Patient presents with chief complaint of malaise and fatigue.  Symptoms onset was reported as [gradual/sudden] approximately [duration] ago.  Patient describes fatigue as [constant/intermittent], characterized by [description of fatigue; e.g., overwhelming tiredness, lack of energy, difficulty concentrating, inability to complete daily tasks].  Malaise is described as a general feeling of discomfort, illness, or uneasiness.  Patient denies [or reports] associated symptoms such as fever, chills, weight loss, night sweats, lymphadenopathy, or body aches.  Review of systems is otherwise negative except as noted.  Patient's medical history includes [list relevant medical history, e.g., hypothyroidism, anemia, depression].  Current medications include [list current medications].  Physical examination reveals [objective findings; e.g., normal vital signs, no palpable lymphadenopathy, alert and oriented].  Differential diagnosis includes viral infection, anemia, depression, hypothyroidism, sleep disorders, chronic fatigue syndrome, and other medical conditions.  Initial diagnostic workup may include complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH), and urinalysis.  Further evaluation may be warranted based on initial results.  Patient education provided on importance of adequate rest, hydration, and balanced nutrition.  Follow-up scheduled in [timeframe] to review lab results and discuss further management based on findings.  Diagnosis: Malaise and Fatigue (R53.83).  ICD-10 code R53.83 is used for generalized fatigue and malaise.  This documentation supports medical necessity for evaluation and management services.