Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
New diagnosis of cutaneous melanoma
Follow-up for known cutaneous melanoma
II. History of Present Illness:
New diagnosis:
Discovery of a new suspicious skin lesion (describe location, size, color, shape, change in appearance)
Any personal or family history of melanoma
Follow-up:
Date of prior melanoma diagnosis and treatment
Any new or worsening symptoms (e.g., new skin lesions, bleeding, itching)
Adherence to follow-up recommendations
III. Past Medical History:
Significant medical conditions
Previous surgeries (including any prior melanoma excision)
Family history of melanoma or other skin cancers
IV. Medications:
Current medications (including any blood thinners)
V. Social History:
Sun exposure habits (history of sunburns, tanning)
Occupational sun exposure
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp)
Skin exam:
Detailed examination of the entire skin surface for suspicious lesions (ABCD rule – Asymmetry, Border irregularity, Color variation, Diameter > 6mm)
Close examination of the primary melanoma site (size, color, bleeding, ulceration)
Lymph node examination (palpate for enlargement or tenderness)
VII. Diagnostic Studies (consider as appropriate):
Dermoscopy: Non-invasive examination of the lesion with a dermatoscope to aid in melanoma diagnosis.
Skin biopsy: Definitive diagnosis of melanoma requires excisional biopsy with pathological examination.
Sentinel lymph node biopsy (SLNB): May be performed after primary melanoma excision to assess lymph node involvement.
Imaging studies (if indicated for suspected advanced disease): Chest X-ray, CT scan, PET scan – to evaluate for potential metastasis.
VIII. Assessment:
New diagnosis: Suspected or confirmed cutaneous melanoma based on clinical presentation (suspicious lesion) and dermoscopy findings (if performed). Definitive diagnosis awaits biopsy results.
Follow-up: Evaluate status of known melanoma and any signs of recurrence or metastasis.
IX. Plan:
New diagnosis:
Wide local excision of the melanoma with adequate surgical margins is the mainstay of treatment.
Sentinel lymph node biopsy may be indicated depending on tumor characteristics and Breslow thickness (depth of invasion).
Further workup (imaging studies) may be needed to assess for potential metastasis in advanced stages.
Follow-up:
Management plan depends on the stage of melanoma at initial diagnosis and presence of recurrence.
Regular skin cancer screenings are crucial for early detection of new or recurrent melanomas.
X. Prognosis:
Discuss the prognosis based on the stage and other factors of the melanoma. Early-stage melanomas treated with surgical excision have a good prognosis.
The importance of sun protection and regular skin self-exams should be emphasized.
XI. Notes:
Include any additional observations or concerns, such as patient’s understanding of the diagnosis and treatment plan, potential side effects of surgery, need for emotional support, and referral to a dermatologist or surgical oncologist for definitive management.
XII. Resources:
Consider providing patient education materials on cutaneous melanoma from reputable sources (e.g., American Academy of Dermatology, Skin Cancer Foundation).