Patient presents with right proximal humerus fracture.  Onset of symptoms occurred on [Date of onset] following a [Mechanism of injury - e.g., fall onto outstretched hand, direct blow].  Patient reports [Character of pain - e.g., sharp, throbbing] pain in the right shoulder and upper arm, exacerbated by movement.  Associated symptoms include [List associated symptoms - e.g., swelling, bruising, limited range of motion, crepitus].  Physical examination reveals [Objective findings - e.g., tenderness to palpation over the proximal humerus, ecchymosis, deformity, decreased active and passive range of motion of the right shoulder].  Neurovascular status of the right upper extremity is intact, with palpable radial pulse and normal sensation.  Radiographic imaging of the right shoulder, including [Specify views - e.g., AP, lateral, and Y views], confirms a proximal humerus fracture.  The fracture is classified as a [Neer classification] with [Describe fracture displacement and involvement of greater and lesser tuberosities, articular surface].  Differential diagnosis includes shoulder dislocation, rotator cuff tear, and contusion.  Treatment plan includes [Specify treatment plan - e.g., closed reduction, immobilization with a sling and swathe, pain management with analgesics, referral to orthopedics for surgical evaluation if indicated].  Patient education provided on pain management, activity modification, and follow-up care.  Follow-up appointment scheduled in [Duration] to assess healing progress and adjust treatment plan as needed.  ICD-10 code S42.2 assigned for closed fracture of upper end of humerus.  CPT codes for evaluation and management, radiographic imaging, and procedures will be documented separately based on services rendered.