Patient presents with complaints of neck pain and muscle spasm, consistent with a diagnosis of acute cervicalgia.  Onset of symptoms occurred [duration] ago and is described as [quality of pain: e.g., sharp, dull, aching, throbbing].  Pain is located in the [location: e.g., upper, mid, lower] cervical region and radiates to [radiation: e.g., shoulders, head, upper back].  Patient reports [severity of pain: e.g., mild, moderate, severe] pain, rated [pain scale rating] on a numerical rating scale of 0-10.  Associated symptoms include [associated symptoms: e.g., stiffness, limited range of motion, headache, tingling, numbness].  Aggravating factors include [aggravating factors: e.g., movement, prolonged sitting, stress].  Alleviating factors include [alleviating factors: e.g., rest, heat, over-the-counter pain relievers].  Physical examination reveals [physical exam findings: e.g., tenderness to palpation in the paraspinal muscles, restricted range of motion in flexion, extension, and rotation, palpable muscle tightness, trigger points].  Neurological examination is [neurological exam findings: e.g., normal, with intact strength, sensation, and reflexes].  Differential diagnoses considered include cervical radiculopathy, whiplash injury, and degenerative disc disease.  Diagnosis of muscle spasm of neck is supported by clinical presentation and physical exam findings.  Treatment plan includes [treatment plan: e.g., conservative management with rest, ice, heat therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, physical therapy, and patient education on proper posture and ergonomics].  Follow-up scheduled in [follow-up duration] to assess response to treatment.  ICD-10 code M79.1 (Myalgia and myositis, unspecified neck) is assigned.