Here again, it is wise to have a list of diagnostic possibilities (Table 2-1 and Figure 2-1) in mind before you begin questioning the patient. We have already explored the use of anatomy in developing such a list, so this time let’s use the mnemonic MINT, which stands for

Malformation, Inflammation, Neoplasm, and Trauma. Malformation would suggest scoliosis. Inflammation would suggest an epidural abscess, herpes zoster, pyelonephritis, or pleurisy. Neoplasm should suggest primary or metastatic tumors of the spine and lung (mesothelioma, etc.). Trauma should suggest fractures, herniated disc (extremely rare), and sprains.

Onset: Is the thoracic pain acute? If so, consider infections (such as epidural abscess, pleurisy, herpes zoster, etc.) and trauma (fracture, sprain, or herniated disc). If the pain followed an injury, you need the details. If it is chronic, consider neoplasm (spinal cord tumor, etc.) or congenital and degenerative disorders (scoliosis, osteoporosis, osteoarthritis, etc.).

Back pain may also be referred from acute pancreatitis, cholecystitis, pyelonephritis, myocardial infarction, or dissecting aneurysm.

Associated Symptoms: Fever and chills obviously distinguishes an infectious process while symptoms of weakness, numbness and tingling in the lower extremities, erectile dysfunction, or loss of bladder control would point to a space-occupying lesion of the spinal cord (neoplasm, herniated disc, epidural abscess, etc.). Diaphoresis will point to a myocardial infarction or pulmonary embolism.

Review of Systems: Many of the visceral causes of thoracic pain are illustrated in Figure 2-1.

Hemoptysis suggests a pulmonary embolus or neoplasm while nausea and vomiting prompts consideration of an abdominal condition such as pancreatitis, cholecystitis, or ulcer as well as an inferior wall myocardial infarction. Hematuria frequency or burning on urination would suggest a UTI or renal calculus. We’ve already discussed the neurologic review of systems under associated symptoms.

Past History: Previous accidents, operations, and hospitalizations should be listed as well as communicable diseases, although tuberculosis of the spinal column is rarely encountered today. If herpes zoster is considered, you will want to ask whether the patient had chickenpox. A history of excessive alcohol consumption may point to pancreatitis, while drug addiction may identify someone feigning illness simply to receive painkillers. To cover all the bases using anatomy as your guide, simply ask the patient if he/she has had heart disease; intestinal disease; kidney disease; skin, joint, or bone disease, etc.

Family History: This may be helpful in cases of scoliosis, or neuromuscular disorders. Once again, the primary objective in the history is to rule out serious conditions that need aggressive action or immediate referral so that you are left with disorders that can be treated conservatively.

Here again the objective of your examination is to rule out radiculopathy and myelopathy as well as serious conditions such as myocardial infarction, pneumonia with pleurisy, pulmonary embolism, and neoplasms of the lung or pancreas.

Start the examination by observing the patient’s gait (Figure 2-2) for spasticity or ataxia that might indicate myelopathy. Perform a Romberg
test for the same reason (Figure 2-3). Now palpate the paraspinous muscles for muscles spasm or trigger points (Figure 2-4), and while you are at it, look for a rash (herpes zoster). Test range of motion in Lateral Flexion, right and left (Figure 2-5) and Extension and Flexion (Figure 2-6). This will help identify thoracic spondylosis, fractures, and sprains. It may also increase suspicion for less common pathology such as a spinal cord tumor, epidural abscess, or herniated disc. Examine for scoliosis by having the patient bend over and check for protrusions of the scapula on one side or another with the Adams forward bend test (Figure 2-7).¹ Using a pin and cotton applicator or horse hair, examine for dermatomal loss of touch and/or pain that will help identify radiculopathy (Figure 2-8). Check the reflexes (Figure 2-9) and sensation to touch, pain and vibration (Figure 2-10) in the lower extremities. Hyperactive reflexes or diffuse sensory loss would make you suspicious of myelopathy.