Case Melanoma Maligna 1 (Albert)

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Case Melanoma Maligna
Shenna Shuardana
Amanda Padma Nibbana Y.
Paramitha Setiadi
Albert Jonathan

(1015045)
(1015058)
(1015171)
(1015116)

Patient Identity
Name : Ny.M
Age
: 57 years old
Gender
: Female
Address
: Jl.Cimangggu-cilimus bantarujeg
Date
: 10- November – 2014
Room : Musa
Rm. No
: 135617
Check date : 11 November 2014
Pre op Diagnose : Melanoma maligna with inguinal metastase
Post op Diagnose: Melanoma maligna with inguinal metastase

General Problem
General Problem : lump at left inguinal
Patient came with lump at her left ingunal
since 6 months ago, at first the lump size is only the
size of squall egg, but it’s getting bigger, the lump
isn’t hurt at all, without fever, nausea, or vomit.
Early 2012, patient went through surgery
amputation of her left finger of her leg, at first her
toe nail is smashed and her nail is grow back but
with black appereance, and blood leaked out. After
check, it’s some of malignancy.

• History of illness : Hipertension (-) , DM (-) ,
Asthma (-)
• Family illness history : Hipertension (-) , DM (-)
, Asthma (-)
• Alergy history : food allergy (-) . Medicine
allergy (-)

Physical Examination
General condition :
– General appereance: mild pain
– Awareness
: Compos Mentis
– Nutrition status
: Less
Vital sign :
Blood pressure
Pulse
Respiration
Temp

: 120/80 mmHg
: 76 Rpm
: 20x / mnt
: 36,3 C

General Status
• Head

:

– Eye : Conjunciva anemic -/- Sclera Icteric -/– Pupil : Round, isokor, 3mm diameter, light reflek +/+

• Neck
– Trachea central position, symetry right and left

• Chest
– Pulmo : VBS +/+, Rh -/-, Wh -/-

• Abdomen
– Flat , intestinal sound (+)

• Genital
– Normal

• Extremitas
– Warmness (+) , CRT <2’s , Lump at left inguinal, consistency Hard, size :
10x6,5x3 , amputated (+) digiti 1 left pedis

Laboratory examination
• X thorax photo (10 november 2014) :
– Cardiomegali without lung obstruction
– TB lung specific not found.

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