Stiff Neck

Patient presents with acute neck pain and stiffness, consistent with a diagnosis of stiff neck, also known as acute cervicalgia or torticollis.  Onset of symptoms was [Onset timeframe - e.g., two days ago] and is described as [Character of pain - e.g., a constant, dull ache with sharp pain upon movement].  Pain is localized to [Location - e.g., the right posterior cervical region] with radiation to [Radiation - e.g., right shoulder and upper back] and is rated [Pain scale] on a 0-10 pain scale.  Range of motion is limited in [Direction of limitation - e.g., flexion, extension, and rotation to the left].  Patient denies any recent trauma, fever, or neurological symptoms.  Physical examination reveals [Objective findings - e.g., palpable muscle spasm in the right trapezius and sternocleidomastoid muscles, tenderness upon palpation of the cervical facet joints].  No signs of radiculopathy or myelopathy were observed.  Differential diagnoses include muscle strain, cervical spondylosis, and whiplash.  Assessment points to a likely diagnosis of acute stiff neck secondary to [Suspected etiology - e.g., poor posture or muscle strain].  Plan includes conservative management with [Treatment plan - e.g., NSAIDs for pain relief, heat therapy, gentle stretching exercises, and patient education on proper posture and ergonomics].  Patient advised to follow up if symptoms worsen or do not improve within [Follow-up timeframe - e.g., one week].  ICD-10 code M54.2, Cervicalgia, is assigned.