Patient presents with complaints of muscle strain, likely due to [onset mechanism: e.g., overuse, trauma, sudden movement].  Symptoms include [list symptoms: e.g., localized pain, tenderness, muscle spasm, limited range of motion, stiffness, swelling, bruising].  Pain is characterized as [pain quality: e.g., sharp, dull, aching, throbbing] and is [pain severity: e.g., mild, moderate, severe] in intensity.  The location of the muscle strain is identified as [muscle location: e.g., hamstring, quadriceps, lower back].  On physical examination, [physical exam findings: e.g., palpation reveals tenderness and spasm in the affected muscle, range of motion is limited due to pain, ecchymosis present].  The mechanism of injury, physical exam findings, and reported symptoms are consistent with a diagnosis of muscle strain.  Differential diagnoses considered include [differential diagnoses: e.g., muscle tear, ligament sprain, tendonitis, fracture].  Diagnostic tests, such as [diagnostic tests: e.g., musculoskeletal ultrasound, MRI if clinically indicated], may be considered to rule out other conditions if symptoms persist or worsen.  The initial treatment plan includes [treatment plan: e.g., RICE therapy rest, ice, compression, elevation, NSAIDs for pain and inflammation management, gentle stretching and range of motion exercises as tolerated, physical therapy referral if needed].  Patient education provided on proper body mechanics, activity modification, and injury prevention strategies.  Follow-up appointment scheduled in [duration: e.g., one to two weeks] to assess progress and adjust treatment plan as necessary.  ICD-10 code: [appropriate ICD-10 code based on location and severity].