Differential Diagnosis for Right-Sided Rib Pain

The patient presents with a two-week history of constant right-sided rib pain that worsens with deep inspiration, without a history of trauma, recent travel, or recent surgeries, but with a history of breast cancer. Considering these factors, the differential diagnosis can be organized into the following categories:

• Single Most Likely Diagnosis

  • Musculoskeletal Pain: Given the constant nature of the pain and its worsening with deep inspiration, musculoskeletal pain, possibly related to the upcoming lower back surgery or a strain, is a plausible explanation. The lack of improvement with movement or palpation does not strongly argue against this, as some musculoskeletal issues can present with constant pain.

• Other Likely Diagnoses

  • Pulmonary Embolism: Although the patient denies recent surgeries or travel, pulmonary embolism should be considered, especially given the severe and unrelenting nature of the pain that worsens with deep inspiration. The absence of other typical symptoms like dyspnea does not rule out this diagnosis.
  • Pneumonia or Pleuritis: Infection or inflammation of the lung or pleura could cause pain that worsens with deep breathing. The absence of fever or cough does not exclude this possibility entirely.
  • Costochondritis: Inflammation of the cartilage that connects the ribs to the breastbone could cause sharp pains that worsen with movement or deep breathing, though the pain's description as unchanging with movement is somewhat atypical.

• Do Not Miss Diagnoses

  • Metastatic Disease: Given the patient's history of breast cancer, metastasis to the ribs or surrounding structures is a critical consideration. Breast cancer can metastasize to bones, including the ribs, and cause significant pain.
  • Pneumothorax: A spontaneous pneumothorax could cause sudden onset of sharp pain that worsens with deep inspiration. Although the patient's pain has been present for two weeks, a slow leak or small pneumothorax could potentially present with more chronic symptoms.
  • Cardiac Ischemia: Although less common in women, cardiac ischemia or myocardial infarction can present with atypical symptoms, including sharp pains that may be mistaken for musculoskeletal or pulmonary issues.

• Rare Diagnoses

  • Tietze's Syndrome: A rare inflammatory condition affecting the cartilages and surrounding tissues of the ribs, which could cause severe pain.
  • Sickle Cell Crisis: If the patient has sickle cell disease, a crisis could cause severe pain, including in the chest or rib area, though this would typically be accompanied by other symptoms.
  • Osteonecrosis: Though rare, osteonecrosis of the rib could cause pain, especially if the patient has been on long-term steroid therapy or has other risk factors, which are not mentioned in the scenario provided.