Differential Diagnosis for Sharp Upper Back Pain

The patient presents with sharp upper back pain worsened by breathing, deep breathing, sneezing, and movement, which suggests several potential diagnoses. The following categories organize the differential diagnoses based on likelihood and potential impact:

• Single Most Likely Diagnosis

  • Musculoskeletal Strain: The patient's recent 10-hour car ride could have led to poor posture, strain on the muscles, or injury to the musculoskeletal structures in the upper back, resulting in sharp pain and pressure sensation. The worsening of pain with movement, deep breathing, and sneezing supports this diagnosis, as these actions can exacerbate musculoskeletal strain.

• Other Likely Diagnoses

  • Costochondritis: Inflammation of the cartilage that connects the ribs to the breastbone (sternum) could cause sharp pain in the upper back that worsens with deep breathing and movement. The patient's description of a "wrapping sensation" around the back could be consistent with costochondritis affecting multiple areas.
  • Intercostal Muscle Strain: Similar to musculoskeletal strain, but specifically involving the muscles between the ribs, which could cause sharp pain that worsens with breathing and movement.
  • Rib Fracture: Although less likely without a history of trauma, a stress fracture or an occult fracture from the long car ride (e.g., from seatbelt pressure) could cause sharp pain that worsens with movement and deep breathing.

• Do Not Miss Diagnoses

  • Pulmonary Embolism (PE): While less likely given the lack of typical symptoms such as leg swelling or recent long-distance travel without other risk factors, PE can present with sudden onset of sharp chest or back pain that worsens with deep breathing. It is crucial to consider PE due to its high mortality rate if missed.
  • Aortic Dissection: A life-threatening condition where there is a tear in the aorta's inner layer. The patient's complaint of sharp back pain and a history of hypertension (as part of hypercholesterolemia management) increase the suspicion, although the absence of other typical symptoms like radiation of pain to the abdomen or legs and differential blood pressures in limbs makes it less likely.
  • Pneumothorax: Air in the pleural space can cause sharp chest or back pain that worsens with deep breathing. Although the patient does not have typical risk factors or symptoms like shortness of breath, it's a condition that should not be missed due to its potential severity.

• Rare Diagnoses

  • Thoracic Outlet Syndrome: Compression of the nerves or blood vessels that pass into the thoracic outlet (the space between your collarbone and first rib) could cause pain in the upper back, but it typically presents with additional symptoms like numbness in the arms or hands.
  • Spondyloarthropathies: Conditions like ankylosing spondylitis could cause back pain, but they are less likely given the acute onset and the patient's age and lack of other systemic symptoms.
  • Osteoporotic Compression Fracture: Although possible, especially with recent weight loss, this diagnosis would be less likely without a history of osteoporosis or significant trauma, and the pain pattern described does not as typically match that of a compression fracture.