A&P Basics    BIOL 2404                  Case Study: Integument           Dr. Weis

Medical Center                                  Summary Report

Dermatology Service

Admission Date : May 16, 2000

Discharge Date:   May 16, 2000

Signalment: 42 year old Caucasian male

CC: Black nodule with episodic hemorrhaging, AS

Past Hx: Works as a construction foreman, involved in outdoor sports

               No significant findings on previous medical history

Physical Exam:

            Temperature, heart, and respiratory rate were within normal limits.

Blood pressure was 140/85 and auscultation of the thorax revealed that the chest was clear. No heptomegaly or splenomegaly was found during the abdominal exam. Slight lymphadenopathy was noted during palpation of cervical and axial lymph nodes.

During examination of the skin revealed several macules on the shoulders and a 6 mm by 4mm raised black and blue nodule on the superior pinna of the left ear.

Assessment: Suspect malignant melanoma

                     Rule out hyperplasia., dysplastic nevi

Plan: The area was surgically prepped and a local anesthetic was given.

            A punch biopsy was taken and submitted for pathology.

On a follow up visit, the pathology report of malignant melanoma was discussed.

Options for treatment include surgical resection with possible skin graft and regional lymph node biopsy.  Chemotherapy may be included pending lymph node biopsy.

Follow-up exams will be scheduled every six months.