A 38-year-old woman comes to the office due to persistent cough for the past several months. The patient says that at first she was awakened occasionally at night or in the early morning by severe bouts of coughing, but lately this has occurred every 3-4 days. The cough is often accompanied by wheezing and clear sputum; she has no cough during the daytime but has had occasional hoarseness and throat irritation. She has also noticed that her symptoms are worse when she drinks wine with dinner or eats a large meal. The patient began jogging regularly a month ago in an attempt to lose weight and has not noticed any symptom exacerbation or shortness of breath with exercise. She went to the emergency department 2 months ago due to squeezing chest pain, but all workups were normal. The patient has a 2-year history of hypertension, which is well controlled with lisinopril, and also has a history of seasonal allergy. She does not use tobacco or illicit drugs and drinks alcohol socially. Temperature is 36.8 C (98.2 F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 16/min. Pulse oximetry is 99% on room air. BMI is 30 kg/m². Nasal and pharyngeal mucosae appear normal and there is no jugular venous distension. The lungs are clear to auscultation, and heart sounds are normal with no murmur. The abdomen is soft and nontender. Which of the following is most likely to improve this patient's cough?

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Explanation: 11ec2b69_c155_0ebc_8f63_9d7cd3a714fa_MD0005_00 This patient likely has gastroesophageal reflux disease (GERD). Chronic cough is a common presenting symptom of GERD and may be caused by stimulation of cough receptors in the upper or lower respiratory tract (due to aspiration of gastric contents), or through an esophageal-tracheobronchial cough reflex triggered in the distal esophagus. In some cases, cough may be the only presenting symptom of GERD; however, this patient also has hoarseness, throat irritation, and an episode of chest pain (sometimes mimicking ischemic chest pain) that suggests the diagnosis. Alcohol causes a decrease in lower esophageal sphincter tone, and a worsening of symptoms with wine intake is also consistent with GERD. The initial diagnosis of cough-predominant GERD is based on symptomatic presentation, and initial management consists of lifestyle modifications (eg, weight loss, avoidance of alcohol intake) and an 8-week course of proton-pump inhibitor therapy (eg, omeprazole); a trial of histamine blocker, which is an appropriate initial therapy for mild GERD, is typically foregone in patients with significant cough. For patients in whom the cough does not respond to proton-pump inhibitor treatment, 24-hour esophageal pH monitoring is recommended to reevaluate the diagnosis. (Choices A and C) Inhaled beta-2 agonists (eg, albuterol) are used in the management of intermittent asthma, and leukotriene inhibitors (eg, montelukast) are sometimes used in patients with cough-variant asthma when the cough is refractory to other treatment. However, this patient's lack of cough exacerbation with exercise makes asthma less likely. Wheezing, commonly associated with asthma, may also occur in GERD due to aspiration of gastric contents. (Choice B) Intranasal glucocorticoids (eg, fluticasone) are used to treat allergic rhinitis, which is commonly associated with upper airway cough syndrome (UACS). However, in patients with UACS, inflammation of the nasal mucosa and oropharyngeal cobblestoning are expected on physical examination, and worsening of the cough with alcohol intake is not typical. (Choice D) ACE inhibitors (eg, lisinopril) are a common cause of chronic cough and should be considered in the differential diagnosis of cough for any patient taking these medications. However, this patient's hoarseness and throat irritation make GERD a more likely cause of the cough. Educational objective: Chronic cough is a common presenting symptom of gastroesophageal reflux disease (GERD), and in some cases may be the only presenting symptom. The initial management of suspected cough-predominate GERD involves lifestyle modification and 8 weeks of proton-pump inhibitor therapy. References: Chronic cough and gastroesophageal reflux disease: experience with specific therapy for diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/12628862)

A 38-Year-Old Woman Comes to the Office Due to Persistent