[doctor] next patient is sophia jackson , mrnr472348 . she's a 57 year old female who is here for a surgical consult . her dermatologist referred her . she biopsied a 0.7 millimeter lesion which was located on right inferior back . pathology came back as melanoma .
[doctor] mrs. jackson , it's good to meet you .
[patient] likewise , wish it were under better circumstances .
[doctor] yeah , i hear your dermatologist sent you to me 'cause she found a melanoma ?
[patient] yes , that's what the biopsy said .
[doctor] okay and when did you first notice the spot ?
[patient] my mom noticed it when i was visiting her last month .
[doctor] i see . and so you went to the dermatologist on april 10th to get it checked out , right ?
[patient] yes , i wanted to be extra cautious because skin cancer does run in my family .
[doctor] well i'm really glad you took it seriously and got it checked . who in your family has had skin cancer , and do you know if it was melanoma or was it basal cell or squamous cell ?
[patient] my mom and her sister , i think they both had melanoma .
[doctor] okay . do you have any other types of cancer in the family , like breast or ovarian ?
[patient] my grandfather had pancreatic cancer .
[doctor] okay , and was that your mom or dad's father ?
[patient] mother's .
[doctor] okay . and , um , have you personally had any skin spots in the past that you got checked out and they were cancerous or precancerous ?
[patient] no , this was the first time i've been to a dermatologist . um , but my primary care doctor looks over all of my moles every year at my physical and has n't said , um , he's concerned about any of 'em before .
[doctor] good- good . uh , let's go over your medical history from your chart . i have that you're not taking any medications and do n't have any health problems listed , but that you're allergic to augmentin , is that right ?
[patient] yes , that's correct .
[doctor] okay , and for social history can you tell me what you do for work ?
[patient] i own an auto repair shop .
[doctor] okay and have you ever been a smoker ?
[patient] yeah , i still smoke from time to time . i started that awful habit in my teens and it's hard to break , but i'm trying .
[doctor] i'm glad you're trying to quit . uh , what about your surgical history , have you had any surgeries ?
[patient] i had gall bladder and appendix .
[doctor] okay , great , we can get your chart up to date now , thank you . and other than the melanoma , how has your health been , any unintentional weight changes , headaches , fatigue , nausea , vomiting , vision changes ?
[patient] no , i've been feelin' great .
[doctor] good . well let me take a look at your back here where they did the biopsy if you do n't mind .
[patient] sure .
[doctor] okay , i'm gon na describe it in medical jargon what i'm seeing here , so that the recording can capture it , but you and i are gon na go over it together in just a moment , okay ?
[patient] okay , that's fine .
[doctor] all right , so on the right inferior back there's a one centimeter shave biopsy site , including all of the dermis with no residual pigmentation . there's no intrinsic or satellite lesions , no other suspicious moles , no axillary , cervical , or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin , but it's nontender , otherwise normal exam .
[doctor] okay , you can sit up . um , so what i was saying there is that i see your biopsy site , but i do n't see any other s- , um , skin lumps or bumps that look suspicious . uh , i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing , um , and , you know , make sure it's nothing that we need to worry about . uh , the reason we're being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further .
[patient] okay , i should n't worry too much then ?
[doctor] no , i have a low suspicion that it will show anything .
[patient] okay , good .
[doctor] so assuming that the ultrasound is normal , the treatment for you melanoma is to cut out the area where the lesion was . with lesions that are 0.7 millimeters or less , um , and that's what we recommend , and yours was exactly 0.7 millimeters . if it were any bigger , we would have had to do a more complex surgery . but what i recommend for you is what we call a wide local incision , excuse me , excision , meaning that i will make a long incision and then cut out an area a bit wider than your current biopsy site . the incision is long because that's what allows me to close the skin nicely . you'll have a fairly long scar from the incision .
[patient] okay , that is fine with me , i ca n't see back there anyways .
[doctor] yeah , your wife can tell you what it looks like and she may need to help care for the incision at it , as it heals . um , but since we're , we are n't doing the more complex surgery , i actually do n't need to see you back unless you want to check in with me or have any problems . however , it is very important that you continue to follow up with your dermatologist regularly so she can monitor you . uh , your dermatologist will check that this one does n't come back , but she'll also check for other lesions that look suspicious . uh , unfortunately , since you've had one melanoma , you're at a higher risk of developing another one somewhere else .
[patient] yeah , she did say she wants to see me back .
[doctor] good , and i'm sure she's already told you , but it's very important that you apply sunscreen anytime and anywhere that your skin is exposed to sunlight .
[patient] yeah , she definitely went over that , um , several times with me .
[doctor] good . other than that , i think that's all for me . um , we'll get you set up for the ultrasound , the procedure . do you have any questions for me ?
[patient] um , no i ca n't think of any at this time .
[doctor] okay , my nurse will be in to get you scheduled , so sit tight . it was very good to meet you .
[patient] thank you , nice to meet you as well .
[doctor] please add the following pathology r- , to results . a pathology , shave of right inferior back , malignant melanoma , invasive , superficial spreading . histology , superficial spreading . clark level 4 , breslow thickness 0.7 millimeters , radial growth phase present , vertical growth phase not identified . mitotic features , less than one millimeter squared . ulceration not identified , progression not identified , lymphatic invasion not identified , perineural invasion not identified , microscopic satellitosis not identified . infiltrating , uh , lymphocytes , breast . um , melanocytic nevus not identified . predominant cytology epithelioid , peripheral margin positive , deep margin , uh , negative , stage 1 . also note that i reviewed the dermatologist's photo of the lesion which showed an asymmetric black and brown nevus with central a melanotic component and irregular border .
[doctor] for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a one to two centimeter margin .
[doctor] primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up , according to the national comprehensive cancer network guidelines , was reviewed . we also reviewed the principles of sun avoidance , skin self-examination , and the abcdes of mole surveillance .
[doctor] after discussing the procedure , risk and expected outcomes , and possible complications , questions were answered and the patient expressed understanding and did choose to proceed .

Medical orders:
description: ultrasound
order_type: imaging
reason: intermediate thickness melanoma to rule out metastatic disease