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Case #4

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Expand 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.

Expand Imaging

08/03/XX

CXR negative.

Expand Laboratory

08/03/XX

Laboratory work within normal limits.

Expand 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.

Expand 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.

Expand Treatment

08/11/XX

Excisional biopsy right neck lesion and right cervical lymph node excision