Upper Back Pain
HISTORY:
Upper back pain for
Onset: , following
Location:
Radiation:
Severity: , / 10
Type:
Pattern: ,
Worsening factors:
, ,
Treatments tried: ,
Occupation:
Other elements:
EXAM:
Thoracic spine:
- Inspection:
- Palpation:
- Range of motion:
- Flexion:
- Neurovascular: LE , distal pulses , sensation , strengths -R /5 - L /5
- Gait:
ASSESSMENT:
DDx:
PLAN:
- Thoracic spine X-ray
- CT scan of thoracic spine
- Advised that the condition is likely benign and that they should remain active as tolerated
- Encouraged to stretch, keep good posture, and avoid lifting weight
- Physical therapy
- Heat or cold therapy
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-
-
-
- for
- Referral to orthopedic surgeon
- Follow-up in
- Return if pain worsens or if symptoms do not improve with treatment