Family medicine
Back Pain (thoracic)
Thoracic back pain is pain localized to the region between the first and twelfth thoracic vertebrae, often arising from musculoskeletal, degenerative, or, less commonly, serious visceral or structural causes requiring careful evaluation.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Thoracic muscular strain / myofascial pain | Paravertebral tenderness, related to posture/activity, no red flags | 「你最近有冇搬重嘢或者坐得耐？」(Any heavy lifting or prolonged sitting?) |
| Thoracic spondylosis (degenerative) | Age > 50, gradual onset, stiffness, no neuro deficit | 「背脊有冇越嚟越僵硬？」(Getting stiffer?) | |
| Serious Not To Miss | Vertebral compression fracture (osteoporotic) | Post-menopausal / steroid use, acute onset after minimal trauma, point tenderness over spinous process [4] | 「最近有冇跌親？有冇越嚟越矮？」(Any fall? Getting shorter?) |
| Spinal metastasis / cord compression | Thoracic spine is the commonest site for cord compression (70%) [5]; known cancer, night pain, progressive neuro deficit | 「有冇生過癌症？夜晚痛唔痛到瞓唔著？」(Cancer history? Night pain?) | |
| Spinal infection (TB spine / epidural abscess) | Fever, immunocompromised, IV drug use, raised ESR/CRP | 「有冇發燒？有冇去過落後地方？」(Fever? Travel?) | |
| Aortic dissection | Acute tearing interscapular pain, maximum at onset, BP discrepancy between arms [1] | 「痛嘅一開始就最痛？有冇撕裂嘅感覺？」(Worst at onset? Tearing?) | |
| Pitfalls | Herpes zoster | Dermatomal burning/band-like pain ± vesicular rash; can precede rash by days | 「背脊有冇出水泡或者紅疹？有冇好似火燒咁痛？」(Blisters? Burning pain?) |
| Referred visceral pain (pancreatitis, cholecystitis, peptic ulcer) | Epigastric pain radiating to back, food-related | 「食完嘢會唔會痛啲？」(Worse after eating?) | |
| Thoracic disc herniation | Rare but causes myelopathy; band-like chest/abdominal pain + UMN signs in legs | 「有冇胸口或者肚好似有條帶束住咁？」(Band-like sensation?) | |
| Masquerades | Depression / somatic symptom disorder | Multiple vague pains, high health utilisation, comorbid anxiety/depression [7] | 「你心情點？有冇瞓得差、冇胃口？」(How's your mood? Sleep/appetite?) |
| Osteoporosis | Silent until fracture; post-menopausal, steroid use, low BMI | 「有冇做過骨質密度檢查？」(Bone density test?) | |
| Ankylosing spondylitis | Inflammatory back pain: age < 45, insidious onset, morning stiffness > 30 min, improved with exercise, not with rest [3] | 「朝早起身有冇成半個鐘好僵硬？郁下就好啲？」(Morning stiffness > 30 min? Better with movement?) | |
| Trying to Tell Me Something? | Psychosocial stress / fear of serious disease | Work stress, recent bereavement, family member had cancer, fear of disability | 「你最擔心咩？有冇咩嘢特別令你擔心？」(What worries you most?) |
Back Pain (Thoracic) — Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce self, set agenda | 「你好呀，我姓X，係今日嘅醫生。可唔可以叫你個名？今日咩嘢嘢令你嚟睇醫生呀？」(Hi, I'm Dr X. What brought you here today?) | Rapport, patient-centred opening, shows interpersonal skill |
| 0:30–2:00 | History of presenting illness (SOCRATES + red flags) | 「你背脊邊度痛呀？幾時開始？痛嘅性質係點？有冇去到其他地方？有冇嘢令佢好啲或者差啲？嚴重程度1-10分你比幾多分？」 | Core HPI marks; thoracic-specific: onset, character, radiation, aggravating/relieving, severity |
| 2:00–3:00 | Red flags + systems review | 「有冇腳軟、腳痹、去唔到小便大便？有冇發燒、消瘦、夜晚痛到醒？之前有冇生過癌症？」 | Must-not-miss: cord compression, malignancy, infection, fracture |
| 3:00–3:45 | PMH, Drug Hx, Allergy, FHx, Social Hx | 「你有冇長期病？食緊咩藥？有冇藥物敏感？屋企人有冇骨質疏鬆或者癌症？你做咩工作？有冇飲酒食煙？」 | Completeness of history; occupation important for mechanical causes |
| 3:45–4:30 | ICE (Ideas, Concerns, Expectations) | 「你自己覺得背痛嘅原因係咩呢？(Ideas) 你最擔心嘅係咩？(Concerns) 你今日嚟最想我幫到你咩？(Expectations)」 | ICE is directly examined on the Case Report Form — high-yield marks |
| 4:30–5:15 | Uncover hidden agenda / Why today? | 「呢個背痛咁耐，點解揀今日嚟睇呀？有冇咩嘢特別發生咗？」(Why come today specifically?) | Hidden agenda: e.g. fear of cancer, recent family member diagnosed, functional impact on work/ADL |
| 5:15–5:45 | Summarise back to patient, check understanding | 「我總結一下你講嘅嘢：你背脊中間痛咗X個禮拜……我有冇漏咗啲咩？」 | Demonstrates active listening; marks for summarising |
| 5:45–6:00 | Signpost plan, empathic close | 「我會幫你檢查，然後我哋傾下點樣處理。你唔使太擔住，我哋一齊搵原因。」 | Empathy + safety-net + closing |
Uncovering hidden agenda: Ask explicitly "點解今日嚟？" — the patient may have a new symptom (e.g. numbness), a psychosocial stressor (work pressure, caring burden), or a specific fear (cancer, disability). This is often the ONE main reason for consultation.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Site | Where exactly is the pain? Point with one finger | 「可唔可以指俾我睇邊度最痛？」 | Thoracic = T1-T12; localise to rule out cervical/lumbar pathology | Midline → vertebral body; paravertebral → muscular/facet |
| Onset | When did it start? Sudden or gradual? | 「幾時開始痛？係突然間痛定慢慢嚟？」 | Sudden → fracture, dissection; gradual → degeneration, tumour | Acute onset → compression fracture, aortic dissection |
| Character | What does the pain feel like? | 「痛嘅感覺係點？鈍痛、刺痛、撕裂？」 | Tearing → aortic dissection; burning/band-like → radiculopathy | Tearing interscapular pain → aortic dissection [1] |
| Radiation | Does it go anywhere else? | 「有冇痛去其他地方？胸口、腰、腳？」 | Chest → cardiac/aortic; band-like to anterior chest → thoracic radiculopathy | Anterior chest wall radiation → herpes zoster, thoracic disc |
| Aggravating | What makes it worse? Coughing? Movement? Lying flat? | 「咩嘢會令佢痛啲？咳嗽、郁動、瞓低？」 | Worse with cough → disc/fracture; night pain → malignancy/infection | Night pain unrelieved by rest → red flag for tumour [2] |
| Relieving | What makes it better? Rest? Activity? | 「咩嘢會舒服啲？休息定郁動好啲？」 | Better with movement → inflammatory (AS); better with rest → mechanical | Morning stiffness > 30 min improved by exercise → AS [3] |
| Severity | Pain score 0-10? | 「0-10分你比幾多分？」 | Functional impact assessment | — |
| Timing | Constant or intermittent? Morning stiffness? | 「成日痛定時痛時唔痛？朝早起身有冇僵硬？」 | Morning stiffness > 30 min → inflammatory back pain | Ankylosing spondylitis, spondyloarthropathy [3] |
| Neuro red flags | Any leg weakness, numbness, bladder/bowel problems? | 「有冇腳軟、腳痹、去唔到廁所、痾唔出尿？」 | Cord compression / cauda equina = surgical emergency [2] | Urgent MRI + referral |
| Constitutional | Fever, night sweats, weight loss? | 「有冇發燒、夜晚出汗、瘦咗？」 | Cancer, infection (TB spine, epidural abscess) | Malignancy, TB spine [2] |
| Trauma | Any recent injury or fall? | 「最近有冇跌親或者受傷？」 | Compression fracture, especially in osteoporotic elderly | Osteoporotic vertebral compression fracture [4] |
| Cancer history | Any history of cancer? | 「你有冇生過癌症？」 | Spinal metastasis — thoracic spine is the most common site (70%) [5] | Metastatic cord compression |
| Osteoporosis risk | Post-menopausal? Steroid use? | 「有冇收經？有冇食過類固醇？」 | Compression fracture risk | Osteoporotic fracture [4] |
| Rash | Any rash on the back or chest? | 「背脊或者胸口有冇出疹？」 | Herpes zoster (shingles) — dermatomal vesicular rash | Pre-rash zoster can present as isolated thoracic pain |
| Drug Hx | Any medications? NSAIDs? Steroids? | 「食緊咩藥？有冇食止痛藥？」 | NSAIDs → renal impairment [6]; chronic steroids → osteoporosis | Drug side effects, fracture risk |
| Allergy | Any drug allergies? | 「有冇藥物敏感？」 | Safety | — |
| Social Hx | Job? Smoking? Alcohol? | 「你做咩工作？有冇食煙飲酒？」 | Heavy lifting → muscular; smoking → lung cancer + mets | Occupational strain, malignancy risk |
| Functional impact | Can you work/sleep/do daily tasks? | 「有冇影響你返工、瞓覺、做家務？」 | Biopsychosocial assessment | — |
| Psych screen | Feeling stressed, low mood, anxious? | 「最近心情點？有冇壓力大、瞓唔著？」 | Depression as masquerade; somatisation | Depression, somatic symptom disorder [7] |
| Eating / posture | Any difficulty swallowing? | 「有冇嘢難吞？」 | Anterior thoracic disc/osteophyte, oesophageal pathology | — |
Case Report Form Answer Builder
- CC: Thoracic back pain for [duration]
- HPI high-yield points: Site (thoracic), onset (acute/gradual), character, radiation, aggravating/relieving factors, severity, associated symptoms (neuro deficit, constitutional symptoms, rash), red flags screened, functional impact, relevant PMH (cancer, osteoporosis, steroid use), drug history
- Examples: "Worsening back pain affecting sleep/work," "Fear of cancer after neighbour diagnosed," "New numbness in legs," "Wants investigation/X-ray"
- How to phrase: State the single driving reason the patient came today, not just the symptom. Often linked to concern/expectation.
| Likely Content | Exam Phrasing | |
|---|---|---|
| Ideas | "I think it's muscle strain" / "I'm worried it might be a slipped disc" / "Could it be bone problem?" | "Patient thinks the back pain is due to poor posture / muscle strain" |
| Concerns | "Worried it's cancer" / "Afraid of becoming disabled" / "Worried about osteoporosis like my mother" | "Patient is concerned about spinal cancer / becoming unable to walk" |
| Expectations | "Wants an X-ray" / "Wants pain relief" / "Wants referral to specialist" | "Patient expects imaging investigation and reassurance" |
- In a young/middle-aged patient without red flags: Thoracic muscular strain / myofascial pain (paraspinal tenderness, related to activity/posture, no neuro deficit, no red flags)
- In a post-menopausal woman with acute onset after minor trauma: Osteoporotic vertebral compression fracture
- Choose based on stem demographics and presence/absence of red flags. Always state the minimum supporting evidence.
| DDx | Key Discriminator |
|---|---|
| 1. Thoracic spondylosis | Gradual onset, age > 50, stiffness, no neuro deficit, XR shows degenerative changes |
| 2. Osteoporotic vertebral compression fracture | Post-menopausal, steroid use, acute onset, point tenderness over spinous process, height loss [4] |
| 3. Spinal metastasis | Known cancer history, progressive night pain unrelieved by rest, weight loss, neurological deficit [5] |
(Adjust based on the clinical vignette: if young male → consider AS; if rash → consider zoster; if acute tearing → consider aortic dissection)
| Domain | Problem |
|---|---|
| Biological | Thoracic back pain with/without neurological deficit requiring investigation |
| Psychological | Anxiety about serious underlying cause (e.g. cancer); sleep disturbance due to pain; low mood |
| Social/Functional | Unable to work / perform ADLs; caring responsibilities affected; financial impact of sick leave |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Muscular strain / myofascial pain | Paravertebral muscle tenderness with no midline bony tenderness | Palpate paraspinal muscles alongside thoracic spine; press on spinous processes | Muscle tenderness without bony tenderness distinguishes muscular from bony pathology |
| Osteoporotic compression fracture | Point tenderness over the affected spinous process + thoracic kyphosis [4][8] | Gently tap along spine with fist to elicit tenderness [8]; observe increased thoracic kyphosis from lateral view | Localised bony tenderness at fracture site; kyphosis from wedge compression |
| Spinal metastasis / cord compression | Upper motor neuron signs in lower limbs (hyperreflexia, upgoing plantar, clonus) | Test knee/ankle jerks, Babinski sign | UMN signs below the level of cord compression [5] |
| Ankylosing spondylitis | Reduced chest expansion ( < 2.5 cm at nipple/xiphoid level) [3][8] | Tape measure around chest at xiphoid; measure difference between full expiration and full inspiration | Reflects costovertebral joint involvement; T-spine: chest expansion is the key movement to assess [8] |
| Herpes zoster | Dermatomal vesicular rash | Inspect the thoracic dermatome for grouped vesicles on erythematous base | Unilateral dermatomal distribution is pathognomonic |
| Aortic dissection | Blood pressure discrepancy between arms ( > 20 mmHg) | Measure BP in both arms | Suggests dissection involving subclavian artery [1] |
Exam Discriminators and Traps
Top Traps That Lose Marks
- Forgetting to screen for red flags — cord compression (leg weakness, urinary retention, saddle anaesthesia), malignancy (night pain, weight loss, cancer Hx), infection (fever), fracture (osteoporosis, steroid, trauma) → these are MUST-ASK
- Not asking ICE — this is directly scored on the Case Report Form. Ask it explicitly in Cantonese.
- Confusing thoracic and lumbar pain — thoracic pain has different DDx (more likely metastasis, less likely disc prolapse). Thoracic spine is the commonest site for metastatic cord compression (70%) [5]
- Missing herpes zoster before the rash appears — pre-eruptive pain is easily missed; always ask about burning/tingling and inspect the skin
- Forgetting to ask "Why today?" — the hidden agenda is often the ONE main reason for consultation
- Not examining chest expansion for thoracic spine — T-spine: main movement to assess is rotation and chest expansion [8]
- Writing the symptom as the diagnosis — "back pain" is not a diagnosis; commit to a specific diagnosis on the form
| Red Flag | Suggests | Action |
|---|---|---|
| Leg weakness, urinary retention, saddle anaesthesia | Cord compression / cauda equina | Urgent MRI whole spine + same-day referral [2] |
| Known cancer + progressive pain + neuro deficit | Metastatic cord compression | Urgent MRI + oncology + high-dose dexamethasone [5] |
| Acute tearing interscapular pain, BP discrepancy | Aortic dissection | Emergency referral, CT aortic angiogram [1] |
| Fever + back pain + immunosuppression | Epidural abscess / TB spine | Urgent MRI + blood cultures |
| Post-menopausal + acute onset + point tenderness | Compression fracture | XR thoracic spine, DEXA scan, ortho referral [4] |
「如果你發現隻腳開始冇力、痹，或者去唔到小便，呢個係緊急情況，要即刻去急症室。」 (If you notice leg weakness, numbness, or can't pass urine, go to A&E immediately.)
High Yield Summary
What to ASK: SOCRATES for thoracic pain → red flags (neuro deficit, cancer Hx, constitutional symptoms, trauma, steroids) → ICE → "Why today?" → psych screen → functional impact
What to WRITE: CC with duration → HPI with red-flag screening documented → ONE RFC (often fear/concern-driven) → ICE explicitly → Most likely Dx with evidence → 3 DDx with discriminators → 3 biopsychosocial problems → 1 physical sign (paravertebral tenderness for muscular; spinous process tenderness + kyphosis for fracture; reduced chest expansion for AS; UMN signs for cord compression)
What NOT TO MISS: Cord compression (surgical emergency), spinal metastasis (thoracic = commonest site, 70%), aortic dissection (tearing interscapular pain), herpes zoster (before rash), osteoporotic fracture in elderly/steroid users, ICE on the form
Active Recall - Family Medicine Clinical Test
[1] Senior notes: Block A - Sudden severe chest pain_ acute myocardial infarction; aortic dissection.pdf (Aortic Dissection section) [2] Senior notes: Maksim Surgery Notes.pdf (p.222-223, Approach to spine diseases, Red flags) [3] Senior notes: Maksim Medicine Notes.pdf (p.322, Ankylosing spondylitis - inflammatory back pain features) [4] Senior notes: Block A - Back pain in an elderly woman_ osteoporosis and related fractures.pdf (p.1, p.11, p.16) [5] Senior notes: Maksim Medicine Notes.pdf (p.45-47, Cord compression - thoracic 70%) [6] Senior notes: Block A – Nephrology Data Interpretation.pdf (p.11, NSAIDs and renal impairment) [7] Senior notes: Ryan Ho Psychiatry.pdf (p.202, Somatic symptom disorder) [8] Senior notes: Ryan Ho Rheumatology.pdf (p.24, Examination of the Spine - chest expansion for T-spine); Ryan Ho Fundamentals.pdf (p.145)
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