Patient presents with complaints of upper extremity pain.  Onset of pain was (onset date or duration) and is described as (character of pain: sharp, dull, aching, burning, throbbing, etc.).  Pain location is localized to the (specific location: shoulder, elbow, wrist, hand, fingers, etc.)  and radiates to (areas of radiation, if any).  Patient reports (aggravating factors:  lifting, reaching, repetitive movements, etc.) exacerbate the pain, while (alleviating factors: rest, ice, heat, medication, etc.) provide some relief.  The patient denies any (pertinent negatives: fever, chills, numbness, tingling, weakness, trauma, etc.).  Physical examination reveals (objective findings: tenderness to palpation, limited range of motion, swelling, deformity, etc.).  Differential diagnosis includes (potential diagnoses: rotator cuff tear, epicondylitis, carpal tunnel syndrome, arthritis, nerve impingement, etc.).  Assessment: Upper extremity pain, likely (most likely diagnosis). Plan:  Patient education regarding (activity modification, pain management strategies, etc.).  Prescribed (medications, if any) with instructions for use and potential side effects discussed.  Recommended (physical therapy, occupational therapy, further diagnostic testing such as X-ray, MRI, EMG, etc.) as indicated.  Follow up scheduled in (duration) to reassess symptoms and progress.