Patient presents with complaints of trapezius muscle pain, stiffness, and spasm, consistent with a trapezius strain.  Onset of symptoms occurred [Date of onset] following [Mechanism of injury - e.g., lifting heavy object, awkward sleeping position, overuse from repetitive activity].  Patient reports pain localized to the [Location - e.g., upper back, neck, shoulder] region, described as [Character of pain - e.g., aching, sharp, burning].  Pain is exacerbated by [Aggravating factors - e.g., shoulder movement, head rotation, palpation].  Patient denies any radiating pain, numbness, or tingling.  Physical examination reveals [Objective findings - e.g., tenderness to palpation over the trapezius muscle, limited range of motion in the cervical spine and shoulder, palpable muscle spasm, postural abnormalities].  Neurological examination is unremarkable.  Differential diagnoses considered include cervical radiculopathy, rotator cuff tear, and myofascial pain syndrome.  Diagnosis of trapezius strain is supported by clinical presentation and physical exam findings.  Treatment plan includes rest, ice, compression, elevation (RICE), nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management, physical therapy focusing on range of motion exercises and strengthening, and patient education on proper posture and body mechanics.  Follow-up scheduled in [Duration - e.g., one week, two weeks] to assess response to treatment.  ICD-10 code: [Appropriate ICD-10 code - e.g., S46.111A - Strain of right trapezius muscle, initial encounter].