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Old 10-20-2011
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Default Cardiology

A 48-year-old woman comes to the clinic complaining of a persistent dry cough for the last 6 weeks. The cough seems slightly worse at night and is not associated with any fever or chills. Her past medical history includes recently diagnosed diabetes mellitus type 2 and essential hypertension. Her current medications include fosinopril and metformin, both started a few months ago when the patient was diagnosed with diabetes. She has never smoked, does not suffer from seasonal allergies, and except for the annoying cough she reports feeling well. Vital signs are: temperature 37.0 C (98.6 F), blood pressure 128/80 mm Hg, pulse 76/min, and respirations 24/min. Her chest is clear to auscultation bilaterally. Cardiac examination reveals a regular rate and rhythm with a nondisplaced dime sized point of maximal impulse and a jugular venous pressure of approximately 7 cm. The rest of the examination is equally unremarkable. Which of the following is the most appropriate management?
A. Discontinue metformin, change to subcutaneous insulin
B. Prescribe antibiotics to treat early community-acquired pneumonia
C. Prescribe daily diuretic to help reduce pulmonary edema
D. Prescribe empiric macrolide treatment for presumed bronchitis
E. Stop fosinopril and replace with an angiotensin receptor blocker
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Old 10-20-2011
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E. Stop fosinopril and replace with an angiotensin receptor blocker
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Old 10-20-2011
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E--- ACE inhibitor = dry cough ( also angioedema is a serious adverse effect but thats a whole different matter)
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Old 10-20-2011
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Correct Answer Answer

The correct answer is E. This patientís cough is temporally correlated with starting her new medications. A common side effect of ACE inhibitors such as fosinopril is chronic cough that is caused by increased level of kinin activity. Switching to an angiotensin receptor blocker (ARB) offers the benefits of an ACE inhibitor without the cough from increased levels of bradykinin.

Metformin does not need to be discontinued (choice A). Its most common side effect is diarrhea, nausea, or vomiting, not cough.

Antibiotics, either for community-acquired pneumonia (choice B) or bronchitis (choice D), are not appropriate, given this patientís normal examination and lack of fever or productive cough.

A cough from heart failure is often attributed mistakenly to an ACE inhibitor. Given this patientís normal cardiac and chest examination, however, diuretics (choice C) are unlikely to be helpful.
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