XX is an 45 year old man/woman who presents with 3 days of fever and back pain.
Then give your HPI on one chief complaint at a time.
In the review of systems, patient also complains of nonproductive cough, congestion, and nausea
XX has a history of (PMH list goes here)
(If any PMH is pertinent to the complaint you can expound on it more).
He's also had appendectomy/cholecystectomy/orchiectomy/spinal fusion (y years ago)/etc
His family history is noncontributory.
In terms of social history he's a 20 pack-year smoker, drinks 8 beers a day, has a history of IVDA, and lives alone
In terms of the physical:
His vital signs are normal except for a temperature of 100.7 and a HR of 108.
Pt is A&Ox3 and appears uncomfortable
HEENT is normal
lungs are clear
abdominal exam is normal
cardiac exam is regular tachycardia, with a 3/6 holosystolic murmur at the apex
Back exam is notable for midline ttp in the upper lumbar spine.
The remainder of the exam, including mental status and neuro exam is normal.
The assessment and plan is next and depends on what field you're in how you'd present it. That is a generic structure up there though of age/gender/CC followed by HPI, followed by RoS/PMH/PSH/FH/SH. Then physical exam with vitals first, then pertinent positives and negatives. If testing has been done already, you can then summarize labs, imaging, and ancillary testing. if it hasn't been done, you'd address it in the A/P.