CUTANEOUS ONCOLOGY AMBULATORY CARE NOTE
DATE OF VISIT: XXXXXXXX
RE: (Patient’s Name) BIRTH DATE: _______________
UR#: XXXXXX AGE: 68
HISTORY OF PRESENT ILLNESS:
Patient is a 68-year-old white male who is here today because of a melanoma of the right arm.
He has had a lesion at this site for approximately 1 year and it recently changed over the last 3 months. He saw Dr. xxxxx Cxxxxxxxx for routine skin surveillance and an excisional biopsy was done. This was noted to be by our pathologist to be a 1.65-mm malignant melanoma which is without ulceration or regression. There was 1 mitosis per square mm. and was a level IV malignant melanoma. The excision according to the outside pathologist measured 1.2 cm x 1.2 cm x 0.5 cm. The patient is here for further care.
The patient has had a previous melanoma in-situ of the right face treated with excision in 2004 and the margins were clear. He has had other non-melanoma skin cancers treated by Dr. Cxxxxxxxx. The patient has a history of moderate sun exposure as he worked as a construction foreman and plays golf.
He has no history of hypertension, diabetes, heart disease, and does not smoke. He has a history of glaucoma, seasonal allergies and hypercholesterolemia. He takes glaucoma drops, Zyrtec for seasonal allergies, Lipitor for hypercholesterolemia and vitamins.
ALLERGIES:
He is allergic to penicillin manifest with a rash.
ROS: for new patients, dated today
PHYSICAL EXAMINATION: Patient is a well-developed, well-nourished white male, awake and alert, oriented X 3
VITAL SIGNS: Weight 178, temperature 97, blood pressure 131/81, pulse 65, respirations 16, dated today
HEENT: His sclera is white. His mucosa is moist.
PULMONARY: No shortness of breath
CARDIAC: No peripheral edema
EXT: There is no peripheral edema. No musculoskeletal deformity.
SKIN: On the right arm, along the medial anterior aspect at the junction of the distal and central 1/3 of the arm, there is an approximately 1-1/2 cm healing surgical incision without surrounding edema, erythema, induration, pigmentation, ulceration or nodularity.
LYMPH: There is no right axillary adenopathy noted.
IMPRESSION:
Malignant melanoma, right arm.
I reviewed outside medical records available and the hospital records.
PLAN:
We have recommended treatment to include surgical resection of the tumor site and flap or graft reconstruction with simultaneous lymphatic mapping and sentinel node removal. We have talked to the patient and his wife today about the risks and possible complications of surgery, including infection, bleeding, scar, and nerve dysfunction, seroma, and hematoma, and they want us to proceed. We have answered all questions. We discussed the prognosis. We will schedule this to be done under general anesthesia as an outpatient Care will coordinated through my office.
Dictated and Reviewed by: ___________________, MD
Signed by: ______________________
C. Wayne Cruse, MD