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.
Case Questions
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?
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Here are the questions that would have been asked as part of the medical history:
When did the cough start?
How long has it been going on?
Is it worse at night or during the day?
Is it worse when you lie down or when you exercise?
Do you have any other symptoms with the cough, such as fever, shortness of breath, or chest pain?
Are you taking any medications?
Do you have any allergies?
Do you smoke or drink alcohol?
Do you have any other medical conditions?
Here are the physical aspects that would have been completed as part of the physical exam:
General appearance
Vital signs
Neck
Chest
Lungs
Heart
Abdomen
Extremities
Based on the medical history and physical exam, the most likely cause of the patient’s cough is post-nasal drip from his environmental allergies. Other possible diagnoses include asthma, gastroesophageal reflux disease (GERD), and lung cancer.
There are no other tests that need to be completed at this time. The patient’s cough is likely caused by his allergies and will improve with treatment.
The treatment for this patient includes:
Over-the-counter allergy medication
Nasal saline spray
Humidifier
Smoking cessation
Weight loss if obese
Avoiding triggers such as dust, pollen, and smoke
The patient should also be educated about the importance of good follow-up care. If his cough does not improve with treatment, he should see his doctor again.
Here are some additional information about the possible causes of the patient’s cough:
Post-nasal drip: This is a common cause of chronic cough. It occurs when mucus from the nose and sinuses drips down the back of the throat. This can irritate the throat and cause a cough.
Asthma: This is a chronic condition that affects the airways. When a person with asthma has an attack, the airways become inflamed and narrow. This can make it difficult to breathe and can cause a cough.
GERD: This is a condition in which stomach acid backs up into the esophagus. This can irritate the esophagus and cause a cough.
Lung cancer: This is a serious condition that can cause a variety of symptoms, including cough.
If you have a persistent cough, it is important to see your doctor to get a diagnosis and treatment.
