Evaluation of shoulder pain

Jessica 43 year old FedEx employee who presents for evaluation of shoulder pain. She has experienced this pain in the past, but it has always gotten better on its own. Currently, the pain is 8/10. She describes it as an ongoing ache with sharp pain when she tries to reach for objects. It started a few days ago. She has tried OTC analgesics and a heating pad, which helps to reduce the pain for approximately 102 hours, but it doesn’t relieve it completely. She has been unable to complete her activities at work and it is effecting her job performance.

She denies trauma or injury to the shoulder in the past. She denies neck pain or stiffness; she denies numbness or tingling in her arms. She has noticed some increased weakness: she is unable to pick up heavy objects and carry them for long time periods like she did in the past. She was healthy as a child; she did break her arm jumping on a trampoline at age 8. She has hypertension and elevated cholesterol, for which she takes medications. She had a cholecystectomy at age 40. She has only been hospitalized for her surgery.

Her family history is significant for a father who had a stroke at age 72; he currently lives at a assisted living facility. Her mother is still alive, and two grandchildren. They are all healthy.

What is the CC? Using the DB information, what should be included in the HPI?
Using the DB information, what documentation should be included in the history (Hx)?
What systems and documentation would you like to include in the ROS?
What systems and documentation would you like to include in the PE?
What physical findings are you looking for to help determine the diagnosis (Dx)?