Case Study On Melanoma

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This patient has a few complaints of rough sites over his face and a bump on his scalp that will not resolve. He has a history of melanoma on his left upper back near the shoulder as well as has BCC and SCC. He last used 5-FU on his scalp several years ago and he did not repeat this after his last dermatology consult in 12/2015. He never got the product by history. There is no liquid nitrogen available today.

PHYSICAL EXAMINATION
A total body exam was performed. He has extensive tattooing over essentially all of his trunk and extremities. There is a rare seborrheic keratoses noted in scattered pink scaly macules including one up to about 2.5 cm on his face, specifically the large site is over his left mid anterior cheek, all consistent with actinic keratoses. There is a few actinic keratoses over his photo forearms. There is one 6 mm pink nonspecific papule over his posterior crown just left of the midline. There are no sites suspicious for new or recurrent melanoma noted today.

IMPRESSION …show more content…

Multiple actinic keratoses over his face. Advised using 5-fluorouracil 5% cream b.i.d. to his face, ears, and lateral neck for 2-3 weeks. I discussed the use of this with the patient and he is willing to use.

2. Question BCC versus SCC of his crown of the scalp. Please refer to the surgery clinic for excisional biopsy of the scalp lesion as soon as possible.

3. History of melanoma. There is no evidence of new or recurrent melanoma noted. Please return to the dermatology clinic in 3-4

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