Cases/Gastroenterology

Nocturnal Cough — Free SCA Practice Case

Obese man with nocturnal cough

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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Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Gary Wilson

Age

54 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"This cough is driving me (and my wife) mad. It's been 6 weeks."

Medical Records

●
PMH:
- ●Obesity (BMI 34).
- ●Hypertension.
- ●Type 2 Diabetes.
●
Medications:
- ●Ramipril 10mg OD.
- ●Metformin 500mg BD.
●Allergies: NKDA.

Recent Notes

●4 Months Ago: BP uncontrolled. Switched from Amlodipine to Ramipril.

Patient Script

For the friend playing the patient role

Character Overview: You are Gary. You are tired and frustrated. You are a taxi driver, so you sit down all day. The cough is embarrassing with passengers, but the main issue is sleep. You are convinced you have a "chest infection" that hasn't cleared, or that the damp in your house is affecting your lungs.

Opening Sentence: "Doctor, I need you to listen to my chest. I've had this hacking cough for six weeks now. It's keeping the wife awake, and I'm exhausted. It must be an infection deep down."

History if Asked (Data Gathering Phase)

●
The Cough:
- ●"It's dry and tickly. Like a feather in my throat."
- ●"It's worst as soon as I lie down at night, or first thing in the morning when I wake up. I cough until I retch sometimes."
- ●Sputum: "No, nothing comes up. It's just dry."
●
Reflux Symptoms (The Clue):
- ●"Now that you mention it, I do get a bit of heartburn. Especially after a curry or a few beers. I wake up with a sour taste in my mouth sometimes."
- ●"I've been drinking a lot of milk to settle my stomach."
●
Medication Link (The Trap):
- ●"The blood pressure pills? Yeah, Ramipril. I started them a few months back. Can they cause a cough? But I took them for months before the cough started!" (You are skeptical of this link).
●
Red Flags:
- ●Weight Loss: "I wish! I've actually put on a few pounds."
- ●Haemoptysis: "No blood."
- ●Dyspnoea: "I get a bit puffed out on the stairs, but that's just my weight. My breathing feels fine when I'm sitting."

ICE — Ideas, Concerns, Expectations

Do not volunteer any of this unprompted. Only share if the candidate directly explores your perspective.

●Ideas: You are convinced this is a chest infection that hasn't fully cleared, or that the damp patch in your spare bedroom is giving you some kind of lung problem. You have not considered the possibility that it could be related to your medication or your stomach. If the doctor raises either of those ideas, you are genuinely surprised.
●Concerns: You are worried that the cough means something is seriously wrong with your lungs — you've smoked in the past and that plays on your mind, even though you stopped years ago. More immediately, the lack of sleep is making you feel unsafe driving for long shifts, and you're worried you'll nod off at the wheel. You are also embarrassed — passengers have commented on the coughing and you've lost a couple of regulars.
●Expectations: You want your chest properly examined — you feel strongly that a doctor should listen to your chest. You want something that will stop the cough so you can sleep. You are open to trying treatment but you want a clear explanation of what's actually causing it, not just a prescription.

If Asked — Medical History and Medications

Do not volunteer medication or medical history details unless the candidate asks directly.

●Ramipril: "Yeah, I'm on Ramipril — 10mg. They changed me over from the other one, amlodipine I think it was, about four months ago because my blood pressure wasn't coming down. To be honest, the amlodipine was fine — I didn't have any bother with it. This cough started maybe six or eight weeks after they switched me."
●Amlodipine switch: "I didn't really want to change, but the doctor said my BP was still too high. Can I not just go back on the old one?"
●Metformin: "I take metformin twice a day for the diabetes. It was a bit rough on my stomach when I first started — gave me the runs for a couple of weeks — but it settled down. I don't think it's causing any problems now."
●Type 2 Diabetes: "It's diet controlled mostly — well, diet and the metformin. I'm supposed to be watching what I eat but I'm not great at it, honestly. My last sugar check was alright, the nurse said it was okay."
●Blood pressure: "It was really high when they first found it — I can't remember the numbers. They tried me on amlodipine first and it came down a bit but not enough, so they switched me to the ramipril."
●Obesity: If asked about weight: "Yeah, I know I need to lose weight. The doctor's told me plenty of times. It's hard when you're sitting in a cab all day and grabbing food on the go. I've put on a bit more recently if anything."
●Allergies: "No, no allergies to anything that I know of."

Social History and Lifestyle Impact

Volunteer naturally in conversation — not as a monologue.

●Occupation: You are a self-employed taxi driver working long shifts, typically 10–12 hours a day, five or six days a week. You do a mix of local runs and longer airport transfers.
●Smoking: You used to smoke — about 15 a day for roughly 20 years. You stopped eight years ago. You haven't touched one since.
●Alcohol: You drink moderately — a few pints at the weekend, maybe a beer or two in the evenings. You enjoy a takeaway curry on a Friday night.
●Home: You live with your wife, Linda. The house is an older property and there's a damp patch in the spare bedroom that you've been meaning to sort out. You are half-convinced this is contributing to the cough.
●Lifestyle impact: "Honestly, it's ruining my life. I'm not sleeping — I cough the second my head hits the pillow, and Linda's moved into the spare room. I'm doing twelve-hour shifts on no sleep. Last week I nearly went through a red light because I was so tired. And passengers keep asking if I'm alright — one woman actually got out and booked another cab because she thought I was ill. It's costing me money and it's making me miserable."

If Asked — Associated Symptoms

Only respond to these if the candidate asks directly. Keep answers brief and natural.

●If asked about fever or night sweats: "No, no temperatures or anything like that. I feel alright in myself apart from being knackered."
●If asked about chest pain: "No pain in my chest, no. Just the tickle and the cough."
●If asked about wheeze: "I don't think so. There's no whistling or anything. Just the dry cough."
●If asked about nasal symptoms or postnasal drip: "My nose is fine. No stuffiness or dripping or anything like that."
●If asked about voice changes or hoarseness: "Actually, my voice does feel a bit rough first thing in the morning. It clears after a bit. I hadn't really thought about it."
●If asked about difficulty swallowing: "No, swallowing is fine. No problems there."
●If asked about throat clearing: "Yeah, I do clear my throat a lot actually. Especially in the mornings. I just thought that was part of the cough."
●If asked about previous chest X-ray or investigations: "No, I haven't had any X-rays or scans or anything. Nobody's suggested it."
●If asked about contact with anyone unwell: "No, nobody at home or at work has been ill."
●If asked about pets or animal exposure: "No pets. Linda won't have them in the house."
●If asked about any new exposures (dust, chemicals, workplace): "No, nothing new. Just the cab, same as always."
●If asked about ankle swelling: "No, my ankles are fine."
●If asked about orthopnoea (needing extra pillows): "No, I don't need extra pillows. It's the cough that wakes me, not being short of breath."
●If asked about palpitations: "No, nothing like that."
●If asked about appetite: "Appetite's fine — too good, probably. That's part of the problem."
●If asked about stress or low mood: "I'm frustrated more than anything. I wouldn't say I'm depressed, just fed up with it. The tiredness makes everything harder."

Responses to Management (The Negotiation Phase)

●If the Doctor refuses to examine the chest: Reaction: "But how do you know it's not pneumonia if you don't listen? I've got a stethoscope from my kid's toy set, can I put it on the camera?" (Push for the exam).
●If the Doctor blames the weight: Reaction: Defensive. "I know I'm big, Doc. I'm trying. But fat doesn't make you cough, does it?"
●If the Doctor stops the Ramipril: Reaction: Worried. "But my blood pressure was sky high before. If I stop it, will I have a stroke?"
●If the Doctor prescribes a PPI (Omeprazole): Reaction: "A stomach pill for a cough? Okay, I'll try it. But I still think it's my lungs."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 26 indicators checked+0−0

Positive (0/13)

Negative (0/13)

Domain 3: Relating to Others

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Clinical Learning Points

The Two Causes of Chronic Cough in This Case

●This patient has two concurrent and clinically plausible causes of chronic cough: ACE-inhibitor cough from Ramipril and GORD/laryngopharyngeal reflux (LPR). Both must be identified and addressed — treating only one risks an incomplete response and diagnostic confusion.
●A common mistake is anchoring on whichever cause is identified first. The temporal link to Ramipril is strong, but the positional worsening, heartburn, sour taste, and morning hoarseness are independently diagnostic of reflux-mediated cough.

ACE-Inhibitor Cough

●Mechanism: ACE inhibitors block the enzyme that normally degrades bradykinin. Accumulated bradykinin sensitises the cough reflex in the lower respiratory tract, producing a dry, persistent, irritating cough.
●Timing: Cough can develop weeks to months after starting an ACE inhibitor — not only immediately after initiation. A gap of 6–8 weeks, as in this case, is entirely consistent with the diagnosis. Do not dismiss the link because the cough was not immediate.
●Incidence: Affects approximately 10–15% of patients on ACE inhibitors; more common in women and in patients of South Asian or East Asian descent.
●Management: Stop the ACE inhibitor and switch to an ARB (e.g. losartan, candesartan) — ARBs do not affect bradykinin and do not cause cough. An alternative is to return to the previous CCB (amlodipine), though this may be less appropriate if the CCB alone was insufficient for BP control.
●In T2DM: ARBs are preferred over CCBs as the antihypertensive switch in a patient with type 2 diabetes because they provide renoprotective benefit by reducing intraglomerular pressure — a clinically important consideration in this patient.
●Resolution: The cough typically resolves within 1–4 weeks of stopping the ACE inhibitor but can take up to 12 weeks. Set this expectation explicitly so the patient does not assume the diagnosis was wrong if improvement is slow.

GORD and Laryngopharyngeal Reflux (LPR) as a Cause of Chronic Cough

●LPR occurs when acid and pepsin reach the larynx and pharynx, irritating the mucosa and sensitising the cough reflex. It is not the same as classic gastro-oesophageal reflux disease (GORD) and may occur without prominent heartburn ('silent reflux').
●Classic features of reflux-mediated cough in this case: dry nocturnal and postural cough (worse lying flat), morning hoarseness, sour taste on waking, frequent throat clearing, and heartburn triggered by alcohol and spicy food.
●Obesity raises intra-abdominal pressure and impairs lower oesophageal sphincter (LOS) tone, making GORD and LPR significantly more likely in this patient. Weight loss is therefore directly relevant to cough management — not just BP and diabetes.
●Milk: Gary has been drinking milk to settle his stomach. Although milk temporarily buffers acid, it stimulates further gastric acid secretion shortly after — this can paradoxically worsen reflux.

Clinical Management — GORD/LPR

●PPI trial: Prescribe an empirical trial of a PPI (e.g. omeprazole 20–40mg daily) for 4–8 weeks. Standard-dose PPI once daily is the initial approach per NICE CKS. In LPR specifically, higher doses (e.g. 20mg BD) or a longer trial (up to 3 months) may be needed if the initial response is incomplete — review at 4–8 weeks.
●Alginate therapy: Gaviscon Advance (alginate-based) forms a viscous raft on top of gastric contents that physically blocks reflux episodes, particularly postprandially and at night. It can be used alongside a PPI or as an alternative in milder reflux.
●
Lifestyle — specific to this patient:
- ●No food or drink (except water) within 3 hours of lying down
- ●Elevate the head of the bed using blocks or a wedge pillow — extra pillows alone flex the neck and are ineffective
- ●Reduce or eliminate alcohol (relaxes the LOS) and spicy food (identified triggers in this patient)
- ●Avoid caffeine, chocolate, and carbonated drinks, which also reduce LOS tone
- ●Stop drinking milk as a remedy — explain the rebound acid effect

Blood Pressure Management After Stopping Ramipril

●The patient will be anxious about stopping his blood pressure medication, fearing stroke. Address this directly: the switch to an ARB (or return to amlodipine) will maintain BP control — he is not being left unprotected.
●Arrange a BP check within 2–4 weeks of the medication switch to confirm adequate control with the new agent. This is also good clinical practice when changing antihypertensive class.
●Document the reason for switching — ACE-inhibitor cough — clearly in the record. This patient should not be re-prescribed an ACE inhibitor in future.

Red Flags and Chest X-Ray — Getting the Balance Right

●NICE NG12 (Suspected Cancer) recommends an urgent chest X-ray (within 2 weeks) for patients aged 40 and over with an unexplained cough plus any of: haemoptysis, or a cough combined with other features such as fatigue, appetite loss, unexplained weight loss, or signs of malignancy.
●NICE CKS on cough advises that a chest X-ray should be considered for cough persisting beyond 3 weeks where no clear cause has been identified or where initial treatment has failed.
●In this case, Gary has no current red flag features — no haemoptysis, no weight loss, no new breathlessness beyond his baseline — and two clear, treatable causes have been identified. It is clinically reasonable to treat both causes for 4–6 weeks first, then arrange a chest X-ray if the cough has not resolved. This avoids over-investigation while remaining safe.
●His smoking history (~20 pack-years, stopped 8 years ago) means lung malignancy must remain on the safety-netting radar. If the cough does not respond, a chest X-ray is mandatory and should not be delayed further.
●Immediate chest X-ray is indicated if he develops haemoptysis, unexplained weight loss, worsening breathlessness, or any new systemic symptoms — make this explicit to the patient.

Occupational Safety — Professional Driver

●Gary is a self-employed taxi driver working 10–12 hour shifts. He has reported a near-miss at a red light due to fatigue caused by sleep disruption from the cough. This is a patient safety issue that must be addressed in the consultation — it cannot be ignored.
●Discuss whether he should limit his working hours or take short-term sick leave until sleep improves. This is a clinical recommendation, not merely an administrative formality.
●The DVLA advises that drivers must not drive when their ability to do so is impaired. Severe sleep deprivation causing near-misses is relevant to fitness to drive and should be documented. Advise Gary clearly that he must not drive when unfit to do so, and that this is both a legal and safety obligation.
●Document the discussion about driving safety in the consultation notes.

Safety-Netting and Follow-Up

●Advise Gary to return urgently if he develops: coughing up blood, unexplained weight loss, worsening breathlessness, fever, or any new systemic symptoms.
●Arrange GP review at 4–6 weeks to assess: response to stopping Ramipril, response to PPI, and BP on the new antihypertensive.
●If the cough persists at 4–6 weeks despite both interventions: arrange a chest X-ray and reconsider the differential (asthma, postnasal drip, eosinophilic bronchitis, or rarer causes).
●Confirm the follow-up plan clearly with the patient at the end of the consultation — given the complexity of two concurrent diagnoses and a medication change, written or SMS summary is good practice.

Mapped to the RCGP curriculum topic: Gastroenterology.

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