Postimmunization arthropathy, right shoulder
ICD-10 M02.211 is a billable code used to indicate a diagnosis of postimmunization arthropathy, right shoulder.
Postimmunization arthropathy refers to joint pain and inflammation that occurs following vaccination. In the case of the right shoulder, this condition may manifest as pain, swelling, and limited range of motion in the glenohumeral joint, which is the primary joint of the shoulder. Anatomically, the shoulder consists of the humerus, scapula, and clavicle, with the glenoid cavity of the scapula forming a shallow socket for the humeral head. The condition may arise due to an immune-mediated response to the vaccine, leading to synovitis or inflammation of the synovial membrane. Clinically, patients may present with localized pain, tenderness, and stiffness, particularly when performing overhead activities or reaching. The pathophysiology involves an aberrant immune response that may trigger inflammatory cytokines, leading to joint swelling and discomfort. Diagnosis typically involves clinical evaluation, imaging studies such as X-rays or MRI to rule out other causes, and laboratory tests to assess inflammatory markers.
Orthopedic documentation should include imaging results, range of motion assessments, and functional limitations. Detailed notes on joint stability and any surgical interventions are also necessary.
Patients may present with post-vaccination shoulder pain requiring orthopedic evaluation for potential rotator cuff injury or adhesive capsulitis.
Orthopedic assessments should focus on joint-specific evaluations and the severity of symptoms to guide treatment options.
Rheumatologic documentation should include inflammatory markers (e.g., ESR, CRP) and assessments of disease activity. A thorough history of autoimmune conditions is essential.
Patients with a history of autoimmune disorders may experience exacerbation of symptoms post-vaccination, necessitating rheumatologic evaluation.
Consideration of systemic involvement and the potential for chronicity of symptoms is crucial.
Functional assessments should evaluate mobility, strength, and pain levels. Documentation of rehabilitation goals and progress is essential.
Patients may require physical therapy for rehabilitation following postimmunization arthropathy to restore function and reduce pain.
Assessment of mobility limitations and the need for assistive devices should be documented.
Used for follow-up visits to assess postimmunization arthropathy symptoms and treatment response.
Documentation must include history of present illness, physical examination findings, and treatment plan.
Orthopedic or rheumatologic evaluations may require additional documentation of joint assessments.
Common symptoms include localized pain, swelling, stiffness in the affected joint, and limited range of motion, particularly following vaccination.
