Cough-Induced Rib Fractures in a Frequent Tea Drinker

Bruce M. Rothschild, MD


August 11, 2020

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 60-year-old White woman presented for an annual medical examination. Her past medical history included asthma and several episodes of cough-induced rib fractures over the past 10 years. She was nulligravid and postmenopausal with cessation of menses in her early 50s. The patient reiterated that she was a frequent tea drinker, consuming five or six cups of caffeinated tea each day.

Her family history included a mother and sister who died of breast cancer (at age 51 years and 45 years, respectively). Her father had surgically resolved hyperparathyroidism. A review of systems revealed food-induced indigestion, for which she took omeprazole supplemented with aluminum hydroxide and magnesium hydroxide. She did not report any significant back or musculoskeletal pain.

She was asked about and denied having:

  • Fatigue, numbness, tingling, weakness, or paralysis

  • Sleep disturbance

  • Weight loss

  • Falls

  • Headaches

  • Blackouts

  • Hair issues

  • Ringing in the ears or trouble hearing

  • Red eyes, double vision, or dry eyes

  • Sores in the nose or mouth, or sinus problems

  • Difficulty swallowing

  • Chest pain, tightness, squeezing or heaviness, shortness of breath, or rapid heartbeat

  • Abdominal pain, diarrhea or constipation, nausea, vomiting, blood or mucus in bowel movements, burning while urinating, or frequent urination

  • Lumps or bumps

  • Fever, chills, sweats, or cold-induced vasospasm

  • Rashes, itching, or sun sensitivity

  • Seizures

  • Alcohol and tobacco use

In conversation, the patient casually shared a problem she had with a dress that she had fitted 6 months ago for a wedding. The dress was now too long.


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