ACE Angie
Lisinopril lowers her blood pressure beautifully — until the dry cough starts and her lips begin to swell
Try 5 free Pharmacology questions
Try a free question
Answer it, read the rationale, then keep practicing ACE Inhibitors: Cough, Angioedema & Hyperkalemia — free.
Want ACE Angie and all 158 characters on paper?
The Recall Binder collects every story, 659 flashcards and 580 practice questions in one printable PDF.
See the Recall BinderMeet the character
ACE Angie
ACE Inhibitors: Cough, Angioedema & Hyperkalemia
Lisinopril lowers her blood pressure beautifully — until the dry cough starts and her lips begin to swell
Angie started lisinopril three weeks ago and her blood pressure is finally controlled, but now she cannot stop coughing — a dry, hacking tickle that keeps her up at night. This morning she notices her lips look swollen.
mnemonurse.com
The story
Angie started lisinopril three weeks ago and her blood pressure is finally controlled, but now she cannot stop coughing — a dry, hacking tickle that keeps her up at night. This morning she notices her lips look swollen.
Angie takes lisinopril for hypertension, and it works by blocking the conversion of angiotensin I to angiotensin II, dropping her blood pressure and protecting her kidneys. But ACE inhibitors also block the breakdown of bradykinin, and bradykinin buildup causes the two signature problems: a persistent dry, tickling cough and, far more dangerous, angioedema of the lips, tongue and airway. Because less aldosterone is released, potassium is retained, so ACE inhibitors also raise serum potassium — especially with potassium-sparing diuretics or salt substitutes.
The full story of ACE Angie
Angie earned her nickname on the walking track of her retirement community, where she recruits neighbors every morning for laps meant to keep her blood pressure in check. Diagnosed with hypertension in her fifties, she was started on lisinopril, one of the family of ACE inhibitors that block the conversion of angiotensin I into angiotensin II. That blockade relaxes her blood vessels and eases the workload on her heart, but the same enzyme she is suppressing also happens to break down bradykinin, a substance that otherwise gets quietly cleared from her tissues. With ACE blocked, bradykinin builds up in Angie's body, setting the stage for two very different complications: an irritating dry cough that many patients simply tolerate, and a much rarer, potentially airway-closing swelling that can strike without warning.
For nearly two years, Angie does beautifully on her lisinopril, her pressures running a steady 128 over 78, and she jokes to her walking group that the medication is the reason she can still keep pace with women half her age. She does mention, almost as an afterthought, a nagging dry tickle in her throat that has lingered for months, assuming it is simply seasonal allergies or the dry autumn air. Her daughter, a nursing student, urges her to bring it up at her next appointment rather than dismiss it, but Angie waves off the suggestion, more interested in finishing her crossword than worrying about a cough that never actually produces anything. That casual dismissal becomes far more consequential one otherwise ordinary Tuesday evening.
While finishing dinner, Angie suddenly notices her lips feel oddly thick and tingly, and within twenty minutes her tongue has visibly swollen enough that her words come out garbled and slurred. Her daughter rushes her to the emergency department, where the triage nurse documents rapidly progressing facial and tongue edema, a hoarse voice, and audible stridor beginning to creep into her breathing. Angie's oxygen saturation, a comfortable 97 percent just an hour earlier, has already slipped to 91 percent on room air. There is no rash, no hives, and no history of food exposure, which immediately points away from a typical allergic reaction and toward the specific, bradykinin-mediated angioedema that ACE inhibitors can trigger at any point in therapy, even after years of apparently safe use.
The emergency nurse recognizes instantly that this is not the time to wait and observe. She stops the lisinopril immediately and notifies the physician while simultaneously preparing airway equipment at the bedside, because angioedema of the tongue and airway can progress to complete obstruction within minutes rather than hours. She positions Angie upright to maximize airway diameter, applies supplemental oxygen, and anticipates the possibility of emergency intubation or even a surgical airway if swelling advances further. She documents the ACE inhibitor as the causative agent clearly in the chart, ensures Angie will never again be prescribed any drug in that class, and prepares patient education emphasizing that even a long-tolerated ACE inhibitor can suddenly cause life-threatening angioedema.
Remember ACE Angie whenever an NCLEX question pairs a '-pril' medication with facial or airway swelling: her name is your cue that a nagging dry cough is merely annoying, but lip, tongue, or throat swelling is a true emergency demanding immediate drug discontinuation and airway protection. Anchor the physiology that ACE inhibitors raise bradykinin levels, which explains both the cough and the angioedema, distinguishing this reaction sharply from a classic histamine-driven allergy. Remember too that angioedema can appear even after years of safe use, so a long treatment history never rules it out. Whenever you see hyperkalemia paired with an ACE inhibitor and a potassium-sparing diuretic like spironolactone, let Angie remind you that reduced aldosterone means potassium retention is always a lurking risk.
Story arc
The setup
Angie is prescribed lisinopril for stage 2 hypertension and is told it will also protect her kidneys because she has diabetes.
The turn
Two weeks in, Angie develops a dry, nonproductive cough that is worse at night and does not respond to cough syrup.
The crisis
One morning Angie's lips and tongue begin to swell and her voice sounds muffled and thick.
The save
The nurse stops the lisinopril immediately, prepares for airway management, and the provider switches Angie to an ARB with instructions to never take an ACE inhibitor again.
0 of 4 story beats read (0%)Saved on this device — sign in to sync
More characters
Acidotic Andy
Metabolic Acidosis
Alkalotic Alice
Metabolic Alkalosis
Retaining Ray
Respiratory Acidosis
Panicking Pam
Respiratory Alkalosis
Potassium Pete
Hyperkalemia
Low-K Lena
Hypokalemia
Salty Sal
Hypernatremia
Diluted Dana
Hyponatremia / SIADH
Chvostek Chuck
Hypocalcemia
Stony Stella
Hypercalcemia
Magnesium Maggie
Magnesium Imbalance
Septic Sam
Distributive Shock
Pumpless Paul
Cardiogenic Shock
Bleeding Bea
Hypovolemic Shock
Anaphylactic Ana
Anaphylaxis
Embolic Emma
Pulmonary Embolism
Rigid Rita
ARDS
Wheezing Wanda
Asthma Exacerbation
Consolidated Carl
Pneumonia
Vented Vince
Mechanical Ventilation
Ketone Kyle
Diabetic Ketoacidosis
Hyperosmolar Hank
Hyperosmolar Hyperglycemic State
Shaky Shawna
Hypoglycemia
Storming Tori
Thyroid Storm
Sluggish Myra
Myxedema Coma
Addison Ada
Adrenal Crisis
Cushing Cora
Cushing's Syndrome
Dry Dwayne
Diabetes Insipidus
Pressured Priya
Increased Intracranial Pressure
Stroke Stan
Ischemic Stroke
Seizing Simone
Seizures & Status Epilepticus
Failing Frank
Heart Failure
Infarcting Ivan
Myocardial Infarction
Fibrillating Fay
Atrial Fibrillation
Warfarin Wally
Anticoagulation
Ammonia Amy
Cirrhosis & Hepatic Encephalopathy
Anuric Alan
Acute Kidney Injury
Digoxin Dot
Digoxin Toxicity
Preeclamptic Penny
Preeclampsia & Magnesium Sulfate
Pancreatic Pablo
Acute Pancreatitis
Sober Sully
Alcohol Withdrawal & Delirium Tremens
Manic Mia
Bipolar Mania & Lithium Toxicity
Voices Victor
Schizophrenia & Antipsychotic Side Effects (EPS, NMS, tardive dyskinesia)
Sinking Sadie
Major Depression & Suicide Risk
Flashback Felix
PTSD & Panic Disorder
Narcan Nate
Opioid Overdose & Withdrawal
Mirror Mila
Anorexia Nervosa & Refeeding Syndrome
Serotonin Sylvia
Serotonin Syndrome
Wheezy Winnie
Bronchiolitis & RSV
Sickled Simon
Sickle Cell Vaso-Occlusive Crisis
Cystic Cassie
Cystic Fibrosis
Strawberry Kai
Kawasaki Disease
Telescope Tommy
Intussusception
Droopy Dani
Infant Dehydration & Gastroenteritis
Leaded Liam
Lead Poisoning
Gushing Gwen
Postpartum Hemorrhage & Uterine Atony
Previa Paula
Placenta Previa
Abrupting Abby
Placental Abruption
Sugary Selena
Gestational Diabetes
Decel Dina
Fetal Heart Rate Decelerations & Intrapartum Monitoring
Yellow Yusuf
Newborn Hyperbilirubinemia & Phototherapy
Cord Callie
Umbilical Cord Prolapse
Feverish Fiona
Postpartum Infection & Mastitis
Neutropenic Nia
Neutropenia & Chemotherapy Precautions
Lysing Luis
Tumor Lysis Syndrome
Transfusing Tina
Blood Transfusion Reactions
Clotless Clara
Disseminated Intravascular Coagulation
Pale Priscilla
Iron Deficiency Anemia
Spore Sean
Clostridioides difficile & Isolation Precautions
CD4 Hana
HIV & Opportunistic Infections
Butterfly Bella
Systemic Lupus Erythematosus
Compartment Cody
Fractures & Compartment Syndrome
Reflexive Rex
Spinal Cord Injury & Autonomic Dysreflexia
Myasthenic Marge
Myasthenia Gravis & Myasthenic Crisis
Tremor Tomas
Parkinson's Disease
Barrel Bart
COPD
Tarry Tara
Upper GI Bleed & Peptic Ulcer Disease
Blocked Bruno
Bowel Obstruction
Crisis Camila
Hypertensive Crisis
Aneurysm Arturo
Abdominal Aortic Aneurysm
Claudicating Clara
Peripheral Arterial Disease vs Venous Insufficiency
Endocarditis Eli
Infective Endocarditis
Pericardial Pearl
Pericarditis & Cardiac Tamponade
Valve Vera
Valvular Heart Disease & Rheumatic Fever
Paced Pia
Pacemakers & ICDs
Clotted Cliff
Deep Vein Thrombosis & VTE Prevention
Appendix Annie
Appendicitis & Peritonitis
Gallstone Gina
Cholecystitis & Cholelithiasis
Crohn's Colin
Inflammatory Bowel Disease (Crohn's vs Ulcerative Colitis)
Diverticular Dee
Diverticulitis
Hepatitis Hugo
Viral Hepatitis A, B & C
Dialysis Dina
Chronic Kidney Disease & Hemodialysis
Kidney Kwame
UTI & Pyelonephritis
Prostate Percy
BPH & TURP Care
Burned Bella
Burns & Fluid Resuscitation
Ulcer Uma
Pressure Injury Staging & Prevention
Confused Connie
Delirium vs Dementia & Restraint Alternatives
Delegating Deb
Delegation, Assignment & Scope of Practice
Insulin Ike
Insulin Types, Peaks & Administration Safety
Triage Theo
Disaster Triage & Prioritization
Consent Carmen
Informed Consent, Advance Directives & Privacy
Beta Betty
Beta Blockers: Apical Pulse, Masked Hypoglycemia & Rebound
Lasix Larry
Loop Diuretics: Hypokalemia & Ototoxicity
Lithium Lila
Lithium: Therapeutic Levels, Toxicity & Sodium Balance
Tyramine Tessa
MAOIs & the Tyramine Hypertensive Crisis
Nitro Nina
Nitroglycerin: Sublingual Rules, Headache & Dangerous Combinations
Heparin Holly
Heparin: aPTT, Protamine Sulfate & HIT
Phenytoin Phil
Phenytoin: Narrow Range, Nystagmus & Gummy Smiles
Rhabdo Rory
Rhabdomyolysis: Tea-Colored Urine, Potassium & Kidney Rescue
Osteo Opal
Osteoporosis: Silent Bone Loss, Fall Prevention & Bisphosphonates
Glaucoma Gloria
Glaucoma: Silent Peripheral Loss vs Acute Angle-Closure Emergency
Meningitis Mia
Bacterial Meningitis: Stiff Neck, Droplet Precautions & Rapid Antibiotics
Sclerosis Sadie
Multiple Sclerosis: Demyelination, Relapses & Heat Intolerance
Gout Gus
Gout: Uric Acid Crystals, the Angry Big Toe & Purine Teaching
Meniere Mira
Meniere's Disease: Vertigo, Tinnitus & Hearing Loss
Rheumatoid Rosa
Rheumatoid Arthritis: Symmetric Joints, Morning Stiffness & DMARDs
Obsessive Owen
OCD: Obsessions, Compulsions & Anxiety Relief
Hyperemesis Hazel
Hyperemesis Gravidarum: Vomiting, Ketones & Dehydration
Mastitis Mabel
Mastitis: Flu-Like Fever, a Red Wedge & Keep Nursing
Nephrotic Nolan
Childhood Nephrotic Syndrome: Puffy Eyes, Frothy Urine & Protein Loss
Phosphate Franklin
Phosphorus Imbalance: The Calcium See-Saw & Binders With Meals
Overloaded Olive
Fluid Volume Overload: Crackles, Bounding Pulse & Stop the Infusion
Collapsing Callum
Tension Pneumothorax & Chest Tubes: Tracheal Deviation and the Water Seal
Ascending Abe
Guillain-Barré Syndrome: Weakness That Climbs Toward the Lungs
Sundowning Sid
Alzheimer's Disease: Sundowning, Safety and Calm Redirection
Quarantined Quinn
Tuberculosis: Airborne Precautions, Rifampin and the Orange Secret
Croupy Cora
Croup vs Epiglottitis: The Barking Cough and the Child You Never Lie Down
Fractured Frida
Hip Fracture & Fat Embolism: The Shortened Leg and the Confusion That Follows
Shingles Sheila
Herpes Zoster: The One-Sided Band of Blisters and Airborne Rules
Warfarin Winnie
Warfarin & INR: Vitamin K, Bleeding Precautions and the Salad Problem
Slow-Drip Delia
IV Potassium Safety: Never Push, Always Dilute, Always Pump
Central Line Cesar
Central Lines & Air Embolism: Clamp It, Position It, Protect It
Infiltrated Ivy
Infiltration vs Extravasation vs Phlebitis: Cool and Swollen or Red and Warm
Trach Tomas
Tracheostomy & Suctioning Safety: Oxygenate First, Suction Out Only
Feeding Fiona
Enteral Feeding & Aspiration Prevention: Head of Bed Up, Placement Verified
Steroid Stan
Corticosteroid Therapy: Never Stop Abruptly, Watch Sugar and Hidden Infection
Levo Lucy
Levothyroxine: Empty Stomach, Same Time, Lifelong — and the Signs of Too Much
Vanco Vera
Vancomycin: Slow the Infusion, Watch the Trough, Protect the Kidneys and Ears
Oxygen Omar
Oxygen Delivery Devices: Matching the Mask to the Need — and Fire Safety
Post-Op Priya
Postoperative Complications: The Day-by-Day Timeline Every Nurse Watches
PCA Pablo
PCA & Opioid Safety: Only the Patient Presses the Button
Restraint Rita
Restraints & Fall Prevention: Least Restrictive First, and the Order Rules
Vaccine Vivian
Immunizations: Live Vaccines, Real Contraindications and the Reactions to Expect
TPN Tessa
Total Parenteral Nutrition: High Sugar, Central Line, and Never Stop It Suddenly
Listening Theo
Therapeutic Communication: What to Say, and What Never to Say
Milestone Maya
Growth, Development and Age-Appropriate Safety
Labor Lena
Stages of Labor and the Normal Newborn Assessment
Screening Sam
Cancer Warning Signs and Screening Teaching
Pressure Pam
Antihypertensive Classes: Orthostatic Safety and Client Teaching
Ectopic Erica
Ectopic Pregnancy: The Pain on One Side and the Shoulder That Screams Rupture
Tet Spell Tilda
Tetralogy of Fallot: The Blue Spell and the Squat That Saves It
Pyloric Piper
Pyloric Stenosis: The Olive, the Fountain and the Hungry Baby
Phantom Petra
Amputation Care: The Limb That Is Gone but Still Hurts
Glomerular Greta
Post-Streptococcal Glomerulonephritis: The Tea-Colored Urine After the Sore Throat
B12 Bianca
Pernicious Anemia: The Beefy Red Tongue and the Wobbly Walk
Retinal Rhea
Retinal Detachment: The Curtain, the Flashes and the Painless Emergency
Ostomy Oscar
Ostomy Care: The Rose-Red Stoma and the Skin That Must Stay Whole
Unlock all 158 characters
Unlock all 158 characters — see passes