SOAP Note: Acute Cough

“I’ve had this cough that just won’t go away for the past few weeks.”

The patient is a 37-year-old male presenting with a persistent, dry, nonproductive cough lasting approximately three weeks. He reports the onset was gradual and initially thought it was due to a common cold. He denies fever, hemoptysis, weight loss, or chest pain. The cough worsens at night and when lying flat. No history of asthma or gastroesophageal reflux disease (GERD). He has been using over-the-counter cough suppressants without significant relief. No history of similar symptoms in the past. He reports recent exposure to cold air and dust in his work environment as a construction foreman.

Occasional acetaminophen for muscle aches.

OTC dextromethorphan-based cough syrup as needed.

No significant medical history. No chronic illnesses reported.

Allergies:

No known drug or food allergies.

Medication Intolerances: None reported.

Chronic Illnesses/Major traumas

No history of chronic disease or major injury.

Hospitalizations/Surgeries

No previous surgeries or hospital admissions.

Father has hypertension; mother has seasonal allergies. No history of asthma, cancer, TB, or psychiatric illness in the family.

Completed vocational training. Works in construction. Married, lives with spouse and two children. Occasionally drinks beer on weekends. Non-smoker. No recreational drug use. Feels safe at home and work. Reports adequate sleep and moderate exercise.

No fever, fatigue, or night sweats. Normal energy levels.

Denies chest pain, palpitations, or edema.

No rash, bruising, or changes in skin noted.

Chronic dry cough; no wheezing, dyspnea, or hemoptysis.

No visual changes or need for corrective lenses.

Denies nausea, vomiting, or abdominal pain. Regular bowel movements.

No ear pain, discharge, or hearing changes.

No urinary complaints. No history of STIs. Sexually active with spouse.

Mild throat irritation from coughing. No sinus congestion, hoarseness, or bleeding.

No joint or back pain. No fractures or stiffness.

No concerns reported.

No weakness, dizziness, or blackout spells.

No unusual bleeding, bruising, or gland swelling. HIV negative. No endocrine complaints.

Denies depression, anxiety, or sleep disturbances. No psychiatric history.

Well-groomed, alert, cooperative, and in no acute distress.

Warm, dry, and intact. No lesions or rashes observed.

Normocephalic, atraumatic. Pupils equal and reactive. No nasal discharge. Throat mildly erythematous without exudate. No lymphadenopathy.

S1 and S2 regular. No murmurs, rubs, or gallops. No edema. Pulses 3+ bilaterally. Cap refill 2 seconds.

Chest expansion symmetrical. Breath sounds clear bilaterally with occasional dry cough during exam. No wheezing, rales, or rhonchi.

Soft, non-tender abdomen. Normal bowel sounds. No organomegaly.

No tenderness or masses.

Male exam deferred. No reported complaints.

Normal gait and posture. Full ROM in all extremities.

Alert. Speech with normal volume and rate. Cranial nerves intact. Gait stable.

Appropriate affect and mood. Oriented to person, place, and time. Maintains eye contact. No signs of distress.

·         Rapid strep test: Negative

·         COVID-19 antigen test: Negative

·         Chest X-ray: Ordered (pending)

Peak Expiratory Flow Rate (PEFR): Within normal limits

o    1- Allergic rhinitis with post-nasal drip (J30.9) – The patient works in a dust-exposed environment and reports a nocturnal cough, which can be triggered by post-nasal drip.
However, he denies sneezing, nasal congestion, or itchy eyes, making allergic etiology less likely (Akhouri & House, 2023).

o    2- Gastroesophageal reflux disease (K21.9) – The patient has nighttime coughing and symptom exacerbation in the supine position suggests possible reflux-related irritation.
However, the patient denies heartburn, regurgitation, or other classic GERD symptoms, making this diagnosis unlikely (Azer et al., 2024).

o    3- Asthma, mild intermittent (J45.20) – He presents with dry cough and nighttime symptoms may reflect cough-variant asthma. However, the diagnosis is unlikely because of no wheezing, dyspnea, or personal or family history of asthma reported (Sinyor & Perez, 2023).

Diagnosis

o    Acute Cough (R05) – Most likely viral or irritant-induced. Duration less than 3 weeks, no signs of pneumonia or systemic infection, and no red flags present (Arai et al., 2022).

§  Further testing: Await chest X-ray to rule out lower respiratory tract pathology. No antibiotics initiated.

§  Medication: Prescribed benzonatate 100 mg, one capsule TID PRN for cough. Continue OTC lozenges.

§  Education: Advised patient on supportive care, including hydration, humidifier use, and avoiding cold air or dust exposure. Instructed to monitor for red flags such as fever, hemoptysis, and SOB.

§  Non-medication treatments: Saline nasal spray for possible post-nasal drip. Warm fluids encouraged.

The patient was cooperative and receptive to teaching. He asked questions regarding occupational exposure and felt reassured with the care plan. He demonstrated understanding of the management strategy and agreed to follow up as recommended. No concerns at the end of the visit. Follow-up is in 10 days or sooner if symptoms worsen or persist beyond three weeks.