What is a sample SOAP note for a patient with a persistent cough and hypertension on ACE inhibitor therapy, such as lisinopril (angiotensin-converting enzyme inhibitor)?

Sample SOAP Note: Persistent Cough in Hypertensive Patient on Lisinopril

SUBJECTIVE

Chief Complaint: "I've had this dry cough for the past 3 weeks that won't go away."

History of Present Illness:

• 58-year-old female presents with persistent dry cough × 3 weeks 1
• Describes tickling/scratching sensation in throat 2
• Cough is non-productive, worse at night, interfering with sleep 3
• No fever, chest pain, shortness of breath, or weight loss 1
• Denies recent upper respiratory infection, postnasal drip, or heartburn 1
• Started lisinopril 10 mg daily approximately 6 weeks ago for newly diagnosed hypertension 1

Past Medical History:

• Hypertension (diagnosed 2 months ago)
• No history of asthma, COPD, or heart failure 1

Medications:

• Lisinopril 10 mg PO daily 4

Social History:

• Non-smoker 1
• No occupational exposures 1

Review of Systems:

• No orthopnea, paroxysmal nocturnal dyspnea, or lower extremity edema 4
• Denies gastroesophageal reflux symptoms 1

OBJECTIVE

Vital Signs:

• BP: 128/82 mmHg (sitting)
• HR: 72 bpm
• RR: 16/min
• Temp: 98.4°F
• O2 Sat: 98% on room air

Physical Examination:

• General: Well-appearing, no acute distress
• HEENT: Oropharynx clear, no postnasal drip 1
• Neck: No jugular venous distention 4
• Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi 4
• Cardiovascular: Regular rate and rhythm, no S3 gallop, no murmurs 4
• Extremities: No edema 4

Diagnostic Studies:

• Chest X-ray (if obtained): Normal, no infiltrates or masses 1

ASSESSMENT

Primary Diagnosis: ACE inhibitor-induced cough 1, 2

Rationale:

• Temporal relationship between lisinopril initiation (6 weeks ago) and cough onset (3 weeks ago) strongly suggests ACE inhibitor-induced cough, which can develop within hours to months after starting therapy 2
• Classic presentation: dry, non-productive cough with throat tickling, worse at night 2, 3
• Female gender and non-smoking status are established risk factors (females have 37.9% incidence vs. 15.5% in males) 5
• Physical examination and history exclude other common causes of chronic cough (upper airway cough syndrome, asthma, GERD) 1
• Per ACCP guidelines, ACE inhibitor should be discontinued regardless of temporal relationship, as the original cause of cough may have resolved and persisting cough could be due to the drug 1

Secondary Diagnosis: Essential hypertension, currently controlled 4

PLAN

1. ACE Inhibitor-Induced Cough Management

Immediate Action:

• Discontinue lisinopril immediately, as this is the only uniformly effective treatment (ACCP Grade B recommendation) 1, 2
• Switch to valsartan 80 mg PO daily (ACC/AHA Class I, Level A recommendation for patients intolerant to ACE inhibitors due to cough) 2, 6
• Counsel patient that cough typically resolves within 1-4 weeks after ACE inhibitor cessation, though may take up to 3 months in some patients 1, 2

Critical Pitfalls to Avoid:

• Do not attempt dose reduction of lisinopril—cough is not dose-dependent and will persist at any dosage 2
• Do not switch to alternative ACE inhibitor—cough is a class effect and will recur with any ACE inhibitor 2
• Allow at least 36 hours between last lisinopril dose and starting valsartan to minimize risk of adverse effects 2

2. Hypertension Management

Medication Changes:

• Start valsartan 80 mg PO daily (provides comparable antihypertensive efficacy to lisinopril with significantly lower cough incidence: 19.5% vs. 68.9%) 6, 7
• Target blood pressure: <130/80 mmHg

Monitoring:

• Check blood pressure, renal function (serum creatinine), and potassium levels within 1-2 weeks after starting valsartan 2
• Monitor for cough resolution at 2-week follow-up 2

3. Patient Education

• Explain that ACE inhibitor-induced cough occurs in 5-35% of patients and is a well-documented class effect 2
• Reassure that switching to ARB (valsartan) maintains cardiovascular protection with significantly lower cough risk 1, 6
• Advise to report any persistent cough beyond 4 weeks, as this may indicate alternative etiology requiring further evaluation 1
• Instruct to avoid taking any ACE inhibitor in the future 1

4. Follow-Up

• Return to clinic in 2 weeks to:
  • Assess cough resolution 2
  • Check blood pressure control 2
  • Review laboratory results (renal function, potassium) 2
• If cough persists beyond 4 weeks on valsartan, consider alternative diagnoses (UACS, asthma, GERD) and proceed with systematic evaluation per chronic cough algorithm 1

5. Prescriptions

• Valsartan 80 mg PO daily #30, refills × 3
• Discontinue lisinopril

6. Orders

• Basic metabolic panel (BMP) in 1-2 weeks 2