| Physical Exam |
01/11/XX |
Patient presents with a black discoloration of the right thumb which has recently started bleeding. The edges of the lesion are ragged, and entire lesion is elevated. Palpable right axillary lymph nodes. |
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| Imaging |
01/11/XX |
Chest X-Ray negative. |
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| Laboratory |
01/15/XX |
LFT, CBC within normal limits. |
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| Surgical Observations |
01/17/XX |
Radical resection of skin and soft tissue of right thumb; Right axillary sentinel lymph node dissection. |
| 01/25/XX |
Amputation of distal phalanx of right thumb. |
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| Pathological Reports |
01/17/XX |
Skin & soft tissue of right thumb: malignant melanoma, poorly differentiated, at least 2.5mm in thickness to the base of specimen. Clark’s Level II. No Ulceration present.
Right axillary lymph node dissection: 2 of 5 are positive for melanoma, metastasis 3.5 cm in greatest dimension.
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| 01/25/XX |
Distal phalanx right thumb, amputation: foci of residual neoplasm found, margins clear, greater than 1 cm. |
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| Treatment |
01/17/XX |
Surgery: Excision of right thumb lesion and right axillary lymph node dissection. |
| 01/25/XX |
Surgery: Amputation of distal right thumb phalanx |
| 02/28/XX |
Immunotherapy: Began Interferon |
