CRIMEAN STATE MEDICAL UNIVERSITY

NAMED AFTER SI GEORGIEVSKY

Department Of Oncology
Head of Chair : Prof. Sorkin Vitaly Markovich
Teacher : Dr. Tatyana Sergievna Efetova
CASE HISTORY
Name: Tatyana Nikolaevna Bimuseva
Age : 50
CLINICAL DIAGNOSIS
Main disease : Superficial Spreading Melanoma at the back of the
trunk, with suspicious of regional metastasis to right
axillary lymph nodes
Accompanied disease : - none
Complication : - none
STUDENT : Chong Eng Ngen
COURSE : 5th Course
GROUP : 530

PASSPORT DATA
1. Full name : Tatyana Nikolaevna Bimuseva
2. Age : 50 years old
3. Birthday : 2-8-1958
4. Nationality : Russian
5. Family status : married
6. Occupation : school teacher
7. Home address : Feodosia
8. Date of admission : 26th January 2009
9. weight : 92 kg
10. height : 165 cm

COMPLAINTS
The patient complaints of scanty bleeding from irregular skin outgrowth site at the
back of trunk, which located between scapula. There is no complaints of itching and
scaling but the outgrowth is hyperpigmented. She has no change on appetite nor
complains of general weakness. No complains of pain or headache is recorded. Body
temperature is normal.

ANAMNESIS MORBI
Patient has the mole at her back since young age, but she never bother about it.
About 3 months ago, she went for a massage and it was too intense which caused tearing
lesion on the mole. She never bother about the bleeding and just do simple hemostatic
procedures to stop bleeding. So in the past 2-3 months she never went to see doctor even
though there is inconstent bleeding at the back from the outgrowth site due to simple
friction by cloth, until early this year in January 2009 she went to see doctor in Sudak
hospital and seek for consultation. After that she was adviced to come to oncology
hospital and was admitted on 26th January 2009.

STATUS LOCALIS
The ulcerative lesion with the suspicion of necrosis on the back between the
scapula was started to grow from a typical skin mole. The growth is nodular form, with
around 20mm diameter and bluish-purple in color. Borders are irregular and elevated.
Bloody discharge happens from time to time.
Lymph nodes status:
Generally all lymph nodes are normal in size except right axillary lymph nodes
which clumps together.
Regional lymph nodes near the neck along the sternocleidomastoid muscle,
supraclavicular and subclavicular lymph nodes are not palpable.

ANAMNESIS VITAE
Patient was born on 2nd December 1958. She is married with 2 daughters and
staying with her husband at Feodosia. All her family members are healthy and clear of

any history of hereditary diseases. Most of her family members have numberous nevus on
their body.
She began walking and talking in time without any other related problems. Her
school life was satisfactory. The condition of her child hood was satisfactory.
Patient is a teacher working in schools. Her working environment was
satisfactory. Her working timetable was variable. Leaves and holidays were utilized fully.
Work conflicts are rare. She likes to sun-bathing, and every summer she will went to
seaside for sun-bath under the umbrella
She does not smoke and dont take alcohol. She has been having good appetite all
time long.
The patient does not have any hereditary diseases. She doesnt have history of
tuberculosis or any venerological diseases. She dont have any allergies.

GENERAL SYSTEM EXAMINATION

Status Praesens
General condition of the patient is satisfactory. Consciousness is clear, posture is
active, gait is not determined. Body structure is hypersthenic.
Skin is pale, clean and elastic. Lips and other visible mucous are pinkish, moist.
Edema is absent
The muscles are developed moderately; tone and muscles force are identical on
both sides. Tenderness of the extremities muscles during palpation is marked. Palpation
and tapping of the bones are painless. Joints are of regular shape, painless during
palpation and movements. Active and passive movements in joints are full. Skin above
joints is not changed.
Temperature of body: 36.9 C
Height: 165cm
Weight: 92kg
Respiratory System
She breathes through the nose. Nose wings in breathing do not participate. Voice
is normal. Forms of the chest is regular, normosthenic constitution with well developed
muscles of the shoulder girdle and directed upwards. The anteroposterior
(sternovertebral) diameter of the chest is smaller than the lateral ( transverse ) one and the
supraclavicular fossae are slightly pronounced. There is a distinct angle between the
sternum and the manubrium,the epigastric angle nears 90.The ribs are moderately
inclined as viewed from the side, the shoulder blades closely fits to chest and are at the
same level, the chest is about the same height as the abdominal part of the trunk.
Respiratory type is abdominal respiration. The chest markedly broadens and
slightly lowers. Breathing is rhythmic. Respiration rate is 20 per minute. Vocal fremitus is
louder in the upper parts of the chest and softer in its lower part.
In comparative percussion of the lungs, the percussion sound is clear lung sound.Traubes
space gives tympanic sound during percussion.
In topographic percussion, upper level of the apices on both sides,anteriorly is 3cm and
posterior is at the level of spinous process of the 7th cervical vertebra.

Lower border of the lungs :

LINES
Parasternal
Mid-clavicular
Ant-axillary
Mid-axillary
Post-axillary
Scapular
Paraspinal

RIGHT LUNG
LEFT LUNG
5th costal interspace
th
6 rib
th
7 rib
7th rib
8th rib
8th rib
9th rib
9th rib
th
10 rib
10th rib
Spinous process of the 11th
Spinous process of the 11th
thoracic vertebra
thoracic vertebra
Mobility of the lower edge of the left lung on mid-axillary line is 6cm,scapular
line is 5cm.Mobility of the lower edge of the right lung on midclavicular line is
4cm,midaxillary line is 6cm and scapular line is 4cm.
In auscultation, vesicular breathing is heard over the anterior surface of the chest, below
2nd rib, laterally of the parasternal line, in axillary regions and below the scapular
angle.Bronchiol breathing is heard anteriorly over the manubrium sterni, at the point of
its junction with the sternum and posteriorly in the interscapular space at the level of the
3rd and 4th thoracic vertebra.
Cardiovascular System
Apex beat is palpated in the 5th intercostals space,1cm toward the sternum from
the left midclavicular line with width : 2cm in diameter.Cats murmur was not
determined.
In percussion,relative cardiac dullness :
Right border 1cm laterally of the right edge of the sternum
Left border 1.5cm medially of the left midclavicular line
Upper border 1cm to the left of the left sternal line
Absolute cardiac dullness :
Right border on the left edge of the sternum
Left border 1cm medially of the border of relative cardiac dullness
Upper border on the lower edge of the 4th rib
Right and left borders of vascular dullness are found along the edges of the
sternum.
On auscultation of the heart,two sounds are heard in all the points.The sounds are
rhythmic, and weakened. The first sound is louder than the second sound at the heart apex
and tricuspid valve. The second sound is louder than the first one on the heart base.
Cardiac rate is 78 per minute.
Pulse is equal on both arms. Its rate is 75 per minute. Pulse is rhythmic. Temporal
and carotid arteries are well palpated, pulsation on both side is equal.
Arterial pressure : systolic 120 mm Hg, diastolic 70 mm Hg.

Digestive System
The tongue is of usual size, moist, coated with white layer. Number of teeth in the
patient is normal.Mucous of mouth is light pink colour.Tonsils are present.
Abdomen is of a regular form, symmetric.Abdominal wall participates in
breathing. Tympanic sound is heard over all parts of the abdomen during percussion. In
superficial palpation, abdomen is soft, painless.Hernias and superficial tumors are
absent.Shchetkin-Blumbergs symptom are negative.
Deep palpation : sigmoid is palpable in the left iliac region as a smooth firm
cylinder 2cm in diameter, it is painless, does not produce rumbling sounds, caecum is
palpable in the right iliac region as a smooth soft cylinder with diameter 3cm.Other parts
of the intestine are not palpable.
On auscultation of the abdomen,peristalsis of the intestine is of moderate sound
and frequency is heard.Vessel murmurs are absent.
Greater curvature of the stomach is determined as soft smooth ridge 4cm above
the navel,it is painess, not displaced, produces slightly rumbling sound.Other parts of the
stomach are not palpable.
Visible enlargement of the liver is absent. Upper border of absolute hepatic
dullness on the right mid-clavicular line is on the 6th rib, lower on the edge of costal
arch. Gall bladder is not palpable. The symptoms of pressing and concussion of gall
bladder is negative. Tenderness in the points of gall bladder is not determined. Pancreas is
not palpable. Tenderness in the points of conforming to the head, to the body and to the
tail of pancreas and in points of phrenic nerve and costo-vertebral to the left is not
determined. Spleen is not palpable.
Urinary System
Visible pathology of the lumbar region is absent. Kidneys are not palpable.
Palpation of the kidneys region is painless. Palpation along the course of ureters is
painless. Pasternatskys symptom is negative on the both sides. The urinary bladder is not
palpable.
Endocrine System
Changes of the eyes ( exopthalmus or enophthalmus ) are not determined. Thyroid
gland is of usual size. Its isthmus is palpated as soft, painless band 1.2 cm in diameter.
Ocular symptoms ( Graefes , Kochers ,Moeubius, Stelwags, Dalrympls )
are negative
Blood System
Hemorrhagia on the skin and mucosa are absent. Spleen is impalpable. The
borders f the spleen dullness is determined between 9th to 11th ribs.
Genital System (Gynecological)
Condition of the external sexual organ was satisfactory. Vaginal examination
revealed clear and satisfactory condition of the vagina. There was no infiltration present.
Bimanual palpation didnt reveal any pathology.

INITIAL DIGNOSIS
From the anamnesis and clinical examination on the patient makes it possible to
formulate the following initial diagnosis :Main disease: Superficial Spreading Melanoma at the back of the trunk, with suspicious
of regional metastasis to right axillary lymph nodes. Staging cant be done because
histo-pathological examination is not been done yet.
Accompanied disease: absent
Complications: absent

PLAN OF INVESTIAGATION

biochemical test
Complete blood count
Urine analysis
Cytological investiagtion :smear biopsy of skin outgrowth
Chest x-ray
Liver ultrasound

INVESTIGATIONS RESULT
( a ) Biochemical test
Common bilirubin 12.8mkmol/L
Direct bilirubin 9.7mkmol/L
Indirect bilirubin 3.1mkmol/L
Protein 68.2 g/L
Blood sugar 5.5 mmol/l
Cloride 100mmol/l
Urea 12.34mmol/l
Conclusion : Normal
( b ) Complete Blood Count :
Erythrocytes 3.9 x 1012 /L
Hemoglobin 125 g/L
Color index 0.9
Platlets 230 x 109/L
Leucocytes 6.0 x 109/L
Basophils 0 %
Stab neutrophils 3%
Segmented neutrophils 66%
Eosinophil - 1%
Monocytes 12%
Lymphocytes 18%
ESR 5 mm/h
Conclusion : Blood analysis is normal.

( c ) Urinanalysis :
Colour: straw yellow
Specific gravity: 1004
Reaction: acidic
Protein : 0.05
Glucose: +
Erythrocytes: Leucocytes: Conclusion : Normal
( d ) Cytological Investigation :
Conclusion : Samples can be be received by taking smear from the ulcerated
growth for biopsy. Atypical melanocyte found
( e ) chest x-ray
Conclusion : No pathology revealed.
(f) Ultrasound of liver
Conclusion : No pathology revealed.

DIFFERENTIAL DIAGNOSIS
Pigmented basal cell carcinomas
They are brown, black, or blue; they are usually of the nodular type and can look like a
melanoma.
Some general:
irregular or ragged borders
non-symmetrical shape
a change in color
a size greater than 0.2 inches (6 mm)
Melanocytic tumors
-slight elevated,black or brown color lesion.
Features
Benign mole

Malignant melanoma

1-Clinical pictures
>symmetry
>border
>colour
>diameter

Symmetrical
Well demarcated
Uniformly pigmented
Small, less than 6mm

Asymmetry
Border irregular
Color change
Diameter more than 6mm

2-location

skin of fave,mucosa

Skin,mucosa of
nose,bowel,anal region

3-histopathology
>architecture
>cell morphology

Nests of cells
Uniform lookin naevus cell

Various patterns
Malignant cells,atypia

>melanin pigment
>inflammation

Irregular,coarse lumps
May or may not present

Fine granules
present

FINAL DIAGNOSIS
The findings of the patient together with the differential diagnosis,make it
possible to formulate the following final diagnosis:Main disease: Superficial Spreading Melanoma at the back of the trunk, with suspicious
of regional metastasis to right axillary lymph nodes. Staging cant be done because
histo-pathological examination is not been done yet.
Complications: absent
Other accompanied Diseases : absent

TREATMENT
Regime Ward
Free diet
Wide local excision-during the excision, 1-2 centimeters of normal skin tissue
around the growth should b taken out with full thickness excision to make sure all
the growth is taken out fully.
sentinel lymph node biopsy and/or elective lymph nodes dissection of right axillary
lymph nodes
Lymphadenoectomy- dissection of lymph node is done if there is lymph node
enlargement and may be done later till the symptoms of enlargement arises.
Adjuvant therapy
- prescribing immunostimulating drug
Rp: Tab Amixini 0.125-No 10
D.S. 1 tab PO 1-2 t.d after meal,
after 2 days 1 tab every alternate days
-prescribing antineoplastic drug
Rp. Tab. Tamoxifeni 0.02 N 20
D.S 1 tab PO 2 t.d after 4th day of surgery

EPICRISIS
The patient was admitted on the 26th January 2009 for checkup to evaluate her
medical condition and perform further investigations. She was diagnosed with Superficial
Spreading Melanoma and went for surgery to remove the growth on 3rd Febuary 2009.

RECOMMENDATIONS
Patient is suffering from a malignant disease. According to her diagnosis she should
control her diet, life style and should get enough rest to prevent recurrence of the disease.
She should regularly follow her check up in hospital every 2 or 3 months once.
Medication should not be skipped.

PROGNOSIS
Almost all patients survive stage Ia malignant melanoma, and the suvivorship for stage I
overall is more than 90%. Survival drops in stage IIa to about 65% at five years and is
worse yet for stage IIb at slightly over 50%. Stage III has a survival rate at 5 years of
10% to 47%, depending on the size and number of regional nodes involved. Stage IV
malignant melanoma is almost always a fatal disease

Prepared by :__________________
(CHONG ENG NGEN)