Patient presents with weight gain, medically documented as excessive or unwanted weight increase.  The patient reports a gradual increase in weight over [timeframe], with a total weight gain of [amount].  Differential diagnoses considered include hypothyroidism, Cushing's syndrome, medication-induced weight gain, polycystic ovary syndrome (PCOS), and lifestyle factors such as increased caloric intake and decreased physical activity.  Assessment includes a review of the patient's medical history, current medications, dietary habits, and exercise regimen.  Physical examination reveals [objective findings related to weight, such as BMI, waist circumference, distribution of body fat].  Laboratory tests, including [list tests such as thyroid panel, fasting glucose, lipid panel], were ordered to evaluate potential underlying medical causes.  Patient education provided on healthy lifestyle modifications, including dietary counseling focusing on portion control and balanced nutrition, and recommendations for increased physical activity.  Treatment plan includes [mention specific interventions such as referral to a registered dietitian, exercise program, behavioral therapy for weight management, or pharmacotherapy if indicated].  Follow-up appointment scheduled in [timeframe] to monitor progress and adjust the treatment plan as needed. The patient's weight gain is being monitored for potential complications such as obesity, metabolic syndrome, type 2 diabetes, cardiovascular disease, and osteoarthritis.  ICD-10 code [relevant code such as E66.9 for unspecified obesity or R63.5 for overweight] assigned based on patient's BMI and clinical presentation.