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Case #3

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Expand 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.

Expand Imaging

01/11/XX

Chest X-Ray negative.

Expand Laboratory

01/15/XX

LFT, CBC within normal limits.

Expand 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.

Expand 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.

01/25/XX

Distal phalanx right thumb, amputation: foci of residual neoplasm found, margins clear, greater than 1 cm.

Expand 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