Patient presents with symptoms consistent with a musculoskeletal strain.  Onset of [acute or chronic] pain reported as [location of strain, e.g., lower back, hamstring, neck] pain, initiated by [mechanism of injury, e.g., lifting heavy object, sudden movement, overuse].  Patient describes the pain as [character of pain, e.g., sharp, dull, aching, throbbing] and rates its severity as [pain scale rating, e.g., 5/10 on the visual analog scale].  Palpation reveals [tenderness, swelling, spasm, trigger points] at the [specific anatomical location, e.g., lumbar paraspinal muscles, proximal hamstring tendon, trapezius muscle].  Range of motion is [limited, normal] with [specific movements, e.g., forward flexion, lateral bending, cervical rotation] producing increased pain.  No neurological deficits noted.  Assessment: Muscle strain of the [specific muscle or muscle group].  Differential diagnoses considered include [e.g., muscle tear, ligament sprain, nerve impingement].  Plan: Conservative management initiated with RICE protocol (rest, ice, compression, elevation).  Patient advised to avoid aggravating activities.  Prescribed [medications, e.g., NSAIDs, muscle relaxants] for pain management.  Referral to physical therapy for [therapeutic exercises, modalities] to restore function and strength.  Follow-up appointment scheduled in [timeframe, e.g., 2 weeks] to assess response to treatment and adjust plan as needed.  ICD-10 code: [appropriate ICD-10 code, e.g., S20.109A for unspecified strain of cervical muscle].