Patient presents with complaints of upper back pain, consistent with a diagnosis of upper back strain (thoracic strain).  Onset of pain was reported as [onset - e.g., gradual, sudden] and began [duration - e.g., two days ago, one week ago] following [possible cause - e.g., lifting heavy objects, strenuous activity, prolonged sitting, awkward sleeping position, fall, MVA].  Pain quality is described as [pain quality - e.g., aching, sharp, dull, throbbing, burning] and located in the [location - e.g., upper back, between the shoulder blades, right paraspinal muscles, left trapezius region].  Patient denies any radiating pain, numbness, or tingling in the extremities.  Pain is aggravated by [aggravating factors - e.g., movement, deep breathing, certain postures] and relieved by [relieving factors - e.g., rest, heat, over-the-counter pain medication].  Physical examination reveals [physical exam findings - e.g., muscle tenderness to palpation in the upper back, paraspinal muscle spasm, limited range of motion in the thoracic spine, no neurological deficits].  Differential diagnoses considered include muscle strain, myofascial pain syndrome, and vertebral fracture.  Vertebral fracture is considered unlikely due to the [reasoning, e.g., mechanism of injury, lack of significant trauma].  Diagnosis of upper back strain is supported by the patient's history and physical examination findings.  Treatment plan includes [treatment plan - e.g., rest, ice, heat therapy, over-the-counter NSAIDs such as ibuprofen or naproxen, gentle stretching, physical therapy referral].  Patient education provided on proper body mechanics, posture, and lifting techniques.  Follow-up appointment scheduled in [duration - e.g., one week, two weeks] to assess response to treatment and adjust plan as needed.  ICD-10 code M75.1 (thoracic strain) is appropriate for this diagnosis.