MKSAP Quiz: Daily, nonproductive cough without hemoptysis
MKSAP Quiz: Daily, nonproductive cough without hemoptysis
A 48-year-old woman is evaluated for a cough that has lasted for 3 months. She describes the cough as occurring daily, nonproductive, and without hemoptysis. She has experienced no associated dyspnea, wheezing, fever, weight loss, night sweats, or recent illness. She has not traveled recently or been exposed to anyone else who has been ill. She has never smoked. She was diagnosed with essential hypertension 6 months ago and has taken lisinopril daily since her diagnosis.
Physical examination is unremarkable. She has no oral or pharyngeal exudates or drainage. A chest radiograph is normal.
Which of the following is the most appropriate management option for this patient at this time?
A. Discontinue the lisinopril
B. Order a chest CT
C. Order spirometry
D. Start an antihistamine/decongestant combination
E. Start a proton-pump inhibitor
MKSAP Answer and Critique
The correct answer is A) Discontinue the lisinopril. This item is available online to MKSAP 15 subscribers in the General Internal Medicine section, Item 4.
The most appropriate management option for this patient is to discontinue the angiotensin-converting enzyme (ACE) inhibitor lisinopril. This patient presents with a cough of longer than 8 weeks' duration and thus meets the definition for chronic cough. According to American College of Chest Physicians guidelines, the initial evaluation of all patients with a chronic cough involves a history and physical examination to determine likely etiologies, followed by a chest radiograph to identify obvious abnormalities. If the chest radiograph is normal, one should recommend discontinuing ACE inhibitors and smoking, if these factors are identified in the history, or pursue empiric management of chronic cough if the patient is a nonsmoker and is not taking an ACE inhibitor. There may be no obvious temporal relationship between the initiation of ACE inhibitor therapy and the onset of cough. The median time to resolution is 26 days from withdrawal of the ACE inhibitor.
In patients with chronic cough and a normal chest radiograph, a chest CT is only indicated for those at high risk for lung cancer. A chest CT is not indicated in this young, otherwise healthy, nonsmoking patient.
Asthma and nonallergic eosinophilic bronchitis may present without any symptoms other than cough. Spirometry would be indicated in the evaluation of chronic cough that has not resolved after the initial management measures (history, physical examination, chest radiograph, cessation of ACE inhibitor, treatment for upper-airway cough syndrome).
Upper-airway cough syndrome (UACS) is a common cause of chronic cough. A trial of a first-generation antihistamine/decongestant combination for several weeks is appropriate treatment for UACS. In a nonsmoking patient who is taking an ACE inhibitor, however, the ACE inhibitor should be discontinued for several weeks before treating for UACS. Similarly, although empiric therapy for gastroesophageal reflux disease (GERD) is appropriate if prominent symptoms of GERD accompany the cough or if initial management measures fail, discontinuing the ACE inhibitor always should precede empiric therapy for either UACS or GERD.
Key Point
- In patients taking an angiotensin-converting enzyme inhibitor who present with a chronic cough and a normal chest radiograph, discontinuing the angiotensin-converting enzyme inhibitor may be both diagnostic and therapeutic.