Patient presents with complaints of mid back pain, also described as middle back pain or thoracic back pain.  Onset of pain is reported as [Onset - e.g., gradual, acute, insidious] and occurred approximately [Duration] ago.  The pain is characterized as [Character - e.g., sharp, dull, aching, burning, stabbing] and located in the thoracic spine region, specifically [Location - e.g., between the shoulder blades, right paraspinal muscles, left of midline at T8 level].  Patient rates pain as [Pain Scale Rating] on a 0-10 numerical rating scale.  Aggravating factors include [Aggravating Factors - e.g., prolonged sitting, bending, twisting, lifting].  Alleviating factors include [Alleviating Factors - e.g., rest, heat, over-the-counter pain medication].  Associated symptoms include [Associated Symptoms - e.g., stiffness, muscle spasms, limited range of motion, radiating pain to chest or ribs, numbness, tingling].  Patient denies [Pertinent Negatives - e.g., fever, chills, weight loss, bowel or bladder incontinence, trauma, history of cancer].  Physical examination reveals [Physical Exam Findings - e.g., tenderness to palpation at T6-T8, decreased range of motion in thoracic spine, paraspinal muscle spasm, normal neurological exam].  Differential diagnosis includes musculoskeletal strain, thoracic facet joint syndrome, intercostal neuralgia, myofascial pain syndrome, and referred pain.  Diagnostic testing considered includes [Diagnostic Testing - e.g., thoracic spine X-ray, MRI if indicated].  Initial treatment plan includes [Treatment Plan - e.g., conservative management with rest, ice, heat, over-the-counter analgesics such as ibuprofen or naproxen, physical therapy referral for range of motion exercises and strengthening, patient education on proper posture and body mechanics].  Follow-up scheduled in [Follow-up Duration] to assess response to treatment and adjust plan as needed.  ICD-10 code considerations include [ICD-10 Codes - e.g., M54.6, M54.8].