Patient presents with complaints of right leg pain.  Onset, duration, character, aggravating and alleviating factors, and radiation of the pain were assessed.  Patient reports experiencing right leg pain for (duration), describing the pain as (sharp, dull, aching, throbbing, burning, cramping, electric, etc.).  The pain is located in the (specific location, e.g., anterior thigh, calf, posterior knee) and (radiates to, does not radiate).  Aggravating factors include (e.g., weight-bearing, walking, sitting, standing, specific movements).  Alleviating factors include (e.g., rest, elevation, ice, heat, medication).  Patient denies (or reports) any associated symptoms such as numbness, tingling, weakness, swelling, discoloration, or changes in temperature.  Medical history includes (relevant medical history, e.g., diabetes, peripheral artery disease, prior leg injury, arthritis).  Surgical history includes (relevant surgical history, e.g., knee replacement, hip surgery).  Medications include (list current medications).  Allergies include (list allergies).  Physical examination reveals (tenderness, edema, erythema, palpable mass, limited range of motion, diminished pulses, neurological deficits, etc.).  Differential diagnosis includes muscle strain, ligament sprain, sciatica, peripheral neuropathy, deep vein thrombosis, peripheral artery disease, and osteoarthritis.  Plan includes (e.g., further investigation with imaging studies such as X-ray, MRI, or ultrasound, blood tests, physical therapy referral, pain management consultation, medication prescription, patient education on activity modification and home exercises).  Patient education provided regarding pain management strategies, potential causes of leg pain, and when to seek further medical attention. Follow-up scheduled for (date).  ICD-10 code (e.g., M79.601, M79.602, R26.2, M79.10, etc.) and CPT code (e.g., 99213, 99214, 99203, 99204, etc.) will be determined based on the final diagnosis and complexity of the visit.