Name: Barbara G.
MRN: 123456
DOB: 08/12/1942
Age: 69
CC: “Burning” pain in posterior aspect of the left knee for the past two months. Referred from PCP
after identifying “Baker’s cyst” on ultrasound.
Subjective:
Patient is a pleasant 69 y/o Caucasian female. Last week she visited her primary care physician, Dr Dan
Oboe due to a “nagging” pain in the posterior aspect of her left knee that began approximately two
months ago. This was her first visit with a physician in approximately four years. At this appointment
Ms. G was diagnosed with stage 1 hypertension and hyperthyroidism. She was sent for an ultrasound of
the left knee, which displayed a 6cm X 3cm X 2cm fluid filled cyst in the posterior aspect of the left calf.
She was then referred to the orthopedics clinic for evaluation of the cyst. Patient states that her pain is
currently a 4/10, with 10 being the pain from the birth of her son. It is worse after exertion and in the
evening. Patient claims the pain is better in the mornings. She describes it as a burning pain that
radiates from the mid posterior thigh to the mid posterior calf. Denies weakness of extremities. She
had previously used Tylenol and ibuprofen with some relief, but after her PCP prescribed her new
medications for the hypertension and hyperthyroidism, she was afraid of a drug interaction and has not
taken anything for pain relief in the last week. Patient denies experiencing any trauma.
Family Hx: Patient is widowed and lives with her son; Past family history is significant for hypertension,
hyperthyroidism and cardiovascular disease.
Social Hx: Retired school teacher; Denies tobacco use, alcohol consumption or illicit drugs.
Allergies: NKDA
Immunizations: Current
Medications: Atenolol 25 mg PO BID; levothyroxine 100 mcg PO daily
PMH: Denies any significant past medical history of musculoskeletal or neurological origin
Objective: Vitals: Temperature: 97.7F P: 88 R: 24 BP: 130/86 Height: 63 inches Weight: 210lbs.
BMI: 37.2
General Appearance: Pleasant affect, alert and oriented X3
Lungs: Clear to auscultation
Heart: RRR no m/g/r/
Musculoskeletal: Egg-sized, palpable mass noted on the posterior left calf. The mass was approximately
5cm wide, 4cm long and elevated 1 cm. No cyanosis, pallor, asymmetry, or deformities noted; Negative
Homan’s sign, negative McMurray’s, negative anterior/posterior drawer tests, negative Lachman’s test;
no restriction of range of motion of knees; distal pulses present and strong, +2/4; tenderness noted over
the posterior left knee, notably in the proximal gastrocnemius area, worse with extension of the knee;
mild crepitus of the right knee also noted; no increased warmth, erythema or edema of the lower
extremities noted; strength +5 and equal bilaterally; Patellar and Achilles reflexes intact and equal
bilaterally +2/4; light touch sensation intact and equal in lower extremities; capillary refill approximately
2 seconds in lower extremities
Skin: Warm, with no erythema noted in the lower extremities
Neurologic: Sensation and light touch perception intact in extremities.
Labs/Tests: X-rays (AP, lateral and sunrise): joint space narrowing and bone spurs noted bilaterally
Ultrasound: displays a 6cm X 3cm X 2cm fluid filled mass in left calf
Assessment: 1) Mass noted on posterior left calf
2) Crepitus of right knee
3) Obese
Differential Diagnosis: Baker’s Cyst; osteoarthritis of knees; soft-tissue sarcoma;
thromobophlebitis
Plan:
Tx: Discussed with the patient the pathology of a Baker’s cyst, which is a collection of synovial fluid from
the knee joint, likely secondary to the osteoarthritis of her knee and subsequent inflammation. We
discussed treatment options including no treatment, aspiration and surgical removal. Patient agreed to
referral to Dr Bucks, an orthopedic surgeon trained to aspirate the cyst under ultrasound guidance. In
addition we discussed the osteoarthritis of her knees. Patient and I agreed to allow PCP to determine
what NSAID therapy would be acceptable with her current medicine regimen. We also discussed
scheduling a mammogram, colonoscopy and pelvic exam with Pap smear. Patient stated that she was
already in the process of getting these exams scheduled under the coordination of her PCP. After
scheduling an appointment with Dr Bucks to aspirate the cyst, patient was informed to follow up with
her PCP and seek our care as needed for her osteoarthritis. Patient verbally stated she understood
directions and would comply.
Vanessa G Wittstruck, PA-S
6/7/12
27/30
18:47