Cases/Cardiovascular Health

Cough for Months That Her Inhalers Have Not Touched — Free SCA Practice Case

Woman with a cough for months that her inhalers have not touched

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

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Patient Profile

Full Name

Wendy Lau

Age

58 years

Consultation Type

Video

Age

Situation

Video Consultation. Booked by the patient.

Reason for Encounter

"Cough for five months, not improving. Has had inhalers and antibiotics. Would like it looked into."

Medical Records

●PMH: Type 2 diabetes. Hypertension. Ex smoker.
●Medications: Ramipril 5 mg daily (started 7 months ago at 2.5 mg, increased after 6 weeks). Metformin 500 mg twice daily. Atorvastatin 20 mg. Salbutamol as required. Beclometasone 100 micrograms twice daily (10 weeks ago).
●Allergies: NKDA.

Recent Notes

●Nurse practitioner, 4 months ago: Dry cough, chest clear. Post viral.
●Out of hours, 5 weeks ago: Night cough, chest clear. Doxycycline.

Patient Script

For the friend playing the patient role

Character Overview: You are Wendy Lau, a 58 year old customer service adviser for a building society. You work in a call centre, on a headset all day, and drive there. You live in Liverpool with your husband Kenny and your dog Bruno. You have type 2 diabetes, found three years ago, and high blood pressure, found about a year ago at a diabetes check. For about five months you have had a dry cough that will not go away. Two inhalers and antibiotics have made no difference, and nobody has done any tests. You have not connected the cough with your blood pressure tablet. Underneath it all you are frightened it is lung cancer: your mum died of it after months of antibiotics and an inhaler. You smoked yourself until you were 36. You are chatty and warm but sound worn down, and your voice catches when your mum comes up.

Opening Sentence: "It's this cough. I've had it about five months now and it just won't shift. I've had two inhalers and a course of antibiotics from the out of hours, and none of it's touched it. I'm worn out with it, honestly."

History if Asked (Data Gathering Phase)

●What the cough is like: "It's dry. Nothing comes up at all. It's a tickle at the back of my throat, and once it starts I can't stop. I'll go for a minute or two at a time."
●When it is worst: "Evenings, and when I get into bed. And at work, when I've been talking a lot. Some nights it wakes me two or three times."
●How long, and how it started: "About five months, the same the whole time. I don't remember a cold first. It just crept up on me."
●Phlegm or blood: "No phlegm. And no blood, never. Believe me, I check the tissue every time."
●What the treatments did: "The blue inhaler, once or twice a day, did nothing. Then the doctor on the phone gave me a brown one, two puffs morning and night. I've been on that about ten weeks, hardly missed a dose, and it's made no difference. The five days of antibiotics made no difference either. I've tried cough mixture too."
●Her blood pressure tablet (if asked about new medicines, or when her tablets were started or changed): "The only new one is the ramipril. I started it about seven months ago on a small dose, and they doubled it after about six weeks because my blood pressure was still up. The cough must have come on a few weeks after that. I've been fine on it otherwise."
●Swelling: "No, never had anything like that with my lips, tongue, face or throat."
●Smoking: "About ten a day from sixteen. I stopped the week my mum was diagnosed, so I was thirty six. Twenty two years ago."
●Work and exposures: "No dust or fumes. I've always worked in offices."

Ideas, Concerns, Expectations

Gating note: Wendy does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

●Ideas: She has no explanation that makes sense to her. She wondered about asthma coming on late, but the inhalers did nothing: "Something's not right in my chest." She has not linked the cough with her blood pressure tablet.
●Concerns: She is frightened it is lung cancer. Her mum smoked twenty a day all her life and died of lung cancer at 67. "My mum had a cough for months. They kept giving her antibiotics and an inhaler, and by the time they did a scan it was everywhere. She was gone within the year. And I smoked for twenty years. So when I'm on my third lot of treatment and nobody's even done an X ray, I can't help thinking it's the same thing." Her voice wavers.
●Expectations: "I just want someone to actually find out what it is. I was going to ask if I could have a scan, a proper one, to be sure."

If Asked: Medical History and Medications

Gating note: Wendy answers each of these plainly when the doctor asks about it.

●Diabetes and blood pressure: Type 2 for about three years on metformin, sugars good. She has a home blood pressure machine and the nurse said the last reading was good.
●Medicines: Ramipril, metformin, atorvastatin at night for a couple of years, and the two inhalers. She never misses tablets: "The nurse told me I must never stop my blood pressure tablets."
●Past and family: Never had asthma or an inhaler before this. No allergies to tablets, no heart problems, gallbladder out ten years ago. No tuberculosis contact and no recent travel. Her father is 84 with diabetes.

Social History and Lifestyle Impact

●Work: "Work's the worst. I keep muting myself in the middle of calls, and last week a customer asked if I should even be at work. My team leader's been nice, but I know people are fed up of hearing me."
●Home life: She and her sister used to go to the pictures every Friday and she has stopped because she cannot sit through a film without people turning round. The cough wakes her two or three times a night and Kenny has been sleeping in the spare room for a couple of months: "It isn't like us at all."
●Bladder (if asked about leaking, or anything else the cough causes): Embarrassed, quieter. "When I have a really bad coughing fit I leak a bit. I've started wearing a pad for work."
●Lifestyle: A glass of wine on a Saturday at most. She walks Bruno for half an hour daily and is careful with her diet. Her weight is stable.

If Asked: Associated Symptoms

Gating note: Wendy answers these only when the doctor asks about them directly.

●Cancer and general features: No coughing up blood, no weight loss, appetite fine, no night sweats or fevers, no hoarse voice, no trouble swallowing, no lumps in her neck, no tiredness except from poor sleep. Her ribs ache down the sides after a bad fit, but she has no other chest pain.
●Breathing and heart: No breathlessness, wheeze or tight chest, fine walking the dog and on stairs. No ankle swelling, and she can lie flat: "It's the coughing that starts when I lie down, not my breathing."
●Other causes of cough: No heartburn, indigestion or sour taste. No blocked or runny nose, sneezing or dripping at the back of the throat: "It's a tickle, not a drip." No birds, and nobody at home or work with a cough.
●Fainting: No fainting or near blackouts in a fit. "I go red in the face, but I've never passed out."
●Mood: Fed up and worried, not depressed.

Responses to Management (The Negotiation Phase)

●
If the doctor explains that her blood pressure tablet is the likely cause:
- ●Reaction: Surprised and doubtful. "The blood pressure tablet? But I was on it for weeks before the cough started. How can a tablet make you cough?" If told it can start weeks or months later, or after a dose increase: "So they put the dose up and then it started. Nobody's ever asked me about my tablets. Five months, two inhalers and antibiotics." She is frustrated at first, then relieved.
●
If the doctor says she should stop the ramipril, or suggests a replacement tablet:
- ●Reaction: Worried. "The nurse told me never to stop my blood pressure tablets. Won't my blood pressure shoot up? And I've got the diabetes as well." She settles once she hears it is a swap to another tablet, not stopping treatment, and asks practically: "When do I stop one and start the other? Tonight? Tomorrow?" and "What if that one makes me cough as well?" If a different kind of tablet is offered she checks it is alright with her diabetes. If told to carry on with the ramipril and add a cough medicine she is deflated: "I've had two bottles of cough mixture already. Is that it, then?"
●
If the doctor recommends a chest X ray, or talks about cancer:
- ●Reaction: Relieved that something is being done, then pushes a little: "Finally. Would an X ray show it, though? Could I not have a proper scan?" She accepts an X ray first if the doctor explains why, and asks how she will get the result. If told it is definitely not cancer: "How can you be sure without doing anything? That's what they told my mum." If told cancer is unlikely but being checked: "Right. So it's most likely the tablet, but you're making sure. I can live with that."
●
If the doctor stops the inhalers, orders tests, or explains how long the cough may last:
- ●Reaction: On the inhalers: "So it's not asthma? Good, I hated that brown one. Should I keep the blue one just in case?" On blood tests: "Can I go first thing, before work?" On duration: "A month? Longer? I'm on the phones all day. Is there nothing to help in the meantime?" She is reassured by simple, honest advice. If the leaking is raised, embarrassed then grateful: "Will it stop when the cough stops?"
●
If the doctor asks her to check her blood pressure at home, explains what happens if the cough persists, or says the reaction will go on her record:
- ●Reaction: Practical. "I can do that. Tell me how many readings you want and when." On the persisting cough: "Good, because I'm not going round in circles again." On the record: "Good. I don't want anyone putting me back on it."
●
If the doctor gives vague safety netting, asks her to do something on camera, or offers a fit note:
- ●Reaction: On "come back if it gets worse": "Worse how? It's been bad for five months. What would mean I should ring you straight away?" If asked to check her pulse, take her blood pressure or show her throat she declines politely: "I'm happy to come in. I'd feel better if someone actually listened to my chest." On a fit note: "No, I don't want to be off. I just want it to stop."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Wendy has a five month dry cough that inhalers and antibiotics have not touched, and she fears lung cancer like her mother. The task is to recognise a likely ACE inhibitor cough from the medicine timeline, without dropping the possibility of cancer in a 58 year old ex smoker who has never had a chest X ray, and to replace her blood pressure treatment safely.
●Model answer: ramipril is the most likely cause; arrange a chest X ray now, to be done within 2 weeks, in parallel with the switch; stop ramipril and start an angiotensin receptor blocker (ARB), losartan 50 mg once daily or candesartan 8 mg once daily, the next day; check kidney function and potassium in 1 to 2 weeks and blood pressure at 4 weeks; stop the beclometasone and salbutamol; arrange spirometry and fractional exhaled nitric oxide (FeNO); record the intolerance; review in 4 to 6 weeks with a plan if the cough persists; give a specific safety net.
●Also acceptable: a chest X ray requested without the 2 week timescale, another ARB at its usual starting dose, a calcium channel blocker named as the fallback if an ARB is not tolerated, and spirometry and FeNO either now or at review.

Recognising an ACE Inhibitor Cough

●ACE inhibitors cause a dry, irritating cough in a substantial minority of people; NICE Clinical Knowledge Summaries (CKS) quotes 4 to 35%, and the British National Formulary (BNF) lists cough as common for every ACE inhibitor. It can begin hours to months after the first dose or after a dose increase, as Wendy's did.
●The British Thoracic Society (BTS) chronic cough statement (2023) describes cough hypersensitivity: the cough reflex becomes oversensitive, so talking or lying down sets off a bout. It does not respond to bronchodilators, inhaled steroids, antibiotics or cough mixtures, which is why her treatments failed. It is a class effect, so another ACE inhibitor will not help.
●Chronic cough lasts over 8 weeks. Common causes are smoking, ACE inhibitors, upper airway cough syndrome, asthma, reflux and eosinophilic bronchitis; others include lung cancer, heart failure, interstitial lung disease, bronchiectasis and tuberculosis. BTS advises stopping the ACE inhibitor in every chronic cough and treating each contributor found.
●Review every medicine with its start date and set it against the onset of the cough. Ask about red flags (haemoptysis, hoarseness, weight loss, night sweats, breathlessness, dysphagia). Before choosing an ARB, ask about angioedema, because ARBs can also trigger it.

The Chest X Ray and Lung Cancer Risk

●NICE NG12 recommends an urgent direct access chest X ray within 2 weeks for people aged 40 and over who have ever smoked and have one or more unexplained symptoms such as cough. Unexplained means not diagnosed after initial assessment in primary care. Wendy is 58, has smoked, and three assessments and three treatments have not explained a five month cough.
●An ACE inhibitor cough is only confirmed once the cough settles off the drug, so a likely medicine cause does not yet explain it. BTS advises a chest X ray and full blood count for every chronic cough, so the X ray is not deferred until the switch has been tried.
●Refer on the suspected cancer pathway if the X ray suggests cancer, or for anyone 40 or over with unexplained haemoptysis. A normal X ray does not exclude cancer, so keep investigating if concern remains. CT is not a routine test for chronic cough.
●BTS recommends a face to face history and examination including the ears, nose and throat; a video consultation cannot do this, so an in person appointment belongs in the plan.

Choosing and Prescribing the Replacement

●NICE NG136 recommends an ACE inhibitor or an ARB at step 1 for adults with type 2 diabetes of any age, and says that if an ACE inhibitor is not tolerated because of cough an ARB should be offered. Never combine an ACE inhibitor and an ARB.
●Without diabetes, a woman of 58 would normally start a calcium channel blocker, which is why the diabetes in her brief matters. With type 2 diabetes the ARB is the guideline answer; a calcium channel blocker is a reasonable fallback if an ARB is not tolerated.
●ARBs do not block bradykinin breakdown, so they are much less likely to cause this cough, though the BNF still lists it.
●Take the last ramipril today and start the ARB tomorrow, with no washout. Losartan 50 mg once daily can rise to 100 mg (25 mg in those aged 76 and over or volume depleted). Candesartan usually starts at 8 mg once daily.
●Check kidney function and potassium before starting and 1 to 2 weeks after starting and after each dose increase, in diabetes preferably within a week, then annually. Titrate every 4 weeks; the targets are below 140/90 in clinic or below 135/85 at home. Advise against potassium based salt substitutes.

What to Expect, and Stopping What Has Not Worked

●The cough settles within a month for most people after stopping the ACE inhibitor, but occasionally takes several months. Judge the effect at 4 to 6 weeks. Evidence for cough mixtures is weak; warm drinks, honey and sips of water are reasonable.
●Asthma should not be diagnosed on symptoms alone. NG245 advises measuring the blood eosinophil count or FeNO, then bronchodilator reversibility on spirometry, before diagnosing it. Inhaled steroids make those tests more likely to be normal, so testing is more informative after the steroid is stopped.
●Ten weeks of beclometasone with no response, no wheeze and no breathlessness means it should be stopped; CKS notes an empirical inhaled steroid trial should stop after 2 to 4 weeks without response. Salbutamol is not needed. Antibiotics are not indicated for a five month dry cough without fever or sputum (NICE NG120).

If the Cough Persists

●Refer to a respiratory clinic if the cough persists with a normal chest X ray despite stopping the ramipril (BTS). Before that, reassess for rhinosinusitis (a trial of nasal steroid), reflux (a proton pump inhibitor only if there is heartburn or definite evidence) and weight, and complete spirometry and FeNO.
●Specialist options for refractory chronic cough include speech and language therapy, low dose slow release morphine, and gabapentin or pregabalin.

Complications of the Cough

●Urinary incontinence is common and often hidden. BTS advises asking everyone with chronic cough and referring those who report it to the continence service. Supervised pelvic floor training for at least 3 months is first line for stress incontinence (NICE NG123).
●Cough syncope matters because Wendy drives. A car driver who has a blackout must stop driving and tell the Driver and Vehicle Licensing Agency (DVLA); the usual period is 6 months after one episode. Treating the cough does not shorten it.
●Broken sleep, rib pain, embarrassment at work and fear of serious disease are common, and the impact on quality of life is similar to chronic obstructive pulmonary disease.

Recording the Intolerance, Follow Up and Safety Netting

●Record ACE inhibitor intolerance with cough in the allergy and intolerance record so that it is not restarted, for example after a hospital admission.
●Review at 4 to 6 weeks, act on the X ray result as soon as it is reported, and check kidney function, potassium and blood pressure as the ARB starts.
●Coughing up blood needs same day contact. New weight loss, night sweats, a hoarse voice that does not settle or breathlessness should prompt contact before the review. Swelling of the lips, tongue or throat, or difficulty breathing or swallowing, needs 999. Dizziness on the new tablet should prompt a blood pressure check, including standing. Any blackout during a coughing bout means stopping driving and seeking advice.

Common Mistakes in This Station

●Treating the cough as asthma or infection again, or adding a third inhaler.
●Not asking when the ramipril was started or increased, so the link is never made.
●Changing to another ACE inhibitor, or carrying on with ramipril and adding a cough mixture.
●Waiting to see whether the switch works before arranging a chest X ray in a 58 year old ex smoker.
●Telling her it is definitely not cancer, which is what her mother was told.
●Choosing a calcium channel blocker because she is over 55, without noticing that type 2 diabetes makes an ARB the recommended alternative.
●Starting the ARB with no kidney function and potassium check and no blood pressure target.
●Leaving the beclometasone running with no objective diagnosis of asthma.
●Not recording the intolerance, missing the bladder leakage, and not asking about blackouts in a driver.
●Safety netting limited to "come back if it gets worse".

Mapped to the RCGP curriculum topic: Cardiovascular Health.

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