One day a very interesting patient came to the clinic and said anxiously, “Doctor, I’ve had a cough for a long time, and I’ve taken a lot of medicine, but it’s not getting better, what should I do?” I said, “Don’t worry, sit down first and tell me how long you have had this cough?” He replied, “I’ve had this cough for a few months, but I have no other symptoms, my chest CT is fine, my blood tests are normal, and I’ve used a lot of cough medicine, but nothing works. What is the problem? This is how most patients present their condition. Their focus is on the long cough and the use of many cough suppressants, but there is a lot of information that they have not told the doctor, which requires us to discover from it. So I asked, as I am wont to do when asking about medical history, trying not to miss anything: “Don’t worry, first of all, you describe the cough in more detail, is it predominantly daytime or nighttime, and is it strong at night before bedtime or obvious in the early morning?” The patient replied, “I think it is predominantly daytime and basically no cough at night, doctor does this cough diagnosis have much to do with the time of day?” I said, “Of course it does. We diagnose the same as solving a case, first catch the main problem, narrow down the disease, and then catch some traces to quickly find the suspect. The relationship between cough and time is particularly helpful for the diagnosis of certain diseases, such as cough variant asthma the most prominent feature of this disease is a more intense cough in the second half of the night and early morning, well although this can not be completely ruled out but asthma is very unlikely. Then tell me if your cough is a bout or persistent? When is the cough more severe?” The patient replied, “My cough is a bout that seems to get worse within half an hour after eating, does that mean anything?” I continued, “And do you have any acid reflux, throat discomfort, or a burning sensation behind the sternum?” The patient said, “I sometimes have acid reflux, especially when I eat something spicy. “I asked, “Do you have a runny nose, sneezing, or nasal congestion? ” The patient said, “No, not really. Doctor, you have asked so many questions, what exactly is my problem? “I replied, “Actually, I basically have a number of your problems. I am now considering that your cough is caused by GERD. “The patient said, “I had it a few years ago, and I had a gastroscopy for superficial gastritis, does it matter? ” I replied, “That helps me to determine the diagnosis. But the degree of coughing is not necessarily proportional to the gastroscopic presentation.” The patient asked, “Gastroesophageal problems can also cause a cough; I had always thought that only bronchial and pulmonary problems could cause a cough.” I replied, “Gastroesophageal reflux disease causing cough is not uncommon, accounting for about 20% of chronic cough in Europe and the United States, and about 12% in recent epidemiological studies in China, accounting for chronic cough and the third to fourth highest level.” The patient says, “Such a high percentage! But why don’t I cough at night? It makes sense that the gastroesophagus forms a straight line after sleep at night, just as water flows out more easily when the water bottle is flattened, so stomach acid should flow more easily into the esophagus causing a cough.” I replied, “This concept is the understanding of many people, including many doctors, but it is actually wrong. In fact, the cough in this disease is predominantly daytime, and about 75% of patients have a daytime cough. According to 24-hour acidity monitoring, reflux actually occurs more often in the awake and upright positions, and the lower esophageal sphincter is contracted after sleep and in the lying position, so the possibility of transient sphincter relaxation and reflux is smaller than during the day; on the contrary, reflux is greater when the lower esophageal sphincter is relaxed in the upright position.” The patient asked, “Then why is the cough worse every time I eat?” I replied, “This symptom is actually highly suggestive of a cough caused by GERD, why? Because of the expansion of the stomach after eating, which leads to a brief relaxation of the lower esophageal sphincter through some reflex mechanism, as well as the direct action of food leading to lower lower esophageal pressure, eating irritating food that damages the esophageal mucosa, and other reasons, so your symptoms are worse after eating.” The patient asked, “So is it true that most patients with GERD have a post-feeding cough?” I said, “I have not studied this condition, but according to a study by the Guangzhou Institute of Respiratory Diseases, it was found that 55% of people with reflux symptoms such as acid reflux, belching and heartburn, and 65% of people with feeding-related cough, are more common than other diseases that cause chronic cough. Of course there are some patients with GERD where these symptoms are not all obvious, and this is when diagnosis can be difficult.” The patient asked, “What tests are available for this disease?” I replied, “The best way to determine the presence of GERD in this disease is to use esophageal acidity measurement, but this test is not yet popular because it is relatively troublesome to perform and requires the patient’s cooperation. The most common approach now is to do a gastroscopy to observe the presence of inflammation, erosions and ulcers in the esophagus, but this cannot be ruled out in patients who do not have mucosal damage.” The patient asked, “In that case, how do I stop this surgical cough? ” I replied, “The treatment of this disease has two components, one is the adjustment of living and eating habits, and the other is medication. Let’s talk about medication first. There are three kinds of medications, one is drugs that inhibit gastric acid secretion, such as omeprazole and ranitidine; one is pro-gastric motility drugs such as morpholine; and one is gastric mucosal protective agents such as Daxil and thiosemicarbazone. Omeprazole is usually preferred and is recommended to be taken in high doses, such as 20 mg twice a day, which needs to be taken for a long time, for at least 2 to 4 weeks continuously to be effective. Taking a prokinetic agent such as mosapride on top of this will further increase the success of treatment. Remember that this medication both treats and in turn helps to confirm my diagnosis. In the guidelines developed by the American College of Gastroenterology, a double dose of the more acid-suppressive Nexium is recommended for one week. “The patient said, “Thank you, doctor, but what do I need to take care of in my life? What should I eat and what should I not eat? ” I replied; “I want to highlight this issue, that is, to avoid foods that can trigger the relaxation of the lower esophageal sphincter, such as high fat, coffee, strong tea, chocolate, etc.; and acidic or spicy stimulating drinks or foods, such as onions, garlic, mint, etc. Do not smoke and drink. The head of the bed is appropriately elevated when the night tone is lying flat, and the left side is lying.” The patient said, “Thank you, I will use the medicine as you prescribed and see you again in two weeks.” After two weeks, this patient arrived as scheduled, and this time when I saw him he was much more comfortable and in a much better mood. He rushed to me and said, “Dr. Shen, thank you so much for finding out the cause of my illness and solving my big problem. I feel much better after taking the medicine for a week. Do you see how much longer I have to take it?” I laughed, “Actually, I don’t usually encounter many typical patients like you, and I took it with the idea of giving it a try. But now the treatment seems to be effective and in turn confirms my diagnosis. Generally speaking, after the cough disappears, the treatment should be continued for another 3 months and then gradually stopped. So don’t be in a hurry, take your time.”