What are the next steps for a 38-year-old male with hyperlipidemia and hypertension, who presents with sore throat, anterior chest pain, shortness of breath, and productive cough, and has a history of childhood rib fracture, with lab results showing elevated white blood cell count (leukocytosis), depressed lymphocytes and monocytes, and a normal electrocardiogram (ECG) and chest X-ray (CXR) with an old rib fracture, after incomplete resolution of symptoms with N-Acetylcysteine (NAC) treatment?

Diagnosis and Management of Persistent Respiratory Symptoms with Chest Wall Findings

Most Likely Diagnosis

This patient most likely has musculoskeletal chest wall pain (costochondritis or intercostal muscle strain) with an upper respiratory tract infection that is resolving. The key diagnostic features are: reproducible chest wall tenderness on palpation (low-pitch squeaking noise on late inspiration suggests pleural friction or chest wall movement), normal vital signs, normal chest X-ray, and pain characteristics that vary with respiration—all of which strongly argue against cardiac ischemia 1, 2.

Critical Differential Considerations

What the CBC Tells Us

• Neutrophilia (72.7%) with relative lymphopenia (19.7%) suggests a bacterial infection or stress response, though the patient reports no fever 1
• Monocytopenia (4.2%) is nonspecific but can occur with acute infections or stress states
• The absence of fever with these findings makes active bacterial pneumonia less likely, especially given the normal chest X-ray 1

Cardiac Risk Assessment

Cardiac ischemia is highly unlikely based on multiple protective factors 1:

• Pain affected by breathing and body position
• Pain reproducible with palpation (the "low pitch squeaking noise" on chest wall examination)
• Normal ECG (per patient report)
• Age 38 with only hyperlipidemia and hypertension as risk factors
• Pain characteristics inconsistent with acute coronary syndrome

Immediate Next Steps

1. Complete the Physical Examination

Perform targeted chest wall palpation to identify the exact source of pain 2:

• Palpate each rib, particularly the 5th left anterolateral rib (site of old fracture) and adjacent ribs
• Assess for costochondral junction tenderness (costochondritis)
• Evaluate for intercostal muscle tenderness
• Check for reproducibility of the "squeaking" sound with chest wall pressure

2. Obtain Dedicated Rib Imaging

Order a dedicated rib series radiograph with a radio-opaque skin marker placed at the site of maximal tenderness 2:

• Standard chest X-rays miss up to 50% of rib fractures 2
• Cough-induced rib fractures occur in 82.4% of patients with post-tussive chest pain, most commonly affecting the 10th rib 2
• This patient has chronic cough with productive sputum—a setup for stress fracture

3. Rule Out Ongoing Infection

Obtain a repeat CBC with differential and consider sputum culture if productive cough persists 1:

• The neutrophilia without fever is concerning but may represent resolving infection
• If sputum production continues despite N-acetylcysteine, consider bacterial superinfection requiring antibiotics 1

Treatment Algorithm

For Chest Wall Pain (Primary Treatment)

Initiate regular acetaminophen as first-line analgesia 2:

• Acetaminophen 650-1000 mg every 6-8 hours scheduled (not as-needed)
• If inadequate, add NSAIDs (ibuprofen 400-600 mg every 8 hours) as second-line, monitoring for GI and cardiovascular effects given his hypertension 2

Apply non-pharmacological measures 2:

• Ice packs to chest wall for first 48 hours
• Avoid activities that reproduce pain
• Gentle breathing exercises to prevent splinting

For Respiratory Symptoms

Continue N-acetylcysteine but monitor for adverse effects 3, 4:

• The FDA label warns that increased liquified secretions may require mechanical clearance if cough is inadequate 3
• Watch for bronchospasm, particularly given the chest findings—discontinue immediately if wheezing develops 3
• Adverse reactions occur frequently with both oral and IV formulations, including nausea and bronchospasm 4

Consider adding a first-generation antihistamine-decongestant if upper airway symptoms persist 1:

• The ACCP guidelines recommend starting with antihistamine-decongestant therapy for chronic cough when chest X-ray is normal 1
• Expect improvement within 1-2 weeks if upper airway cough syndrome is contributing 1

For Cardiovascular Risk Modification

Optimize his existing medications 1:

• Ensure he is on a statin targeting LDL <100 mg/dL (or <70 mg/dL given hypertension and hyperlipidemia) 1
• Verify blood pressure control <140/90 mmHg 1
• Beta-blockers are not contraindicated and are effective antihypertensives 1

Follow-Up Plan

Schedule reassessment in 1 week 2:

• If rib fracture confirmed: pain typically improves within 6-8 weeks but may take up to 2 years for complete resolution 2
• If symptoms worsen or new symptoms develop (fever, hemoptysis, severe dyspnea): return immediately
• If no improvement after 2 weeks of treatment: consider point-of-care ultrasound for occult rib fracture or CT chest if malignancy concern arises 2

Critical Pitfalls to Avoid

1. Do not assume the old rib fracture is irrelevant—the same mechanism (trauma or stress) may have caused a new fracture 2
2. Do not rely solely on the initial chest X-ray—dedicated rib views are essential when clinical suspicion is high 2
3. Do not continue N-acetylcysteine indefinitely without reassessment—it is indicated for COPD exacerbation prevention in moderate-severe disease, not for simple acute bronchitis 1
4. Do not dismiss the neutrophilia—if fever develops or symptoms worsen, bacterial pneumonia must be reconsidered despite the normal chest X-ray 1