|
|||||
|
|
|||||
|
| Physical Exam | 08/03/XX |
Patient presents with bluish-black lesion on skin of right neck which patient reports is changing in size and color. No cervical lymph node enlargement. |
| Imaging | 08/03/XX |
CXR negative. |
| Laboratory | 08/03/XX | Laboratory work within normal limits. |
| Surgical Observations | 08/03/XX | Shave biopsy, skin right side neck: may represent superficially spreading melanoma, however, difficulty evaluating because lesion was not completely excised. Re-excision highly recommended. |
| 08/11/XX | Excisional biopsy, skin right neck. Large surgical margins. Right cervical lymph node dissection. |
|
| Pathological Reports | 08/03/XX | Shave biopsy results inconclusive; recommend repeat excision biopsy with at least 1 cm surgical margins. |
| 08/11/XX | Excisional biopsy: malignant superficial spreading melanoma, Breslow’s thickness 0.4 mm; Clark's level II; surgical margins are approximately 8.5 mm and are free of residual tumor. Right cervical lymph node excision: 0 of 10 nodes positive. |
|
| Treatment | 08/11/XX | Excisional biopsy right neck lesion and right cervical lymph node excision |
