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Case #1

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Expand Physical Exam

04/20/XX

Upon routine skin exam, dime-sized brownish-black lesion found on skin of right cheek. Patient reports recent changes in color, which is uneven in distribution. Patient also states that lesion itches. No palpable lymph nodes.

Expand Laboratory

04/20/XX

Labwork within normal limits.

Expand Imaging

04/20/XX

CXR: Negative.

Expand Surgical Observations

04/26/XX

Wide excision of right cheek and reconstructive closure of open wound.

Expand Pathological Reports

04/26/XX

Brownish-black skin specimen from excision, 1.2 cm in size. Non-invasive melanoma, Clark's Level I. Basement membrane of epidermis is intact. No ulceration present. Margins clear, but within 3 mm of lateral edge. 1 sentinel node removed; negative.

Expand Treatment

04/26/XX

Surgery: Excision of right cheek lesion and sentinel lymph node biopsy