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| Physical Exam | 06/11/XX |
Upon full skin examination, abnormal lesion found on right thigh. Patient also presents with persistent cough. |
| 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. |
| Laboratory | 06/15/XX |
Elevated serum LDH, less than 1.5 times the upper limit of normal. |
| Surgical Oberservations | 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. | |
| 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. | |
| Treatment | 06/11/XX |
Surgery: Excision of right thigh lesion and inguinal lymph node dissection. |
| 06/30/XX | Surgery: Wedge resection of RUL metastasis | |
