Patient presents with complaints of right shoulder pain, consistent with a right shoulder strain.  Onset of pain was reported as [Date of onset] and is described as [Character of pain: e.g., sharp, aching, dull].  Pain is exacerbated by [Exacerbating factors: e.g., lifting, reaching overhead] and alleviated by [Alleviating factors: e.g., rest, ice]. Patient denies any history of trauma, dislocation, or previous shoulder injury.  Physical examination reveals [Specific findings: e.g., tenderness to palpation over the anterior deltoid, limited range of motion with abduction and external rotation, no ecchymosis or edema noted].  Strength testing reveals [Strength findings: e.g., 5/5 strength throughout the right upper extremity, with mild pain on resistance].  Neurological examination of the right upper extremity is unremarkable.  Diagnosis of right shoulder strain is made based on patient history, physical exam findings, and absence of indications for more serious pathology.  Differential diagnosis includes rotator cuff tear, shoulder impingement, and frozen shoulder.  Treatment plan includes rest, ice, compression, elevation (RICE), over-the-counter pain medication such as ibuprofen or naproxen, and gentle range of motion exercises.  Patient education provided regarding proper body mechanics and activity modification.  Follow-up appointment scheduled in [Duration] to assess response to treatment.  Patient advised to return sooner if symptoms worsen or new symptoms develop.  ICD-10 code: [Appropriate ICD-10 code, e.g., S43.401A - Sprain of unspecified muscle(s) and tendon(s) at shoulder level, right shoulder, initial encounter].