Right Upper Extremity Pain

Patient presents with complaints of right upper extremity pain.  Onset of pain is reported as gradual/acute (choose one) and began approximately (duration) ago.  The patient localizes the pain to the (specific location: e.g., shoulder, elbow, wrist, hand, fingers) and describes the pain as (quality of pain: e.g., sharp, dull, aching, throbbing, burning).  Pain is aggravated by (aggravating factors: e.g., movement, lifting, rest) and relieved by (relieving factors: e.g., rest, ice, heat, medication).  The patient denies/reports (choose one) associated symptoms such as numbness, tingling, weakness, swelling, redness, or warmth in the affected extremity.  Past medical history includes (relevant medical history: e.g., arthritis, prior injury, surgery) and current medications include (list current medications).  Physical examination reveals (objective findings: e.g., tenderness to palpation, limited range of motion, deformity, edema, erythema).  Neurological examination of the right upper extremity is intact/reveals deficits (choose one, if deficits, specify).  Differential diagnosis includes (list of possible diagnoses: e.g., rotator cuff tear, epicondylitis, carpal tunnel syndrome, cervical radiculopathy).  Assessment: Right upper extremity pain, likely secondary to (presumptive diagnosis).  Plan:  Patient education provided regarding (relevant education: e.g., activity modification, pain management).  Prescribed (medications prescribed: e.g., NSAIDs, analgesics).  Ordered (diagnostic tests ordered: e.g., x-ray, MRI, EMG).  Referral to (specialist referral if applicable: e.g., orthopedics, physical therapy).  Follow-up scheduled in (duration) to reassess symptoms and response to treatment.