Station 71

Dorothy Evans

Age: 80 years old female

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis 

  • Begin by thanking the paramedic practitioner for reviewing the patient at the care home.  
  • Ask about the onset and duration of the cough
  • Ask whether the cough is productive or dry
  • If cough is productive, ask about the presence of haemoptysis
  • Ask if there has been any wheeze reported or heard on examination
  • Ask whether the patient has experienced any associated symptoms, such as fever, shortness of breath, chest pain, or palpitations
  • Ask if there are any precipitating or aggravating factors
  • Ask whether the symptoms are worse at night (reflux cough tends to be worse at night) 
  • Ask about any flu-like symptoms or signs of postnasal drip, including blocked nose, runny nose, or the sensation of mucus at the back of the throat
  • Ask specifically about reflux symptoms, such as heartburn or a sour taste in the mouth
  • Ask whether the patient has experienced hoarseness of voice
  • Screen for red flag features suggestive of malignancy, such as unexplained weight loss, night sweats, fatigue, or loss of appetite
  • Ask whether the patient currently smokes or has ever smoked
  • Give a diagnosis of Reflux-related cough. 

Example of explanation to the Paramedic Practitioner​

Thanks very much, John, for reviewing Mrs Evans and giving such a clear picture, that’s really appreciated. From what you and the care staff have observed, especially with the cough being worse after meals and at night and given her previous history of reflux and a normal chest X-ray, I think this could well be related to gastro-oesophageal reflux.

You mentioned you were wondering about her Ramipril, and that’s a good consideration, it is known to cause a dry cough. That said, before stopping or switching her antihypertensives, I wonder if it would make sense to start with a trial of omeprazole, perhaps 20 mg once daily for two weeks, just to see if there’s a response, as that might point us more firmly toward reflux as the cause.

Would you be happy with that approach?

And if so, would you also be happy to review her in a couple of weeks to see how she’s doing with it? 

In the meantime, we can ask the care home staff to support some simple measures, like giving her smaller, lighter meals, keeping her upright after eating, and slightly raising the head of her bed at night, just to help minimise reflux symptoms.

If there’s no improvement with the PPI or if red flag symptoms develop, like haemoptysis, weight loss, or breathlessness, then we can look at next steps, including reviewing the Ramipril or possibly organising further investigations.

Does that sound like a good plan to you?

Management

Management

  • Advise  a trial of omeprazole 20 mg once daily for 2 weeks to treat suspected reflux-related cough
  • Advise that nursing staff should be informed of lifestyle measures to help manage reflux symptoms, including offering smaller but more frequent meals; avoiding lying the patient flat after eating; slightly elevating the head of the bed at night; and avoiding known food triggers such as spicy meals if identified.
  • Arrange a follow-up review after 2 weeks, this can be done either by yourself or by the paramedic practitioner if appropriate and agreeable  
  • If symptoms persist despite PPI treatment, consider withdrawing ramipril, which is known to cause a dry cough, and switching to an alternative antihypertensive
  • Safety net: Ask the paramedic to inform care staff that if symptoms worsen, or if the patient develops new symptoms such as haemoptysis, shortness of breath, chest pain, or significant weight loss, they should contact the GP promptly for reassessment

Learning point from this station: ​

Cough is a non-specific protective reflex triggered by irritation anywhere from the pharynx to the lungs. It is classified by duration:

  • Acute cough: lasts less than 3 weeks
  • Subacute cough: lasts 3–8 weeks
  • Chronic cough: persists for more than 8 weeks

In non-smokers, the most common causes of chronic cough are:

  • Postnasal drip syndrome (upper airway cough syndrome)
  • Asthma
  • Gastro-oesophageal reflux disease (GORD)
  • Chronic refractory cough may also follow a viral respiratory tract infection, where the cough persists despite resolution of the initial illness.

Other recognised contributors include:

  • Environmental pollution, particularly fine PM10 particulates from sources such as traffic (tyre and brake wear), heating fuels, agriculture, sea salt, volcanic ash, and construction dust
  • ACE inhibitors, a well-known class of medication that can cause a dry, persistent cough
  • Occupational exposure to irritants — for example, bottle factory workers exposed to acidic vapours, farm workers, or individuals handling hot chilli peppers

This case highlights the importance of working collaboratively with allied healthcare professionals, such as paramedic practitioners, recognising their role in community-based care and involving them in shared decision-making.

Further reading