Patient presents with complaints consistent with rotator cuff injury.  Symptoms include shoulder pain, weakness, and limited range of motion.  Onset of symptoms began approximately [duration] ago and is described as [character of pain: e.g., sharp, dull, aching] and located in the [location of pain: e.g., anterior, posterior, lateral] aspect of the shoulder.  The pain is [exacerbating factors: e.g., aggravated by overhead activities, lifting, sleeping on affected side] and [relieving factors: e.g., relieved by rest, ice].  Patient reports [impact on activities of daily living: e.g., difficulty with dressing, reaching, driving].  Physical examination reveals [positive or negative findings: e.g., tenderness to palpation over the rotator cuff tendons, positive Neer impingement sign, positive Hawkins-Kennedy test, limited active and passive range of motion in abduction, external rotation, and internal rotation].  Differential diagnoses include rotator cuff tendinitis, rotator cuff tear, shoulder impingement syndrome, adhesive capsulitis, and cervical radiculopathy.  Preliminary diagnosis is rotator cuff injury.  Plan includes [diagnostic tests: e.g., shoulder x-ray, MRI if indicated], [treatment: e.g., conservative management with rest, ice, compression, elevation (RICE), NSAIDs, physical therapy referral for range of motion exercises and strengthening, corticosteroid injection if indicated], and follow-up in [duration] to assess response to treatment.  Patient education provided regarding rotator cuff injury care, activity modification, and expected recovery.  ICD-10 code [appropriate ICD-10 code, e.g., M75.11 - Rotator cuff tear or rupture, right shoulder] and CPT codes [appropriate CPT codes for evaluation and management, injections, or procedures performed] will be assigned based on final diagnosis and treatment plan.  Prognosis is [prognosis: e.g., good with conservative treatment, guarded if surgery required].