Patient presents with complaints of right elbow pain, possibly indicative of a right elbow injury.  Onset of pain was (onset date or duration) and is characterized as (sharp, dull, aching, throbbing, etc.).  Pain is aggravated by (specific movements or activities, e.g., lifting, extending, flexing) and alleviated by (rest, ice, medication, etc.).  Patient reports (presence or absence of) associated symptoms such as swelling, bruising, numbness, tingling, weakness, or limited range of motion.  Mechanism of injury reported as (fall, direct blow, overuse, etc.).  Physical examination reveals (tenderness to palpation over lateral epicondyle, medial epicondyle, olecranon, etc.),  (range of motion limitations in flexion, extension, supination, pronation), and (positive or negative) instability testing.  Differential diagnosis includes lateral epicondylitis, medial epicondylitis, cubital tunnel syndrome, radial tunnel syndrome, olecranon bursitis, and elbow sprain or strain.  Assessment suggests (working diagnosis, e.g., right elbow sprain).  Plan includes (conservative treatment, e.g., RICE protocol rest, ice, compression, elevation, NSAIDs nonsteroidal anti-inflammatory drugs, physical therapy referral) or (further investigation, e.g., X-ray, MRI magnetic resonance imaging) to rule out fracture or other significant pathology.  Patient education provided regarding activity modification, pain management, and follow-up care.  Follow-up scheduled in (duration) to assess response to treatment.  ICD-10 codes to be considered include (appropriate codes based on working diagnosis, e.g., S50, S51, M77).  CPT codes for today's visit will reflect evaluation and management services provided (e.g., 99201-99205 or 99211-99215).