Patient presents with complaints of upper back pain, thoracic back pain, and discomfort between the shoulder blades.  Onset of pain is described as [acute/gradual/insidious], occurring [duration] ago, potentially related to [possible causative factor, e.g., lifting heavy objects, prolonged sitting, recent injury, stress].  Pain quality is reported as [sharp, dull, aching, burning, throbbing, radiating], with intensity rated [numeric pain scale 0-10].  Pain location is specified in the [cervicothoracic, mid-thoracic, thoracolumbar] region.  Associated symptoms may include muscle spasms, stiffness, limited range of motion, numbness, tingling, or radiating pain to the neck, shoulders, or arms.  Patient denies any fever, chills, night sweats, unexplained weight loss, or history of trauma.  Physical examination reveals [tenderness to palpation, muscle tightness, reduced spinal mobility, crepitus].  Neurological examination is [within normal limits/reveals sensory deficits/reveals motor deficits].  Differential diagnosis includes musculoskeletal strain, myofascial pain syndrome, thoracic facet joint dysfunction, degenerative disc disease, costochondritis, and referred pain.  Diagnostic imaging, such as X-ray or MRI of the thoracic spine, may be considered if indicated by clinical findings.  Initial treatment plan includes [conservative management with rest, ice, heat, over-the-counter pain relievers such as NSAIDs, physical therapy, postural education, ergonomic modifications].  Patient education regarding proper body mechanics, stretching exercises, and activity modification was provided.  Follow-up appointment scheduled in [timeframe] to assess response to treatment and adjust management plan as needed.  ICD-10 code considerations include [M54.6, M54.8, M54.9 depending on specific clinical presentation].