I would focus on the specific characteristics of his persistent cough. The cough was noted to begin around three months ago, which was a significant time after he started taking Lisinopril (about six months prior). I would ask detailed questions about what triggers his cough, what time of the day it worsens, and any associated symptoms he might have. I would specifically inquire about any recent changes to his medication, especially Lisinopril, given the known association with dry coughs, to determine if the cough might be drug-related (UpToDate, 2024). I would also consider the patient’s long-term use of over-the-counter allergy medications due to his history of environmental allergies, which could contribute to his symptoms. However, since the cough hadn’t improved with these treatments, it seems less likely to be the cause.

During the physical exam, I would assess multiple systems. His blood pressure was slightly above the desired goal level, indicating hypertension. I would evaluate his respiratory system for abnormal sounds that could point to pulmonary issues, but there doesn’t seem to be any. Since a cough can be a symptom of gastrointestinal reflux disease, I would also perform an abdominal examination to rule out GERD. Additionally, I would review his history of colon polyps to rule out a connection between his gastroenterological history and his current respiratory symptoms.

For diagnostic tests, I would start with a chest X-ray and spirometry to exclude potential pulmonary conditions that might cause a chronic cough. Given the normal findings in the physical exam, a chest X-ray seemed like a rational initial step to rule out any gross pulmonary pathology quickly.

Based on the medical history and physical exam findings, It can be deduced that the most likely cause of the cough was the ACE inhibitor Lisinopril (UpToDate, 2024). The timeline between the medication initiation and the onset of the cough supports this thought process. I kept in mind other possibilities for the differential diagnosis, such as allergic rhinitis, asthma, and GERD, while more serious conditions like lung cancer, heart failure, or interstitial lung disease, but less likely given his age and the duration of the cough.

For treatment, I would discontinue his Lisinopril and consider an alternative antihypertensive medication, like an angiotensin II receptor blocker, which typically doesn’t cause a cough (Epocrates, 2024). For this patient, I would choose to prescribe Losartan 50 MG PO QD (Epocrates, 2024). I would educate the patient about the reasons for changing his medication, the expected outcomes, possible side effects, and the importance of adhering to the new regimen (Epocrates, 2024). I would also address the proper use and expectations for his allergy medications to ensure effectiveness. A follow-up after changing his medication would be in my plans to reevaluate his blood pressure control and to check if the cough had resolved. This would also be an excellent opportunity to review his diabetes management as well. If the cough persisted despite these interventions, it would indicate the need for further diagnostic testing.

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