Patient presents with complaints consistent with urinary hesitancy.  Symptoms include difficulty initiating urination, weak urine stream, straining to void, and a feeling of incomplete bladder emptying.  Onset of symptoms is reported as gradual over the past [timeframe].  Patient denies dysuria, hematuria, and fever.  Medical history includes [list relevant medical history, e.g., benign prostatic hyperplasia, diabetes, neurological conditions, medications].  Physical examination reveals [relevant findings, e.g., enlarged prostate on digital rectal exam, distended bladder].  Differential diagnosis includes benign prostatic hyperplasia, urethral stricture, bladder neck contracture, neurogenic bladder, and medication side effects.  Assessment of urinary hesitancy includes consideration of patient age, symptom duration, and associated symptoms.  Preliminary diagnosis of urinary hesitancy is made based on patient reported symptoms and clinical findings.  Plan includes [list planned interventions, e.g., urinalysis, prostate-specific antigen PSA test, uroflowmetry, post-void residual measurement, referral to urology].  Patient education provided regarding bladder health, fluid management, and potential treatment options for urinary hesitancy.  Follow-up scheduled in [timeframe] to review test results and discuss further management of urinary retention and voiding dysfunction.  ICD-10 code R39.15 (other difficulty in micturition) is considered pending further evaluation.  Medical decision making complexity is low to moderate based on the current clinical picture.