Kimberly Moriarty
Very focused SOAP #1
S: “I have a lump on my left wrist.” Appeared 3 weeks ago, suddenly, unchanged since appearance. Does not hurt unless wrist is flexed and pressure is applied. Does not affect ADLs. Had a ganglion cyst removed on right posterior wrist 3 years ago. Denies any wrist trauma and any other similar lumps on body.
O: Healthy appearing 57yo AAF. 1cm by 1cm round, easily observed lump on left anterior medial wrist. It is mobile, hyperpigemented. No pain with palpation. Full ROM in wrist joint. CRT WNL. Denies numbness tingling in fingers, wrist. Trans- illuminates with pen light.
A: Probable ganglion cyst. Possible thrombophlebitis, callus, sebaceous cyst.
P: Continue to monitor. Patient will call if it worsens, gets larger, or experiences increasing pain. Recommend a hand specialist if she desires. Educated on ganglion cysts, recurrence.
Commentary
I found this rather interesting to investigate. She seemed quite worried at first that she didn’t know what this was, and then went on to mention she had one removed on the other wrist. This was my first time seeing a ganglion cyst. I had seen one on some medical show once where they smashed it with a book and it went away. This was just in a spot where her vasculature was running over it. It was difficult to just look at it and not jump to seeing a huge blood clot. We trans-illuminated it with a light and it was glowing. My preceptor reassured her it was indeed not a blood clot, given her history of a previous cyst. It was soft, squishy and moved very easily. I learned that they have a high percentage of recurrence, less if surgically removed. Given the relatively small size, my preceptor wanted to watch it (no aspiration) and see how it goes. I learned they commonly appear near a tendon, and sure enough it was right by the tendons in the wrist. He also taught me they can disappear suddenly, return suddenly and grow or shrink suddenly. Treatment varies by patient and how it interferes with daily life (emedicincehealth.com). He also would recommended a wrist specialist if she desired something to be done. She chose to just watch and see under the hopes it would suddenly resolve. We advised to limit activity in the wrist which brought on pain, but she assured us that it was nothing she “couldn’t live with”. My preceptor also shared with her about his experience with one, and how it spontaneously disappeared. This reassured her greatly. In any event, I know it’s a short soap and commentary, but I wanted to get my feet wet again. The next one I pick will be more complicated. As an interesting side note, I was trying to look up more information regarding these cysts and my book collection (patho, adult health) offered no information regarding these. The Advanced Assessment book by Goolsby offered minimal data. The usual internet sites (emedicinehealth.com) offered the most information. My preceptor did not want to do any testing to confirm his diagnosis. As a new practitioner, I may have wanted an ultrasound, just to be sure. I would have also checked some lymph nodes in the neck, axilla to make sure they were not swollen or tender. Overall, it was a rather simple case, but I learned a lot.