What is the diagnosis and recommended treatment for a 43-year-old female patient with a history of hypertension and palpitations, taking Amlodipine (amlodipine) 5 mg, who presents with symptoms of fever, itchy throat, and cough, and has a history of smoking (1 pack year) and occasional drinking?

Diagnosis and Management of Acute Upper Respiratory Tract Infection with Consideration of ACE Inhibitor-Induced Cough

This patient most likely has an acute viral upper respiratory tract infection (common cold/flu-like illness), but the chronic dry cough component is highly suspicious for ACE inhibitor-induced cough from her Amlodipine regimen, which should be evaluated and potentially discontinued if the cough persists beyond resolution of the acute illness.

Primary Diagnosis: Acute Viral Upper Respiratory Tract Infection

Clinical Presentation Analysis

• The 6-day history of dry itchy sore throat, dry cough triggered by throat irritation, followed by frontal headache and fever is classic for viral URTI 1
• The temporal progression (throat symptoms → systemic symptoms) and lack of productive cough, dyspnea, or chest pain makes lower respiratory tract infection (pneumonia/bronchitis) unlikely 1
• Temple tenderness may represent tension-type headache associated with viral illness or mild sinusitis 1

Key Diagnostic Considerations to Rule Out

• Pneumonia is unlikely given absence of dyspnea, productive cough, or chest pain; however, chest examination findings were not documented 1
• Chronic lung disease (asthma/COPD) should be considered given her 1 pack-year smoking history and chronic cough, though the acute presentation favors infectious etiology 1
• ACE inhibitor-induced cough must be strongly considered as Amlodipine is a calcium channel blocker, but if she were on an ACE inhibitor previously or if there's medication history error, this would explain the chronic dry cough component 1

Critical Medication Review Issue

ACE Inhibitor-Induced Cough Consideration

• ACE inhibitor-induced cough presents as a dry, persistent cough with tickling/scratching throat sensation, occurring in 5-35% of patients 1
• Onset ranges from hours to months after initiation, and cough may persist 1-4 weeks (up to 3 months) after cessation 1
• The cough is not dose-dependent and occurs more commonly in women and nonsmokers 1
• Important caveat: The history states "Amlodipine 5 mg" which is a calcium channel blocker, NOT an ACE inhibitor, so this should not cause ACE inhibitor-induced cough 1, 2
• However, verify medication history carefully as medication errors in documentation are common, and if she's actually on an ACE inhibitor (perindopril, enalapril, lisinopril), this would explain the chronic cough 1

Recommended Treatment Plan

Immediate Symptomatic Management

• Ibuprofen 400-600 mg every 6-8 hours as needed for fever, headache, and throat pain 3
• Adequate hydration and rest 3
• Short-term topical decongestants (≤3 days) if nasal congestion develops to avoid rhinitis medicamentosa 1, 3
• Throat lozenges and saline nasal drops for symptomatic relief 3

Monitoring and Red Flag Symptoms

Patient should return immediately if she develops 3:

• Difficulty breathing or painful/labored breathing
• Hemoptysis (blood in sputum)
• Altered mental status (somnolence, confusion, disorientation)
• Fever persisting >4-5 days without improvement or worsening symptoms
• Systolic blood pressure <100 mmHg or signs of hemodynamic instability 4

Medication Management Decision Algorithm

If cough persists beyond 7-10 days after resolution of acute viral symptoms:

1. Confirm current antihypertensive medication - verify if actually on ACE inhibitor vs. amlodipine 1

2. If on ACE inhibitor:

   • Discontinue the ACE inhibitor immediately as this is the only uniformly effective treatment 1
   • Switch to angiotensin receptor blocker (ARB) or continue amlodipine as ARBs have similar efficacy with significantly lower cough incidence 1
   • Cough should resolve within 1-4 weeks after cessation 1

3. If confirmed on amlodipine only:

   • Consider pulmonary function testing if cough persists, given smoking history and need to rule out asthma/COPD 1
   • Indications for PFT: presence of ≥2 of: wheezing, prolonged expiration, smoking history, allergy symptoms 1

Amlodipine Safety Profile

• Amlodipine does NOT cause ACE inhibitor-type cough 2, 5, 6
• Common adverse effects include peripheral edema (most common), headache, dizziness, and flushing - not dry cough 2, 5, 6
• The medication can be safely continued for hypertension management 2, 5

Follow-Up Plan

• Reassess in 7-10 days if symptoms persist or worsen 3
• If cough becomes productive, fever persists, or dyspnea develops: obtain chest X-ray to rule out pneumonia 1, 7
• Blood pressure monitoring to ensure adequate control, especially if medication changes are needed 2
• Smoking cessation counseling given her current 1 pack-year history and ongoing use 1

Common Pitfall to Avoid

Do not attribute all cough to the acute viral illness without considering medication-induced causes, especially in patients on antihypertensives, as ACE inhibitor-induced cough can be wholly or partially causative regardless of temporal relationship to medication initiation 1