Patient presents with complaints of left shoulder pain, consistent with a suspected left rotator cuff tear.  Onset of pain was reported as [gradual/acute] and occurred [duration] ago, potentially related to [mechanism of injury, e.g., lifting heavy object, fall, repetitive overhead activity].  Patient reports pain is [character of pain, e.g., sharp, dull, aching, burning] and located [location of pain, e.g., anterior, posterior, lateral shoulder, radiating down arm].  Pain is exacerbated by [aggravating factors, e.g., abduction, external rotation, reaching overhead] and relieved by [relieving factors, e.g., rest, ice].  Patient reports [presence/absence] of night pain and difficulty sleeping on the affected side.  Physical examination reveals [positive/negative] Neer impingement sign, [positive/negative] Hawkins-Kennedy test, and [positive/negative] Empty Can test.  Strength testing demonstrates [grade of strength, e.g., 4/5, 3/5] strength in left shoulder [abduction, flexion, external rotation, internal rotation].  Range of motion is limited in [specific movements] due to pain.  Differential diagnosis includes rotator cuff tendinopathy, adhesive capsulitis, shoulder osteoarthritis, and cervical radiculopathy.  Imaging studies including [X-ray, MRI, ultrasound] are recommended to confirm the diagnosis and assess the extent of the tear.  Initial treatment plan includes conservative management with rest, ice, compression, elevation, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy focusing on range of motion and strengthening exercises.  Corticosteroid injection may be considered.  Surgical intervention, such as rotator cuff repair, will be discussed if conservative treatment fails to provide adequate relief.  Follow-up appointment scheduled in [duration].  ICD-10 code: [appropriate ICD-10 code, e.g., M75.11].