Prolonged Dry Cough: Case Study Case Study

Introduction

Case studies are an effective learning method from examples that one can encounter in practice. This paper presents an analysis of the case of a 75-year-old man with prolonged dry cough. A similar symptom can indicate various diseases, so it is crucial to study and consider the details of the situation. Critical aspects for diagnosis and subsequent treatment may be the patient’s medical history, contact with other people, medication taken, and similar factors. The paper considers the questions to the patient, the stages of physical examination, the potential cause of the problem, alternative diagnoses, possible additional tests, and treatment proposals.

Questions to patient

Interviewing the patient and finding out his medical history is essential in establishing the diagnosis. There are several approaches to the survey; for example, Goldberg (n.d.) proposes the abbreviation OLD CARTS, which stands for “Onset, Location/radiation, Duration, Character, Aggregating factors, Relying factors, Timing and Severity” (para. 17). Glashan & Mahmoud (2019) offer a SCHOLAR (Symptoms, Characteristics, History, Onset, Location, Aggregating Factors, Remitting Factors) approach for cough assessment. Methods have many common goals, and one can identify several key questions for the studied case:

• What are the symptoms and their duration? What is the characteristic of symptoms?
• Is there sputum discharge?
• Are there accompanying problems like vomiting, urinary incontinence, or pain during coughing? Do you feel pain when swallowing, have wheezing, and similar issues?
• How much does the problem interfere with everyday life? Does coughing prevent you from sleeping?
• Do you experience fatigue, shortness of breath, heartburn, fever, or chills?
• Have there been similar problems before?
• Do you smoke?
• What medicine are you taking? How long?
• Have you had contact with sick people?
• Are there factors exacerbating the cough? For example, exercise, conversation, laughter, or cold air?
• Do you notice cough triggers?
• Is there any allergy?
• Have you tried any remedies for treatment? Did they help?

Physical examination

The next step after collecting the patient’s history is a physical examination. The proposed sequence of actions is as follows:

1. Washing hands.
2. HEENT (head, eyes, ears, nose, throat) examination, specifically concentrating on the oropharynx.
3. Palpation of lymph nodes on the neck and head (“Case 18: Cough,” 2021).
4. Cardiovascular examination: auscultation of the heart and blood pressure check.
5. Pulmonary examination, including chest inspection and palpation, pulmonary field percussion, pulmonary auscultation, and examination for fremitus.
6. Inspection of extremities.

Possible cause of cough

The patient from the case describes his cough as dry and hacking, lasting about three months. According to Glashan and Mahmoud (2019), a cough that lasts more than eight weeks is chronic. One can distinguish the main etiologies of cough into three groups: infection, pathology, and medication-related (Glashan & Mahmoud, 2019). When evaluating the case, attention is drawn to the fact that the patient has been taking lisinopril for six months. Lisinopril is applicable in hypertension treatment and is an angiotensin-converting enzyme (ACE) inhibitor (Sinha, 2021). Dry cough is a common side effect of taking ACE inhibitors, and nearly 5-35% of patients using this medication may suffer from it (Borgh & Veronesi, 2019; Glashan & Mahmoud, 2019). Cough caused by inhibitors can develop within days or even months after starting medication (Glashan & Mahmoud, 2019). Consequently, the physician may assume that the patient’s problem is a side effect of taking lisinopril, which corresponds to the etiology of cough.

Differential diagnosis

Since the patient’s cough lasts more than eight weeks, it is chronic. Except for the reasons connected with medications, chronic cough can be caused by upper airway cough syndrome (UACS), gastroesophageal reflux disease (GERD), asthma, or nonasthmatic eosinophilic bronchitis (NAEB) (Glashan & Mahmoud, 2019). Moreover, differential diagnoses can include obstructive sleep apnea, interstitial lung diseases, tonsillar enlargement and recurrent tonsillitis (Morice et al., 2020). Spanevello et al. (2020) note that several conditions can trigger cough simultaneously. Before prescribing treatment, consideration should be given to the presence of any of these diseases.

Required tests

Conducting various tests is expected in establishing a diagnosis for patients. In particular, chest X-ray, computerized tomography (CT) scans, spirometry, gastrointestinal investigation, and special scope tests are applied when the cough is a symptom (Mayo Clinic Staff, 2019; Morice et al., 2020). However, given that in the case under study, the most likely cause of the problem is the side effect of the inhibitor, additional tests are not necessary. The patient’s cough should stop 1-4 weeks after abandoning the ACE inhibitor (Ding et al., 2020). Tests will be required if the refusal of the medicine does not eliminate the cough.

Treatment

Considering the side effect of lisinopril as the cause of the patient’s cough, the physician needs to focus on this aspect for treatment. Stopping taking an ACE inhibitor will stop the cough, but its re-prescription could bring the side effect back (Glashan & Mahmoud, 2019). Therefore, it is necessary to find another method for treating the patient’s hypertension. For example, angiotensin II receptor blocker (ARB) is effective for the same problems as inhibitors (Glashan & Mahmoud, 2019). In such a case, the patient’s education should include information about the new drug and the method of its use. Moreover, the patient should learn what possible side effects to monitor.

Conclusion

The current paper analyzes the case of a man who contacted a doctor with complaints of prolonged dry cough. The fact that the patient began taking lisinopril six months before the events of the case attracts attention since a common side effect of ACE inhibitors is a dry hacking cough. Replacement of the drug should solve the problem within 1-4 weeks. However, if the cough does not disappear, the patient will need additional tests to establish another diagnosis.

References

Borghi, C., & Veronesi, M. (2019). Cough and ACE inhibitors: The truth beyond placebo.Clinical Pharmacology & Therapeutics, 105(3), 550-552. Web.

Case 18: Cough. (2021). Amboss. Web.

Ding, H., Shi, C., Xu, X., & Yu, L. (2020). Drug-induced chronic cough and the possible mechanism of action.Annals of Palliative Medicine, 9(5), 3562-3570. Web.

Glashan, E., & Mahmoud, S. H. (2019). Cough. In S. H. Mahmoud (Ed.), Patient assessment in clinical pharmacy (pp. 67-78). Springer, Cham. Web.

Goldberg, C. (n.d.). Practical guide to clinical medicine: History of present illness (HPI). UC San Diego School of Medicine. Web.

Mayo Clinic Staff. (2019). Chronic cough. Mayo Clinic Website. Web.

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Sinha, S. (2021). Lisinopril. Drugs.com. Web.

Spanevello, A., Beghé, B., Visca, D., Fabbri, L. M., & Papi, A. (2020). Chronic cough in adults.European Journal of Internal Medicine, 78, 8-16. Web.