What is the best course of action for a 65-year-old female patient with a lingering dry cough and complaints of rib pain, taking Tessalon (benzatropine), with clear lungs and no signs of swelling, deformity, or bruising on the chest or rib cage?

Management of Post-Tussive Rib Pain in a 65-Year-Old Female

Direct Recommendation

Continue Tessalon (benzonatate) for symptomatic cough relief, add scheduled NSAIDs (naproxen 220-440 mg twice daily) for rib pain, and reassess in 48-72 hours—if cough persists beyond 3 weeks total or pain worsens, obtain chest X-ray to exclude occult rib fracture or other pathology. 1, 2

Understanding the Clinical Picture

This presentation is classic for musculoskeletal chest wall pain secondary to repetitive coughing, not pleuropulmonary disease. 3 The key diagnostic features supporting this are:

• Clear lung fields on auscultation rule out pneumonia, pleural effusion, or significant parenchymal disease 2
• Absence of swelling, deformity, or bruising makes acute traumatic fracture less likely but does not exclude post-tussive rib fracture 1
• Lingering dry cough indicates the inciting mechanical stress continues 1

The pain pattern—sharp and exacerbated by coughing—represents irritation of intercostal muscles, costochondral junctions, or potentially occult rib fractures from repetitive cough stress. 3, 1

Optimizing Current Cough Management

Benzonatate (Tessalon) Assessment

Continue benzonatate as prescribed (typically 100-200 mg three times daily) since it works peripherally by anesthetizing stretch receptors in respiratory passages, reducing the cough reflex at its source with onset in 15-20 minutes and duration of 3-8 hours. 4

Critical duration consideration: If this cough has already lasted 2+ weeks and continues beyond 3 weeks total, benzonatate should be discontinued and diagnostic workup initiated rather than prolonged antitussive therapy. 5 Acute cough lasting >3 weeks requires evaluation for post-viral cough, pertussis, pneumonia, or chronic conditions rather than continued symptomatic suppression. 3, 5

Augmenting Cough Suppression

If benzonatate alone provides insufficient relief:

• Add dextromethorphan 60 mg (not the subtherapeutic 15-30 mg OTC doses) for maximum cough reflex suppression, ensuring sugar-free formulation 1, 5
• Menthol inhalation (menthol crystals or proprietary capsules) provides acute short-lived relief for breakthrough symptoms 1, 5
• Simple home remedies like honey and lemon mixtures are effective for benign viral cough and should be recommended 1, 2

Avoid codeine or pholcodine—they have no greater efficacy than dextromethorphan but significantly more adverse effects (drowsiness, nausea, constipation, dependence). 1, 5

Managing the Rib Pain

First-Line Analgesic Strategy

Scheduled NSAIDs are the cornerstone of rib pain management, not PRN dosing:

• Naproxen 220-440 mg twice daily with food provides superior anti-inflammatory effect for musculoskeletal chest wall pain 2
• Continue for 7-10 days even if pain improves to prevent recurrence with ongoing cough 2
• Screen for contraindications: active GI bleeding, severe renal impairment, aspirin allergy 2

Acetaminophen 650-1000 mg every 6 hours can be added for breakthrough pain or if NSAIDs are contraindicated, though it lacks anti-inflammatory properties. 2

When to Image

Obtain chest X-ray with dedicated rib views if:

• Pain persists or worsens despite 5-7 days of appropriate analgesia 1
• Any new symptoms develop (fever, dyspnea, hemoptysis) 3, 2
• Cough extends beyond 3 weeks total duration 3, 5
• Patient is >60 years old with risk factors (osteoporosis, chronic steroid use, smoking) 1

Post-tussive rib fractures occur in up to 82% of patients presenting with chest pain after severe coughing, most commonly involving ribs 8-10. 1 Standard chest X-rays miss many rib fractures; dedicated rib views with radio-opaque skin markers at the pain site improve detection. 1

Critical Red Flags Requiring Urgent Evaluation

Immediately escalate care if any of these develop:

• Hemoptysis (any amount) 3, 2
• Fever >72 hours or new fever 3, 2
• Worsening dyspnea or hypoxemia (oxygen saturation <90%) 3, 2
• Unilateral leg swelling (concern for DVT/PE, especially in older female) 1
• Weight loss or night sweats (TB, malignancy) 3, 2

Reassessment Timeline

48-72 hour follow-up (phone or in-person) to ensure:

• Cough frequency is decreasing 2
• Rib pain is improving with NSAIDs 2
• No red flags have emerged 3, 2

If cough persists at 3 weeks total: Discontinue benzonatate, obtain chest X-ray, and evaluate for post-viral cough, pertussis (increasingly common in adults with waning vaccine immunity), atypical pneumonia, or chronic conditions (asthma, GERD, upper airway cough syndrome). 3, 5, 6

Common Pitfalls to Avoid

• Don't dismiss chest pain as "just muscular" without excluding pneumonia or rib fracture, especially in patients >60 years 1, 3
• Don't continue benzonatate indefinitely—it's for short-term symptomatic relief only, not a substitute for diagnosis when cough becomes chronic 5
• Don't prescribe PRN NSAIDs for rib pain—scheduled dosing provides superior anti-inflammatory effect for musculoskeletal injury 2
• Don't overlook pertussis in adults—it presents as persistent cough and adults are increasingly recognized as reservoirs 3
• Don't use first-generation sedating antihistamines unless specifically for nocturnal cough, as they cause significant drowsiness 5

Non-Pharmacologic Adjuncts

• Cough suppression techniques: Voluntary cough suppression and central modulation can reduce cough frequency through simple behavioral modification 1, 5
• Adequate hydration to thin secretions 2
• Humidified air to reduce airway irritation 5
• Avoid irritant exposures (smoke, strong odors, cold air) 5