Patient presents with left lower quadrant abdominal pain (LLQ pain), onset [duration] ago.  Character of pain described as [sharp, dull, cramping, aching, burning, stabbing, intermittent, constant].  Pain severity reported as [mild, moderate, severe] on a scale of 0-10, currently rated as [number].  Associated symptoms include [nausea, vomiting, diarrhea, constipation, fever, chills, bloating, flatulence, dysuria, hematuria, change in bowel habits].  Patient denies [relevant negatives, e.g., trauma, recent travel, bloody stools].  Physical examination reveals [tenderness in the left lower quadrant, guarding, rebound tenderness, distension, bowel sounds present or absent or hypoactive or hyperactive].  Differential diagnosis includes diverticulitis, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), constipation, ovarian cyst, ectopic pregnancy, endometriosis, inguinal hernia, renal colic, pyelonephritis, and sigmoid volvulus.  Initial impression suggests [leading suspected diagnosis based on presentation].  Plan includes [complete blood count (CBC), urinalysis, abdominal X-ray, CT scan of the abdomen and pelvis with or without contrast, pelvic ultrasound, stool studies, pregnancy test if applicable].  Patient education provided regarding [diagnosis, treatment plan, follow-up instructions].  Patient advised to return to clinic if symptoms worsen or new symptoms develop.  Medical decision making (MDM) complexity [low, moderate, high].  ICD-10 code R10.31, Left lower quadrant pain, will be used for billing, pending further diagnostic studies.  CPT codes for evaluation and management (E M) services, laboratory testing, and imaging studies will be determined based on the services provided.