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| 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. |
| Laboratory | 04/20/XX | Labwork within normal limits. |
| Imaging | 04/20/XX |
CXR: Negative. |
| Surgical Observations | 04/26/XX | Wide excision of right cheek and reconstructive closure of open wound. |
| 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. |
| Treatment | 04/26/XX | Surgery: Excision of right cheek lesion and sentinel lymph node biopsy |
