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History of hypertension, diabetes, and environmental allergies

A 75-year-old man with a history of hypertension, diabetes, and environmental allergies, 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, and his blood pressure today is 150/92. 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.

What questions would have been asked as part of the medical history?
What physical aspects would have been completed as part of the physical exam?
Based on the medical history and physical exam, what is the most likely cause of his cough?
What other possible diagnoses should be considered?
Are there any other tests that should be completed before producing a diagnosis? Why or why not?
What is the treatment for this patient, including education?

Sample Answer

This is a classic case presentation with a likely culprit, but it’s important to rule out other possibilities. Here’s a breakdown of the questions and considerations:

1. Medical History Questions:

Detailed Cough History:
- Onset, duration, frequency, and severity of cough.
- Triggers (e.g., exertion, cold air, specific foods, time of day).
- Character of cough (dry, productive, hacking, wheezing).
- Associated symptoms (e.g., shortness of breath, chest pain, postnasal drip, heartburn, fever, chills, night sweats, weight loss).
- Sputum production (color, amount).
- Any recent illnesses or exposures.
Medication History:
- Detailed list of all medications (prescription, over-the-counter, herbal supplements).
- Timing of medication initiation relative to cough onset.
- Any recent changes in medication dosage or regimen.

Full Answer Section

Allergy History:
- Specific allergens, severity of reactions.
- Environmental exposures (e.g., mold, dust, pets).
Past Medical History:
- Detailed history of hypertension, diabetes, and other chronic conditions.
- History of respiratory illnesses (e.g., asthma, COPD, pneumonia).
- History of GERD, or heart failure.
Social History:
- Smoking history (current, former, pack-years).
- Alcohol consumption.
- Occupational exposures.
- Travel history.
Family History:
- History of respiratory illnesses or other relevant conditions.

2. Physical Exam Components:

Vital Signs:
- Blood pressure, heart rate, respiratory rate, temperature, oxygen saturation.
General Appearance:
- Level of distress, overall health status.
HEENT (Head, Eyes, Ears, Nose, Throat):
- Examination of nasal passages for congestion or postnasal drip.
- Oropharyngeal examination for erythema or drainage.
Respiratory System:
- Auscultation of lung sounds for wheezing, crackles, or rhonchi.
- Assessment of respiratory effort.
Cardiovascular System:
- Auscultation of heart sounds for murmurs or irregularities.
- Assessment of peripheral edema.
Neurological Exam:
- Assessment of reflexes, sensation, and motor function, especially due to diabetic neuropathy.
Abdominal Exam:
- Palpation for tenderness or masses.

3. Most Likely Cause:

The most likely cause of his dry, hacking cough is lisinopril-induced cough. ACE inhibitors like lisinopril are known to cause a persistent dry cough in some patients. The timing of the cough onset relative to the initiation of lisinopril supports this diagnosis.

4. Other Possible Diagnoses:

Postnasal Drip Syndrome: Although the physical exam was negative, this can still be a cause of chronic cough.
Gastroesophageal Reflux Disease (GERD): Acid reflux can irritate the esophagus and trigger a cough.
Chronic Bronchitis: Especially if there is a history of smoking or environmental exposures.
Asthma: Although he has environmental allergies, an asthma exacerbation is possible.
Heart Failure: Although he is not short of breath, a cardiac cough is possible.
Lung Cancer: Although less likely given the dry cough and lack of other symptoms, it cannot be completely ruled out, especially in a 75 year old.
Upper Respiratory Infection: While he has had the cough for 3 months, a lingering cough after an infection is possible.

5. Additional Tests:

Chest X-ray: To rule out pulmonary causes such as pneumonia, lung cancer, or heart failure.
Pulmonary Function Tests (PFTs): To assess lung function and rule out asthma or COPD.
Sputum Culture (if productive cough develops): To identify any bacterial infection.
Esophageal pH Monitoring or Upper Endoscopy: If GERD is suspected.
ECG: to assess cardiac function.
CBC and CMP: to assess general health, and renal function.
Allergy testing: If allergies are suspected to be the main cause.

Given the strong suspicion of lisinopril-induced cough, it is reasonable to start with a chest x-ray and then consider stopping the lisinopril before pursuing more invasive testing.

6. Treatment and Education:

Discontinue Lisinopril: The first step is to discontinue lisinopril and switch to an alternative antihypertensive medication (e.g., an angiotensin II receptor blocker (ARB), thiazide diuretic, or calcium channel blocker).
Patient Education:
- Explain the common side effect of ACE inhibitor cough.
- Emphasize the importance of adherence to the new antihypertensive medication.
- Advise the patient to monitor his blood pressure regularly.
- Instruct the patient to report any worsening symptoms or new concerns.
- Educate the patient on lifestyle modifications for hypertension and diabetes management.
- If GERD is suspected, educate the patient on lifestyle modifications, and medications related to GERD.
Follow-up:
- Schedule a follow-up appointment to assess the resolution of the cough and monitor blood pressure control.
- Adjust medication as needed.
- Follow up on any tests that were ordered.

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