Patient presents with complaints of lumbar back pain.  Onset of pain is reported as gradual over the past [duration] and is described as [character of pain: e.g., aching, sharp, burning, throbbing].  Pain is localized to the [specific location: e.g., lower back, radiating to buttock,  radiating down the leg] and is exacerbated by [exacerbating factors: e.g., bending, lifting, prolonged sitting] and alleviated by [alleviating factors: e.g., rest, ice, heat].  Patient denies any [associated symptoms: e.g., bowel or bladder incontinence, numbness, tingling, weakness].  Pain severity is reported as [pain scale rating] out of 10.  Past medical history includes [relevant medical history: e.g., previous back injury, arthritis, osteoporosis].  Surgical history includes [relevant surgical history].  Medications include [current medications].  Allergies include [allergies].  Physical examination reveals [objective findings: e.g., tenderness to palpation in the lumbar region, limited range of motion, positive straight leg raise test].  Neurological examination is [neurological exam findings: e.g., intact, diminished reflexes, sensory deficits].  Assessment: Lumbar back pain.  Differential diagnoses include lumbar strain, lumbar spondylosis, herniated disc, spinal stenosis.  Plan includes [treatment plan: e.g., conservative management with NSAIDs, physical therapy,  referral to specialist, imaging studies such as X-ray or MRI of the lumbar spine].  Patient education provided regarding proper body mechanics, activity modification, and pain management strategies.  Follow-up scheduled in [duration] to assess response to treatment.  ICD-10 code: [relevant ICD-10 code, e.g., M54.5].