Patient presents with complaints of neck pain, upper back pain, and shoulder pain, consistent with a trapezius muscle strain.  Onset of symptoms occurred [Date of onset] after [Mechanism of injury - e.g., lifting heavy objects, sudden movement, prolonged poor posture].  Patient reports [Character of pain - e.g., sharp, dull, aching, throbbing] pain localized to the [Location of pain - e.g., right upper back, left neck, between shoulder blades] with pain radiating to [Area of radiation, if applicable - e.g., right shoulder, base of skull].  Pain is aggravated by [Aggravating factors - e.g., shoulder movement, neck rotation, overhead reaching] and relieved by [Relieving factors - e.g., rest, ice, heat].  Physical examination reveals [Physical exam findings - e.g., tenderness to palpation of the right trapezius muscle, limited range of motion in the right shoulder, muscle spasm, trigger points].  Neurological examination is [Neurological findings - e.g., intact, with no sensory or motor deficits].  Diagnosis of right trapezius muscle strain is made based on patient history, physical exam findings, and absence of other neurological or musculoskeletal pathology.  Differential diagnoses considered include cervical radiculopathy, rotator cuff tear, and thoracic outlet syndrome.  Treatment plan includes [Treatment plan - e.g., rest, ice, heat, over-the-counter pain relievers such as ibuprofen or naproxen, physical therapy, muscle relaxants].  Patient education provided on proper posture, lifting techniques, and stretching exercises.  Follow-up appointment scheduled in [Duration - e.g., one week] to assess response to treatment and adjust plan as needed.  ICD-10 code: [Appropriate ICD-10 code].