Patient presents with complaints of right shoulder pain, consistent with a suspected labral tear.  Onset of pain was reported as [gradual/sudden] and began [ timeframe, e.g., three weeks ago] after [mechanism of injury, e.g., lifting a heavy object/a fall].  Patient localizes the pain to the [specific location, e.g., anterior/posterior aspect of the shoulder] and describes the pain as [quality of pain, e.g., sharp, aching, burning].  Pain is exacerbated by [aggravating factors, e.g., overhead activities, reaching behind back] and relieved by [alleviating factors, e.g., rest, ice].  Patient reports [presence/absence] of mechanical symptoms such as clicking, popping, catching, or grinding in the shoulder.  Physical examination reveals [positive/negative] Neer impingement sign, [positive/negative] Hawkins-Kennedy test, and [positive/negative] OBrien test.  Range of motion in the right shoulder is [limited/within normal limits] with [specific ROM limitations, e.g., abduction, external rotation].  Strength testing of the right shoulder musculature is [grade, e.g., 5/5] throughout.  Differential diagnosis includes rotator cuff tear, shoulder instability, biceps tendinopathy, and adhesive capsulitis.  Based on clinical presentation and examination findings, the presumptive diagnosis is labral tear of the right shoulder.  Plan includes MRI of the right shoulder without contrast to confirm the diagnosis and evaluate the extent of the tear.  Treatment options will be discussed with the patient following review of the MRI results and may include conservative management with physical therapy, corticosteroid injection, or surgical intervention such as arthroscopic labral repair.  Patient education provided on activity modification, pain management strategies, and the importance of follow-up care.  ICD-10 code: [appropriate ICD-10 code, e.g., M25.411, S43.411A].  CPT codes for anticipated procedures: [anticipated CPT codes, e.g., 73221 for MRI, 29806 for arthroscopic labral repair].