Patient presents with generalized weakness, asthenia, fatigue, and malaise.  Onset of symptoms is reported as (gradualonset, sudden onset, insidious onset) approximately (duration) ago.  The weakness affects (upper extremities, lower extremities, both upper and lower extremities) and is characterized by (difficulty with activities of daily living ADLs, decreased exercise tolerance, reduced muscle strength, inability to perform usual tasks).  Patient denies (or reports) any associated symptoms such as fever, chills, weight loss, night sweats, pain, numbness, tingling, or changes in bowel or bladder function.  Review of systems is otherwise unremarkable except as noted.  Physical examination reveals (normal muscle strength, reduced muscle strength grade (scale used), muscle atrophy, tremors, fasciculations).  Neurological examination is (normal, abnormal) with (detailed findings). Differential diagnosis includes but is not limited to metabolic disorders, electrolyte imbalances, infections, autoimmune diseases, neuromuscular disorders, endocrine dysfunction, and deconditioning.  Initial laboratory workup includes complete blood count CBC, comprehensive metabolic panel CMP, thyroid stimulating hormone TSH, vitamin B12 level, and erythrocyte sedimentation rate ESR.  Further investigation may include electromyography EMG, nerve conduction studies NCS, muscle biopsy, or imaging studies as clinically indicated.  Plan is to evaluate for underlying medical conditions contributing to the generalized weakness.  Patient education provided regarding energy conservation techniques, symptom management, and the importance of follow-up care.  Return to clinic scheduled in (duration) for reevaluation and discussion of test results.  ICD-10 code R53.1, Generalized weakness, is considered.  Medical necessity for testing and treatment will be documented.