Patient presents with generalized muscle weakness, impacting both proximal and distal muscle groups.  Onset of weakness is reported as [gradual/sudden], occurring over [timeframe].  Patient denies any focal neurological deficits such as numbness, tingling, or sensory changes.  Symptoms include difficulty with activities of daily living, such as [examples: climbing stairs, rising from a chair, lifting objects, gripping utensils].  Review of systems reveals [positive/negative] findings for fatigue, muscle pain (myalgia), muscle cramps, and decreased exercise tolerance.  Medical history includes [relevant medical conditions, e.g., hypothyroidism, autoimmune disorders, electrolyte imbalances].  Medications include [list current medications].  Family history is [positive/negative] for neuromuscular disorders.  Physical examination reveals [objective findings, e.g., reduced muscle strength graded on Medical Research Council scale, decreased deep tendon reflexes].  Differential diagnosis includes neuromuscular disorders, metabolic myopathies, endocrine disorders, electrolyte imbalances, and medication side effects.  Initial laboratory workup includes complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid function tests (TFTs), creatine kinase (CK), and inflammatory markers.  Further evaluation may include electromyography (EMG), nerve conduction studies (NCS), and muscle biopsy if clinically indicated.  Assessment: Generalized muscle weakness, etiology undetermined.  Plan:  Symptomatic treatment, referral to [specialist, e.g., neurologist, rheumatologist] for further evaluation and management.  Patient education provided regarding potential causes of muscle weakness, diagnostic testing, and treatment options.  Follow-up scheduled in [timeframe] to reassess symptoms and review laboratory results.  ICD-10 code: [appropriate ICD-10 code, e.g., M62.81].