What is the appropriate next step in evaluating and managing a patient who had severe cough and dyspnea two weeks ago treated with triamcinolone and a methylprednisolone (Medrol) dose pack and now presents with severe right‑shoulder and right‑anterior chest‑wall pain after a chest‑wall X‑ray?

Evaluation and Management of Post-Cough Chest Wall Pain Following Corticosteroid Treatment

Immediate Next Step

The appropriate next step is to obtain a chest CT scan without contrast to evaluate for cough-induced rib fractures, which are frequently missed on plain radiography and are a common complication of severe coughing episodes. 1

Clinical Context and Rationale

The patient's presentation is highly suggestive of cough-induced rib fractures, a well-recognized complication of severe coughing episodes that can be easily missed on standard chest radiography:

• Chest radiography has poor sensitivity for detecting rib fractures in nontraumatic settings, identifying fractures in only 4.9% of cases in one series of 183 stable outpatients with nontraumatic chest pain 1
• The ACR Appropriateness Criteria specifically state that chest radiographs are insensitive for detecting abnormalities of the rib cartilages, costochondral junctions, and chest wall soft tissues 1
• CT chest is superior for detection and characterization of chest wall abnormalities, though it should be reserved for patients requiring evaluation when clinical suspicion is high 1

Diagnostic Algorithm

Primary Imaging Recommendation

• CT chest without IV contrast is the most appropriate next imaging study for this clinical scenario 1
• Unfolded rib reformatted images should be incorporated to improve diagnostic accuracy and decrease reading time for rib fractures 1
• CT may also identify alternative diagnoses such as mediastinal fat necrosis, which can present with chest wall pain 1

What to Look For on CT

• Rib fractures (particularly anterior and lateral ribs from forceful coughing) 1
• Costochondral separation or widening of rib spaces 1
• Chest wall soft tissue abnormalities including hematomas or muscle tears 2
• Pleural complications such as pneumothorax or effusion 3

Critical Clinical Considerations

Corticosteroid Complications

The recent use of triamcinolone and methylprednisolone (Medrol dose pack) raises important considerations:

• While these medications are appropriate for treating severe cough and dyspnea related to reactive airways disease 1, they do not prevent mechanical complications from forceful coughing
• The corticosteroids may have masked inflammatory pain initially, with pain becoming more apparent as the medication effect wanes 4, 5

Pain Management Strategy

If rib fractures are confirmed:

• Multimodal analgesia is essential to prevent respiratory complications from pain-related splinting 1
• Adequate pain control prevents atelectasis, secretion accumulation, and potential respiratory failure 1
• Consider regional anesthesia techniques for severe pain that limits respiratory function 1

Common Pitfalls to Avoid

• Do not rely solely on chest radiography to exclude rib fractures in patients with severe chest wall pain following coughing episodes 1
• Do not attribute pain to musculoskeletal strain without imaging confirmation, as this can delay diagnosis of significant fractures 1
• Do not assume corticosteroid treatment has resolved all pathology—mechanical complications from coughing can occur despite appropriate medical management 1

Alternative Diagnoses to Consider

If CT is negative for fractures, consider:

• Costochondritis (though typically bilateral and less severe) 1
• Intercostal muscle strain or tear (visible on CT or ultrasound) 2
• Pleural pathology including pleuritis or small effusion 3
• Mediastinal fat necrosis (characteristic CT appearance) 1

Follow-up Considerations

• If significant rib fractures are identified, assess for flail chest or multiple displaced fractures that might benefit from surgical stabilization (SSRF) in severe cases 1
• Monitor for pulmonary complications including pneumonia, which can develop from pain-related hypoventilation 1
• Ensure adequate pulmonary hygiene and chest physiotherapy to prevent atelectasis 1