IT'S BEEN ON MY NECK FOR YEARS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Initial patient encounters with patients who are poor historians can be extremely challenging. Physical exam is of utmost importance. The nature, history and prognosis exophytic melanoma has been controversial uncertain. CASE PRESENTATION: A 91 year old Caucasian female no apparent medical comorbidities had not seen a physician in 30 years presented to the emergency department after her family stated they could longer care for her. chest X-ray revealed large mass like opacity over left lung apex. She also urinary tract infection. was started on Ceftriaxone admitted internal medicine. Upon our exam, examining neck removing bandage, we found an external exophytic, pedunculated from inferior lateral measuring 4.6 x 3.7 5.7 cm which concerning malignancy. pulsatile bleeding certain areas without evidence frank hemorrhage. CT scan then pursued reinforced physical findings. further questioning family, it reported that said present 10 + always covered up abdominal pads seeking attention. There white blood cell count elevation indicating infectious foci. General surgery consulted excision pathology. taken operating room next day lesion excised at skin zone 2 margin normal subcutaneous tissue around it. measured 15 20 (L W H). discharged nursing home stable fashion. Her pathology came back ulcerated malignant negative margins. Histologic type nodular melanoma. Maximum Breslow thickness 17mm microsatellites. distance invasive closest peripheral 10mmwith mitotic rate 8 per mm2. Tumor infiltrating lymphocytes were tumor regression. cells demonstrated strong positivity SOX10 Melan-A stain focally positive HMB-45. DISCUSSION: Nodular accounts less than 15% all melanomas. Usual prognostic indicators driven by histologic subtype being neglected. melanoma, however, known include as factor. Majority these cases have metastasis prognosis. CONCLUSIONS: With neglected, she still only local disease removal, adjunctive therapy needed. Clinicians should made aware lookout different types melanomas their respective presentations. REFERENCE #1: Clark WH, Elder DE, Guerry D, Epstein MN, Greene MH, Van Horn M. study progression: precursor lesions superficial spreading Hum Pathol. 1984;15(12):1147-1165. doi:10.1016/S0046-8177(84)80310-X #2: Shaikh WR. Contribution Subtype Melanoma Mortality United States, 1978 2007. Arch Dermatol. 2012;148(1):30. doi:10.1001/archdermatol.2011.264 DISCLOSURES: No relevant relationships Ahmad Abu Hashyeh, source=Web Response Mohamed Suliman, disclosure file Toufeeq Suliman