D: How may I help you?

P: Hi, yes it's nice to meet you. I've been having this cough that's been going on for the last few days and I have had difficulty breathing.

D: Oh, I'm so sorry to hear that. When did this start?

P: Oh, so the cough started about 3 days ago. Yeah, the shortness of breath has come on since then.

D: OK, well let's focus on the shortness of breath first and then we'll talk about your cough as well. So you noticed that you had difficulties with breathing sometime within the past three days. When do you find that it's difficult for you to breathe? Is there anything that makes breathing more difficult for you?

P: Yeah, not really. Actually, it's been well, but just bad after I cough.

D: So say walking up the stairs or doing any exercise doesn't make it worse?

P: Not really, I've been able to do the same amounts of of activity I guess. 

D: OK, so there's really no relationship with activity with your shortness of breath. OK, and I can see that you're able to sort of talk in full sentences.  OK, how is it making it difficult for you to do things at home, your difficulty breathing?

P: I am a little bit, I mean, I feel I just haven't been feeling very good overall so I've been resting these last couple of days mostly.

D: OK, and your cough, you said that started three days ago. Is it a dry cough or wet cough?

P: It's dry. It's a dry cough. 

D: OK, and there's no sputum production with it? Anything coming up at all?

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

D: OK, and is there anything that's making the cough better? Did you take anything? Any medications for it? 

P: I tried some over the counter stuff but it didn't help.

D: OK alright. Other than the difficulty breathing and the cough, have you noticed any other symptoms?

P: Yeah, I've been really tired. I guess I've just sort of been  resting the these last few days and I've had a headache as well.

D: OK. Can you tell me a bit more about your headache?

P: Yeah, it feels like somebody is just squeezing the top of or just squeezing the sides of my head.

D: Have you had a headache like this before?

P: I have, yeah. I usually get them when I'm dehydrated. Or maybe I haven't slept well. And that's also been the case for the past two to three days. Yeah, it's been kind of off and on, there are some times that are worse than others, but I've noticed that I had it for the most part for the last few days, OK,

D: Have you taken anything for your headache? Any pain meds?

P: Yeah, I've been taking some Advil, it's helped.

D: And so you talked about being tired, having a headache, difficulties breathing, and coughing over the past three days. Have any of these symptoms gotten worse overtime?

P: Yes, I would say, but both the cough and the shortness of breath has been getting worse over these last few days.

D: OK, and have you had any chills or have you checked your temperature?

P: I haven't checked my temperature, but I felt like I've had a fever or might be getting a fever.

D: We can check your temperature here. And have you had any muscle aches?

P: Yeah, I guess I felt a bit achy.

D: Any redness in the eyes? Or any runny nose or sore throat like flu-like symptoms?

P: Umm, I have, I don't know maybe my nose is a little bit congested, but not really running.

D: OK. And have you had any change in your sense of smell?

P: No, I haven't noticed that.

D: What about your sense of taste? Are you able to taste things?

P: Yeah, I think so. 

D: Have you noticed any rash anywhere on your body?

P: Umm, no,  I haven't.

D: OK, any changes in your bowel movement, diarrhea or constipation?

P: No, no, nothing like that.

D: Any chest pain?

P: No, I haven't had any.

D: OK. Alright, well it sounds like you have multiple symptoms right now that started about 3 days ago. You're feeling tired, you have a headache, difficulties breathing, some muscle aches and you've been feeling feverish. You've also had this cough, and your nose is feeling congested. Is there anything else that that you've been experiencing over the past three days that I haven't talked about yet?

P: No, as you mentioned, the headache's there too, then yeah, that's everything. 

D: OK, umm, alright, can you tell me about your past medical history? Do you have any medical conditions?

P: Yeah, I have asthma and GERD I think.

D: Umm, does the shortness of breath that you're experiencing feel similar to the asthma attacks in any way?

P: No, I haven't had any issues with like asthma attacks in a long time. 

D: Do you have an inhaler?

P: I do but I don't use it very often.

D: I see, did you use it over the past three days at all?

P: Yeah I did try it and it didn't really seem to help that much.

D: Uh, and other than that, have you had any any surgeries in the past?

P: Uh, I had a colonoscopy two years ago.

D: Any reason for that? 

P: Uhh, my father had colon cancer when he was in his 60s. 

D: I see OK, and any hospitalizations?

P: No. 

D: OK. Do you take any medications? I know you have puffers. Any medications, including over the counter pills?

P: Yeah, I'll take like a Zantac or like Tums sometimes for reflux.

D: And, uh, any allergies to food, medications, or environmental allergies?

P: Yeah, I have environmental allergies. I think like usually they come on in the springtime.

D: In terms of family histories, you did mention that your dad had colon cancer. Any other medical problems that that run in your family?

P: Umm, no. 

D: OK. And do you currently smoke?

P: No, I don't and have never smoked in the past.

D: OK, what about marijuana?

P: Umm, no. 

D: OK, do you or have you ever had alcohol?

P: I will have some wine on the weekends, maybe a glass or two with dinner.

D: OK, sounds good and have you ever had any street drugs?

P: Like a long time ago, maybe when I was in college, once or twice.

D: Alright, sounds good, and have you had any contact with any sick people? Anyone who's sick recently?

P: Not that I know of. I mean, I went to a few stores here and there that I had been going to. I've been working from home so maybe at one of the stores. And I would imagine I were wearing a mask and of course trying to maintain social distancing as much as possible. But yeah, you never, really know. 

D: What about any other travels or any travels at all outside the city or the country recently?

P: Umm, no, I had been at home.

D: Alright. So I guess that's all I wanted to know. I'll go talk to the attending and we'll come back and do a physical exam and maybe ask a couple more questions and then discuss the management with you. Does that sound good to you?

P: Yeah, that sounds great.

D: Thank you. OK alright.