Differential Diagnosis

The patient's presentation of intermittent pain around the right posterior rib area, which intensified recently, warrants a thorough differential diagnosis. The following categories outline potential causes:

• Single most likely diagnosis
  • Rib fracture nonunion or malunion: Given the patient's history of a confirmed rib fracture from a fall in November 2024 and the recent increase in pain, it's plausible that the fracture has not healed properly, leading to nonunion or malunion. The persistent brownness in the area could indicate ongoing healing issues or soft tissue damage.
• Other Likely diagnoses
  • Costochondritis: Inflammation of the cartilage that connects the ribs to the sternum could be a cause of the patient's pain, especially if the fall led to costochondral junction injury.
  • Musculoskeletal strain: The intensified pain with movement could suggest a strain in the muscles around the fractured rib, possibly exacerbated by the recent fasting and potential dehydration.
  • Soft tissue injury: The overlying soft tissue contusion from the initial fall could still be causing pain, especially if the healing process is slow or if the area is subjected to further stress.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Pulmonary embolism: Although the patient does not report recent travel, immobilization, or other typical risk factors, the sudden increase in pain and its sharp nature, along with the exacerbation by deep breaths, necessitate considering pulmonary embolism due to its potentially fatal outcome.
  • Pneumothorax: A complication of rib fractures, pneumothorax could present with sharp pain that worsens with deep breathing. The absence of recent cough or fever does not rule out this condition entirely.
  • Hepatic rupture or hemorrhage: Given the patient's history of liver enzyme abnormalities, any increase in abdominal or rib pain should prompt consideration of liver pathology, including rupture or hemorrhage, especially if there's a possibility of trauma to the liver during the initial fall.
• Rare diagnoses
  • Osteomyelitis: Infection of the bone could be a rare complication of the rib fracture, potentially causing persistent or worsening pain.
  • Tumor: Although extremely rare and unlikely without other systemic symptoms, a tumor could cause persistent pain in the rib area, especially if it involves the bone or soft tissues.