Left Upper Arm Pain

Patient presents with left upper arm pain.  Onset of pain was [duration] ago and is described as [quality of pain; e.g., sharp, dull, aching, burning] and [frequency; e.g., constant, intermittent].  Pain severity is rated [scale; e.g., 0-10] with exacerbating factors including [list exacerbating factors; e.g., lifting, reaching overhead] and alleviating factors including [list alleviating factors; e.g., rest, ice].  Location of pain is specified as [specific location; e.g., anterior, posterior, medial, lateral aspect of upper arm] and radiates [radiation pattern; e.g., to the elbow, shoulder, neck, fingers; or, no radiation].  Associated symptoms include [list associated symptoms; e.g., numbness, tingling, weakness, swelling, redness, warmth].  Patient denies [list pertinent negatives; e.g., fever, chills, trauma, recent infection].  Medical history includes [list relevant medical history; e.g., hypertension, diabetes, prior shoulder injury].  Surgical history includes [list relevant surgical history].  Medications include [list current medications].  Allergies include [list allergies].  Physical examination reveals [objective findings; e.g., tenderness to palpation over the [specific muscle or area], limited range of motion in the shoulder, normal pulses, intact sensation].  Differential diagnosis includes [list potential diagnoses; e.g., rotator cuff tear, biceps tendinitis, brachial plexus neuropathy, cervical radiculopathy].  Assessment:  Left upper arm pain, likely due to [most likely diagnosis].  Plan:  [Outline plan; e.g., Recommend conservative management including rest, ice, and over-the-counter pain relievers such as ibuprofen.  Prescribed [medication, if any].  Referred to physical therapy.  Follow-up appointment scheduled in [timeframe].  Return sooner if symptoms worsen or new symptoms develop].