Patient presents with complaints of shoulder pain, consistent with a rotator cuff tear.  Symptoms include pain with abduction and external rotation, weakness, and limited range of motion.  Onset of symptoms occurred [Timeframe] following [Mechanism of injury, e.g., a fall, repetitive overhead activity].  Patient reports difficulty with activities of daily living, including [Specific examples, e.g., reaching overhead, dressing, sleeping].  Physical examination reveals positive findings for [Specific tests, e.g., Neer impingement sign, Hawkins test, empty can test].  Imaging studies, including [Specify imaging, e.g., MRI, ultrasound], confirm a full-thickness tear of the [Specify tendons involved, e.g., supraspinatus, infraspinatus] tendon.  Diagnosis of rotator cuff tear confirmed.  Treatment plan includes [Conservative or surgical options, e.g., physical therapy, NSAIDs, rotator cuff repair surgery].  Patient education provided regarding rotator cuff injury, treatment options, post-operative rehabilitation, and potential complications.  Follow-up scheduled in [Timeframe] to assess progress and adjust treatment plan as needed.  ICD-10 code: [Appropriate ICD-10 code, e.g., M75.111].  CPT codes for procedures will be determined at the time of service.  Differential diagnosis considered and ruled out [List ruled out diagnoses, e.g., adhesive capsulitis, bicipital tendinitis].  Prognosis for recovery is [Good, fair, poor] based on [Factors influencing prognosis, e.g., tear size, patient age, comorbidities].