Patient presents with complaints consistent with L4 compression fracture.  Onset of low back pain is reported as [onset date or duration], potentially following [mechanism of injury if applicable, e.g., fall, lifting heavy object, or atraumatic if applicable].  Pain is localized to the lower back, potentially radiating to [location of radiating pain, e.g., buttock, thigh, or leg] and described as [quality of pain, e.g., sharp, aching, burning].  The patient exhibits [level of pain using pain scale, e.g., 710 pain].  Physical examination reveals [positive or negative findings, e.g., point tenderness over the L4 vertebra, paraspinal muscle spasm, limited lumbar range of motion, neurological deficits including sensory changes, muscle weakness, or diminished reflexes if present].  Diagnostic imaging, including [imaging modality, e.g., lumbar spine X-ray, CT scan, or MRI], confirms the diagnosis of L4 compression fracture, demonstrating [specific imaging findings, e.g., loss of vertebral height, wedge deformity, or retropulsion of bone fragments].  Differential diagnoses considered include lumbar strain, herniated disc, spinal stenosis, and spondylolisthesis.  The patient's current medications include [list current medications].  Allergies include [list allergies].  Assessment includes L4 compression fracture.  Plan includes pain management with [medication name and dosage], physical therapy for lumbar stabilization exercises, activity modification, and bracing if indicated.  Patient education provided on fall prevention, proper body mechanics, and pain management strategies.  Follow-up scheduled in [duration] to assess response to treatment and adjust the plan as needed.  ICD-10 code [appropriate ICD-10 code, e.g., S32.0XXA] is assigned.