ICD-10: M71.111

ICD-10 code M71.111 refers to "Other infective bursitis, right shoulder." This code is part of the broader category of bursitis, which is an inflammation of the bursa, a small fluid-filled sac that acts as a cushion between bones and soft tissues, such as muscles, tendons, and skin. Here’s a detailed overview of this condition, including its clinical description, symptoms, causes, diagnosis, and treatment options.

Clinical Description

Definition

Infective bursitis occurs when a bursa becomes inflamed due to an infection, often caused by bacteria. The right shoulder is a common site for bursitis, particularly in individuals who engage in repetitive overhead activities or have underlying health conditions that predispose them to infections.

Symptoms

Patients with infective bursitis in the right shoulder may experience:
- Localized pain: This pain is typically sharp and may worsen with movement or pressure on the shoulder.
- Swelling: The affected area may appear swollen and tender to the touch.
- Redness and warmth: The skin over the bursa may become red and feel warm, indicating inflammation.
- Limited range of motion: Patients may find it difficult to move their shoulder due to pain and swelling.
- Systemic symptoms: In cases of severe infection, patients might experience fever, chills, and malaise.

Causes

Infective bursitis can be caused by:
- Bacterial infections: The most common pathogens include Staphylococcus aureus and Streptococcus species. These infections can occur following trauma, surgery, or through the bloodstream.
- Underlying conditions: Conditions such as diabetes, rheumatoid arthritis, or immunosuppression can increase the risk of developing bursitis.

Diagnosis

Clinical Evaluation

Diagnosis typically involves a thorough clinical evaluation, including:
- Medical history: Understanding the patient's symptoms, medical history, and any recent injuries or infections.
- Physical examination: Assessing the shoulder for signs of swelling, tenderness, and range of motion.

Imaging Studies

• Ultrasound or MRI: These imaging techniques can help visualize the bursa and surrounding tissues, confirming inflammation or the presence of fluid.

Laboratory Tests

• Aspiration: In some cases, fluid may be aspirated from the bursa for analysis to identify the causative organism.
• Blood tests: These may be conducted to check for signs of infection or underlying conditions.

Treatment

Conservative Management

Initial treatment often includes:
- Rest: Avoiding activities that exacerbate the pain.
- Ice therapy: Applying ice packs to reduce swelling and pain.
- Nonsteroidal anti-inflammatory drugs (NSAIDs): Medications like ibuprofen can help alleviate pain and inflammation.

Antibiotic Therapy

If a bacterial infection is confirmed, appropriate antibiotics will be prescribed based on the identified organism and its sensitivity profile.

Surgical Intervention

In severe cases or when conservative treatment fails, surgical drainage of the bursa may be necessary to remove infected fluid and debris.

Conclusion

ICD-10 code M71.111 captures the clinical essence of other infective bursitis in the right shoulder, highlighting the importance of prompt diagnosis and treatment to prevent complications. Understanding the symptoms, causes, and management strategies is crucial for healthcare providers to effectively address this condition and improve patient outcomes. If you suspect infective bursitis, it is essential to seek medical attention for a comprehensive evaluation and tailored treatment plan.

The ICD-10 code M71.111 refers to "Other infective bursitis, right shoulder." This condition involves inflammation of the bursa, a small fluid-filled sac that acts as a cushion between bones and soft tissues, specifically in the right shoulder area. Understanding the clinical presentation, signs, symptoms, and patient characteristics associated with this diagnosis is crucial for effective management and treatment.

Clinical Presentation

Definition and Overview

Infective bursitis occurs when a bursa becomes inflamed due to infection, often resulting from bacteria entering the bursa through a break in the skin or from nearby infections. The right shoulder is a common site for bursitis due to its anatomical structure and the range of motion involved in shoulder activities.

Common Patient Characteristics

• Age: While bursitis can occur at any age, it is more prevalent in adults, particularly those over 40 years old.
• Gender: Males may be more frequently affected than females, although this can vary based on activity levels and occupational hazards.
• Activity Level: Individuals engaged in repetitive overhead activities, such as athletes (e.g., swimmers, baseball players) or manual laborers, are at higher risk.
• Comorbidities: Patients with diabetes, rheumatoid arthritis, or other immunocompromising conditions may be more susceptible to infections leading to bursitis.

Signs and Symptoms

Localized Symptoms

• Pain: Patients typically report localized pain in the right shoulder, which may worsen with movement or pressure on the area.
• Swelling: There may be noticeable swelling over the shoulder joint, indicating inflammation.
• Redness and Warmth: The skin over the affected bursa may appear red and feel warm to the touch, suggesting an inflammatory response.

Functional Impairment

• Limited Range of Motion: Patients often experience difficulty in moving the shoulder, particularly in raising the arm or performing overhead activities.
• Weakness: There may be associated weakness in the shoulder muscles due to pain and inflammation.

Systemic Symptoms

In cases of severe infection, systemic symptoms may also be present:
- Fever: Patients may develop a fever as the body responds to the infection.
- Chills: Accompanying chills can occur, indicating a more systemic infection.

Diagnosis and Evaluation

Clinical Examination

A thorough physical examination is essential to assess the range of motion, tenderness, and swelling in the shoulder. The healthcare provider may also evaluate for signs of systemic infection.

Imaging Studies

• Ultrasound or MRI: These imaging modalities can help visualize the bursa and assess for fluid accumulation or other abnormalities.

Laboratory Tests

• Blood Tests: Elevated white blood cell counts and inflammatory markers (e.g., C-reactive protein) may indicate infection.
• Bursa Aspiration: In some cases, aspiration of the bursa may be performed to analyze the fluid for the presence of bacteria or other pathogens.

Conclusion

Infective bursitis of the right shoulder (ICD-10 code M71.111) presents with specific clinical features, including localized pain, swelling, and functional impairment. Understanding the patient characteristics and symptoms associated with this condition is vital for timely diagnosis and effective treatment. Early intervention can help prevent complications and improve patient outcomes, particularly in those with underlying health issues or risk factors for infection.

ICD-10 code M71.111 refers specifically to "Other infective bursitis, right shoulder." This code is part of the broader category of bursopathies, which are conditions affecting the bursae—small fluid-filled sacs that cushion bones, tendons, and muscles near joints. Below are alternative names and related terms associated with this diagnosis:

Alternative Names

1. Infective Bursitis of the Right Shoulder: A straightforward alternative that emphasizes the infectious nature of the condition.
2. Right Shoulder Bursitis: A more general term that may not specify the infective aspect but is commonly used in clinical settings.
3. Right Shoulder Bursopathy: This term encompasses various conditions affecting the bursae, including infective types.
4. Right Shoulder Bursal Infection: Highlights the infection aspect specifically affecting the bursa in the shoulder.

Related Terms

1. Bursitis: A general term for inflammation of a bursa, which can be caused by various factors, including infection.
2. Infectious Bursitis: Refers to bursitis caused by an infection, which can be bacterial, viral, or fungal.
3. Shoulder Pain: While not specific, this term is often associated with bursitis and can encompass various shoulder conditions.
4. Subacromial Bursitis: A specific type of bursitis that occurs under the acromion of the shoulder, which may be related to M71.111 if infection is present.
5. Bursa Inflammation: A broader term that can refer to inflammation in any bursa, including those in the shoulder.

Clinical Context

In clinical practice, the terminology used may vary based on the specific symptoms, underlying causes, and the healthcare provider's preference. Understanding these alternative names and related terms can aid in better communication among healthcare professionals and improve patient understanding of their condition.

In summary, M71.111 is associated with various terms that reflect its nature as an infective condition affecting the right shoulder's bursa, and recognizing these can enhance clarity in medical documentation and discussions.

The ICD-10 code M71.111 refers to "Other infective bursitis, right shoulder." This diagnosis is part of the broader category of bursitis, which is inflammation of the bursa, a small fluid-filled sac that acts as a cushion between bones and soft tissues. Understanding the criteria for diagnosing this condition involves several key components.

Diagnostic Criteria for M71.111

1. Clinical Presentation

• Symptoms: Patients typically present with localized pain, swelling, and tenderness in the shoulder area. The pain may worsen with movement or pressure on the affected shoulder.
• Physical Examination: A thorough physical examination is essential. The healthcare provider will assess the range of motion, tenderness, and any signs of swelling or warmth over the bursa.

2. Medical History

• Infection Risk Factors: A detailed medical history should be taken to identify any risk factors for infection, such as recent trauma, surgery, or underlying conditions like diabetes or immunosuppression.
• Previous Episodes: Information about any previous episodes of bursitis or other joint issues can provide context for the current diagnosis.

3. Imaging Studies

• Ultrasound or MRI: Imaging studies may be utilized to visualize the bursa and surrounding structures. These can help confirm the presence of fluid accumulation or inflammation indicative of bursitis.
• X-rays: While X-rays are not typically used to diagnose bursitis directly, they can help rule out other conditions such as fractures or arthritis.

4. Laboratory Tests

• Aspiration and Analysis: If there is significant swelling, aspiration of the bursa may be performed. The fluid can be analyzed for signs of infection (e.g., presence of white blood cells, bacteria, or crystals).
• Blood Tests: Blood tests may be conducted to check for systemic signs of infection or inflammation, such as elevated white blood cell counts or inflammatory markers.

5. Differential Diagnosis

• It is crucial to differentiate infective bursitis from other conditions that may present similarly, such as:
  • Non-infective bursitis
  • Rotator cuff injuries
  • Tendonitis
  • Arthritis

6. ICD-10 Coding Guidelines

• According to the ICD-10 coding guidelines, the specific code M71.111 is used when the bursitis is confirmed to be infective and localized to the right shoulder. Proper documentation of the diagnosis, including the clinical findings and any imaging or laboratory results, is essential for accurate coding and billing.

Conclusion

Diagnosing M71.111 involves a comprehensive approach that includes clinical evaluation, medical history, imaging studies, and laboratory tests to confirm the presence of infective bursitis in the right shoulder. Accurate diagnosis is crucial for effective treatment and management of the condition, ensuring that patients receive appropriate care tailored to their specific needs.

When addressing the standard treatment approaches for ICD-10 code M71.111, which refers to Other infective bursitis of the right shoulder, it is essential to understand the condition's nature, symptoms, and the typical management strategies employed by healthcare professionals.

Understanding Infective Bursitis

Infective bursitis occurs when the bursa, a small fluid-filled sac that reduces friction between tissues, becomes inflamed due to infection. This condition can lead to pain, swelling, and limited range of motion in the affected joint, in this case, the right shoulder. The infection may be caused by bacteria, fungi, or other pathogens, and it often requires prompt medical intervention to prevent complications.

Standard Treatment Approaches

1. Initial Assessment and Diagnosis

Before treatment can begin, a thorough assessment is necessary. This typically includes:
- Medical History: Understanding the patient's symptoms, duration, and any previous shoulder issues.
- Physical Examination: Assessing the shoulder for swelling, tenderness, and range of motion.
- Imaging Studies: X-rays or MRI may be used to rule out other conditions and confirm the diagnosis.
- Laboratory Tests: Blood tests or aspiration of the bursa fluid may be performed to identify the causative organism.

2. Antibiotic Therapy

If the bursitis is confirmed to be infectious, antibiotic treatment is crucial. The choice of antibiotics may depend on the suspected organism:
- Empirical Therapy: Broad-spectrum antibiotics may be initiated while awaiting culture results.
- Targeted Therapy: Once the specific pathogen is identified, treatment may be adjusted to target that organism specifically.

3. Pain Management

Managing pain is a critical component of treatment. Common strategies include:
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Medications like ibuprofen or naproxen can help reduce pain and inflammation.
- Corticosteroid Injections: In some cases, corticosteroids may be injected into the bursa to alleviate severe inflammation.

4. Physical Therapy

Once the acute infection is under control, physical therapy may be recommended to restore function and strength to the shoulder. This can include:
- Range of Motion Exercises: To improve flexibility and mobility.
- Strengthening Exercises: To support the shoulder joint and prevent future injuries.

5. Surgical Intervention

In severe cases where there is an abscess or if conservative treatments fail, surgical intervention may be necessary. This could involve:
- Bursa Drainage: To remove infected fluid.
- Debridement: To clean out infected tissue.

6. Follow-Up Care

Regular follow-up appointments are essential to monitor the patient's recovery and adjust treatment as necessary. This may include:
- Re-evaluation of Symptoms: To ensure that the infection is resolving.
- Continued Physical Therapy: To maintain shoulder function.

Conclusion

The management of Other infective bursitis of the right shoulder (ICD-10 code M71.111) involves a comprehensive approach that includes diagnosis, antibiotic therapy, pain management, physical therapy, and possibly surgical intervention. Early recognition and treatment are vital to prevent complications and ensure a full recovery. Patients experiencing symptoms of bursitis should seek medical attention promptly to initiate appropriate care.