Patient presents with complaints of left shoulder pain, consistent with a left shoulder strain.  Onset of pain occurred [Date of onset] while [Mechanism of injury - e.g., lifting heavy objects, playing sports, falling].  Patient reports [Character of pain - e.g., sharp, dull, aching, throbbing] pain located in the [Location of pain - e.g., anterior, posterior, lateral] aspect of the left shoulder, exacerbated by [Exacerbating factors - e.g., movement, palpation, overhead activities] and relieved by [Relieving factors - e.g., rest, ice, analgesics].  Pain is rated [Pain scale rating] on a 0-10 scale.  Physical examination reveals [Findings - e.g., tenderness to palpation over the left deltoid muscle, limited range of motion in the left shoulder, no obvious deformity or ecchymosis].  Neurovascular examination of the left upper extremity is intact.  Differential diagnosis includes rotator cuff tear, frozen shoulder, and shoulder impingement.  Assessment: Left shoulder strain.  ICD-10 code: [Appropriate ICD-10 code - e.g., S43.409A].  Treatment plan includes rest, ice, compression, elevation (RICE), over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen for pain management, and physical therapy for range of motion and strengthening exercises.  Patient education provided on proper body mechanics and activity modification.  Follow-up appointment scheduled in [Duration - e.g., one week, two weeks] to assess response to treatment and adjust plan as needed.  Prognosis is good for full recovery with conservative management.