Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for chronic cough, evaluation of persistent cough, or new diagnostic workup.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of the cough:
Duration (more than 8 weeks)
Frequency and severity
Characteristics (productive vs. non-productive, wet vs. dry, hacking vs. barking)
Worsening or alleviating factors (time of day, position changes, exposure to irritants)
Presence of any associated symptoms (fever, chest pain, shortness of breath, wheezing, hemoptysis – coughing up blood)
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying conditions that might contribute to chronic cough (e.g., asthma, COPD, postnasal drip, GERD, smoking history)
Previous medications or treatments for cough
Social History:
Inquire about smoking history (current and past) and exposure to secondhand smoke or other environmental irritants (dust, fumes).
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Perform a focused physical exam, including:
Ear, Nose, and Throat (ENT) exam: Look for signs of nasal congestion, sinusitis, or postnasal drip.
Chest exam: Listen for wheezing, crackles, or other abnormal lung sounds.
Cardiovascular exam: Evaluate for signs of heart disease that may cause cough (less common).
Assessment (A):
Differential Diagnosis:
Based on the history, physical exam, and any additional testing, consider a differential diagnosis for the chronic cough, including:
Upper airway cough syndrome (postnasal drip, rhinitis)
Asthma
COPD
GERD (gastroesophageal reflux disease)
Medications (e.g., ACE inhibitors)
Smoking-related cough
Diagnostic Testing (if indicated):
Order additional tests based on the suspected cause, such as:
Chest X-ray
Spirometry (lung function tests)
Allergy testing (if allergic rhinitis suspected)
Bronchoscopy (visualizing the airways – less common)
Empiric treatment trial (e.g., proton pump inhibitors for GERD)
Plan (P):
Treatment Plan:
Develop a treatment plan based on the identified cause of the cough. Options may include:
Medications:
Inhalers (bronchodilators, steroids) for asthma or COPD.
Antihistamines or nasal corticosteroids for allergic rhinitis.
Proton pump inhibitors for GERD.
Non-pharmacologic therapy:
Smoking cessation counseling.
Airway hygiene measures (humidifier, saline nasal irrigation).
Referral to an ENT specialist, pulmonologist, or allergist for further evaluation and management (if indicated).
Follow-up:
Schedule follow-up visits to assess treatment response, symptom improvement, and adjust the plan as needed.
Define the frequency of follow-up based on the severity of symptoms and response to treatment.
Patient Education:
Educate the patient about the likely cause of their chronic cough and the rationale for the treatment plan.
Provide information on how to use medications or devices properly.
Discuss potential side effects of medications and the importance of reporting any concerns.
Offer resources for smoking cessation programs (if applicable).