Patient presents with complaints of shoulder pain, possibly indicating a shoulder injury.  Onset of symptoms occurred [Date of onset] following [Mechanism of injury; e.g., fall, overuse, sports injury].  Patient reports [Character of pain; e.g., sharp, dull, aching, burning] pain localized to [Location of pain; e.g., anterior, posterior, lateral shoulder; specify if radiating] with [Exacerbating factors; e.g., movement, rest, lifting] and alleviated by [Alleviating factors; e.g., rest, ice, heat, medication].  Pain severity reported as [Pain scale rating; e.g., 3/10 on numerical rating scale].  Physical examination reveals [Objective findings; e.g., tenderness to palpation, limited range of motion, crepitus, swelling, deformity, muscle weakness, positive impingement signs such as Neer or Hawkins test].  Differential diagnosis includes rotator cuff tear, shoulder impingement syndrome, frozen shoulder (adhesive capsulitis), shoulder instability, labral tear, biceps tendonitis, arthritis, and fracture.  Diagnostic imaging including [Imaging studies ordered; e.g., X-ray, MRI, ultrasound] may be indicated to further evaluate the shoulder joint and surrounding structures.  Initial treatment plan includes [Treatment plan; e.g., rest, ice, compression, elevation (RICE), nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy referral, corticosteroid injection].  Patient education provided regarding activity modification, pain management strategies, and potential complications.  Follow-up appointment scheduled in [Duration; e.g., 2 weeks] to assess response to treatment and determine further management.  ICD-10 code[s] [Insert appropriate ICD-10 code(s); e.g., M75.1, S43.401A] may be considered based on clinical findings.  CPT code[s] for evaluation and management (E/M) services and procedures will be assigned based on the complexity of the visit and specific interventions performed.