Left Upper Trapezius Strain Case Study

Satisfactory Essays
Reason for visit: s/p ESI X 28 visits Left Upper Trapezius Strain
S: TM completed total of 28 ESI visits for his Left Upper Trapezius Strain that started in 8/25/2016. TM reports his pain at rest is 1-2/10; tightness, but with movement at work his pain can be up to 7/10. The pain is gradual as the shift progresses. ESI help him with manage his symptoms. For the fast couple of weeks, heat and the light massage of his left upper trapezius has improved his current condition. TM denies cervical neck pain, radiating pain, tingling, numbness, or loss of movement in his upper extremities. TM is not taking naproxen or acetaminophen as ordered.
O: Left Upper trapezius (LUT) muscle larger than the right when compared; no edema, no discoloration noted
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