| 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. |
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| Imaging |
08/30/XX |
Chest X-ray: Negative. |
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| Laboratory |
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N/A |
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| 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. |
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| 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. |
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| 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. |
