GE: A 64-year-old man never smoker with a history of dyspnoea and cough was referred for a respiratory opinion. The cough was sporadic but progressive over a 9 month period. It was associated with unpredictable, brief nocturnal paroxysms of breathlessness. There were also coughing bouts associated with phonation and with meals but no sputum production, fever or weight loss. There was no significant past medical history and he was not taking any medication. Physical examination was unremarkable.

IM: This gentleman presents with a chronic, non-productive cough and episodic breathlessness. The duration of his symptoms makes an infective cause unlikely and in the absence of a smoking history, the most likely diagnosis is an asthmatic cough. However, in this age group, a de novo presentation of asthma is unusual and other common causes of chronic cough such as gastro-oesophageal reflux should be considered. There are no specific pointers to a rarer diagnosis or to lung cancer; however, the latter must be actively excluded. Cough and dyspnoea are common manifestations of bronchiecetasis, interstitial lung disease and left ventricular failure but one would expect other associated features. Further investigations are required to clarify the differential diagnosis.

GE: Chest radiograph was normal with no cardiomegaly and normal lung fields. Spirometry was normal (forced expiratory volume in the first second 2.9L, 95% predicted; forced vital capacity 3.6L, 91%; maximal expiratory flow 50 130%). There was poor R wave progression on ECG and an echocardiogram showed left ventricular hypertrophy with an estimated pulmonary artery systolic pressure of 44 mm Hg+right atrial pressure. Left ventricular systolic function was reported as good. He achieved 525 m on a 6-min walk with no desaturation on oximetry but …