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Case #5

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Expand Physical Exam

06/11/XX

Upon full skin examination, abnormal lesion found on right thigh. Patient also presents with persistent cough.

Expand Imaging

06/15/XX

CT of Abdomen/Pelvis, Chest: 8mm lower lobe pleural nodule. Peri-tracheal lymph node mass suspicious for metastasis.
CAT: Multiple pulmonary nodules consistent with metastasis.

Expand Laboratory

06/15/XX

Elevated serum LDH, less than 1.5 times the upper limit of normal.

Expand Surgical Observations

6/11/XX

Right thigh surgery: wide local excision of lesion on right thigh. Right inguinal lymph node dissection.

6/30/XX

Thorascopic surgery: RUL wedge resection - nodules consistent with metastatic melanoma.

Expand Pathological Reports

06/11/XX

Tissue, right thigh: Malignant melanoma, extends to underlying muscle, margins clear, approximately 1.5 cm.
Nodal dissection: 0 inguinal nodes positive.

06/30/XX

Tissue, right lung: Metastatic melanoma.

Expand Treatment

06/11/XX

Surgery: Excision of right thigh lesion and inguinal lymph node dissection.

06/30/XX

Surgery: Wedge resection of RUL metastasis