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Difficulty: EasyMedical History Evaluation

A 62-year-old male establishes care at a primary care clinic for a persistent, dry cough that has bothered him for the past three months. The patient states the cough often wakes him at night and is not relieved by over-the-counter antitussive syrups. He denies any fever, weight loss, hemoptysis, or shortness of breath. His past medical history is notable for hypertension, hyperlipidemia, and osteoarthritis. Vital signs are within normal limits. Auscultation of the lungs reveals clear breath sounds bilaterally with no wheezes or crackles. Laboratory testing shows an absolute eosinophil count of 350/μL350/\mu L (normal: 15−500/μL15 - 500/\mu L). A recent chest radiograph shows no abnormalities. Which of the following historical inquiries is the most appropriate next step to establish the diagnosis?

  1. Reviewing the patient's active medication list for angiotensin-converting enzyme inhibitorsAnswer
  2. B
    Investigating a detailed lifetime occupational history for silica or asbestos exposure
  3. C
    Questioning the patient about childhood asthma and recent seasonal allergen triggers
  4. D
    Assessing the patient's adherence to daily low-dose aspirin therapy for cardiovascular protection
  5. E
    Inquiring about the concomitant use of herbal supplements that induce cytochrome P450 enzymes

Answer

Reviewing the patient's active medication list for angiotensin-converting enzyme inhibitors
The correct answer involves identifying the use of angiotensin-converting enzyme (ACE) inhibitors. The patient presents with a classic chronic, dry cough and a normal cardiopulmonary workup. Given his history of hypertension, an ACE inhibitor is a highly likely culprit. Inhibition of the ACE enzyme prevents the breakdown of bradykinin; its subsequent accumulation in the respiratory tract causes this characteristic cough. Therefore, reviewing the medication history is the most critical and highest-yield next step to establish the diagnosis.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and demographics.
The patient is an older adult with a chronic, dry, non-productive cough, a normal physical examination, a normal chest radiograph, and a history of hypertension.
Identifying the chronicity of symptoms and the lack of structural pulmonary findings helps narrow the differential diagnosis away from infections and malignancies.
2
Evaluate the relationship between the patient's comorbidities and potential iatrogenic causes.
The patient has hypertension, which is frequently managed with angiotensin-converting enzyme (ACE) inhibitors. A classic side effect of ACE inhibitors is a chronic, dry cough.
A thorough medication history is the most cost-effective and direct method to diagnose medication-induced adverse effects before pursuing invasive or expensive testing.

Key Concept

Medication-induced adverse effects, particularly ACE inhibitor-induced cough, must be evaluated as a primary step in the medical history of patients presenting with chronic cough and a normal chest radiograph.
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Topics

Medical History Evaluation

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