Management of Persistent Chest Pain and Cough in a 26-Year-Old Female After ER Visit
The next step is to determine whether this represents post-infectious cough with musculoskeletal pain (most likely costochondritis from persistent coughing) versus an undiagnosed serious condition that was missed in the ER, requiring focused physical examination for chest wall tenderness and consideration of cardiac troponin if not already obtained. 1, 2
Immediate Risk Stratification
Life-Threatening Conditions to Exclude First
Even though she already visited the ER, you must verify that the following were adequately ruled out:
- Acute coronary syndrome (ACS): While uncommon at age 26, it can occur even in young patients without traditional risk factors 2. The American College of Cardiology emphasizes that young age does not exclude ACS 2.
- Pulmonary embolism: Particularly if she has risk factors such as oral contraceptive use, recent immobilization, or family history of thrombosis 1
- Pneumonia or pleural complications: Persistent symptoms after ER visit may indicate evolving pneumonia or pleural effusion 1
Critical Questions About the ER Visit
Determine what was done during the initial ER evaluation:
- Was a 12-lead ECG obtained? 1, 2
- Was cardiac troponin measured? 1, 2
- Was a chest X-ray performed? 1
- What was the working diagnosis at discharge? 1
Most Likely Diagnosis: Post-Infectious Syndrome
Subacute Cough Classification
Since symptoms persist beyond the acute phase but likely less than 8 weeks, this represents subacute cough (defined as 3-8 weeks duration) 1. The CHEST guidelines recommend first determining whether this is post-infectious versus another cause 1.
Post-infectious cough is the most common cause of subacute cough, often accompanied by:
- Transient bronchial hyperresponsiveness 1
- Upper airway cough syndrome (UACS) 1
- Musculoskeletal chest pain from persistent coughing 3
Costochondritis as Primary Pain Source
Costochondritis is highly likely given the history of persistent cough 3. The American College of Cardiology notes this can be diagnosed through:
- Pain on palpation of costochondral joints 3
- Pain that worsens with movement or deep breathing 3
- Retrosternal or parasternal chest wall tenderness 3
Focused Physical Examination
Perform a targeted examination looking for:
- Chest wall tenderness: Palpate costochondral junctions, sternum, and intercostal spaces for reproducible pain 3
- Respiratory examination: Listen for wheezing (suggests bronchial hyperresponsiveness), crackles (suggests pneumonia), or decreased breath sounds (suggests effusion) 1
- Cardiac examination: Assess for tachycardia, new murmurs, or signs of heart failure (extremely unlikely at this age but must be excluded) 1
- Vital signs: Fever >38.5°C, tachypnea, or hypoxia would indicate ongoing infection requiring further workup 1
Diagnostic Testing Strategy
If ER Workup Was Incomplete
If cardiac evaluation was not performed in the ER:
- Obtain 12-lead ECG now 1, 2
- Measure high-sensitivity cardiac troponin 1, 2
- This is critical even in young patients, as the American Heart Association emphasizes that women are at risk for underdiagnosis of ACS 2
If ER Workup Was Complete and Normal
If ECG, troponin, and chest X-ray were normal in the ER:
- No additional cardiac testing is needed unless new concerning features develop 1
- Chest X-ray does not need to be repeated unless symptoms worsen or fever develops 1
Additional Testing to Consider
- Spirometry: Only if wheezing is present or asthma is suspected 1
- Cough severity assessment: Use validated tools to track improvement 1
Treatment Approach
For Post-Infectious Cough
Symptomatic treatment for bothersome dry cough:
- Dextromethorphan or codeine can be prescribed 1
- The European Respiratory Journal guidelines specifically recommend against expectorants, mucolytics, antihistamines, or bronchodilators for acute lower respiratory tract infections 1
For Costochondritis
If chest wall tenderness is present:
- NSAIDs (ibuprofen 400-600mg three times daily or naproxen 500mg twice daily) for 7-10 days 3
- Reassurance that this is a benign, self-limited condition 3
- Avoid activities that worsen pain 3
For Possible GERD Component
If there is any suggestion of reflux symptoms:
- Trial of high-dose proton pump inhibitor (omeprazole 40mg or equivalent) for 1-2 weeks 3
- GERD can coexist with costochondritis and contribute to chronic cough 3
Follow-Up and Red Flags
Mandatory Follow-Up
The CHEST guidelines recommend routine follow-up in 4-6 weeks to reassess cough severity and quality of life 1. Schedule this visit to ensure symptoms are resolving.
Red Flags Requiring Immediate Re-Evaluation
Return to the ER or seek urgent evaluation if any of the following develop:
- Hemoptysis 1
- Prominent dyspnea, especially at rest or at night 1
- Fever lasting >4 days 1
- Systemic symptoms (weight loss, night sweats) 1
- Worsening chest pain with exertion 1, 2
- Syncope or near-syncope 1
- New peripheral edema 1
Common Pitfalls to Avoid
- Do not assume nitroglycerin response indicates cardiac origin: Esophageal spasm can also respond to nitroglycerin 2, 4, 3
- Do not use "atypical" to describe chest pain: The American College of Cardiology recommends describing pain as cardiac, possibly cardiac, or noncardiac instead 1
- Do not dismiss symptoms based solely on young age: ACS can occur in young adults without risk factors 2
- Do not prescribe antibiotics for post-infectious cough: Unless there is evidence of bacterial pneumonia (fever >4 days, new infiltrate, purulent sputum), antibiotics are not indicated 1
Summary Algorithm
- Verify ER workup included ECG, troponin, and chest X-ray - if not, obtain now 1, 2
- Perform focused physical examination for chest wall tenderness 3
- If chest wall tenderness present: Diagnose costochondritis, treat with NSAIDs 3
- If dry cough is bothersome: Prescribe dextromethorphan or codeine 1
- Consider PPI trial if any reflux symptoms 3
- Schedule 4-6 week follow-up to reassess 1
- Provide clear return precautions for red flag symptoms 1