Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of a congenital melanocytic nevus (CMN) noted since [birth/early infancy]. Location: [Anatomical site]. Size: [Dimensions in cm]. Patient/parent reports [stable size/progressive growth/color change/surface irregularity]. No history of pruritus, bleeding, or ulceration. Family history of melanoma or dysplastic nevi: [Positive/Negative].
Clinical Examination Findings
Dermatologic examination reveals a [well-demarcated/irregular] pigmented lesion measuring [X] x [Y] cm, located on the [Anatomical site]. Surface texture is [smooth/verrucous/hypertrichotic]. Color is [uniform/variegated] with shades of [brown/black/tan]. No palpable subcutaneous nodules, satellite lesions, or regional lymphadenopathy. ABCDE criteria: [Asymmetry/Border/Color/Diameter/Evolution] noted as [Normal/Abnormal].
Treatment Protocol
Treatment plan discussed: [Observation/Serial excision/Surgical excision with primary closure/Tissue expansion/Skin grafting]. Risks and benefits of surgical intervention vs. conservative management explained, including scarring, recurrence, and risk of malignant transformation. Patient/guardian consents to [Procedure name] with [Local/General] anesthesia. Post-operative wound care instructions provided.