Patient presents with complaints of shoulder pain consistent with a shoulder muscle strain.  Onset of pain occurred [Date of onset] while [Mechanism of injury - e.g., lifting heavy objects, playing sports, falling].  Patient localizes pain to [Specific location - e.g., anterior, posterior, lateral shoulder], describing it as [Character of pain - e.g., sharp, dull, aching, throbbing].  Pain is aggravated by [Aggravating factors - e.g., movement, palpation, raising arm overhead] and relieved by [Relieving factors - e.g., rest, ice].  Patient denies any numbness, tingling, or radiating pain.  Physical examination reveals [Objective findings - e.g., tenderness to palpation over [Specific muscle - e.g., rotator cuff muscles, deltoid, trapezius], limited range of motion in [Specific movement - e.g., abduction, flexion, external rotation], no obvious deformity or ecchymosis].  Strength testing is [Strength testing results - e.g., 5/5 throughout, 4/5 in abduction].  Neurovascular examination is intact.  Differential diagnosis includes rotator cuff tear, shoulder impingement syndrome, frozen shoulder, and cervical radiculopathy.  Assessment:  Shoulder muscle strain, likely involving [Specific muscle - e.g., rotator cuff muscles].  Plan:  Conservative management with rest, ice, compression, elevation (RICE).  Patient advised to avoid activities that exacerbate pain.  Over-the-counter pain medication such as ibuprofen or naproxen recommended for pain management.  Referral to physical therapy for range of motion exercises and strengthening as needed.  Follow-up appointment scheduled in [Duration - e.g., 2 weeks] to assess response to treatment.  ICD-10 code: [Appropriate ICD-10 code - e.g., S46.0].