A 75-year-old man with a history of hypertension, diabetes, environmental allergies, and colon polyps presents to the office with a complaint of persistent dry hacking cough that does not improve with over-the-counter treatment with antitussives and allergy medications. The man reports that he has had the cough for 3 months and is tired of the coughing spells he experiences. His medical history reveals that he started taking lisinopril 6 months before this appointment, has taken an over-the-counter allergy medication for several years, had his last colon polyps removed 6 years ago, and his blood pressure today is 145/70. Other medications include metformin XR 500 mg daily, aspirin 81 mg once daily, and loratadine 10 mg daily. The physical exam is negative for any issues other than his mild neuropathy from long-term diabetes. The cough is noted to be dry and hacking as the patient has described. The man is not in acute distress.
1. What questions would have been asked as part of the medical history?
2. What physical aspects would have been completed as part of the physical exam?
3. Based on the medical history and physical exam, what is the most likely cause of his cough?
4. What other possible diagnoses should be considered?
Cough is a common clinical presentation in the primary care setting. Respiratory or cardiac illnesses may cause cough. It may also be related to allergic reactions or a side effect of medication (Gibson, 2019). Asking specific questions during medical history helps narrow down the differential diagnosis, thus preventing delayed treatment. In the current case, the patient presents with a persistent dry cough. Some of the assessment questions that the provider should ask include when the patient first noticed the coughing spell, what the patient was doing when they first experienced the cough, what makes the coughing worse, and what makes it better. It would also be essential to inquire whether the patient has traveled outside the country in the last few months and whether she has recently had a cold or flu (Morice et al., 2019).
A physical exam focuses on assessing for system abnormalities that may cause a cough in patients presenting with a cough. For example, a review of the HEENT can help assess for indicators of upper respiratory infections, such as wheezing, nasal congestion, and throat pain. Likewise, a chest review regarding breathing sounds and lung sounds can help assess lower respiratory infections. Besides, a review of the cardiac system regarding heart rhythm and sounds would be essential for evaluating cardiac illnesses (Porter et al., 2019).
The patient reports that the cough has not responded to antitussives and allergy medications. Besides, physical assessment is normal; thus, the cough is not associated with any other symptom. This suggests that the cough is not related to cardiac or pulmonary illness; the most likely diagnosis is a drug-induced chronic cough. The cough could be a side effect of Lisinopril. Chronic dry cough is one of the most common side effects of this ACE inhibitor because it irritates the airways (Shim, Song & Morice, 2020). Besides, the patient reports the cough began three months after starting the Lisinopril prescription.
The other possible diagnosis that should be considered is an allergic reaction. An allergy cough may present as a cough without any other associated symptoms (Jo & Song, 2019). Besides, the patient reports a history of environmental allergies.
Gibson, P. G. (2019). Management of cough. The Journal of Allergy and Clinical Immunology: In Practice, 7(6), 1724-1729. https://doi.org/10.1016/j.jaip.2019.03.050
Jo, E. J., & Song, W. J. (2019). Environmental triggers for chronic cough. Asia Pacific Allergy, 9(2).
Morice, A. H., Kitt, M. M., Ford, A. P., Tershakovec, A. M., Wu, W. C., Brindle, K., … & Wright, C. (2019). The effect of gefapixant, a P2X3 antagonist, on cough reflex sensitivity: a randomized placebo-controlled study. European Respiratory Journal, 54(1). DOI: 10.1183/13993003.00439-2019
Shim, J. S., Song, W. J., & Morice, A. H. (2020). Drug-induced cough. Physiological research, 69, S81-S92. https://doi.org/10.33549/physiolres.934406