Rotator Cuff Tear

Patient presents with complaints consistent with rotator cuff tear, including shoulder pain, weakness, and limited range of motion.  Onset of symptoms began approximately [duration] ago and is described as [character of pain: sharp, dull, aching, etc.]  The pain is located [location of pain: anterior, posterior, lateral shoulder, etc.] and radiates to [radiation pattern: upper arm, neck, etc.].  Aggravating factors include [activities that worsen pain: lifting, reaching overhead, sleeping on affected side, etc.]  Alleviating factors include [activities that lessen pain: rest, ice, over-the-counter pain relievers, etc.].  Patient reports [impact on daily activities: difficulty dressing, driving, working, etc.].  Physical examination reveals [positive or negative findings: tenderness to palpation, positive Neer impingement sign, positive Hawkins-Kennedy test, limited active and passive range of motion, muscle atrophy, crepitus, etc.].  Diagnostic imaging, including [imaging modalities:  X-ray, MRI, ultrasound], was ordered to confirm the diagnosis and assess the extent of the tear.  Differential diagnoses considered include rotator cuff tendinitis, impingement syndrome, frozen shoulder, and cervical radiculopathy.  Assessment: Rotator cuff tear (ICD-10 code: M75.1). Plan:  Conservative management will be initiated, including rest, ice, compression, elevation (RICE), nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy focusing on range of motion and strengthening exercises.  Patient education provided regarding proper body mechanics and activity modification.  Surgical intervention, such as rotator cuff repair, will be considered if conservative treatment fails to provide adequate symptom relief.  Follow-up appointment scheduled in [timeframe] to reassess progress and adjust treatment plan as needed.