DATE OF SERVICE: MM/DD/YYYY
DIAGNOSES:
1. Acrolentiginous melanoma of the left heel, T1N0M0, with 2.2 mm Breslow thickness.
2. Wide local excision with left heel full thickness skin graft as well as a left inguinal sentinel lymph node biopsy.
3. ECOG performance status of 1-2.
4. No adjuvant therapy indicated at that time.
SUBJECTIVE: The patient comes in for a regularly scheduled six-month followup. She has no cough, chest pain or shortness of breath. No new headaches, no dizziness, no swelling in the leg. No pain in the foot or the leg. No changes in the foot or the leg. She does report one small little discolored area on the skin. A new finding, likely a new nevus that has appeared on the medial aspect of her left foot.
Since her last visit, she underwent an exploratory laparotomy with primary repair of a mesenteric defect. She seems to be recovering from her surgery and is not reporting any abdominal-related problems.
OBJECTIVE:
VITAL SIGNS: Temperature 98.2, heart rate 84, blood pressure 132/62, weight 222 pounds. She is alert, oriented, and ambulatory.
NECK: Supple.
LUNGS: Clear.
HEART: Regular rate, normal rhythm.
ABDOMEN: Soft, nontender, and nondistended. She has some scar tissue in the midline abdomen at the site of her recent surgical incision. It is well healed with no unusual palpable masses or tenderness. She has no cervical, supraclavicular, axillary or inguinal lymphadenopathy.
EXTREMITIES: Inspection of her left foot is normal. The skin graft appears normal. There are no unusual skin findings. She does have two small areas on that foot, darkened, hyperpigmented, potentially a couple of new nevi that have popped up since her last visit. Otherwise, no swelling and no lymphadenopathy is noted.
Chest x-ray is stable with no acute finding and CBC with differential as well as comprehensive metabolic panel and LDH is within normal limits.
ASSESSMENT AND PLAN: Acrolentiginous melanoma of the left heel, status post surgical excision with skin grafting diagnosed and treated approximately a year and a half ago with no evidence of recurrence. The patient is doing well. We see no signs of melanoma recurrence or distant disease.
We would like to see her back in six months with pre-clinic chest x-ray and blood work. She does have an appointment with Dermatology early November to follow up on these new lesions that have appeared, and we think that it is fine to wait and to keep that appointment to have these areas inspected. The patient is comfortable with this plan, and she will call us should she need anything prior to her next visit.
