Case Study A 75-year-old man with a history of hypertension

Posted: May 13th, 2023

Case Study A 75-year-old man with a history of hypertension, diabetes, environmental allergies, and colon polyps presents to the office with a complaint of persistent dry hacking cough that does not improve with over- the-counter treatment with antitussives and allergy medications. The man reports that he has had the cough for 3 months and is tired of the coughing spells he experiences. His medical history reveals that he started taking lisinopril 6 months before this appointment, has taken an over-the-counter allergy medication for several years, had his last colon polyps removed 6 years ago, and his blood pressure today is 145/70. Other medications include metformin XR 500 mg daily, aspirin 81 mg once daily, and loratadine 10 mg daily. The physical exam is negative for any issues other than his mild neuropathy from long-term diabetes. The cough is noted to be dry and hacking as the patient has described. The man is not in acute distress. Case Questions 1. What questions would have been asked as part of the medical history?
When did the cough start?
How often does the cough occur?
What does the cough sound like?
Is there any sputum produced with the cough?
Are there any other symptoms associated with the cough, such as fever, shortness of breath, or chest pain?
What medications is the patient taking?
Does the patient have any allergies?
Does the patient smoke?
Does the patient have any other medical conditions?

The doctor would also ask about the patient’s lifestyle, such as their diet, exercise habits, and exposure to environmental irritants.

The doctor would also perform a physical exam, which may include listening to the patient’s lungs with a stethoscope.