Patient presents with right lower leg pain.  Onset of pain was (duration) and is described as (character: sharp, dull, aching, throbbing, burning, etc.).  The pain is located in the (specific location: calf, shin, ankle, foot, etc.) and radiates to (location if applicable).  Aggravating factors include (activities, positions, etc.) and alleviating factors include (rest, ice, elevation, medication, etc.).  Patient denies any history of trauma, injury, or recent strenuous activity.  Review of systems is negative for fever, chills, numbness, tingling, swelling, redness, or skin changes in the affected area.  Medical history includes (relevant medical conditions such as diabetes, peripheral artery disease, deep vein thrombosis, etc.).  Surgical history includes (relevant surgical procedures).  Medications include (list current medications).  Allergies include (list allergies).  Physical examination reveals (tenderness, swelling, warmth, redness, palpable cords, pulses: dorsalis pedis and posterior tibial, range of motion, etc.).  Differential diagnoses include muscle strain, shin splints, stress fracture, compartment syndrome, deep vein thrombosis, peripheral artery disease, sciatica, and referred pain.  Assessment: Right lower leg pain, likely due to (most likely diagnosis).  Plan includes (diagnostic tests if needed: X-ray, ultrasound, MRI, D-dimer, etc.), (treatment plan: RICE therapy, pain medication such as ibuprofen or naproxen, referral to physical therapy, specialist referral if needed, etc.), and patient education regarding activity modification, proper stretching techniques, and follow-up care.  Patient advised to return if symptoms worsen or do not improve with treatment.