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Q: About five months ago, I began having this uncomfortable pain in the middle of my back on the right side. I did nothing to strain my back and have been careful since then not to. I also get sharp pain under my ribs. When I breathe in deeply or sneeze, the pain goes into my back on both sides, behind my lower ribs. I'm also very tired all the time.

I was diagnosed with endometriosis and had a hysterectomy. Seven months later I had to have an emergency appendectomy, so needless to say, I am feeling as though I am slowly falling apart and all before I'm 30. I will appreciate anything you can tell me.

-- J.M.
A: You certainly have a full plate with a lot of things happening at the same time, but I don't think you're falling apart. Before trying to help you with your back and rib pain, it's important to understand about the process of diagnosis.

Aside from complicated surgery, diagnosis is the most challenging part of medicine. That's why it most excites and frustrates health professionals.

Despite the advanced techniques and equipment available today, diagnosis is often difficult even when the patient's symptoms, exam results and medical history are available and straightforward.

Accurate diagnosis is even more difficult when not everything is known. So diagnosis requires information. Symptoms and medical history are the information provided by the patient. Your first step in working with your doctors to solve your problem is to present an accurate and complete package of medical history and symptoms.

Back pain is a common condition with a myriad of symptoms, causes, treatments and prognoses. In general, back pain usually occurs because of something wrong with nerve, muscle, bone or organs at or near the source of pain.

That something wrong can include trauma, anatomic defects, disease (either local or systemic), infection and inflammation, and cancer. It's also important not to jump to conclusions too quickly. For example, you may have strained or damaged muscles or ligaments in your back without knowing it at the time or remembering it.

Important questions that you and your health professional need to evaluate are:

Is your pain continuing or intermittent, sharp or dull?

Is the pain relieved or worsened by particular movements?

What else makes the pain better or worse?

Do you also experience numbness or weakness?

What testing have you had and what were the results?

Answers to these and other questions will give clues as to what other questions need to be asked and answered.

For example, if your symptoms were limited to chronic, widespread (beyond just the back) achy pain and fatigue, you could have fibromyalgia, a long-term disorder more prevalent in women age 20-50. Chronic fatigue syndrome is another condition characterized by muscle pain and fatigue that affects people 20 to 50 years of age, mostly women.

It's also important to remember that you may have more than one problem at a time. Even if you have fibromyalgia, the sharp pain you feel under your ribs may be caused by pleurisy or other similar pulmonary problems.

My recommendations are two: Compile a detailed history of your problems and present this information to a health-care provider in whom you have confidence. And keep sharing information and asking questions until you at least feel you're on the right track.

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Dr. Allen Douma welcomes questions from readers. Although he cannot respond to each one individually, he will answer those of general interest in his column. Write to Dr. Douma in care of Tribune Media Services, 435 N. Michigan Ave., Suite 1400, Chicago, Ill. 60611. His e-mail address is

This column is for informational and educational purposes only. It is not intended to provide medical advice or take the place of consultation with a doctor or other health-care provider.

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