Cases/Cardiovascular Health

Dry Cough Several Months After His Heart Attack — Free SCA Practice Case

Man with a dry cough several months after his heart attack

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

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Ian Docherty

Age

63 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"I've had this dry, tickly cough for a few months now, ever since my heart attack really. It's driving me and the wife mad. I looked it up and I think it might be one of my heart tablets."

Medical Records

●PMH: NSTEMI 5 months ago (stented). Hypertension. Current smoker.
●Medications: Ramipril 5 mg OD, bisoprolol 2.5 mg OD, atorvastatin 80 mg OD, aspirin 75 mg OD, ticagrelor 90 mg BD.
●Allergies: NKDA.
●Recent results: Post-MI echocardiogram (3 months ago) — normal left ventricular function, no significant valve disease. ECG at cardiology follow-up — normal sinus rhythm. No recent chest X-ray on file. Smoking status: ~20/day, ~40 pack-years.

Patient Script

For the friend playing the patient role

Character Overview: You are Ian, a 63-year-old warehouse supervisor. You are down-to-earth and a bit of a self-diagnoser — you have decided the cough is from the ramipril because you read about it online, and you are keen for the doctor to just swap the tablet. You are slightly defensive about your smoking. You feel physically well otherwise. You have not connected your smoking or anything else to the cough — you are focused on the tablet.

Opening Sentence: "Hello, Doctor. Right — I've had this dry cough for months, on and off, ever since the heart attack. No phlegm, just a tickle that sets me off. I've been reading and it says the ramipril can do it. So can we just change it? That'll sort it, won't it?"

History if Asked (Data Gathering Phase)

●The cough: "Dry, tickly, no phlegm to speak of. Comes in fits. Worse when I lie down at night and when I talk a lot. Been going three or four months, maybe a bit longer."
●Timing relative to the ramipril: "I started the ramipril after the heart attack, five months ago. The cough came on... a couple of months after that, I suppose. Hard to say exactly."
●Smoking: "Yeah, I still smoke. About twenty a day. I know, I know — I keep meaning to pack it in, especially after the heart do. Been on the go since I was a lad, forty-odd years."
●General health: "Otherwise I feel alright. The stent sorted the chest pain. I'm back at work."
●What he's tried: "Bit of honey and lemon, some cough sweets. Nothing touches it."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Ian is convinced it is the ramipril and has effectively closed the case in his own mind. He has not considered his smoking, reflux, or anything more serious. "I'm pretty sure it's the tablet — it fits with what I read. Never even crossed my mind it could be anything else."
●Concerns: When gently explored, he does have a flicker of worry about cancer because of his smoking, but he has pushed it down and would rather believe it is the tablet. "I mean... you do wonder, don't you, with the smoking. But I'd rather it was just the tablet, if I'm honest. That's an easy fix."
●Expectations: He wants the ramipril swapped and expects that to be the end of it. "Just swap the tablet and I'll be on my way. That's all I'm after really."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●The heart attack: "Five months ago. Not the crushing kind — they called it an NSTEMI. Had a stent. Been on all the tablets since."
●Current medications: "Ramipril, bisoprolol, the big statin, aspirin, and ticagrelor — two of those a day."
●Blood pressure: "They said it's fine on the tablets."
●Previous chest problems: "No, never had asthma or bronchitis or owt. First time I've had a cough like this."
●Family history: "My dad had lung trouble, but he was a heavy smoker an' all."

Social History and Lifestyle Impact

Ian is a warehouse supervisor. He lives with his wife. He is a long-term smoker.

●Smoking: "Twenty a day, forty years. I've cut down a bit since the heart attack but not stopped. The heart nurse keeps on at me."
●Work: "Back at the warehouse full time. On my feet, bit of lifting. The cough's embarrassing when I'm briefing the team — I have to keep stopping."
●Home: "Wife's fed up of me coughing all night. It's keeping her awake."
●Alcohol: "A couple of cans at the weekend, nothing much."

If Asked — Associated Symptoms

The patient answers these only when directly asked.

●If asked about coughing up blood: "No. No blood. I'd have been straight in if I'd seen blood."
●If asked about weight loss: "Now you mention it, my trousers are a bit loose. Maybe half a stone over a few months? I put it down to being back at work."
●If asked about appetite: "Eating alright, I think. Maybe a bit less than I was."
●If asked about breathlessness: "No worse than before. Bit puffed on the stairs at work but I've always been."
●If asked about chest pain: "No, no chest pain since the stent."
●If asked about orthopnoea / PND / ankle swelling (heart failure screen): "I don't wake up gasping, no. Ankles aren't swollen. I use one pillow, always have."
●If asked about heartburn / acid / reflux: "I do get a bit of heartburn, especially at night, and a sour taste sometimes. Never mentioned it, didn't think it mattered."
●If asked about post-nasal drip / catarrh / blocked nose: "No, nose is fine, no dripping down the back of my throat that I've noticed."
●If asked about fever, night sweats: "No fevers. No sweats."
●If asked about hoarseness or voice change: "Voice is the same, just interrupted by the coughing."

Responses to Management (The Negotiation Phase)

●If the Doctor wants to arrange a chest X-ray: "An X-ray? I thought it was just the tablet. Is that really necessary? What are you looking for?" (The tested point is whether the candidate explains, honestly but without alarm, why a chronic cough in a long-term smoker warrants a chest X-ray regardless of the ACE-inhibitor question.)
●If the Doctor explains they will not just swap the tablet yet: "So you're not going to change the ramipril? But that's the whole reason I came."
●If the Doctor asks about smoking cessation: "I knew you'd bring up the smoking. Do you really think stopping now makes any difference after all these years?"
●If the Doctor raises the reflux as a possible cause: "Heartburn causing a cough? I didn't know they were connected."
●If the Doctor safety-nets about red flags: "So what exactly am I watching out for?"

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 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Chronic Cough in a Smoker — Think Cancer First

●A persistent cough (typically more than 3 weeks) in a current or ex-smoker aged over 40 must prompt consideration of lung cancer and, as a minimum, a chest X-ray (NICE NG12).
●The presence of haemoptysis, unexplained weight loss, appetite loss, fatigue, chest pain, breathlessness, or hoarseness raises concern and lowers the threshold for urgent action.
●The trap in this case is a plausible benign explanation (ACE-inhibitor cough) that can seduce the clinician into skipping the red-flag work-up in exactly the patient who most needs it.

The NICE NG12 Lung-Cancer Pathway

●Offer an urgent chest X-ray (within 2 weeks) to people aged 40 and over with unexplained symptoms such as persistent cough, chest pain, weight loss, or breathlessness — particularly smokers.
●Refer using a suspected-cancer pathway (2-week-wait) for those with chest X-ray findings suggestive of lung cancer, or aged 40+ with unexplained haemoptysis.
●Clinical suspicion can justify referral even where imaging is pending or normal — a normal chest X-ray does not fully exclude lung cancer.

ACE-Inhibitor Cough

●A dry, tickly cough affects roughly 10–15% of patients on ACE inhibitors, mediated by bradykinin accumulation. It can begin within days or be delayed by weeks to months after starting.
●Management is to switch to an angiotensin-receptor blocker (ARB) (e.g. candesartan, losartan), which does not cause the cough and retains cardioprotective benefit after myocardial infarction.
●Crucially, the ACE-inhibitor cough is a diagnosis reached after excluding serious causes in a high-risk patient — not a reason to bypass investigation.

Excluding Heart Failure After MI

●A post-MI patient with a cough warrants consideration of heart failure: ask about orthopnoea, paroxysmal nocturnal dyspnoea, exertional breathlessness, and peripheral oedema.
●A recent normal echocardiogram with preserved left-ventricular function, and the absence of congestive symptoms, reasonably excludes heart failure as the cause here.

Gastro-Oesophageal Reflux as a Cause of Chronic Cough

●Reflux is a common and under-recognised cause of chronic cough, often worse at night and lying flat, and may occur without prominent heartburn.
●A trial of lifestyle measures and a proton-pump inhibitor is reasonable where reflux is contributing, as part of a structured approach to chronic cough.

Upper-Airway Cough Syndrome

●Post-nasal drip (upper-airway cough syndrome) from rhinitis or sinusitis is another common cause of chronic cough; ask about nasal symptoms and catarrh and treat the underlying cause where present.

Smoking Cessation After Myocardial Infarction

●Stopping smoking is the single most effective secondary-prevention measure after an MI, reducing further cardiac events substantially — the benefit begins quickly and it is never "too late."
●Offer behavioural support plus pharmacotherapy (varenicline where available, or nicotine replacement therapy, or bupropion), and refer to local stop-smoking services.
●Counter fatalism with evidence: risk falls measurably within the first year of quitting.

Structuring the Assessment of Chronic Cough

●Approach chronic cough systematically: exclude serious causes (malignancy, especially in smokers), consider cardiac causes post-MI, and address the common treatable causes — ACE-inhibitor cough, reflux, and upper-airway syndrome — while optimising smoking cessation.
●Investigations and treatable-cause trials can proceed in parallel, but red-flag investigation is not deferred.

Safety-Netting and Follow-Up

●Give specific safety-netting: return urgently for haemoptysis, worsening breathlessness, further weight loss, or new chest pain.
●Actively follow up the chest X-ray result rather than relying on the patient to chase it, and review after any drug switch or reflux trial.

Common Candidate Mistakes in This Case

●Premature closure on the ACE-inhibitor cough: switching ramipril and stopping there, without a chest X-ray, in a heavy smoker with weight loss — the key patient-safety failure.
●Missing the minimised red flags: not asking about, or not registering, the weight loss and appetite change the patient plays down.
●Not quantifying the smoking: failing to appreciate the 40-pack-year history that reframes the whole presentation.
●Treating smoking cessation as a tick-box: mentioning it without offering real support, or accepting "too late now."
●Colluding with the patient's simple-fix expectation: doing only what he asked (swap the tablet) rather than the fuller, safer work-up.

Free MRCGP SCA practice case for GP registrars covering Dry Cough Several Months After His Heart Attack — Cardiovascular Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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