can get some antibiotics for it.

D: OK, um and has this happened before at all?

P: She's had some ear infections on and off since she was like uh 2.

D: OK, then has she required antibiotics?

P: Yes.

D: OK, when was their last ear infection? Do you remember?

P: It was actually last year when she was seven?

D: OK, and so is it just one ear that she's having the pain? Or is it both?

P: It's one ear.

D: OK. In which which ear is it?

P: It's the right ear,

D: Right ear. And when did you notice that she started having this pain?

P: Um I noticed it like 3 days ago.

D: Three days ago, OK. Was she irritable, like or was he kind of tugging her ears in pain? Or how? How would you describe it?

P: Yeah, she basically, while she told me she's been having some ear pain. And yeah, she's been pulling at it. And you know she's tried like mineral oil and things like that to see if she can unblock it but I I looked in there, it doesn't seem like there's a lot of wax in there. Um yeah.

D: Um has it been so painful that she has been crying at all?

P: Yeah, she's cried a few times.

D: OK, have you noticed any kind of drainage coming out of her ears? Any fluids?

P: No, I didn't notice that.

D: Um, any fevers or chills?

P: Yeah, she's had a fever for the past two days.

D: Past 2 days. OK, did you get a chance to measure it at all?

P: Uh 38.8.

D: 38.8 OK. OK, and she had any other symptoms recently like a cough, runny nose, sore throat, any viral or cold like symptoms?

P: No, not that I've noticed.

D: OK, um. And she had any headaches?.

P: No headaches.

D: OK. Any recent travel or contact with anyone who's been sick?

P: Um no.

D: No, any nausea or vomiting?

P: Uh No.

D: Any changes in her bowel movements?

P: Uh nope.

D: OK. And any fatigue or just feeling very tired?

P: Uh she's been pretty tired.

D: Has she had to miss any school or anything like that?

P: Yeah, she wasn't going to school for the past three days.

D: OK. And any issues that are sleep or appetite?

P: No.

D: OK. And any medical conditions that she's been diagnosed with in the past.

P: No, she's been pretty healthy. Besides the recurrent ear infections.

D: OK, has her hearing been affected at all?

P: Not that I've noticed.

D: OK. And you mentioned it's recurring how she ever had to see an ear, nose and throat specialist?

P: So when she was younger, when she was like 4 she saw one, but then she hadn't had an ear infection between the age of 4 to 7 so we didn't go back to them.

D: OK yeah.

P: After.

D: OK. And if she ever had tubes put into your ears or anything like that?

P: Uh no they were. They were talking about it, but we never ended up doing that.

D: OK, OK. Any medications that she takes everyday?

P: Uh no just multivitamins.

D: OK. Any allergies?

P: No.

D: OK. Any? Contacts at all. Any hospitalizations or surgeries in the past?

P: No.

D: How about her birth?  Was it a vaginal delivery or C-section?

P: It was vaginal.

D: And was she premature or at term choose that term?

P: She was at term.

D: Any complications at all during your pregnancy with her?

P: No no.

D: OK, after she was born, does she have to stay in an ICU or any complications afterwards?

P: No, she was healthy.

D: OK. That's good, and in terms of her development throughout the years, any issues with her growth, learning or anything like that?

P: Uh no she's been pretty good with hitting all those milestones.

D: OK, alright, and currently right now. So is she doing online school or she doing in person?

P: Ah she is going in person.

D: OK, and how about her living situation currently?

P: Ah should also at home with myself from her father and her younger sibling.

D: OK. Uh, and uh? Any, anyone smoke in the house at all?

P: No.

D: No. OK. Alright, so those are all the questions I had for her today, so definitely since there is a risk that she might be having another ear infection, we will need to do like a full physical examination. I'll have to look into her ear to see if I see any inflammation or perforation and then based on that we'll discuss some management. She may require some antibiotics like she has had before, but that will depend on what. I see on physical examination she has been having a fever so she might. And it's only been three days, right? So we may even do some conservative management and get her to take some maybe pain medications and then go from there. Or ear drops.

P: OK.

D: Uh, but yeah, so we'll do the examination and then go from there. She said she has, besides the fever and that your pain she's not really having any other symptoms so? I don't think she needs to get tested for Covid right now, but that's something we can consider as well if she develops other symptoms.

P: OK, that sounds great. Thank you.

D: Your Welcome. Take care

P: You too.


D: What brings you in here today?

P: Yeah, I'm just bringing in my old daughter who's really been complaining about having a runny nose and has been sneezing a lot over this past over this past week. I think the symptoms maybe started three or four days ago.

D: OK, and what symptoms started first?

P: I think the runny nose is what, what started first. And like kind of the nasal congestion. She was telling you that she felt that there was like pressure or congestion in her nose.

D: OK, and then this, when did this sneezing start?

P: Surely after that probably maybe the same day or or the next day.

D: OK, does she have any coughing at all?

P: Yeah, so she she did start to cough actually after that so that the cough has been there for the last, for the last maybe two to three days. It's a dry cough.

D: OK, for the last two to three days. OK, is she at all, coughing up any green or yellow material or any blood at all?

P: No, nothing like that.

D: OK. So, and are her symptoms constant? Or do they come and go?

P: They've been pretty constant, and they've gotten a little bit worse since they started. Three or four days ago, I I think now yeah, her symptoms are at her, at the worst right now. Just not feeling very well.

D: OK, and have you been in contact with anyone at home or at school? If she's going to school versus at home for the pandemic right now, but any ill contacts at all?

P: Well, she has been going to school. There hasn't been any Covid cases where she goes and they've been cautious, but she is going to school right now.

D: OK. Any, anything that you've tried that has helped her like any over the counter cold medications?

P: Uhm, uh, no.

D: OK. Any other symptoms like fevers, chills, shortness of breath, um, anything like that?

P: Uh, she did feel a bit warm to touch and has looked a bit flushed in her face. Just doesn't look like herself.

D: Does she behave like herself Like is she more tired at all? More irritable, anything like that?

P: Yeah, she's been a, maybe a bit more, maybe a bit more tired and and a bit more irritable, but not not too bad. She, she missed school today but went yesterday.

D: OK. Any recent travel at all?

P: No, we've been at home.

D: Any headaches, nausea or vomiting?

P: Uhm, no.

D: OK, any chest pain that she's described?

P: No chest pain.

D: OK. Any changes in her bowel movement, constipation, diarrhea?

P: No, that's been normal.

D: OK. Any urinary problems?

P: No, she had a urinary tract infection when she was like little but hasn't had any since.

D: OK, any issues with their sleep or appetite?

P: She has been a bit a bit fussy, but she's been sleeping OK.

D: OK. Uhm, has she lost any weight recently?

P: No, no no. She's been gaining weight well.

D: OK, any exposure to any allergens or like fumes, dust animals?

P: No, I can't think of anything like that. We don't have any pets at Home and she's she's been hasn't been going anywhere else.

D: OK, has she been diagnosed with any medical conditions in the past?

P: No, she just said, ah, just yeah had a urinary tract infection when she was younger and that's about it.

D: OK. Any allergies to medications that you know of?

P: Not that I'm aware of.

D: Is she on any medications?

P: No.

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

P: No.

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

P: Uhm, I I have high cholesterol but, and ah, and I'm taking a, a medication for it, but no, nothing else.

D: OK, does, has she lost a sense of taste or smell at all?

P: No, she hasn't said any anything like that, just the nasal congestion.

D: OK. Did you feel any pressure in around her face at all?

P: Uh, yeah, well yeah, I think so. She doesn't say, well, no pain but does feel like a bit of pressure with the congestion, I think.

D: OK, uhm any issues developmentally as she was growing up like to meet are all our milestones at an appropriate age?

P: She did yeah, she has met she was walking at the appropriate times and able to talk and does work really well in school and is social with with her classmates and peers.

D: So no, no issues or no complaints at all?

P: No, there hasn't been any concerns. I feel that she's been developing normally.

D: OK. In our immunizations up to date?

P: They are, yeah.

D: OK and were there any complications at all during your pregnancy with her or after the pregnancy?

P: No, it was a vaginal delivery at 38 weeks and she was a normal weight. We were able to go home right away with with no complications. So yeah, things were good.

D: OK, and currently who does she live with?

P: So myself and my, and my husband.

D: OK, and does anyone smoke in the house?

P: Uhm, my husband does smoke, but uh, I mean he smokes outside usually and and he smokes, I don't know, maybe a half a pack a day.

D: And I think that's all all the questions I have. Do you have any questions or concerns?

P: Nothing else right now.

D: OK. So yeah, based on her symptoms, she does seem to have some just a cold like symptoms, viral symptoms. And it's been, it's been you said three or four days in total, right?

P: Yeah yeah.

D: Yeah, and so most likely it's just caused by a viral infection like common cold perhaps, it she doesn't have any worrying signs of any systemic things going on right now, so and no signs of like a bacterial infection that I would be concerned about that I would give antibiotics for right now. But definitely if her symptoms get worse at home and if she starts having any kind of shortness of breath, increased coughing with producing, more yellow or green material and if she gets more feverish, so will also do a physical exam and take her temperature today as well. But yeah, some of these things you just look out for, but yeah, so that that we'll do the physical examination and go from there.

P: Alright, thank you.

D: Hey, you're welcome. Take care.


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

P: So I've had this, uh, this cough that it started two days ago and it's been getting worse. I've been bringing up this rust colored sputum.

D: OK, and so that's been going on for a few days?

P: Yeah, yeah about two days.

D: OK, and how often are you coughing?

P: It's it's happening all day. Really, throughout the day and really any type of exertion or or movement, I'm getting short of breath and it's triggering a cough.

D: OK, and the shortness of breath, is it just with the exertion or it can, is it happening at rest? How are you feeling right now?

P: Yeah, even right now it feels like I'm not able to get, I don't know, a full breath, it just feels like it's more difficult to to breathe.

D: OK, have you felt any kind of dizziness or fainting episodes?

P: No, I haven't.

D: OK. Have you been feeling any chest pain at all?

P: Uh, no, I, I I haven't had any chest pain.

D: OK, and so with your coughing you're producing the rust colored sputum, but how much would you say you're producing?

P: Uh I would say, yeah, maybe three or four teaspoons every every couple hours.

D: OK, are you producing any blood like in your cough or sputum at all?

P: No, it wasn't really red, it's kinda orange.

D: Orange, OK. Any greenish or yellow material?

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

D: OK. Any fevers or chills?

P: Yeah, I have had, I've had both of those. I've had a I I checked my temperature this morning and it was 38.2 and I was pretty chilly last night.

D: OK. Uhm, and before these symptoms started, were you having any similar symptoms at all before?

P: Ah, no, I mean a few weeks ago, probably like a yeah a couple of weeks ago I had a runny nose. And and sore throat for a couple of days. It went away on its own though.

D: OK. Uhm, any anything that makes your symptoms better or worse that you've tried?

P: I did try some over the counter cold medicine. It, I think it might have helped me sleep last night, but didn't really do a whole lot.

D: OK, does your shortness of breath improve with any positions or does it improve when you're not exerting yourself?

P: Uh, not really. It's kind of always there,

D: It's ok. Do you have to wake up at night to take a deep breath? Or do you feel any kind of shortness of breath with laying down at all?

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

D: OK and do you notice any kind of swelling in your feet, ankles, arms, legs, anything like that?

P: No, I haven't.

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

P: Uh, I don't I, I mean I see my granddaughter and I might have got a cold from her a few weeks ago, but recently I haven't seen anybody.

D: OK, are you having any night sweats?

P: No, just a chills last night.

D: OK. Are you breathing faster?

P: Yeah, I have felt like I've been been breathing a bit faster.

D: You have any muscle aches or anything like that?

P: Ah no, not really.

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

P: Uh, no. Just been really tired these last couple of days and I've just felt like sleeping all day. Haven't felt like eating either, my appetite has been really poor.

D: OK, uhm. And other than that, have you experienced any kind of headaches, nausea or vomiting?

P: No, I haven't.

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

P: I have yeah.

D: OK. And then a fever too. Kind of a sensation of your heart racing at all?

P: Ah, yeah, right. It doesn't feel like it's well, it does feel like it's beating a bit faster than usual, just not feeling too well.

D: Yeah, so yeah, we'll do a physical examination and get all your vital signs as well right after. Any, so you said you haven't been able to eat, ave you noticed any significant weight changes recently?

P: No, my weight's been about the same.

D: OK, any exposure to any dusts or animals, fumes, anything that might have triggered some of these symptoms?

P: No, I don't think so. My husband and I, we moved into a new kind of apartment here and it, it's brand new.

D: OK, any kind of loss of sense of taste or smell?

P: No, that's been normal.

D: OK, any exposure or any travel outside of the country at all.

P: No, nothing like that.

D: OK, so just mainly the coughing with the rusty material as well as just the shortness of breath. Umm, and do you get any pain at all in your chest when you breathe in or out?

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

D: OK, any past medical conditions that I should know of?

P: Yeah, I, umm, I had a stroke like that like six years ago. And I have type 2 diabetes. As well as GERD.

D: OK, and uh, yeah, I'm sorry you had you had a stroke six years ago or how are you after that? Were there any kind of, like did, after rehabilitation, do you have any symptoms still going on at all?

P: Yeah my, my left hand, still, still it gives me some some problems. I get uh, uh, Botulinum toxin injections for, for the tightness in my hand.

D: OK, OK, and are you taking any other medications at all?

P: Yeah, I use metformin. Empagliflozin or an SGLT2, insulin and uh, and aspirin, I think.

D: OK, and any over the counter medications?

P: Yeah, I take a multivitamin and in vitamin D.

D: OK. Any allergies to any medications at all?

P: No.

D: OK, any environmental allergies?

P: No.

D: OK, any ill contacts at all?

P: No, no.

D: Any recent or prior hospitalizations?

P: No, the last time I was in the hospital was I was for rehab after my stroke.

D: OK and so, but after that, no other hospitalizations or surgeries?

P: No.

D: OK, any surgeries in the past?

P: Yeah, well I did have a C-section for my son but that was many years ago now and everything for that was, was OK. Yeah.

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

P: Uhm, yeah, my dad had had a heart attack actually, but he was in his 80s when that, when that happened.

D: OK, uhm and currently right now, are you working at all?

P: No, I'm retired. I used to be a teacher for Grade 3, uhm, but yeah, but since retired and my husband and I just moved into a smaller apartment to make it a bit easier on us. It was a lot trying to look after the house.

D: OK, well congratulations on your new home. Are you at all, you or your husband requiring any kind of supports outside of the home at all?

P: No, between us two we managed to get the shopping done, the cooking and and all the cleaning, and that sort of thing. I use a walker to get around when we're going longer distances.

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

P: Uh, yes I, I spoke about half a pack per day or maybe even less.

D: OK, and how, how long have you have smoked for?

P: Since I was 15 maybe?

D: OK.

P: So yeah for like 45 years.

D: And have you, at all been diagnosed with COPD or anything like that?

P: No, I was tested actually, uh, a couple of years ago and that the results were normal.

D: OK. Alright, and have you thought of quitting at all? I know you've been smoking like for a very long time, but have you at all tried to quit before?

P: Like I've considered it, but I I just don't think it, it'll be possible at this time.

D: OK, well if you at all are wanting any information or want to talk about quitting at all, um, we can provide more resources. Do you besides smoking, do you use any recreational drugs like marijuana?

P: No.

D: No. Any alcohol at all?

P: No.

D: OK. Yeah, so those are some of the questions I had a, I will be doing a physical examination with your shortness of breath. I just want to get a good listen to your lungs and take all your vitals as well. However, yeah so after that since you're having some symptoms of what might be a pneumonia, it can be a bacterial infection, a viral infection, we will have to get some blood work done as well as a chest x-ray. And right now, with the pandemic going on, we will also do Covid swab test for you as well, just in case. Does that sound good?

P: Yeah, that makes sense, thank you.

D: Alright and, if if you're while you're here, if your shortness of breath gets any worse at all, just let us know and we'll help you out.

P: OK, thank you, will do.

D: Thank you, bye.

P: Bye.


D: What brings you in here today?

P: Um, I've just had difficulties with breathing for the past, I want to say eight, nine months. And um, my wife just told me to come in. It's just, she was worried about it and uh, I thought I'd just come in and have it checked out.

D: Okay, so it's been going on for the last eight to nine months. Has it been getting worse at all?

P: Yeah, I would think so. I would say so, yeah. So,

D: Sorry, go on.

P: So, it was just um, I feel like I just get short of breath more easily now.

D: Okay, and is it short of breath with activities? Or are you getting short of breath with uh, sitting or resting as well?

P: So when I'm, when I'm, with activity.

D: With activity, okay. And the cough that you're getting, is it a wet cough or a dry cough?

P: It's a dry cough.

D: Okay. And are you bringing up any material at all, like any um, yellow or green sputum?

P: No, no.

D: Any blood?

P: Um, no, no blood.

D: No blood, okay. And with your shortness of breath, is it, are you having difficulty taking deep breaths, or do you find that you're taking more fast, shallow breaths?

P: Um, just, I guess, just uh, shallow breaths.

D: Okay, okay. And um, so this is over the last eight or nine months. Have you noticed any other symptoms at all, like chest pain, dizziness or fainting? No?

P: No.

D: Okay. And do your symptoms get, get worse at all when you're lying flat, like when you're sleeping?

P: No.

D: No. And do you ever wake up gasping for air?

P: No.

D: Okay. Um, and have you tried anything that's helped you uh, relieve some of these symptoms?

P: Sorry, could you say that again?

D: Uh, have you tried anything like over the counter, to help you relieve these symptoms?

P: No, no I haven't.

D: Um, have you traveled at all recently?

P: No.

D: Have you been in contact with anyone that's been sick?

P: Um, no, not really. I, I did go out to the pharmacy to get my medications, but that's, that's the only time I actually interact with anyone outside of my home.

D: And what, what medications do you take?

P: Um, I just take aspirin.

D: Aspirin, okay. Have you been diagnosed with any medical conditions?

P: I had a heart attack.

D: Oh okay, well when was that?

P: Last year.

D: Last year, well I'm so sorry and um, did they give you any medications to go on after that?

P: Yeah yeah, yeah there, there were a couple of other medications as well. Something um, something, something -pril. And uh, I think there's uh, uh, rosuvastatin.

D: Okay, and do you still take those?

P: Yeah, I take those. Sometimes I forget that I do, I try to take them as much as I can.

D: Okay, and you also take the aspirin. Alright, have you noticed any fevers or chills?

P: No.

D: Nausea or vomiting?

P: Nope.

D: And any chest pain?

P: Uh, no.

D: No, okay. Any increased fatigue?

P: No.

D: Any diarrhea or constipation?

P: No.

D: Any numbness or tingling anywhere?

P: No.

D: Any confusion or memory, like memory loss?

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

D: Any trouble urinating?

P: Um, no.

D: Okay, have you noticed any swelling um, in your feet, ankles, legs at all?

P: No.

D: Okay. Um, and how's your appetite been like?

P: Um, it's been, it's been the same.

D: Okay, and any um, significant weight changes? Have you lost any weight?

P: No.

D: No. Um, any exposure to fumes or dust within your environment?

P: Um, not right now. When I was young, yeah.

D: Okay, now did you, so did you have exposure to fumes or dust?

P: Um, I used to work in a mine so.

D: A mine?

P: Yeah, lots of chemicals and things like that.

D: Okay. And any exposure to any pets or animals?

P: Uh, no.

D: Besides your medical history of having a heart attack and some blood pressure, um, any other medical conditions?

P: Uh, I just have high blood pressure.

D: Okay, any allergies to any medications or any environmental allergies?

P: No.

D: Okay. Um, any hospitalizations besides when you had a heart attack, previously?

P: No.

D: Any surgeries?

P: No.

D: Okay. Did they tell you at all what the cause of your heart attack was?

P: Um, they just uh, they said it was my, my diet.

D: They said diet, okay.

P: Yeah, something about cholesterol.

D: Did you require any stents, or did you have to get a bypass surgery or anything like that?

P: Uh, they put in, I think they put in stents.

D: Stents, okay. Um, any family history of any heart or lung conditions?

P: Yeah, um, my um, mom had heart failure.

D: Okay, um, and how old was she when she had her heart failure?

P: She was young, she was uh, 55.

D: 55, okay. Um, and currently, right now, or sorry, do you have any family history of any cancers, any lung cancer or anything like that?

P: No.

D: And currently do you work or are you retired?

P: I'm retired.

D: Okay. And what's your living situation like right now? Do you live with anyone?

P: I live with my wife.

D: Okay, and do you smoke?

P: Uh, no.

D: Have you ever smoked?

P: I did when I was young.

D: How long would you say you smoked for?

P: Um, I'd say 45 years.

D: And how much would you smoke in an average day?

P: Um, about a pack a day.

D: Um, any recreational drugs like marijuana?

P: No.

D: And do you drink alcohol?

P: Yeah I do. Um I'll, I'll drink a glass at night, every night.

D: And a glass of, what would you drink?

P: Oh just a, a glass of wine, white wine.

D: Okay, so those are all the questions I have for you today. Any questions for me?

P: No.

D: Okay, so yeah, there's definitely like the coughing and shortness of breath are definitely concerning, and they've been going on for a pretty long time. Do you ever have any night sweats or anything like that?

P: No.

D: Okay. So there's a few things that we think about with the chronic shortness of breath and a cough. One could be just a COPD diagnosis with your long history of smoking. And this pulmonary function test, get an x-ray, chest x-ray as well. Um another thing that we need to look out for is uh, lung cancer. And since you have been smoking for a pretty long time, even though you may have quit, which is really great, but that long history of smoking, especially also with um, you working in a mine, those are some things that means we can test as well, and so we may require like a chest x-ray, and even um, a CT scan of your lungs as well. Um, so yeah, first we'll just do a couple tests, do a physical examination, get your vitals, do some blood work and do some of those tests and then we'll also get a COVID swab test done for you as well, just in case. Does that sound good?

P: Yeah.

D: Alright, so we'll be with you shortly.


D: I was uh, wondering what I could help you with today?

P: Yeah hi, um, I have been coughing nonstop for the past three days, and today I have been feeling very short of breath. So I just wanted to get it all checked out.

D: Yeah, for sure. And, so you said the cough started uh, three days ago. Were there any triggers to the cough or anything that, uh that changed three days ago?

P: No, nothing that I can think of um, I have, like the only thing that I've been doing is going to the grocery stores, uh the bank, and laundromat. Um, and once I ran all these errands, like, I just started having this coughing fit that hasn't stopped.

D: Okay, uh, has the cough gotten any better, or stayed the same, or gotten worse these past three days?

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

D: Okay, are you bringing up any uh, sputum or phlegm?

P: Um yes, it's yellow.

D: Okay, is this um, any different from before? Like have you had a cough in the past and, and brought up phlegm, or is this entirely new for you?

P: Um no, this has happened to me before, um, like I don't know, like maybe a year or two years back. Uh, and it kind of feels the same, but just a little bit worse.

D: Okay. Um, and uh, have you seen any blood in the sputum?

P: No, no blood.

D: Okay. Um, and you mentioned you've been short of breath as well. Uh, how has that come on?

P: Um, it was, I, I don't know if it's because of all the coughing that I've been doing, but it just started this morning.

D: Okay, um, and have you been experiencing uh shortness of breath um, on exertion otherwise, like prior to this?

P: Um no, no.

D: Okay. And have you had any shortness of breath after, like if you lie down flat?

P: Um, no, not that I've noticed

D: All right, and have you had a wheeze?

P: A little bit, yeah.

D: Okay um, uh, and have you had any um, infectious-like symptoms such as like red eyes, runny nose, or, or a sore throat?

P: No, nothing like that.

D: Okay, um, have you had any, any chest pain?

P: Nope, nothing like that.

D: Have you had any lightheadedness or, or feeling dizzy?

P: No.

D: Or feeling like your heart's racing or, or beating really fast?

P: No.

D: Okay. And, um, have you had any fevers or chills?

P: No, not that I've noticed.

D: Have you had any night sweats?

P: No.

D: And how has your weight been over the last several months? Have you had any weight loss or gain?

P: Uh no, it's been pretty stable.

D: Okay. Um, and have you had any abdominal pain?

P: Um, no.

D: Any diarrhea?

P: No.

D: Or any urinary problems?

P: No.

D: Okay. Um, and in the past um, oh sorry, before that, have you had any nausea or, or vomiting?

P: No.

D: Okay. Uh, and any confusion or, or changes to um, um memory?

P: No.

D: Okay, uh, or loss of taste or sense of smell?

P: Uh no.

D: Okay uh, so the, you've been experiencing this cough that's been getting worse over the last couple of days, as well as bringing up some yellow sputum, um, and been short of breath. Have you been experiencing any other symptoms?

P: No, that's pretty much it.

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

P: Um, I have diabetes, I have high blood pressure and I have high cholesterol.

D: I see. Alright, and do you take uh, medications for those things?

P: Yes, so I am on ramipril for the high blood pressure, rosuvastatin for the cholesterol, and insulin for the diabetes.

D: Okay, thank you. And uh, you mentioned you had a similar episode in the past. Um, what, uh, were you diagnosed with COPD before?

P: I was, I was diagnosed with COPD about five years back.

D: Okay, did you have pulmonary function tests for this? The test where you had to breathe into a tube.

P: Um yeah, I had that done like five years ago.

D: Okay, um, alright um, just wanted to see if it was uh like formally diagnosed. Sometimes people uh, um, yeah, it's important to have that, uh, those tests done. Um, and do you have any allergies?

P: Um, no none. None, yeah.

D: Okay. Um, and uh, are your immunizations up to date?

P: Yes, I believe so.

D: Okay, um and have you had any surgeries or, or um, hospitalizations?

P: Um, I had my Gallbladder removed when I was in my 50s. Um, and I had a hip fracture three years ago.

D: Okay, and how is your mobility now?

P: Um pretty good. My hips still give me some issues once in awhile, but um, for the most part, it's been okay.

D: Okay, that's good. It sounds like the rehab went well.

P: Yeah.

D: And uh, right now, can you tell me um, a little bit about your living situation? Like where you're living and who you're living with?

P: Um, I live by myself in an apartment on the 1st floor.

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

P: Uh no, I quit two years ago.

D: Okay, and that's, that's great. Um, prior to that, how long did you smoke for, and how much?

P: Oh, for like 40-plus years um, I used to smoke a pack a day.

D: Okay, well that's great that uh, that you quit, so congratulations.

P: Thank you.

D: And do you drink alcohol?

P: I drink once in a while. Like maybe every other day, I'll have a glass of wine.

D: Okay, and um, uh anybody, or sorry, have you been around anybody who's been sick recently?

P: Uh no.

D: You said you went to the stores and stuff like that.

P: Yeah, maybe from there, yeah.

D: Okay, and have you traveled anywhere else, outside of the city?

P: Um, not recently, no.

D: Alright, um, and any exposures to any like dust, chemicals, things like that?

P: Um, I live in an old building so maybe. Um, but it hasn't bugged me before.

D: Okay, uh, and are you working currently or, or retired?

P: I'm retired.

D: Okay, well, what did you do before?

P: I used to work uh, on the assembly line for Chrysler.

D: Okay, were there any exposures uh, there that you were aware of, like things that you were breathing in?

P: Uh not that I was aware of, but they were always like smoke and fumes and things like that because it was like a factory, so maybe.

D: Right, okay, that makes sense. Um, and in the family, are there, anybody who, who's had problems with their hearts or lungs?

P: Um, my mom had lung cancer when she was 50. And, like, all the, like diabetes, hypertension and high cholesterol runs on my, ran on my father's side of the family.

D: I see, did anybody have uh, heart attacks or, or stroke?

P: Uh, yeah, so my father had a heart attack when he was 49. Uh, stroke I'm not too sure about.

D: Okay, thank you. And, um, so that was all I wanted to ask about. Um, was there anything else that you wanted to add that I maybe forgot?

P: Um, no, that's about it, but I, how can I treat myself now? How do I make this cough go away?

D: For sure, so, um, we will first get your vitals here and we'll see if your oxygen levels um, are low, then it would be important to put on some oxygen first, um, just to make sure that that's stable. Um, and from there we will um, get a chest x-ray um, and uh, run some lab work to, to try to help figure out the, the diagnosis better, but in the meantime, we'll use um, some inhalers because it's possible that this is a COPD exacerbation similar to uh last year, um, and the inhalers should help open up the airways and dilate, so make breathing easier, and then um, also if it is a COPD exacerbation, it will likely require antibiotics, as well as some steroids for the, the inflammation for five days. Uh, but since your symptoms currently overlap with uh, COVID as well, you'll have to get a, a COVID nasal swab.

P: Okay, okay for sure.

D: Okay, so uh, we'll get that started.

P: Okay. Thank you so much.


D: What brings you in?

P: Hi, I've I've had um this pain in my left knee that's been going on now for the last uh three or four months um but it's gotten a bit a bit worse, it used to only really bug me while I was doing activity, and now its started to uh hurt even more um afterwards as well, so I'm getting the pain at at rest. and so I wanted to come and get that checked out.

D: OK yeah, for sure. Um and you said it started a few weeks ago?

P: Uh well, I think it first started a few months ago, but in the past couple of weeks it has started to um kinda like last longer and and happen at rest as well.

D: Yeah, and so does anything make it worse or better? I assume doing any sort of physical activity makes it worse and rest makes it better, but how about anything other than that?

P: Uhm not really, yeah, it's mostly just the the activity, if I'm going upstairs or um downstairs or uh during running is really where it hurts the most and that's what's bugged me the um yeah, the most, running.

D: OK, OK, and if you were to describe the quality of this pain, would you say sharp, dull, achy, crampy?

P: Uh it's a sharp pain, uh almost like every time my foot hits the ground I get like a sharp stabbing pain and while I'm at at rest it feels a bit more dull, while, yeah, yeah while I'm at rest.

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

P: A six.

D: OK, alright, and have you ever experienced this type of pain before?

P: Uh I did have something similar like many years ago. I used to be a rower uh in undergrad and I got some similar pains before, and I mean with some stretching and um other I don't know kind of strengthening stuff, it it kind of helped but I didn't go see anybody for it at that time because it it kind of went away after a little while,

D: OK, OK, um and you said you were, are you still rowing?

P: No, no, the only activity that I'm doing now is is running.

D: Running, OK and from when it started to now, in the past couple of weeks has it changed like dramatically, um is it affecting your day to day life?

P: Uh a little bit, yeah, like even now, just walking I can I can feel it. Um the pain's not as severe but like as when I'm running but I can, I'm starting to notice it uh daily.

D: OK, alright, and um are you otherwise healthy? Do you have any um symptoms like fevers or chills?

P: No, nothing like that.

D: No, any weight loss?

P: Uh no weight loss.

D: No, any rashes?

P: Uh no rashes.

D: No, uh changes to your uh vision, hearing, taste or smell?

P: Uh no changes there.

D: OK. How about a cough, shortness of breath, or um wheezing?

P: Nothing like that.

D: OK. How about uh chest pain, heart palpitations?

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

D: OK. Um any changes to your bowel movements?

P: No, I haven't had any diarrhea, or yeah, everything's been normal there.

D: OK, nausea or vomiting?

P: Nope.

D: No, um how about abdominal pain?

P: No, I haven't had any uh any abdominal pain, nothing like that.

D: OK, any changes to your urine?

P: No, uh no I haven't had any issues with that.

D: OK, how about uh headaches?

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

D: OK. Um any pain elsewhere on your body?

P: Uh nope, I've, it's just my, yeah just my knee.

D: OK, any numbness or tingling in the area?

P: No, I haven't had anything like that, it's just the uh sharp pain.

D: OK. How about confusion or memory loss?

P: No, I haven't had that.

D: OK. Um any um muscle aches around the knee, like so just above your knee where your quads are or just below?

P: Um no, nothing, nothing like that.

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

P: Um yeah, I'm otherwise healthy, I it's nothing that I see the doctor for, I've never been diagnosed with anything.

D: OK. Um how about hospitalizations or surgeries in the past?

P: Um nothing like that. no.

D: No, OK. Um any medications that you're on?

P: Um nope, I I don't take anything just well, no medications, but I do take a like a multivitamin.

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

P: I am yeah, I'll get the flu shot each year.

D: OK, how about allergies? Do you have any?

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

D: No, OK. Um any family history of musculoskeletal issues?

P: Uh nope, I don't think so.

D: How about um heart or lung conditions?

P: Uh I think my dad has like high blood pressure um and high cholesterol, but uh nobody's had a heart attack or, and no cancer.

D: OK, um how about autoimmune conditions?

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

D: No, OK. Um any um, do you do you do any smoking?

P: Uh no, I've tried uh like smoking marijuana in the past, but didn't really like it, so I've stayed away from that.

D: OK, how about um other recreational drugs?

P: Uh no, no, I I I haven't used anything like that before.

D: OK, um and then where do you live right now? And who do you live with?

P: So um right now I just live on my own, actually I'm um just finishing up my my my Masters um and just live in a small apartment.

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

P: No, I don't believe so.

D: OK. Um how about um travel?

P: Uh no, I've just been yeah finishing up the the thesis and running.

D: OK, alright, um those were all the questions I had for you, um we'll move on to the physical exam component of this. Um so if you can take a look at both your knees, um do you see any visible redness or swelling in the area?

P: Uh no no swelling or yeah, nothing visible that I can see.

D: OK, so no bruises?

P: Uh no, no no bruises

D: OK. Do you notice any like muscle atrophy, any deformities or skin changes otherwise?

P: No, everything looks looks normal.

D: OK, and if you can just um place your hand just kinda at the top of your, on top of your kneecap on both sides, do you notice any temperature changes from your, uh between your right knee to your left knee?

P: No, no temperature changes, they they feel the same.

D: OK. Um and then when you palpate your knee cap as well as um yeah, just if you could palpate just at the center of your kneecap, do you feel any pain there?

P: No pain over the kneecap, that feels fine.

D: OK. How about when you palpate kind of like the medial ligaments of your kneecap, do you feel any pain there?

P: No, everything on the medial side feels feels normal and fine.

D: How about when you palpate the lateral ligaments of your kneecap?

P: Yeah, the ligaments feel feel OK, on the lateral side though I I do get some pain along the um like above the joint line.

D: Above the joint line?

P: Yeah.

D: OK, OK, and how about when you palpate uh that big muscle group on your thighs like the quadriceps?

P: That feels OK, no pain in the muscles.

D: OK, how about like the patellar tendon?

P: Uh no pain there.

D: OK. And then when you go lower below your kneecap, um when you palpate like the top part where the proximal parts of your tibia and fibula are, do you feel any pain there?

P: Uh, yeah, no pain there.

D: OK, and now let's do some um movements with your leg. Um are you sitting down?

P: Uh, yeah, I am.

D: OK, I'm gonna get you to stand up from a sitting position, does that, is that painful?

P: It is, yeah it's, I get a sharp pain if, when doing that.

D: OK yeah, uhm how about when you um sit back down, does that hurt?

P: Um yeah, that hurts too.

D: That hurts too, OK. Um and then how about when you flex your knee inwards, um so that your heel is touching your bum like does that hurt?

P: Uh like I, I'll get up, uh no that doesn't hurt, that feels OK.

D: OK, how about when you extend your knee back out, straighten it all the way?

P: Yeah, that feels OK too if I'm just sitting and doing that, I can um, I can do that OK.

D: OK. Um how about when you, so you're standing and then you uh you abduct your hip so you basically, um you flex your hip but laterally and you kind of bring it upwards so that it's almost, so that your your, the action is like you're uh trying to touch the ceiling.

P: OK yeah I um, it, if, it does feel, it feels like it's kind of pulling um like it feels tight when I do that uh like on that side, it's, I don't get the same sharp pain, but it's uncomfortable.

D: OK, uhm, so I'm gonna try a special test, it's called the Ober test. So can I get you to lie on the side um with the injured knee?

P: Yep.

D: OK, and then I'm gonna get you to flex your knee at 90 degrees and um abduct and extend the hip uh while your thighs maintain in line with your trunk. Um so I'm gonna get you to adduct your thigh, so bring it back towards you, the the median, um as far as possible.

P: Oh yeah, I can't really, it's kind of like stuck out there. It feels really tight if I'm trying to like bring it, bring it back down, my leg almost like floats up if I just leave it there.

D: OK, so that is a positive Ober test. Um OK, so what it sounds like is you, it sounds like you have something called um iliotibial um band syndrome, so ITB syndrome, and basically that happens in um athletes, so depending on your like position, like how much you're using those joints um and like repetitive actions um of like knee flexion extension um kind of triggers that. And to treat it, uh we can try some conservative um things first, so the first thing would be um for you um to have some sort of activity modification to prevent aggravating that joint even more, so you're doing a lot of running, so maybe uh switching to things like swimming um for the time being can help with that. And then other things include ice or heating pads, uh taping and stretching, um and then if the pain is, if the pain uh persists, you can try some like ibuprofen for temporary relief. Um we can talk about other treatments as well, like physiotherapy because um it'll be important to kind of strengthen those muscles around that joint as well as um increase your range of motion, so we can do, we can put in a referral for that. Um and if none of those work, we can also discuss um some other things like ultrasound therapy or like muscle stimulation, um shockwave therapy, and then eventually if none of those other things work, we can discuss surgical management but uh it's rare that it ever gets to that point. Does that sound OK?

P: It does, yeah, thank you so much.

D: OK yeah, no worries.


D: How may I help you?

P: So I've just been having this pain in my knee since I um just fell, uh, just three days ago slipping on the stairs. Since then I've been having a lot of pain.

D: I see uh so did this pain start right after like falling on the stairs?

P: Yeah, yeah, I've been having the pain since then.

D: OK.

P: And that was three days ago.

D: Three days ago, OK. And you're feeling the pain in your in your right knee?

P: Yeah, in my right knee.

D: OK, uh. And what would you say the character of the pain is, or how would you describe the pain?

P: It's kind of like a dull aching pain.

D: OK. And has the pain been getting um, any better or any worse?

P: Uhm, it's kind of getting worse actually just in my right knee as well as my whole right calf as well.

D: OK, OK. Uh. What is the intensity of the pain on a scale of 1 to 10, 10 being the worst pain you've ever felt?

P: Probably around 6.

D: OK. Um. And. Did your knee hurt before this at all, or did you have any trauma to the leg before?

P: No, no before 3 days ago before my slip I was fine.

D: OK, are you feeling the pain anywhere else besides your right knee?

P: In my calf I'm getting a lot of pain as well. In my right calf.

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

P: Yeah, if I am If I'm walking or if I'm moving that leg and putting weight on it, it's definitely worse, so it's definitely like better if I just stay seated and stay resting.

D: OK. Is there anything she said resting that helps, is there anything else that's helped?

P: I did take some Advil which did help for a few hours, but then it just kind of went back to the same.

D: OK. Uhm. And. Yeah, have you had any other, uh, like associated symptoms with the right knee and calf pain?

P: Yes, I also think there's some swelling in my right calf as well. Since yesterday.

D: OK. OK, there's some swelling there.

P: Mmm

D: Have noticed if your calf was red or if there was a rash over it?

P: I don't see any rashes or redness, but it definitely does seem swollen and then it hurts as well when I move it or press it.

D: OK, uh, OK, and when you fell did you injure any other parts of your body like your your hands or wrists?

P: Um just a few scratches on my hands, but nothing too bad.

D: And how about your head? Did you lose consciousness or or hit your head?

P: No, no, I didn't hit my head at all. I caught myself before then and no, I didn't lose any consciousness.

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

P: No.

D: OK, have you had any chest pain?

P: No.

D: Have you had any cough?

P: No cough.

D: Have you have you had any shortness of breath?

P: No.

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

P: No.

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

P: No, nothing like that.

D: OK, uh. And. Have you had any like infectious symptoms, such as like. Like a runny nose or sore throat?

P: No, nothing like that.

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

P: No.

D: Have you had any abdominal pain?

P: No.

D: OK, have you had any changes to your bowel movements like diarrhea or or constipation?

P: No, nothing like that.

D: Alright, so have you had any urinary problems?

P: Nope.

D: Alright, so have you had any recent weight changes?

P: No, nothing like that.

D: OK. Uhm, And. Um, have you have you noticed any any rashes anywhere else over your whole body?

P: No, not that I've noticed.

D: Alright have you noticed any muscle weakness?

P: No.

D: Have you had any numbness to the skin?

P: Not that I've noted, no.

D: And have you had any tingling?

P: No. OK.

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

P: I do have some high cholesterol and high blood pressure.

D: I see, and do you take any medications?

P: Yeah, so cholesterol. I'm taking a like a Crestor medication and then for high blood pressure I'm taking a Ramipril.

D: OK. Have you had any hospitalizations or surgeries before?

P: Um. Just a. No, I I don't, um just besides a c-section for one of my children. I don't have any other surgeries.

D: OK. I'm and. Have you had any thrombosis before, or a blood clot in the past?

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

D: OK, and uh, have you been so you. You've had the birth of your you pregnant at other times in the past?

P: Um No, that was that was it.

D: OK so have you had a miscarriage before?

P: No.

D: OK, any allergies to medications?

P: No allergies.

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

P: Yeah, I live with my husband and our daughter. And it's just in a small townhouse, just in the city.

D: OK, and are you working currently?

P: I I do work from home, I'm actually just an accounting clerk, but I most of my work is from home right now.

D: OK. And any exposures to anybody who's been sick?

P: No.

D: Have you traveled anywhere recently?

P: Um nope.

D: OK. Uh. And over the last couple of days with that with the leg pain, do you feel as though you've been like immobilized?

P: Yeah, I've been trying to just like stay rested, just stay seated otherwise it hurts a lot, especially after my fall so. I've tried to stay immobilized.

D: OK for the last couple of days. OK, uh, and uh, do you drink alcohol?

P: Just socially, sometimes when I'm with friends or relatives like a glass of wine.

D: OK, and do you use recreational drugs like marijuana or or other things such like cocaine?

P: No, I've never tried that.

D: OK. And do you smoke cigarettes?

P: Uhm, No, I don't.

D: OK, I'm OK so. Oh, and uh in the family are there any history of heart or lung conditions?

P: Um so I don't know about heart or lung conditions, but uh my Mother had a stroke in her late 60s and my Father is pretty healthy.

D: OK. Has there been any blood clots in the family before?

P: I'm not sure about blood clots, but my mother had a stroke that's, is that kind of like a blood clot?

D: It could be, a stroke could have had many different type of types of causes for it, and one of them could be 'cause caused by blood clot. But I wouldn't be able to say for sure.

P: OK.

D: Just because, yeah, there are so many different types or reasons for for having a stroke .

P: I see OK.

D: So yeah, so you mentioned your leg has some swelling, um do you feel as though there's any any like temperature change to your calf like is it hot?

P: Uhm, I think I I don't know if it's maybe a little bit warm, but definitely swollen.

D: OK, and do you feel, is there any pain to palpation? Like if you touch your calf or something like that is there pain?

P: Yeah if I touch my right calf it's painful and then if I press down on it's really painful and then just on the outside of my right knee if I touch or press down it really hurts as well.

D: OK. And if you move your foot so it yeah, if you dorsiflex your ankle. Or bending your your toe up towards your nose, do you end up getting any calf pain? Doing the Homan test.

P: Yeah, yeah I'll try that. And yeah, I think it definitely hurts. When I when I move my or point my toes towards my nose.

D: OK. OK, so I think that was everything that I wanted to ask today on history. Was there anything else that that maybe I missed?

P: No, I think that's all.

D: OK yeah alright so with the. I fall 2 days ago. Things that I'm thinking about right now would be possibly a muscle strain, so this could be a gastrocnemius strain to the calf muscle itself, from from the fall which could have pain when you touch it, there could be some swelling and said it would be aggravated by movements. Also could be like injuries to some of that, the ligaments there as well. And however, with this the swelling immobilization for the last two days, as well as the pain kind of being a bit progressive that with swelling and a positive Homan in test and your temperature is a little bit elevated today not quite a fever, but feverish. It does increase the suspicion for deep vein thrombosis and so I think the most likely thing right now is actually a DVT or deep vein thrombosis. And so we will order some diagnostic studies, get an ultrasound of your right calf as well as an X Ray of the right knee to to start OK.

P: OK sounds good. Thank you so much.


D: How may I help you?

P: Hi I just want to talk about these, these times when I feel like I'm just I'm suffocating and I just can't breathe. It's pretty scary and I don't know what's going on.

D: Yeah, certainly, um, feeling short of breath like that can be quite scary for sure. When, when do these episodes kind of happen? Are they spontaneous? Or can you think of things that you're doing when they when they come on.

P: Uhm? I, I don't know, it's just like. Uhm? Sometimes, like before interviews, sometimes just kind of random. Uhm, yeah. I can kind of tell when they're about to come on. Uhm? Yeah, I think. It's mostly like job interviews.

D: OK, have you had many of those recently?

P: Job interviews?

D: Yeah.

P: I got I got laid off because of the pandemic and now I've been looking for jobs and it's just like it's kind of nerve wracking. But also like I don't know, I'm just worried it could be something else like it's just, yeah, it's like I really just can't breathe, it's so weird.

D: OK, yeah, it's certainly. It sounds like there's been a lot of stress recently. Certainly plenty for with the pandemic as well. And so when you get short of breath, you you said you have this, you could feel that it's coming on and how long does it last for?

P: Like 15 minutes 15, 20 minutes.

D: Is there anything you do to help it go away?

P: I'll just say go and lie down and close my eyes.

D: OK. And do you get shorter breath if you walk far distances or exert yourself?

P: Oh no, no. I go out for a run every single day. Nothing happens at that time.

D: OK. And. Have you had a cough?

P: No.

D: Any wheezing?

P: No.

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

P: Yeah, I kind of feel like this pressure at that time is just like yeah, someone's like pressing my chest inwards, kind of. It's hard to explain.

D: I see do you it is it um like, do you feel it in any one particular spot or?

P: No.

D: OK.

P: I just feel like my chest is really tight and it's just it's like I can't like expand my lungs.

D: I see and does this last around 15 minutes as well?

P: Yeah.

D: OK. And similarly you like going for runs and stuff like that you on't ever get any chest pain?

P: No, no, no.

D: OK. And and I know you mentioned you didn't have a cough, but have you brought up any phlegm or brought up any any blood?

P: No, no, I have not had a cough.

D: Oh no, OK, I'm sorry.

P: That's OK.

D: And have you otherwise been well? Or if you had any infectious symptoms, like a runny or red eyes, runny nose or sore throat?

P: No. None of those.

D: Alright, have you had any headaches?

P: No.

D: How about any fevers or chills?

P: No.

D: Have you had any night sweats?

P: No, but I get really sweaty when these episodes happen. Just like yeah, my face is like sweating, and my neck.

D: OK. Yeah, Um, OK, and How is your weight been recently? Any weight gain or loss?

P: Yeah, I've gained quite a bit of weight since the pandemic started. Yeah, gained about 10 pounds.

D: OK, any changes to your diet or appetite?

P: Oh yeah, I've been eating quite a bit, been baking a lot at home.

D: OK. And, and have you had any abdominal pains?

P: No.

D: Any diarrhea?

P: Uhm? No.

D: OK. Any nausea or vomiting?

P: No.

D: Alright, and any urinary problems like pain or frequency?

P: No.

D: Any rashes or skin changes?

P: No.

D: And, any muscle aches, body pains or joint pains or swelling?

P: Nothing like that, no.

D: OK and how's your energy been?

P: Um. Well, I've been feeling a little low. Since I've been laid off just like worried about my finances and I kind of sleep all day. I'm not feeling very energetic.

D: OK. How is your interest in activities been?

P: I don't know, I just feel like staying at home and just being in bed all the time.

D: OK, so you're um, have you had a low mood?

P: Yeah.

D: Alright and are you sleeping more than usual?

P: Yeah.

D: OK, is there anything that you're feeling particularly guilty about right now?

P: No.

D: OK. How is your concentration been?

P: Uhm, not great.

D: OK. You haven't been able to focus and have you felt like things are moving in slow motion?

P: No.

D: Alright, so have you had any thoughts of hurting or harming yourself?

P: No.

D: OK. And have you had depression or anxiety in the past?

P: Um I've been diagnosed with depression.

D: OK. And have you had panic attacks before?

P: No, but do you think that's what's going on?

D: Potentially, it certainly can't rule out. Inorganic cause meaning something going on, otherwise just yet we might need to do some physical exam and some investigations first, but it certainly could be related to that. With all of the stressors that are going on. And so you had a low mood. Have you had any periods in your life where you felt really energetic, like you didn't need any sleep, you're really talkative, you had all the energy in the world.

P: I wish, no, I've never really felt that way,

D: OK. And have you had any concerns with eating disorders in the past?

P: No.

D: Alright. And then you mentioned, even diagnosed with depression, if you had, are you have you been diagnosed with any other medical conditions?

P: No.

D: OK, are you on any medications right now?

P: No, I was doing pretty well. I used to have these episodes of depression when I was younger as a teenager and they kind of went away. I was on meds at that time, but I think I think it's coming back now.

D: OK, so you haven't been on medication now for for quite awhile for years.

P: For like 12 years 13 years.

D: OK, what did you use that, if you can remember?

P: Prozac?

D: OK, and did you find it helped?

P: Yeah, yeah it was very helpful, was very good.

D: OK. That's good. Any allergies to medications?

P: No.

D: Alright and any hospitalizations or surgeries?

P: No.

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

P: I I live, I live with my girlfriend.

D: OK. And. Has there been anybody around that that has been sick that they have been around?

P: No.

D: OK, have you traveled anywhere?

P: No no.

D: And do you smoke cigarettes?

P: Oh no, I don't.

D: OK, do you drink alcohol?

P: I don't.

D: OK. And. Are you currently sexually active?

P: Yeah.

D: OK, and any chance that you could be pregnant currently?

P: No.

D: And have you been pregnant in the past?

P: No.

D: OK. And do you smoke cigarettes?

P: I don't.

D: Do you drink alcohol?

P: No.

D: And do you use any recreational drugs?

P: No.

D: OK, and any family history of heart or lung problems?

P: My grandfather had lung cancer. But that's about it.

D: Did he smoke for a long time?

P: Oh yeah, he was a big smoker.

D: OK, and anybody in the family have problems with mental illness?

P: My mom has uh depression too.

D: OK. Anybody in in the family have problems with substance, substance use?

P: no.

D: OK. Um, and  I think that's everything that I I wanted to ask on history today. So you been having these episodes where you get really short of breath and you get chest pain, you'll get sweaty and have what sounds like what sounds like an impending sense of doom where you kind of feel like it's coming on and it lasts for 15 minutes and not related to exercise. Were there any other symptoms or things that you've been experiencing recently?

P: Yeah, it's also,  I also feel like my heart's like breathing really fast.

D: Oh, OK. And I does that, how long does it last for?

P: Same time. Like everything is just sort of comes on at the same time. Just kind of goes away together.

D: OK, would you say that it comes on like kind of like at the snap of your fingers sort of thing like really quickly and then?

P: I can kind of tell it's gonna come on like I have a sense of it and then it just like starts. It suddenly just happens.

D: OK. So you you have the heart racing, are there any other symptoms as well?

P: I don't think so.

D: OK, so, uh, we will get an ECG and  I will look at that, but I've been concerned now thinking that this might be related to anxiety or panic attacks and so, I guess that would be something that we could discuss more about in regards to like I guess previous traumas and things that and the stresses that you might be dealing with currently to help manage manage stress better.

P: Sure, thank you.


D: I’m just going to have a chat with you get an idea of what's going on and then I can go over it with. The doctor will come back together and talk to you about the next steps. How does that sound to you?

P: Thats great, thank you.

D: Awesome OK. It says here that you have been having a sore throat. Can you tell me a little bit more about that?

P: Sure, yeah the sore throat it started about four days ago. And it's really it's it's very sore. I can drink fluids OK but I'm even having some issues swallowing food.

D: OK, so you said four days ago?

P: Yes, four days ago.

D: OK. So it's been kind of sore, some issues swallowing food OK, and over the last four days has it gotten worse, Better that it stayed the same?

P: Um the sore throat has it's got, it's getting worse for sure.

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

P: I I, I guess when I was younger I had mono. And I had a sore throat when I had that, yeah.

D: OK, is there anything that makes it worse or like anything that makes it feel better right now?

P: No, not really. I've tried, you know, I've tried gargling with salt water. I've tried some painkillers like nothing, nothing seems to be working.

D: Uhm OK, and you said you've also had some difficulty breathing.

P: Yeah, that's right.

D: Did that start around the same time?

P: That actually started yesterday, and it's gotten me very concerned.

D: OK. Yeah, I can understand how that would be concerning. We're definitely going to try to get to the bottom of it today. Um OK so started yesterday, said then has it gotten any worse? Is it the same way better?

P: Um the, well, I guess it's getting worse, yeah.

D: Do you feel like it's all the time or is it on and off?

P: It's it's just there all the time.

D: Have you ever had any difficulty breathing in the past?

P: Um no no, no, not like this.

D: OK. Uh. Have you have you recently been in contact with anyone that's been sick?

P: Um. I have, no. I don't leave the house much nowadays. I go to the grocery store, I go to the bank. Just essential things.

D: OK, have you traveled recently?

P: Um no, no, I haven't left the city for anything.

D: OK. Do you know if your immunizations are up to date?

P: Ah yes, everything's up to date.

D: OK. That’s good. See you so I'm just gonna ask you about a few other symptoms. I just like to get an idea if there's anything else you been experiencing. Have you had a cough at all?

P: No.

D: Have you had a runny nose?

P: No runny nose.

D: Have you had any headaches?

P: No.

D: Have you had any chest pain?

P: Ah nope, no chest pain.

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

P: Um maybe taste a little bit but not smell.

D: OK, OK, when did that start?

P: The taste ah. Maybe two days ago?

D: OK. OK taste two days ago. Has it been on and off or has it been kind of constantly like a reduced sense of taste?

P: It's it's. It's been pretty constant.

D: OK. Have you had anything like that before?

P: No.

D: Have you had any fevers?

P: I don't think so.

D: OK. Have you had any chills or night sweats?

P: No.

D: Have you felt overall really tired and weak?

P: I. I felt tired, maybe not weak, but my I feel like my muscles all ache.

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

P: That started. Like immediately after my sore throat.

D: OK. OK. OK, well we might circle back. I think there is any more questions you want to ask. Right now, but just in general, in terms of your overall health, do you have any chronic conditions that you take medications for or see a doctor for regularly?

P: Um I have mild COPD.

D: OK. And what medications are you currently taking?

P: Um I'm on a long acting beta agonist.

D: OK, is that the only medication you take?

P: Pardon me.

D: Is that the only medication that you take?

P: And I also take a couple of vitamins.

D: OK. Do you have any allergies?

P: Um no, no allergies.

D: Just gonna ask you few questions about your lifestyle. Do you live here in town?

P: I do.

D: Do you ah live alone or with family?

P: I live alone.

D: OK. And do you smoke?

P: I quit two years ago.

D: Oh congratulations, before that did you did you smoke for many years?

P: I did, I smoked for 40 years.

D: OK. Do you drink alcohol?

P: I drink occasionally, maybe like on the weekends.

D: OK. Uhm, and do you use cannabis?

P: No.

D: OK any other drugs?

P: No, no other drugs.

D: OK. And are you retired? Do you work?

P: I am retired, yeah.

D: OK, what did you do for work before?

P: I worked for GM.

D: Crock. OK. And do you have any family history of respiratory problems, heart problems and?

P: No.

D: OK. Uhm. OK, I think that that about covers my questions for you right now. Is there anything else that you wanted to add that I didn't ask you about?

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

D: OK. I’m going to go over this with the document I'm working with today, I'm guessing just because some of your symptoms are in line with common symptoms of covid 19, that will probably do a covid swab, and what happens with that is since we do have some syptoms, will have to isolate until the result come back and potentially after that if you still have symptoms, even if it is negative. So that's just kind of a heads up on that. Maybe one of the next things that happens. We will probably get you a chest xray 'cause we want to get an idea of what's going on in there. Did you have any other questions?

P: No, thank you very much.

D: OK well thanks for chatting with me we should be back shortly to kind of let you know with the next step.

P: OK, great, thank you.

D: Thanks.


D: How may I help you?

P: Yeah I just came in here today I've been experiencing some difficulties with my right hand, especially at the bases of the 4th and 5th digits. I notice this happening over the last I'd say probably last few months it's been getting worse. I've been having trouble just kind of extending those two fingers and I kind of see like this little bump at the base of those two fingers. So yeah overall it's just been difficult working, I'm a construction worker and I don't know if this just keeps getting worse.

D: OK. And you noticed um, and sorry, when exactly did it start?

P: Probably two months ago months ago.

D: About two months ago, and it's the 4th and 5th digits or any other fingers involved or any parts other parts of your hand?

P: No, it's just those two.

D: OK. Uhm and how would you describe the the pain that you're feeling, is it a sharp pain and an achy pain or a burning pain?

P: Uhm, it's more a kind of like a aching, aching pain which gets worse with if I try to extend those fingers. And yeah, like that I do feel like the little nodules, but like pressing on them doesn't hurt or anything like that.

D: OK, uh, and do you feel any radiation of pain like in into your hand or forearm?

P: Uhm, no, not really.

D: OK, and alright, is there anything that is aggravating or making the pain worse?

P: Uhm I think just a extending, it's it's I would say more than the pain it's just like discomfort and just not being able to extend that is is frustrating, uh, like the pain isn't that bad like there's like minimal pain.

D: OK, and is there any like like clicking or. Yeah any any clicking or catching when you're trying to like extend the finger?

P: Uhm I would say there is a. Yeah there's some like catching I would say if when I'm trying to extend.

D: OK. And has there been anything that that you've tried recently that's improved the discomfort or or helped with the range of motion?

P: No, nothing that I've tried that has really helped and. Yeah, I'm just afraid if I stop kind of exercising and it'll just keep getting worse.

D: OK, yeah, certainly. OK, and what, have you had any problems with your hand before like any trauma there or anything like that?

P: Uh, my my construction worker so there's always like a lot of. I haven't had any falls or injuries on my hands luckily, but there is always just constant lifting. There's I used to drill a lot too, so there's like always constant and I'm right handed as well. So there's always like the vibration yeah so but no no direct like traumas or falls.

D: Have you been having any neurological symptoms, such as like numbness or tingling or loss of sensation to any parts of your hand or upper extremity?

P: No numbness or tingling. And no weakness or anything like that.

D: OK, so no muscle weakness?

P: No.

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

P: No.

D: OK, and how about any night sweats?

P: No.

D: And have you been having any unexpected, have you had any unexpected weight loss?

P: No.

D: OK, and have you had any headaches?

P: Nope.

D: Any sensory changes such as changes to your vision, hearing, loss of taste or sense of smell?

P: No, nothing like that.

D: Have you had a runny nose or felt congested?

P: Nope.

D: Have you had any I redness or or itchy eyes?

P: Nope.

D: Alright and have you had a sore throat or cough.

P: No, nothing like that.

D: How about any shortness of breath or wheezing?

P: Nope.

D: Have you had any chest pain?

P: Nope.

D: Any lightheadedness, dizziness, or feeling as though you might faint?

P: No.

D: You got any feelings of though your heart is racing?

P: Nope.

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

P: No.

D: Any abdominal pain?

P: Nope.

D: Have you had any diarrhea or constipation?

P: Nope.

D: Alright, and have you had like any blood in the stool?

P: No.

D: Any urinary problems like pain or frequency?

P: No.

D: An any skin changes like rashes?

P: No, nothing like that.

D: OK, or any changes to your nails or hair like you'll notice like plaques on the nails or or hair loss?

P: No.

D: OK, and have you been having any muscle aches or joint pains or body pains anywhere else?

P: No, not really.

D: Alright, and uh. Have you had any memory loss or confusion?

P: No, nothing like that.

D: OK, and have you had any appetite loss or fatigue?

P: Uhm no.

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

P: Uhm they say I have like some high cholesterol. I'm taking this medication like a statin and but other than that umm no.

D: OK, so do you take any other medications or is it just the statin?

P: It's just a statin.

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

P: Uhm I did a have a ACL repair just when I was probably 18.

D: OK, do you have any allergies?

P: No, not that I know.

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

P: Yep.

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

P: Yeah, so I just lived with my wife, we live in small apartment.

D: OK, and are you working right now?

P: Yeah, just as a construction worker. Been doing that for the last probably 10 years.

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

P: No.

D: OK, and sorry as a construction worker I have you had any like any puncture wounds to your hands or anything that like any like slivers or things that have gone into the skin?

P: Not any puncture wounds. Like uh yeah, I sometimes get splinters here and there, but nothing like nothing recently that I can think of that has been anything worrying or significant.

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

P: Nope.

D: Been around anybody who's been sick.

P: Nope.

D: Do you smoke cigarettes?

P: Yeah, I smoke probably a pack a day for the last. I don't know like 10 years.

D: OK, and you smoke marijuana?

P: Not that much, probably just a couple times a month.

D: OK, uh. And do you drink alcohol?

P: Yeah, probably. A couple of years a day.

D: OK. Like one or two a day?

P: Yeah. Probably one or two, sometimes 3.

D: OK. And you use any rec other recreational drugs at and or any IV drugs and have you in the past?

P: No, I haven't tried anything beyond weed. I don't wanna try any other stuff.

D: OK, I I see and that's good then uhm anybody in the family have any musculoskeletal or neurological conditions that run in the family?

P: Uhm not that I know.

D: OK, and how about any autoimmune conditions like rheumatoid arthritis or hypothyroidism?

P: Nope.

D: OK, and as anybody in the family had a Dupuytren's contracture before?

P: Uhm no, I haven't I haven't heard it now.

D: OK, and so uh next, I just wanted to go on to the physical exam portion, so just a couple more questions. So when you're looking at your hand, are you seeing any swelling redness?

P: Not swelling, I just yeah just those nodules and I get like a little bit of whiteness around those nodules when I extend my fingers.

D: OK yeah, but no redness?

P: No.

D: OK, and are you are you seeing any, uh like muscle atrophy or any deformities of any of your joints in the fingers or the wrist?

P: Nope.

D: OK, and uh are there any areas that that you can palpate over your hand that causes pain.

P: Yeah, there's just some discomfort, like when I at the bases of those two fingers, like if I press on the nodules like it's sometimes a little bit like uncomfortable but it's not too bad. Like I, I don't, but I don't know I have a pretty high pain threshold too, so it's hard to say.

D: OK, I see an when you're extending your fingers with like passive extension to do with your other hand do you get a lot of pain like along the tendons or the passive extension?

P: Yeah definitely. I would say more painful than if I try to extend it myself. Like just forcing it back but yeah, but not not anything too like I like it's not sharp or anything like that.

D: OK, and with the on the nodules and stuff, do you feel any like crepitations or like crackling or rubbing over those, those areas or your palm?

P: Uhm crackling oh no not that I have noticed.

D: OK, and any issues with your like wrist or or elbow?

P: No, not that I know of.

D: OK. Uhm so I think that's everything that I wanted to ask about today. Did you have anything that you wanted to add or or did you have any questions?

P: No, I think that's all.

D: OK, I'm so right now it's sounding like it's most likely something called Dupuytren's contracture, but also we can't rule out like flexor tenosynovitis just yet or or trigger finger. Based on the the symptoms, but the fact that you're not having a fever, you don't have pain kind of along the the tendon, you're not seeing any swelling or redness that's all pointing away from the tenosynovitis.

P: Mmmm

D: But it'll be important to get some blood work and things to make sure that we're not missing that. But for Dupuytren's contracture. It'll be a uh, do doing what we can with therapy to try it like physiotherapy and activity modification to try and loosen those structures on the on the palm of your hand.

P: OK, sounds good.


D: How may I help you?

P: I just came in because I've been having this just just yesterday it started this sudden just pain over the front of my kind of like a shoulder an also elbow and it was right after doing I was just doing some workout and this pain just started and it's just like a stabbing sharp pain that hasn't really gone away since then.

D: OK, and so what activity were you doing specifically?

P: So I was doing so I was just doing weight training and I was kind of flexing my elbows and I was working on my biceps. I was on that machine where you so know I wasn't using weights or doing curls, but I was working on my biceps and I think I did hear, I don't think I heard like any pop or anything, but right after that I just had this sudden sharp pain in my shoulder as well as my elbow.

D: OK, so you you you think you heard a pop at that time?

P: Um I'm not sure if I heard a pop. Actually, I think I might have though.

D: OK, and did the pain start immediately or or a bit later on?

P: The pain I think it started pretty soon after, like probably within like half an hour of that happening.

D: OK. And where is the pain located now?

P: The pain right now is a. Yeah, just kind of right at the front of my right elbow as well as near my shoulder as well.

D" OK. And. Um I think you mentioned the pain as as being sharp is that how you would describe the character of the pain?

P: Yeah, it's sharp. Yeah, I just feel like something stabbing in there.

D: OK, and does the pain radiate anywhere else?

P: No, it's kind of in the same area as they described.

D: OK, has there been anything you've tried to make the pain better?

P: No nothings I tried like Advil nothings really worked.

D: OK. And, uh, sorry. How long is how many days is the pain been on going on for just just started yesterday?

P: Yesterday.

D: OK, and since then has the pain getting any better or any worse?

P: I think it's the same, probably a bit worse than so it just happened last evening and I I didn't end up coming last night, but I wanted to make sure. I'm just coming this morning since it's just been a really painful night.

D: OK, have you done anything that's made the pain worse since last night?

P: No I just tried to just rest and I tried to use some ice, but nothing. Nothing's been working and I kind of also have like this. It it's weird, it's just like this mass right where my biceps is. It kind of just makes my biceps look really big.

D: OK, alright, well I skip look at that during the physical exam component thank you and so like are you seeing swell is there like swelling there is as well or is is that part painful?

P: Yeah, it's painful there swelling there as well.

D: OK. And well, how severe is the pain on a scale of 10 to 1, 10 being the worst pain that you've ever experienced and one being the least.

P: Probably at least an 8, maybe a 9.

D: OK, so the pain is pretty severe then it sounds like. Uh, OK. Have you had any fevers or chills?

P: No.

D: Have you had any unexpected weight loss?

P: No.

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

P: Uhm no.

D: OK, and have you had any headaches?

P: Uhm no.

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

P: No, nothing like that.

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

P: Nope.

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

P: Uhm no nothing like that.

D: OK, have you had a cough?

P: No.

D: Any shortness of breath?

P: No.

D: OK, any wheezing?

P: No.

D: Um have you had any chest pain?

P: No.

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

P: No.

D: Any lightheadedness or dizziness?

P: Nope.

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

P: No.

D: Any nausea or vomiting?

P: No.

D: Any changes to your bowel movements such as diarrhea or constipation or even blood in the stool.

P: No nothing like that.

D: OK, any urination problems such as pain or frequency?

P: Nope.

D: OK and have you noticed any changes to your skin like rashes or changes to your nails or hair?

P: No.

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

P: No, I don't think so.

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

P: Just just in the in that area, I can't really like. I can't really flex an really move my upper upper arm in my elbow.

D: OK. Do you have any pains in any other joints?

P: Um no that's it's only my right upper arm.

D: OK. Um. And. Have you had any confusion or memory loss?

P: No. OK. And in the past, have you been diagnosed with any other medical conditions?

P: Uhm no I've been pretty healthy, um I they think I do have like pre diabetes but I'm not on any medication.

D: OK, and have you had any issues with your shoulder before like like a subacromial like impingement syndrome or like a rotator cuff pains or problems in the past?

P: A few years ago I did have some pain um with like some, they they told me not to do like overhead work like just things that require like with Physio I need to do some strengthening as well and it was it wasn't the same same shoulder.

D: OK. And do you take any medications regularly?

P: Uh, no.

D: OK, and do you have any allergies?

P: No.

D: Have you had any hospitalizations or prior surgeries?

P: I had my tonsils removed when I was probably like 10 or something, but that's about it.

D: OK, and for the shoulder in the past did you have any imaging done like an ultrasound or or MRI maybe to look at the structures?

P: No, it was just a it kind of went away. I just did some physio they didn't really do any imaging.

D: I see OK. And can you tell me a little about your living situation right now, like you're living with and where?

P: Yeah so I'm living with my wife and um daughter and I'm living just in a condominium in the city.

D: OK, and are you working right now?

P: Yeah, so I'm an accountant. I'm working from home, so it's not that bad, but I I might just take a few days off depending on what I have to do with this injury.

D: OK, and um do you and hobby wise you mentioned like weight lifting, are you an active person like bodybuilding and that sort of thing regularly?

P: I I just actually probably started this past year. I used to. I used to workout a lot. In University and in my early 30s but then I stopped and this year I've kind of gone back into it.

D: OK, well it's good that you're staying active. And um do you smoke cigarettes?

P: No, I uh, probably tried a couple times and. High School and University, but just it was never my thing.

D: OK, and how about cannabis, like smoking marijuana or using any of those types of products?

P: No, I I try to stay away from any drugs.

D: OK, uh, including recreational drugs?

P: Yeah.

D: OK and. Uh, are there any musculoskeletal or neurological problems that that run in the family?

P: Not that I know of, no.

D: OK, now how about any autoimmune diseases?

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

D: OK, so next I just wanted to ask you to have a look at the at the arm. Compared to the other side, are you noticing any swelling, redness, or?

P: Yeah, any swelling or redness, I do see some just like kind of like in the middle of this area, some redness kind of looks like some bruising in in that in that region. Uhm, I also feel like when I like try to flex my biceps kind of have moved upwards.

D: OK, is this the mass or lump that I you were mentioning earlier that you kinda can notice in the in your right arm?

P: Yeah yeah.

D: OK, is there any temperature change, like does it feel warm on that side?

P: Uhm I can't really tell if it's warm or not.

D: OK, and you so you mentioned are you able to bend your elbow all the way up so to flex it all the way up, or is a range of motion limited?

P: It's pretty limited. It's pretty tough to flex. It's really painful and that I also can't like. I can't turn my arm, I can't supinate.

D: OK so yeah, so is that so you have reduced supination as well?

P: Yeah.

D: And how are your shoulder movement, are you able to like if you're lifting your arms straight out in front of you, are you able to to lift them all the way up above your head?

P: Out like at the sides or in front of me?

D: In front of you.

P: Yeah, the shoulder seems to be OK. I am able to lift up, but it's just if I try to move my upper arms at all it hurts a lot.

D: OK, alright so. You'll get some pain at the at the shoulder with the movement.

P: There there is discomfort in the affected side, but I can I can move it much more than I can move my elbows or anything like that.

D: OK, I see. So I think that was everything that I wanted to ask about and and I look for on on the physical today. Was there anything I may be missed or anything like that?

P: Uhm no I think, uh, I don't have any other questions.

D: OK, alright, so based on the history and what you're telling me for the physical as well of having a history of exercising and also shoulder pain with overhead head movements which are risk factors for developing a biceps, tendon tear or biceps tendon injury. And having the swelling and bruising as well as reduced function of biceps or elbow flexion, they all suggests that there is a biceps, tendon tear, or injury there, and so will want to get an ultrasound or MRI to look at will start with the ultrasound, but then possibly get an MRI as well to look at the extent of the tissue damage, but if there is just a long head of biceps tear, it will usually be treated conservatively. And so we'll just need to look to see what the extent of the injury is.

P: OK.