Day 3

Subjective: Mrs. X reported that she has not been sleeping well at all. Her right upper trapezius muscles

have been very tight and are preventing her from turning her head. Would like to focus on trapezius

muscles today to decrease this pain.

Objective: Completed soft tissue movement and trigger point release to decrease pain. Patient

instructed to add new exercises to increase range of motion, flexibility, and mobility. Applies

compression and ice to decrease swelling.

Assessment: Patient responded well to soft tissue movement and releases. PROM continues to improve

for both flexion and extension.

Plan: Continue with PROM in right shoulder for flexion and extension. Re-assess trapezius muscle.