USMLE® Step 2 Question of the Day: Dry cough
Published on Aug 7, 2024. Updated on Aug 7, 2024.
A 55-year-old man comes to the office for the evaluation of a dry, nagging cough for the past several weeks. He does not have chest pain, shortness of breath, runny nose, or itchy eyes. The patient does not report recent respiratory or gastrointestinal infections. The rest of the review of systems is within normal limits. Past medical history is significant for type 2 diabetes mellitus, asthma, and hypertension. Current medications include metformin, lisinopril, atorvastatin, and as needed albuterol inhaler. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 36.6°C (97.9°F), pulse is 90/min, respirations are 18/min, and blood pressure is 135/75 mmHg. Lungs are clear to auscultation bilaterally. Heart sounds are normal without any murmurs. Laboratory results show a serum creatinine of 1.2 mg/dL and potassium of 4.9 mEq/L. Which of the following is the best next step in the management of this patient?
A. Start the patient on chlorpheniramine
B. Switch the patient from lisinopril to losartan
C. Perform a chest x-ray
D. Start the patient on intranasal glucocorticoids
E. Reassure the patient and send home
Scroll down for the correct answer!
The correct answer to today's USMLE® Step 2 CK Question is...
B. Switch the patient from lisinopril to losartan
Before we get to the Main Explanation, let's see why the answer wasn't A, C, D, or E. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
Today's incorrect answers are...
A. Start the patient on chlorpheniramine
Incorrect: First-generation antihistamines such as chlorpheniramine is the suitable treatment option for patients with nonallergic rhinitis. These patients typically present with nasal blockage and postnasal drip in the absence of a trigger factor. This patient’s cough without other symptoms is most likely due to lisinopril.
C. Perform a chest x-ray
Incorrect: The patient most likely has a cough secondary to bronchial irritation caused by bradykinin accumulation. The best step is to discontinue the causative medication. A chest x-ray is not indicated at this time.
D. Start the patient on intranasal glucocorticoids
Incorrect: Intranasal glucocorticoids is the first-line treatment for allergic rhinitis. It typically presents with paroxysms of sneezing, rhinorrhea, nasal obstruction, and nasal itching.
E. Reassure the patient and send home
Incorrect: The patient most likely has a cough secondary to bronchial irritation caused by bradykinin accumulation. The best step is to discontinue the causative medication.
Main Explanation
This patient’s dry nagging cough is most likely a side effect of lisinopril, an angiotensin-converting enzyme (ACE) inhibitor. The best next step is to replace ACE inhibitors with angiotensin receptor blockers (ARBs), which does not affect bradykinin levels and does not cause cough.
ARBs (e.g., losartan and valsartan) bind to angiotensin receptors on vascular smooth muscles and the adrenal glands, which prevent angiotensin II from binding. This results in decreased vasoconstriction and decreased aldosterone synthesis, respectively. They are indicated in the management of hypertension, heart failure, and patients who have had a myocardial infarction.
Unlike ACE inhibitors, ARBs do not increase bradykinin levels in the blood, and therefore, are less likely to cause cough and angioedema. Other than that, the adverse effects of angiotensin II receptor antagonists, just like ACE inhibitors, are hyperkalemia and hypotension.
Major takeaway
The Pringle maneuver involves manually compressing the hepatoduodenal ligament to minimize blood loss l during hepatic surgery. The hepatoduodenal ligament is composed of the hepatic artery, portal vein, and common bile duct.
References
Piardi, T., Lhuaire, M., Memeo, R., et al. (2016) Laparoscopic Pringle maneuver: How we do it?. Hepatobiliary Surgery and Nutrition. 5(4), 345-349. Doi:10.21037/hbsn.2015.11.01.
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