What is the best course of treatment for a 29-year-old female with a persistent, dry cough lasting one month, worsening at night and triggered by outdoor air, with a history of allergies to pollen and a family history of asthma, currently taking Claritin (loratadine) and birth control pills?

SOAP Note: 29-Year-Old Female with Persistent Dry Cough

SUBJECTIVE

Chief Complaint: "I have cough that will not go away"

History of Present Illness:

• 29-year-old Caucasian female with sudden onset persistent dry cough × 1 month
• Cough characteristics: dry, irritating, non-productive
• Triggers: worsens at night, triggered by outdoor air exposure
• Associated symptoms: occasional wheezing, catches breath during coughing episodes, chest tightness during attacks, hoarseness
• Severity: caused vomiting × 2 episodes during intense coughing
• Sleep disruption: wakes at night with inadequate sleep, increased daytime fatigue
• Failed treatment: Robitussin every 6 hours with no relief
• Denies: chest pain, dyspnea, fever, chills, recent URI, shortness of breath with activity

Past Medical History:

• No history of asthma or pulmonary disease
• Last visit: routine check-up 2 years ago (advised weight loss)
• Recent negative TB workup
• LMP: 2 weeks ago
• Allergies: Pollen
• Current medications: Claritin (loratadine), birth control pills

Family History:

• Father: asthma, smoker
• Mother: smoker
• Grandfather: asthma

Social History:

• Works in office building
• Non-smoker, no vaping
• Occasional alcohol (1 glass champagne)

OBJECTIVE

Vital Signs:

• T: 98.5°F, P: 70, R: 16, BP: 124/85
• Ht: 5'2", Wt: 168 lbs, BMI: 30.7 (obese)

Physical Examination:

• General: Well-appearing, cooperative, no acute distress
• HEENT: PERRLA, clear nasal discharge, pink nasal mucosa, no pharyngeal edema, tonsils 2+ without exudates
• Neck: Supple, trachea midline, thyroid normal
• Respiratory: Diffuse expiratory wheezes throughout chest, no crackles, symmetrical chest, resonant to percussion, no accessory muscle use
• Cardiovascular: Regular rate and rhythm, no murmurs or gallops

ASSESSMENT

Primary Diagnosis: Cough-Variant Asthma (Undiagnosed)

This patient presents with classic features of cough-variant asthma rather than simple post-infectious or unexplained chronic cough. The presence of diffuse expiratory wheezes on examination, nocturnal cough predominance, triggers from outdoor air exposure, occasional wheezing with breathlessness, strong family history of asthma (father and grandfather), and pollen allergy all point definitively toward asthma as the underlying cause 1.

Key Clinical Reasoning:

• The American College of Chest Physicians guidelines establish that asthma is one of the three most common causes of chronic cough (>8 weeks), accounting for 24-32% of cases 1, 2
• Physical examination findings of diffuse expiratory wheezes are pathognomonic for bronchial obstruction and strongly support asthma diagnosis 1
• Nocturnal cough worsening is a hallmark feature of asthma due to circadian variation in airway caliber 1
• The failure of simple antitussive therapy (Robitussin/dextromethorphan) indicates this is not simple post-infectious cough but rather requires disease-specific treatment 1

Differential Considerations (Less Likely):

• Upper Airway Cough Syndrome (UACS): While she has pollen allergy and takes Claritin, the presence of wheezing and lack of significant postnasal drainage symptoms makes this secondary 1
• GERD: No gastrointestinal symptoms reported, though "silent GERD" can occur 1
• Post-infectious cough: No preceding URI symptoms reported; duration of 1 month without infectious prodrome makes this unlikely 2

PLAN

Immediate Treatment (Disease-Specific for Asthma)

1. Initiate Inhaled Corticosteroid + Bronchodilator Therapy

• Prescribe: Fluticasone/Salmeterol (Advair) 250/50 mcg, 1 inhalation twice daily 1, 3
  • Inhaled corticosteroids are first-line treatment for asthmatic cough 1
  • Complete resolution may require up to 8 weeks of treatment 1
  • The majority of patients with asthma will respond with at least partial improvement within 1 week 1

2. Add Short-Acting Beta-Agonist for Rescue

• Prescribe: Albuterol MDI 90 mcg, 2 puffs every 4-6 hours as needed for acute symptoms 4
  • For immediate bronchodilation during coughing episodes 4

3. Continue Current Allergy Management

• Continue Claritin (loratadine) for pollen allergy 1
• Consider adding intranasal corticosteroid if upper airway symptoms develop 2, 4

Diagnostic Confirmation (If Available)

4. Consider Bronchoprovocation Challenge Testing

• If available and patient fails to respond to initial therapy, methacholine challenge has negative predictive value close to 100% and positive predictive value of 60-88% 1
• However, given clear clinical presentation with wheezing on exam, empiric treatment is appropriate 1

Escalation Strategy if Initial Treatment Inadequate

5. If Partial Response After 1-2 Weeks:

• Add leukotriene receptor antagonist (montelukast 10 mg daily) before escalating to oral corticosteroids 1, 4

6. If No Response After 2-4 Weeks:

• Consider short course of oral prednisone 40 mg daily × 5-10 days 1
• This provides definitive diagnostic and therapeutic confirmation 1
• Complete resolution of asthmatic cough may require up to 8 weeks of inhaled therapy 1

Address Contributing Factors

7. Environmental Trigger Avoidance

• Counsel on avoiding outdoor air triggers during high pollen seasons 1
• Consider air purifier for bedroom to improve nocturnal symptoms 1

8. Weight Management Counseling

• BMI 30.7 indicates obesity, which can worsen asthma control 1
• Refer to nutritionist for weight loss program as previously recommended 1

Follow-Up and Monitoring

9. Schedule Follow-Up in 2 Weeks

• Assess response to therapy (expect at least partial improvement within 1 week) 1
• Evaluate inhaler technique 1
• Monitor for side effects 1

10. If Cough Persists Beyond 8 Weeks Despite Optimal Asthma Treatment:

• Systematically evaluate for GERD with high-dose PPI trial (omeprazole 40 mg twice daily × 3 months) 1, 2
• Consider UACS with first-generation antihistamine-decongestant combination 1, 2
• Chronic cough is frequently multifactorial; continue effective therapies while adding next intervention rather than stopping and switching 2

11. Red Flags Requiring Urgent Re-evaluation:

• Development of fever, hemoptysis, significant dyspnea, or chest pain 5, 2
• Worsening wheezing or inability to speak in full sentences 4

Critical Pitfalls to Avoid

• Do not treat this as simple post-infectious or unexplained chronic cough when objective wheezing is present on examination 1
• Do not prescribe antibiotics—there is no evidence of bacterial infection 2, 4
• Do not rely solely on antitussive agents (dextromethorphan, codeine) for asthmatic cough—these suppress symptoms without treating underlying disease 1, 5
• Do not discontinue therapy prematurely—complete resolution may take up to 8 weeks 1
• Do not fail to consider multiple contributing causes if partial response occurs 2

Patient Education

12. Counseling Points:

• Explain that cough is likely due to undiagnosed asthma based on wheezing, family history, and clinical pattern 1
• Emphasize importance of daily controller medication (not just rescue inhaler) 1
• Teach proper inhaler technique with spacer if needed 1
• Set realistic expectations: improvement within 1 week, but complete resolution may take 6-8 weeks 1
• Instruct to return immediately if breathing difficulty worsens 4