Patient presents with complaints of neck pain, stiffness, and muscle spasm, consistent with a diagnosis of neck muscle spasm.  Onset of symptoms occurred [duration] ago and is described as [quality of pain: e.g., sharp, dull, aching, throbbing].  Patient reports [exacerbating factors: e.g., turning head, stress, poor posture] and [alleviating factors: e.g., heat, rest, over-the-counter pain relievers].  Pain severity is reported as [pain scale rating] on a 0-10 scale.  Physical examination reveals [objective findings: e.g., tenderness to palpation of [specific muscle(s)], limited range of motion in [direction], palpable muscle tightness, trigger points].  No neurological deficits were noted.  Differential diagnoses considered include cervical radiculopathy, whiplash, and other musculoskeletal disorders.  Assessment supports a diagnosis of acute neck muscle spasm, likely due to [probable cause: e.g., muscle strain, poor posture, stress].  Plan includes conservative management with [treatment plan: e.g., NSAIDs, muscle relaxants, physical therapy referral for range of motion exercises, postural education, heat or ice application].  Patient education provided on proper posture, ergonomics, and stress management techniques.  Follow-up scheduled in [timeframe] to assess response to treatment and adjust plan as needed.  ICD-10 code [appropriate ICD-10 code, e.g., M79.1] is assigned.