M71.111 Other infective bursitis, right shoulder

Name of the Condition

• Other infective bursitis, right shoulder

Summary

Other infective bursitis, right shoulder, refers to an infection of the bursa (a small fluid-filled sac that reduces friction between tissues) in the right shoulder. This condition involves microbial invasion of the bursa, leading to inflammation, pain, and potential functional impairment at the affected site. The infection may be bacterial or non-bacterial, and the right shoulder designation specifies the anatomical location.

Causes

Other infective bursitis, right shoulder, typically results from bacterial infection, often introduced through direct trauma, skin breakdown, or spread from adjacent tissues. Common causative organisms include Staphylococcus aureus. Non-bacterial infections or secondary infection of a pre-existing bursitis may also occur, though the exact etiology varies by case. The right shoulder specification indicates the infection is localized to that anatomical site.

Risk Factors

• Recent injury or surgery near the right shoulder bursa
• Skin infections or open wounds in the right shoulder area
• Immunocompromised states (e.g., diabetes, HIV)
• Chronic inflammatory conditions (e.g., rheumatoid arthritis)
• Repetitive motion or pressure on the right shoulder bursa

Symptoms

• Localized pain, swelling, and warmth over the right shoulder bursa
• Redness or erythema at the site
• Fever or systemic signs of infection
• Limited range of motion in the right shoulder
• Pus drainage if the infection progresses

Diagnosis

Diagnosis involves a physical examination to assess bursal characteristics, including tenderness, warmth, and swelling in the right shoulder. Imaging (e.g., ultrasound) may be used to evaluate the bursa, and fluid aspiration can confirm infection through laboratory analysis. Clinical documentation must specify the right shoulder as the affected site.

Treatment Options

Treatment typically includes antibiotic therapy targeted at the causative organism, often guided by culture results. Rest, ice, and elevation of the right shoulder may reduce inflammation. In severe cases, surgical drainage of the infected bursa may be necessary. Physical therapy can aid in restoring function once the infection is controlled.

Prognosis and Follow-Up

Prognosis is generally favorable with prompt treatment, though delays can lead to chronic pain or functional impairment. Follow-up care involves monitoring for resolution of symptoms and assessing range of motion. Recurrence is possible if underlying risk factors persist, requiring ongoing management.

Complications

Untreated or severe infections may lead to abscess formation, spread to adjacent tissues, or chronic bursitis. Systemic infection (sepsis) can occur in immunocompromised individuals. Long-term complications may include persistent pain or limited shoulder mobility.

Lifestyle & Prevention

Avoid repetitive overhead motions or pressure on the right shoulder. Maintain skin integrity to prevent infection entry. Manage chronic conditions (e.g., diabetes) to reduce infection risk. Promptly treat skin injuries near the shoulder to prevent spread.

When to Seek Professional Help

Seek care if symptoms worsen (e.g., increasing pain, fever) or if there is pus drainage. Immediate evaluation is needed for signs of systemic infection (e.g., chills, confusion) or if the shoulder becomes increasingly immobile.

Tips for Medical Coders

Document the right shoulder as the specific site to justify M71.111. Ensure clinical notes specify the anatomical location and confirm infective bursitis (not non-infective) to support the code. Include details on infection confirmation (e.g., aspiration results) if available.