Patient presents with acute neck pain and muscle spasm, consistent with a diagnosis of neck spasm or acute cervicalgia.  Onset of symptoms was [Date of onset] and is described as [Character of pain: sharp, dull, aching, throbbing, etc.] and located in the [Location: cervical spine, upper back, radiating to shoulder/head, etc.].  Patient reports [Exacerbating factors:  worsening with movement, certain postures, stress, etc.] and [Relieving factors: rest, ice, heat, over-the-counter medications, etc.].  Physical examination reveals [Objective findings:  limited range of motion, muscle tenderness, palpable spasm in the [Specific muscle group:  trapezius, sternocleidomastoid, etc.], trigger points,  crepitus, and postural abnormalities. Neurological examination is [Normal or Abnormal, specify if abnormal] including [Sensory and motor function assessment, deep tendon reflexes]. Differential diagnoses considered include cervical radiculopathy, whiplash injury, and degenerative disc disease.  Initial treatment plan includes conservative management with [Specific treatment modalities: rest, ice/heat therapy, NSAIDs such as ibuprofen or naproxen, muscle relaxants, physical therapy referral for range of motion exercises, stretching, and strengthening]. Patient education provided on proper posture, ergonomics, and activity modification.  Follow-up scheduled in [Duration] to assess response to treatment and adjust plan as needed. Medical necessity for treatment established based on functional limitations and pain interfering with activities of daily living.  ICD-10 code M54.2, Cervicalgia, is documented for billing purposes.