Others (In Murtagh)
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 |
|---|---|---|---|---|
| Probability Diagnosis | Thoracic muscular strain / myofascial pain | Paravertebral tenderness, related to posture/activity, no red flags | ใไฝ ๆ่ฟๆๅๆฌ้ๅขๆ่ ๅๅพ่๏ผใ(Any heavy lifting or prolonged sitting?) | ~50% |
| Thoracic spondylosis (degenerative) | Age > 50, gradual onset, stiffness, no neuro deficit | ใ่่ๆๅ่ถๅ่ถๅต็กฌ๏ผใ(Getting stiffer?) | ~15% | |
| Serious Not To Miss | Vertebral compression fracture (osteoporotic) | Post-menopausal / steroid use, acute onset after minimal trauma, point tenderness over spinous process [4] | ใๆ่ฟๆๅ่ท่ฆช๏ผๆๅ่ถๅ่ถ็ฎ๏ผใ(Any fall? Getting shorter?) | ~3% |
| Spinal metastasis / cord compression | Thoracic spine is the commonest site for cord compression (70%) [5]; known cancer, night pain, progressive neuro deficit | ใๆๅ็้็็๏ผๅคๆ็ๅ็ๅฐ็ๅ่๏ผใ(Cancer history? Night pain?) | ~1% | |
| Spinal infection (TB spine / epidural abscess) | Fever, immunocompromised, IV drug use, raised ESR/CRP | ใๆๅ็ผ็๏ผๆๅๅป้่ฝๅพๅฐๆน๏ผใ(Fever? Travel?) | <1% | |
| Aortic dissection | Acute tearing interscapular pain, maximum at onset, BP discrepancy between arms [1] | ใ็ๅ ไธ้ๅงๅฐฑๆ็๏ผๆๅๆ่ฃๅ ๆ่ฆบ๏ผใ(Worst at onset? Tearing?) | <1% | |
| Pitfalls | Referred visceral pain (pancreatitis, cholecystitis, peptic ulcer) | Epigastric pain radiating to back, food-related | ใ้ฃๅฎๅขๆๅๆ็ๅฒ๏ผใ(Worse after eating?) | ~5% |
| Herpes zoster | Dermatomal burning/band-like pain ยฑ vesicular rash; can precede rash by days | ใ่่ๆๅๅบๆฐดๆณกๆ่ ็ด ็น๏ผๆๅๅฅฝไผผ็ซ็ๅ็๏ผใ(Blisters? Burning pain?) | ~3% | |
| Thoracic disc herniation | Rare but causes myelopathy; band-like chest/abdominal pain + UMN signs in legs | ใๆๅ่ธๅฃๆ่ ่ๅฅฝไผผๆๆขๅธถๆไฝๅ๏ผใ(Band-like sensation?) | <1% | |
| Masquerades | Depression / somatic symptom disorder | Multiple vague pains, high health utilisation, comorbid anxiety/depression [7] | ใไฝ ๅฟๆ ้ป๏ผๆๅ็ๅพๅทฎใๅ่ๅฃ๏ผใ(How's your mood? Sleep/appetite?) | ~10% |
| Osteoporosis | Silent until fracture; post-menopausal, steroid use, low BMI | ใๆๅๅ้้ชจ่ณชๅฏๅบฆๆชขๆฅ๏ผใ(Bone density test?) | ~5% | |
| Ankylosing spondylitis | Inflammatory back pain: age < 45, insidious onset, morning stiffness > 30 min, improved with exercise, not with rest [3] | ใๆๆฉ่ตท่บซๆๅๆๅๅ้ๅฅฝๅต็กฌ๏ผ้ไธๅฐฑๅฅฝๅฒ๏ผใ(Morning stiffness > 30 min? Better with movement?) | ~1% | |
| Trying to Tell Me Something? | Psychosocial stress / fear of serious disease | Work stress, recent bereavement, family member had cancer, fear of disability | ใไฝ ๆๆๅฟๅฉ๏ผๆๅๅฉๅข็นๅฅไปคไฝ ๆๅฟ๏ผใ(What worries you most?) | ~10% |
Back Pain (Thoracic) โ Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00โ0:30 | Friendly opening, introduce self, set agenda | ใไฝ ๅฅฝๅ๏ผๆๅงX๏ผไฟไปๆฅๅ ้ซ็ใๅฏๅๅฏไปฅๅซไฝ ๅๅ๏ผไปๆฅๅฉๅขๅขไปคไฝ ๅ็้ซ็ๅ๏ผใ(Hi, I'm Dr X. What brought you here today?) | Rapport, patient-centred opening, shows interpersonal skill |
| 0:30โ2:00 | History of presenting illness (SOCRATES + red flags) | ใไฝ ่่้ๅบฆ็ๅ๏ผๅนพๆ้ๅง๏ผ็ๅ ๆง่ณชไฟ้ป๏ผๆๅๅปๅฐๅ ถไปๅฐๆน๏ผๆๅๅขไปคไฝขๅฅฝๅฒๆ่ ๅทฎๅฒ๏ผๅด้็จๅบฆ1-10ๅไฝ ๆฏๅนพๅคๅ๏ผใ | Core HPI marks; thoracic-specific: onset, character, radiation, aggravating/relieving, severity |
| 2:00โ3:00 | Red flags + systems review | ใๆๅ่ ณ่ปใ่ ณ็นใๅปๅๅฐๅฐไพฟๅคงไพฟ๏ผๆๅ็ผ็ใๆถ็ฆใๅคๆ็ๅฐ้๏ผไนๅๆๅ็้็็๏ผใ | Must-not-miss: cord compression, malignancy, infection, fracture |
| 3:00โ3:45 | PMH, Drug Hx, Allergy, FHx, Social Hx | ใไฝ ๆๅ้ทๆ็ ๏ผ้ฃ็ทๅฉ่ฅ๏ผๆๅ่ฅ็ฉๆๆ๏ผๅฑไผไบบๆๅ้ชจ่ณช็้ฌๆ่ ็็๏ผไฝ ๅๅฉๅทฅไฝ๏ผๆๅ้ฃฒ้ ้ฃ็ ๏ผใ | Completeness of history; occupation important for mechanical causes |
| 3:45โ4:30 | ICE (Ideas, Concerns, Expectations) | ใไฝ ่ชๅทฑ่ฆบๅพ่็ๅ ๅๅ ไฟๅฉๅข๏ผ(Ideas) ไฝ ๆๆๅฟๅ ไฟๅฉ๏ผ(Concerns) ไฝ ไปๆฅๅๆๆณๆๅนซๅฐไฝ ๅฉ๏ผ(Expectations)ใ | ICE is directly examined on the Case Report Form โ high-yield marks |
| 4:30โ5:15 | Uncover hidden agenda / Why today? | ใๅขๅ่็ๅ่๏ผ้ป่งฃๆไปๆฅๅ็ๅ๏ผๆๅๅฉๅข็นๅฅ็ผ็ๅ๏ผใ(Why come today specifically?) | Hidden agenda: e.g. fear of cancer, recent family member diagnosed, functional impact on work/ADL |
| 5:15โ5:45 | Summarise back to patient, check understanding | ใๆ็ธฝ็ตไธไธไฝ ่ฌๅ ๅข๏ผไฝ ่่ไธญ้็ๅXๅ็ฆฎๆโฆโฆๆๆๅๆผๅๅฒๅฉ๏ผใ | Demonstrates active listening; marks for summarising |
| 5:45โ6:00 | Signpost plan, empathic close | ใๆๆๅนซไฝ ๆชขๆฅ๏ผ็ถๅพๆๅๅพไธ้ปๆจฃ่็ใไฝ ๅไฝฟๅคชๆไฝ๏ผๆๅไธ้ฝๆตๅๅ ใใ | Empathy + safety-net + closing |
Uncovering hidden agenda: Ask explicitly "้ป่งฃไปๆฅๅ๏ผ" โ 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 | ใๅฏๅๅฏไปฅๆไฟพๆ็้ๅบฆๆ็๏ผใ | Thoracic = T1-T12; localise to rule out cervical/lumbar pathology | Midline โ vertebral body; paravertebral โ muscular/facet |
| Onset | When did it start? Sudden or gradual? | ใๅนพๆ้ๅง็๏ผไฟ็ช็ถ้็ๅฎๆ ขๆ ขๅ๏ผใ | Sudden โ fracture, dissection; gradual โ degeneration, tumour | Acute onset โ compression fracture, aortic dissection |
| Character | What does the pain feel like? | ใ็ๅ ๆ่ฆบไฟ้ป๏ผ้็ใๅบ็ใๆ่ฃ๏ผใ | Tearing โ aortic dissection; burning/band-like โ radiculopathy | Tearing interscapular pain โ aortic dissection [1] |
| Radiation | Does it go anywhere else? | ใๆๅ็ๅปๅ ถไปๅฐๆน๏ผ่ธๅฃใ่ ฐใ่ ณ๏ผใ | Chest โ cardiac/aortic; band-like to anterior chest โ thoracic radiculopathy | Anterior chest wall radiation โ herpes zoster, thoracic disc |
| Aggravating | What makes it worse? Coughing? Movement? Lying flat? | ใๅฉๅขๆไปคไฝข็ๅฒ๏ผๅณๅฝใ้ๅใ็ไฝ๏ผใ | Worse with cough โ disc/fracture; night pain โ malignancy/infection | Night pain unrelieved by rest โ red flag for tumour [2] |
| Relieving | What makes it better? Rest? Activity? | ใๅฉๅขๆ่ๆๅฒ๏ผไผๆฏๅฎ้ๅๅฅฝๅฒ๏ผใ | Better with movement โ inflammatory (AS); better with rest โ mechanical | Morning stiffness > 30 min improved by exercise โ AS [3] |
| Severity | Pain score 0-10? | ใ0-10ๅไฝ ๆฏๅนพๅคๅ๏ผใ | Functional impact assessment | โ |
| Timing | Constant or intermittent? Morning stiffness? | ใๆๆฅ็ๅฎๆ็ๆๅ็๏ผๆๆฉ่ตท่บซๆๅๅต็กฌ๏ผใ | Morning stiffness > 30 min โ inflammatory back pain | Ankylosing spondylitis, spondyloarthropathy [3] |
| Neuro red flags | Any leg weakness, numbness, bladder/bowel problems? | ใๆๅ่ ณ่ปใ่ ณ็นใๅปๅๅฐๅปๆใ็พๅๅบๅฐฟ๏ผใ | Cord compression / cauda equina = surgical emergency [2] | Urgent MRI + referral |
| Constitutional | Fever, night sweats, weight loss? | ใๆๅ็ผ็ใๅคๆๅบๆฑใ็ฆๅ๏ผใ | Cancer, infection (TB spine, epidural abscess) | Malignancy, TB spine [2] |
| Trauma | Any recent injury or fall? | ใๆ่ฟๆๅ่ท่ฆชๆ่ ๅๅท๏ผใ | Compression fracture, especially in osteoporotic elderly | Osteoporotic vertebral compression fracture [4] |
| Cancer history | Any history of cancer? | ใไฝ ๆๅ็้็็๏ผใ | Spinal metastasis โ thoracic spine is the most common site (70%) [5] | Metastatic cord compression |
| Osteoporosis risk | Post-menopausal? Steroid use? | ใๆๅๆถ็ถ๏ผๆๅ้ฃ้้กๅบ้๏ผใ | Compression fracture risk | Osteoporotic fracture [4] |
| Rash | Any rash on the back or chest? | ใ่่ๆ่ ่ธๅฃๆๅๅบ็น๏ผใ | Herpes zoster (shingles) โ dermatomal vesicular rash | Pre-rash zoster can present as isolated thoracic pain |
| Drug Hx | Any medications? NSAIDs? Steroids? | ใ้ฃ็ทๅฉ่ฅ๏ผๆๅ้ฃๆญข็่ฅ๏ผใ | NSAIDs โ renal impairment [6]; chronic steroids โ osteoporosis | Drug side effects, fracture risk |
| Allergy | Any drug allergies? | ใๆๅ่ฅ็ฉๆๆ๏ผใ | Safety | โ |
| Social Hx | Job? Smoking? Alcohol? | ใไฝ ๅๅฉๅทฅไฝ๏ผๆๅ้ฃ็ ้ฃฒ้ ๏ผใ | Heavy lifting โ muscular; smoking โ lung cancer + mets | Occupational strain, malignancy risk |
| Functional impact | Can you work/sleep/do daily tasks? | ใๆๅๅฝฑ้ฟไฝ ่ฟๅทฅใ็่ฆบใๅๅฎถๅ๏ผใ | Biopsychosocial assessment | โ |
| Psych screen | Feeling stressed, low mood, anxious? | ใๆ่ฟๅฟๆ ้ป๏ผๆๅๅฃๅๅคงใ็ๅ่๏ผใ | Depression as masquerade; somatisation | Depression, somatic symptom disorder [7] |
| Eating / posture | Any difficulty swallowing? | ใๆๅๅข้ฃๅ๏ผใ | Anterior thoracic disc/osteophyte, oesophageal pathology | โ |
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 โ consider AS; if rash โ consider zoster; if acute tearing โ 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 โ cord compression (leg weakness, urinary retention, saddle anaesthesia), malignancy (night pain, weight loss, cancer Hx), infection (fever), fracture (osteoporosis, steroid, trauma) โ these are MUST-ASK
- Not asking ICE โ this is directly scored on the Case Report Form. Ask it explicitly in Cantonese.
- Confusing thoracic and lumbar pain โ 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 โ pre-eruptive pain is easily missed; always ask about burning/tingling and inspect the skin
- Forgetting to ask "Why today?" โ the hidden agenda is often the ONE main reason for consultation
- Not examining chest expansion for thoracic spine โ T-spine: main movement to assess is rotation and chest expansion [8]
- Writing the symptom as the diagnosis โ "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] |
ใๅฆๆไฝ ็ผ็พ้ป่ ณ้ๅงๅๅใ็น๏ผๆ่ ๅปๅๅฐๅฐไพฟ๏ผๅขๅไฟ็ทๆฅๆ ๆณ๏ผ่ฆๅณๅปๅปๆฅ็ๅฎคใใ (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 โ red flags (neuro deficit, cancer Hx, constitutional symptoms, trauma, steroids) โ ICE โ "Why today?" โ psych screen โ functional impact
What to WRITE: CC with duration โ HPI with red-flag screening documented โ ONE RFC (often fear/concern-driven) โ ICE explicitly โ Most likely Dx with evidence โ 3 DDx with discriminators โ 3 biopsychosocial problems โ 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 โ 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)
Arthralgia / Arthritis
Arthralgia refers to joint pain without inflammation, whereas arthritis denotes joint inflammation characterized by pain, swelling, warmth, and restricted range of motion.
Breast Lump
A palpable mass in the breast that may represent a benign condition such as a fibroadenoma or cyst, or a malignant neoplasm requiring further evaluation with imaging and possible biopsy.