Patient presents with complaints of neck pain, stiffness, and limited range of motion, consistent with a diagnosis of neck muscle strain.  Onset of symptoms reported as [acute/gradual] and attributed to [specific activity or event, e.g., lifting heavy object, prolonged computer use, whiplash injury, sleeping in an awkward position].  Pain described as [aching, sharp, throbbing, etc.] located in [specific location, e.g., cervical spine, upper back, base of skull] and radiating to [shoulder, arm, head, if applicable].  Palpation reveals [tenderness, muscle spasms, trigger points] in the [specific muscle group, e.g., trapezius, sternocleidomastoid, levator scapulae].  Range of motion is [limited/restricted] in [flexion, extension, lateral rotation] with reported pain upon movement.  Neurological examination including assessment of strength, sensation, and reflexes is [normal/abnormal, specify findings].  No signs of radiculopathy or myelopathy.  Differential diagnoses considered include cervical disc herniation, facet joint syndrome, and whiplash associated disorder, but were ruled out based on clinical presentation and examination findings.  Diagnosis of neck muscle strain is supported by the patient's history, physical examination, and absence of neurological deficits.  Treatment plan includes rest, ice therapy, over-the-counter analgesics such as ibuprofen or naproxen, and gentle range of motion exercises.  Patient education provided regarding proper posture, ergonomics, and activity modification.  Follow-up recommended in [timeframe] to assess response to treatment and discuss further management options if necessary, which may include physical therapy, muscle relaxants, or referral to a specialist for pain management.  ICD-10 code: S16.1XXA (for unspecified neck muscle strain, initial encounter).