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Difficulty: MediumGastroenterology and Hepatology

A 52-year-old man presents to the clinic with a 4-month history of a persistent, dry cough that worsens at night and a slightly hoarse voice in the mornings. He reports no fever, weight loss, hemoptysis, or shortness of breath with exertion. His medical history is significant for hypertension treated with amlodipine. He is a lifelong nonsmoker. Vital signs are within normal limits. Physical examination reveals a clear oropharynx and normal breath sounds bilaterally without wheezing or crackles. Chest radiography is unremarkable, and spirometry shows normal lung volumes with no reversibility following bronchodilator administration. Which of the following is the most appropriate next step in management?

  1. Initiate an empirical trial of a daily proton pump inhibitorAnswer
  2. B
    Prescribe an as-needed albuterol metered-dose inhaler
  3. C
    Prescribe a 5-day course of oral azithromycin
  4. D
    Measure serum thyroid-stimulating hormone levels
  5. E
    Discontinue amlodipine and initiate lisinopril

Answer

Initiate an empirical trial of a daily proton pump inhibitor
This patient presents with a chronic cough (lasting >8 weeks) and morning hoarseness. His normal chest radiograph rules out obvious underlying pulmonary pathology, and his normal spirometry effectively rules out asthma and COPD. The three most common causes of chronic cough in a nonsmoker with a normal chest radiograph are upper airway cough syndrome, asthma, and gastroesophageal reflux disease (GERD). The patient's nocturnal exacerbation of the cough and morning hoarseness are classic signs of extraesophageal GERD (laryngopharyngeal reflux). When extraesophageal GERD is suspected in a patient without 'alarm' symptoms (e.g., dysphagia, weight loss, anemia), the gold standard next step in management is an empirical 8-week trial of a daily proton pump inhibitor (PPI).

Step-by-Step Solution

1
Evaluate the clinical presentation of a chronic cough (lasting >8 weeks) with a normal chest radiograph.
The top differential diagnoses include upper airway cough syndrome (postnasal drip), asthma, and gastroesophageal reflux disease (GERD).
To narrow down the etiology based on epidemiological probability for chronic coughs.
2
Assess the specific symptoms and adjunctive test results (normal spirometry).
Asthma is highly unlikely due to the lack of bronchodilator reversibility on spirometry. The patient's nighttime exacerbation and morning hoarseness specifically point to extraesophageal GERD (laryngopharyngeal reflux).
To differentiate between the most common causes using objective data and classic clinical clues.
3
Determine the initial management for suspected extraesophageal GERD.
An empirical 8-week trial of a proton pump inhibitor (PPI) is indicated.
When 'alarm' symptoms (e.g., dysphagia, weight loss) are absent, PPIs serve as both a diagnostic tool and primary treatment for GERD-associated chronic cough.

Key Concept

Extraesophageal GERD is a leading cause of chronic cough and should be evaluated with an empirical trial of a proton pump inhibitor when chest radiography and spirometry are normal.
Estimated Time:1m 30s
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Topics

Gastroenterology and Hepatology

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