Differential Diagnosis for Tightening in Mid Back

The patient presents with tightening in the mid back occurring in 5-second intervals, once a month, accompanied by difficulty breathing. Here's a structured approach to the differential diagnosis:

• Single Most Likely Diagnosis

  • Costochondritis: This condition involves inflammation of the cartilage that connects the ribs to the breastbone, which can cause sharp pains and tightening sensations in the chest and back. The intermittent nature and the difficulty breathing could be related to the pain causing anxiety or shallow breathing.

• Other Likely Diagnoses

  • Anxiety or Panic Attacks: These can cause chest tightness, difficulty breathing, and may be perceived as back pain due to the referred pain pattern. The monthly recurrence could be related to stress or hormonal cycles.
  • Musculoskeletal Strain: Repeated strain or injury to the muscles in the mid back could cause intermittent pain and tightness, especially if the patient has a job or engages in activities that involve heavy lifting or bending.
  • Gastroesophageal Reflux Disease (GERD): GERD can cause chest pain and difficulty breathing, which might be felt in the back. The symptoms could be intermittent and related to eating or lying down.

• Do Not Miss Diagnoses

  • Myocardial Infarction (MI) or Angina: Although less likely given the age and intermittent nature, cardiac causes of chest pain must always be considered, especially if the pain is accompanied by difficulty breathing. The back pain could be referred pain from the heart.
  • Pulmonary Embolism (PE): Sudden onset of difficulty breathing accompanied by chest or back pain could indicate a PE, which is a medical emergency.
  • Aortic Dissection: A severe, tearing pain in the chest or back that moves down the body could indicate an aortic dissection, a life-threatening condition.

• Rare Diagnoses

  • Tietze's Syndrome: Similar to costochondritis but involves the inflammation of the cartilages and surrounding tissues, causing chest pain and swelling.
  • Sickle Cell Crisis: In patients with sickle cell disease, a crisis can cause severe pain episodes, including back pain, due to the sickling of red blood cells.
  • Herpes Zoster (Shingles): Before the rash appears, shingles can cause severe, intermittent pain in a dermatomal distribution, which could be mistaken for back pain.

Each of these diagnoses should be considered in the context of the patient's full medical history, physical examination, and appropriate diagnostic tests to determine the underlying cause of the symptoms.