What should be included in the SOAP note for a patient with post-viral cough and mild wheeze?

SOAP Note Documentation for Post-Viral Cough with Mild Wheeze

For a patient presenting with post-viral cough and mild wheeze, document the clinical presentation systematically, assess for red flags requiring further workup, and outline a stepwise treatment approach prioritizing inhaled ipratropium as first-line therapy.

Subjective Section

Document the following specific elements:

• Duration of cough: Specify if <3 weeks (acute), 3-8 weeks (subacute/post-infectious), or >8 weeks (chronic, requiring reclassification) 1, 2
• Preceding viral illness: Note recent upper respiratory infection symptoms (nasal congestion, sore throat, fever) 3, 1
• Cough characteristics: Frequency, productivity, presence of paroxysms, post-tussive vomiting, or inspiratory whooping (suggests pertussis) 1, 2
• Associated symptoms: Wheeze, breathlessness, chest tightness, fever, fatigue 4, 3
• Red flag symptoms: Hemoptysis, significant weight loss, voice changes, prolonged fever, night sweats 4, 3, 1
• Medication history: Specifically document ACE inhibitor use (common cause of persistent cough) 1
• Smoking history: Current or past use with quantification 1
• Impact on quality of life: Sleep disruption, work/school absence, severity of distress 2

Objective Section

Include these specific findings:

• Vital signs: Temperature, respiratory rate (tachypnea >30/min suggests pneumonia), heart rate, oxygen saturation 4
• Lung examination: Document presence/absence of wheeze, crackles, diminished breath sounds, or normal findings 4
• General appearance: Signs of respiratory distress, use of accessory muscles 4
• Additional findings: Presence of nasal discharge, pharyngeal erythema if relevant 3

Do not routinely order chest radiography unless vital signs are abnormal or clinical examination suggests pneumonia 4. Do not routinely measure procalcitonin 4. Consider C-reactive protein only if pneumonia is suspected (CRP >30 mg/L increases likelihood; <10 mg/L makes it unlikely) 4.

Assessment Section

Structure your assessment as follows:

• Primary diagnosis: Post-viral cough with mild wheeze (if cough duration 3-8 weeks following viral illness) 1, 2
• Differential considerations documented:
  • Upper airway cough syndrome (33.2% of post-infectious cough cases) 1
  • Cough-variant asthma (15.8% of cases) 1
  • Pertussis if cough ≥2 weeks with paroxysms 1, 2
  • Postviral airway inflammation (48.4% of cases) 1
• Severity assessment: Mild (normal vital signs, minimal impact) vs. severe (quality of life significantly affected) 2
• Red flags: Present or absent 3, 1

Plan Section

First-Line Treatment (Document Specific Orders)

• Inhaled ipratropium bromide: Prescribe as first-line therapy (has demonstrated efficacy in controlled trials for post-infectious cough) 3, 2
• Honey: Recommend for patients >1 year old (avoid in infants <1 year due to botulism risk) 3
• Hydration: Advise adequate fluid intake (no more than 2 liters daily) 3
• Positioning: Avoid lying flat on back 3
• Symptomatic relief: Dextromethorphan-containing remedies, menthol lozenges 3

Second-Line Treatment (If First-Line Fails)

• Inhaled corticosteroids: Consider when cough adversely affects quality of life or persists despite ipratropium 3, 2
• Oral prednisone 30-40 mg daily: For severe paroxysms, short finite period only, after ruling out upper airway cough syndrome, asthma, or GERD 3, 2

For Wheeze Component

• Bronchodilator therapy: Short-acting beta-agonist (salbutamol/albuterol) as needed for wheeze 5
• Reassess for asthma: If wheeze persists or recurs, consider trial of inhaled corticosteroids for possible cough-variant asthma 4, 1

What NOT to Do (Document Explicitly)

• No antibiotics: Unless confirmed bacterial infection (post-viral cough is not bacterial) 3, 2
• No routine antipyretics: Do not use solely to reduce temperature 3

Follow-Up Plan

• Routine follow-up in 4-6 weeks 1, 2
• Reclassify as chronic cough if persists >8 weeks: Requires full chronic cough workup at that point 1, 2
• Return precautions: Hemoptysis, worsening breathlessness, high fever, symptoms beyond 3 weeks 3

Patient Education (Document Counseling)

• Expected duration: Post-viral cough typically resolves within 3-8 weeks 1, 2
• Natural history: 10% of viral coughs last >20-25 days 4
• When to seek urgent care: Red flag symptoms 3

Common Documentation Pitfalls to Avoid

• Failing to specify cough duration precisely: This determines classification (acute vs. subacute vs. chronic) and management approach 1, 2
• Not documenting ACE inhibitor review: A frequently missed reversible cause 1
• Prescribing antibiotics without bacterial confirmation: Contributes to antimicrobial resistance 3, 2
• Missing pertussis consideration: Often underdiagnosed in adults with prolonged cough 1, 2