We are excited to see so many of you join our FMEP courses. Several of you have requested we continue to post more practice SAMPs, so here you go!

SAMP

A 48-year-old non-smoking woman presents with an 8-month history of chronic cough. She notes it started at the same time she was diagnosed with hypertension and started on medication. There has been no fever, weight loss, or hemoptysis. She reports occasional heartburn and seasonal allergies. Medications: ramipril, cetirizine PRN. Chest X-ray is normal. (7 points)

1. Most likely diagnosis? (1 point)
   1. ACE-inhibitor-related cough
   2. Non-asthmatic eosinophilic bronchitis
   3. Cough-variant asthma
   4. Gastroesophageal reflux disease (GERD)
   5. Upper-airway cough syndrome (UACS)

   Answer: A

2. Next best step in management? (1 point)
   1. Methacholine challenge test
   2. Switch ramipril to an ARB
   3. Start high-dose ICS
   4. Start PPI trial
   5. Order sinus CT

   Answer: B

3. Which feature least supports cough-variant asthma? (1 point)
   1. Normal spirometry
   2. Response to bronchodilators
   3. Positive methacholine challenge
   4. Eosinophilia in sputum
   5. No history of wheeze

   Answer: A

4. Which is true regarding chronic cough work-up? Select all that apply. (3 points)
   1. ACE inhibitors can cause cough months after initiation
   2. GERD-related cough requires daily heartburn to be likely
   3. Normal chest X-ray rules out chronic sinusitis
   4. UACS can present without rhinorrhea
   5. Trial therapies are acceptable diagnostic tools

   Answer: A, D, E

5. Which medication is least likely to help ACE-I cough? (1 point)
   1. ARB substitution
   2. Inhaled corticosteroid
   3. Cough suppressants
   4. Switching to another ACE-I
   5. Discontinuing ACE-I

   Answer: D