Case #2
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Physical Exam
08/14/XX
Upon routine annual skin examination, dark brown, dome-shaped nodular lesion discovered on right lower back. No clinically palpable lymph nodes.
Imaging
08/30/XX
Chest X-ray: Negative.
Laboratory
N/A
Surgical Observations
08/14/XX
Excision and removal of right, lower back lesion. Surgical margins of 0.5 cm.
09/15/XX
Wide re-excision of right, lower back lesion. Sentinel lymph node biopsy of right groin, 1 node removed.
Pathological Reports
08/14/XX
Tissue from initial excision of lesion: malignant nodular melanoma invading into reticular dermis. Clark's Level IV, Breslow's depth of 2.2 mm. No ulceration.
09/15/XX
Upon re-excision no residual tumor was found. Sentinel lymph node biopsy of right femoral node was negative.
Treatment
08/14/XX
Surgery: Excision of right lower back lesion
09/15/XX
Re-excision of right lower back lesion and sentinel lymph node biopsy.



