Rheumatoid myopathy with rheumatoid arthritis of right shoulder
ICD-10 M05.411 is a billable code used to indicate a diagnosis of rheumatoid myopathy with rheumatoid arthritis of right shoulder.
Rheumatoid myopathy is a condition characterized by muscle weakness and pain associated with rheumatoid arthritis (RA), an autoimmune disorder that primarily affects the joints. In this case, the right shoulder is specifically involved. The pathophysiology involves inflammation of the synovial membrane leading to joint damage and muscle atrophy due to disuse and systemic inflammation. Clinically, patients may present with pain, swelling, and reduced range of motion in the right shoulder, alongside systemic symptoms such as fatigue and malaise. Anatomically, the shoulder joint comprises the humerus, scapula, and clavicle, with surrounding muscles including the rotator cuff, deltoid, and pectoralis major, all of which may be affected by the inflammatory process. The condition can lead to significant functional impairment, impacting daily activities and quality of life.
Orthopedic documentation should include imaging studies (e.g., X-rays, MRIs) to assess joint integrity and functional assessments to evaluate range of motion and strength.
Common scenarios include surgical interventions for joint repair or replacement, and management of acute exacerbations of arthritis.
Joint-specific considerations include the assessment of joint stability, alignment, and the presence of any deformities.
Rheumatologic documentation must include laboratory tests for inflammation markers (e.g., ESR, CRP) and assessments of disease activity (e.g., DAS28 score).
Scenarios often involve managing systemic symptoms and adjusting DMARD therapy based on disease progression.
Consideration of systemic involvement, such as extra-articular manifestations, is crucial for comprehensive care.
Functional assessments should document mobility limitations, pain levels, and the need for assistive devices.
Rehabilitation scenarios may include physical therapy for strength training and range of motion exercises.
Focus on mobility limitations and the impact on daily living activities is essential for effective rehabilitation planning.
Used in conjunction with M05.411 for rehabilitation of shoulder function.
Document specific exercises performed and patient progress.
Physical therapy documentation should reflect the goals of improving range of motion and strength.
Key documentation elements include clear identification of the right shoulder involvement, detailed descriptions of muscle weakness and joint symptoms, results from imaging studies, and any laboratory tests indicating inflammation. Functional assessments and treatment plans should also be documented to support the diagnosis.
