Question of the Week # 187

187) A 34 year old obese man presents with complaints of cough of 3 months’ duration. His cough is non-productive and occurs daily. It is worse in the night. He also reports a need to clear his throat constantly. He denies any nasal congestion. He denies smoking or alcohol. He also reports a chronic history of heart burn for which he uses over the counter antacids intermittently. He works as a nurse in a health care facility. He denies any fever or night sweats or weightloss. On examination, throat is normal in appearance with out any exudate or erythema. Lungs are clear to auscultation. A Chest X-ray is normal. The most appropriate initial diagnostic step in evaluating his cough is :

A) Tuberculin skin test

B) Methacholine challenge

C) Albuterol trial

D) Omeprazole trial

E) 24 Hour esophageal  pH monitoring

9 Responses

  1. great this is dddddd


  3. It sounds like GERD with throat irritation that creates a grunting cough during the day. He needs Proton pump inhibitor to releive the acidity that the pharynx is exposed to during the night. Also he needs to sleep with an angle of 45 degees to lessen his eruptions

    • Correct. Omeprazole trial is the most non-invasive step. It is both diagnostic and therapeutic in case of suspected GERD. A symptomatic response to PPI trial confirms the diagnosis of GERD. Invasive procedures such as 24 hr pH monitoring are reserved for patients with a) persistent or atypical symptoms of GERD despite the PPI trial and b) do not have evidence for mucositis on EGD ( both criteria a and b must be satisfied).
      The approach after failed PPI trial is as follows: If the patient failed PPI trial, next step must be EGD. If the EGD showed evidence of reflux esophagitis, PPI failure must be considered and patient must be referred to surgical management of GERD. If the patient failed PPI trial and EGD did not show evidence of mucositis then 24 hr pH monitoring is justified.

  4. ddd

  5. Sound like gerd
    I would trial proton pump inhibitors. If that doesn’t work….do endoscopy for possible barretts or ulcers

  6. D–gerd

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