Patient presents with complaints of trapezius muscle pain, stiffness, and spasm.  Symptoms include neck pain, shoulder pain, upper back pain, and limited range of motion.  Onset of symptoms was [Date of onset] and is described as [Onset description: gradual or sudden].  Patient reports [Possible causes or aggravating factors: stress, poor posture, overuse, injury, or recent trauma].  Physical examination reveals tenderness to palpation of the trapezius muscle,  muscle tightness, and palpable muscle knots or trigger points.  Range of motion testing demonstrates [Specific limitations in neck rotation, lateral flexion, or shoulder elevation].  Pain is reported as [Pain characterization: sharp, dull, aching, burning] and rated [Pain scale rating] on a 0-10 scale.  Diagnostic assessment includes palpation and range of motion evaluation.  Differential diagnoses considered include cervical radiculopathy, rotator cuff injury, and fibromyalgia.  Diagnosis of trapezius muscle spasm is made based on clinical findings.  Treatment plan includes conservative management with heat therapy, rest, gentle stretching exercises, and over-the-counter pain relievers such as ibuprofen or naproxen.  Patient education provided on proper posture, ergonomics, and stress management techniques.  Follow-up appointment scheduled in [Duration] to assess response to treatment and consider further interventions such as physical therapy or muscle relaxants if necessary.  ICD-10 code M79.1 (Myalgia) is considered.  CPT codes for evaluation and management, therapeutic exercise, or other modalities will be determined based on services provided.