Upper Back Pain
Age: years old
Gender:
HISTORY:
Presents with a - history of upper back pain
Onset was , started
Location is
Radiation to
Rated at / 10
Described as
Pattern
Worsening factors:
Alleviating factors: ,
Occupation:
Associated symptoms: *Try using right-click for negatives*
, , , ,
, over
, up to °, over
Contributing factors:
no history of: , , , ,
no use of:
EXAM:
Thoracic Spine:
Inspection:
Palpation:
Range of motion:
- Flexion:
- Extension:
- Right bending:
- Left bending:
- Right rotation:
- Left rotation:
Neurovascular: , sensation
ASSESSMENT:
DDx: muscle strain, thoracic sprain, thoracic disc herniation, thoracic radiculopathy, costovertebral joint dysfunction, scoliosis, vertebral fracture, ankylosing spondylitis, metastatic cancer to the spine, epidural abscess, spinal stenosis, osteoporotic compression fractures, pancoast tumor, pulmonary embolism, pleurisy, pneumonia, myocardial infarction, aortic dissection, GERD, pancreatitis, gallbladder disease, herpes zoster
PLAN:
Investigations:
- Thoracic spine X-ray
- CT scan of thoracic spine
Treatments:
- 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
-
-
-
-
- for
Further care:
- Referral to orthopedic surgeon
- Follow-up in
- Return if pain worsens or if symptoms do not improve with treatment
HISTORY: Associated symptoms: EXAM: Thoracic Spine: ASSESSMENT: PLAN: