This document provides information about a 52-year-old male patient diagnosed with Stage IV malignant melanoma. It includes his personal and family medical history, physical examination findings, diagnostic workup revealing metastases to lymph nodes and bones, and proposed homeopathic treatment plan. The patient has a non-healing ulcer on his right thumb and swelling in his right axilla, with a family history of melanoma. Diagnostic testing confirmed metastatic melanoma and the patient was given Merc sol, Silicea, and Hydrocotyle to address his symptoms based on the totality of the case.

1. PRESENTATION BY: Mohammed Huzaifa Saud
4th BHMS
UNDER THE GUIDANCE OF: Dr Jyothirmai Maam
HOD & Professor Preventive and Social Medicine
Govt Homoeopathic Medical College & Hospital,
Bangalore

2. Individual Profile:
• Name: Gyan Bahadur Rana
• Age: 52yrs
• Sex: Male
• Religion: Buddhist
• Caste: Not known
• H/O Migration: Nil
• Education: SSLC
• Occupation: Street Food Vendor
• Income: 10000/ month
• Language Known: Bangla, Hindi
• Blood Group: O +ve
• Marital Status: Married
• Address: Toto Para, Jalpaiguri, West Bengal- 735220

3. Important Health Events:
• Long Hospital Stay: 4 months in Alcohol Rehabilitation Centre
(10yr)
• Operations: Matricectomy on Right Thumb .(Complete Extirpation
of the nail matrix, resulting in permanent nail loss.) 10/12/2021
• Injuries/Burn/Accidents: Minor Accident (Scar Mark on left
forearm)
• Regular Medication: 1. Tab. Telma 40mg
2. Tab. Teniva Forte
3. Tab. Rosuva 20mg
• Suicide Attempt: Nil
• Poisoning: Nil
• Others: Nil

4. Family Structure:
No of Males: 2
No of Females: 2
Total: 4
Family Type: Nuclear Family
Sl.
no
Name Age Sex
Marital
Status
Education
Occupatio
n
Incom
e
Medicosocial
status
1
Mr. Gyan Bahadur
Rana
52ys M SSLC
Street
Food
Vendor
10000/
month
DM, HTN,
Cancer
2 Mrs. Ajitmaya Rana
37yr
s
F Married SSLC
House
wife
-
DM, HTN
3 Mr. Abhimanyu Rana
15yr
s
M Unmarried 9th std Student - -
4 Ms. Nagma Rana
20yr
s
F Unmarried Bsc 2nd yr Student - -
FAMILY PROFILE

5. Per capita monthly income = Total Family income
No. of members
2500= 10000/4
According to modified BG Prasad Classification
1733-2886/- is mentioned as Middle Class.
Social Class
Modified BG
Prasad 2015
Upper Class >5775
Upper Middle
Class
2887-5774
Middle Class 1733-2886
Lower Middle
Class
866-1732
Lower Class <866
Socioeconomic Class

6. Clinical Details of the Patient
Presenting Complaints:
1. C/O Pain and Swelling in Right Axillary region since 5 months.
2. C/O Non Healing Ulcer on Right Thumb since 9 months.
H/O Presenting Complaints:
Gradual Onset & Gradual Progression
Location Sensation Modality Concomitant
Right Axillary
Region
Swelling and Painfull
< Pressure
< Morning
No Amel
-
Right Thumb Ulcer Bleeds to touch - -

7. Past History:
1. Acute Liver Disease
Time of illness- 10 yrs ago
Hospitalization – Was in Rehab Center for 4 months
Treatment- Allopathic Treatment
2. Matricectomy on Right Finger.
Time of illness- 2 weeks 10/12/2021
Hospitalization – Was admitted for 2 days
Treatment- Allopathic Treatment
Similar Case in Family:
Elder Brother Died due to Malignant Melanoma 8yrs ago.
Epidemological History:

8. Lifestyle:
• Diet: Mixed
• Appetite: Good, prefer warm food
• Hunger: Normal
• Thirst: 2 lts/day , moderate
• Desire: Sweet 2+
• Perspiration: NS
• Urine: 2-3/0-1 D/N, passes without difficulty
• Bowel: 2 times a day , Satisfactory
• Sleep: Sound & Refreshing Sleep
• Habits: Chronic Alcoholic , 1 Quater / day
Habit of Chewing Betel nut
• Thermals: Chilly

9. General Physical Examination
• Built: Obese
• Height: 5ft
• Weight: 93kg
• Nourishment: Well nourished
• Anemia: NAD
• Cyanosis: NAD
• Jaundice: NAD
• Lymphadenopathy: Right Axillary Lymphadenopathy
• Edema: NAD
Vitals Signs:
PR: 70 bpm
RR: 16 cpm
BP: 130/90
mmHg
Temp: Afebrile

10. Systemic Examination
EXAMINATION OF SKIN & NAILS:
• Inspection: Non Healing Ulcer on Right Thumb
• Palpation: Bleeds on Touch
Crust on Skin, painful only on touch.
• Scraping: Nil Hutchinson's sign
Non Healing Ulcer

11. 13/8/22
1. FNAC from Right Axillary
Lump:
Positive for Metastatic
Deposits of Malignant
Melanoma.
Lab Investigations:

12. 19/8/22
2. PET CT Scan:
Metastatic Subungual Malignant
Melanoma; ill defined lesion in right
thumbnail bed likely representing
primary site.

13. 19/8/22
3. Nail Wedge Biopsy:
Poorly differentiated Malignant Neoplasm
4. IHC (Immuno Histochemistry):
The neoplastic cells are Positive for
S100,MelanA & HMB45.

14. Right Ungual Melanoma with Axillary Lymphadenopathy
Hutchinson's sign Axillary Lymphadenopathy
pTNM Stage IV
Clinical Diagnosis
Non Healing Ulcer

15. pTNM Stage IV
TNM Staging: Tis N1 M1a
Tis : Melanoma in situ
N1 : 1 Tumor involved LN
M1a : Distant metastasis to
skin, soft tissue including
muscle & Bones.
As mentioned in PET Scan Primary Site in
this case is likely to be Right Thumb Nail
bed.

16. Differential Diagnosis
Leukonychia
Onychomycosis
Striate melanonychia
The 2 most common misdiagnoses of subungual melanoma
are
striate melanonychia and onychomycosis.

17. Dynamic Disease
Chronic Disease
Disease with fully developed symptoms
Miasmatic
Complex
Syco - syphilitic
Classification of Disease according to Dr.Hahnemann

18. Common Symptoms
• Ulcer on Right thumb
Uncommon Symptoms
• Pain & swelling in axilla
region.
• < Pressure
< Morning
• Non Healing Ulcer on Right
thumb.
• Desire Sweets, prefer Warm
foods.
Analysis of Case

19. • Optimistic
• Courageous
• Mentally strong
• Desire Sweets
• Prefer warm food.
• Pain & swelling in Axilla
• Non healing ulcer on right
thumb
• Ulcer bleeds on touch
Physical Generals
Mental Generals Particulars
Evaluation of Case

20. Reportorial Totality
• EXTREMITIES – ULCERS – Fingers – Nails
• CHEST – AXILLA ; complaint of – right
• GENERALS – Food and Drinks – sweets – desire
• MIND – COURAGEOUS
• MIND – OPTIMISTIC
• SKIN – CANCER - melanoma

21. Final Prescription
• Merc sol 200 X 3days
5-5-5
• Silicea 6x
2-2-2
• Hydrocotyle Q
10-0-10 drops
Advice:
1. Avoid Alcohol intake.
2. Use Sun Screen & avoid UV Exposure.

22. Agent Factor Host Factor
Biological – Family History of
Malignant Melanoma
Mechanical – Repeated hit on
the Right Thumb.
Inheritance – Family History of
Malignant Melanoma. Elder
Brother died with same
condition.
Others – Chronic Alcoholic.
Environmental Factor Social Factor
Occupational Environment –
Street Food Vendor (Sells
Momo's n Noodles). Repeated
hit on the Right Thumb.
Habits – Chronic Alcoholic.
1 Quater / day
Habit of Chewing Betel
nut
Identification of the Factors Responsible for / Influencing the
Present Condition:

23. Levels of Prevention
Levels of Prevention Which level has failed?
How could have been
prevented?
Primary
Health
promotion
Periodical Check-up.
By quitting alcohol.
Specific
protection
Excessive consumption of Alcohol.
Secondary
Early detection
& proper
treatment
Inspite of knowing that his brother
has been diagnosed with Malignant
melanoma and died because of it, pt
didn’t get screening done.
As early symptoms appeared
(Hutchison Sign), he could
have underwent screening for
Ca marker HMB45.
Tertiary
Disability
limitation
As PET Scan shows the Metastatic
deposits in Right Iliac bone and in
Femur, there are high chance of
necrosis.
-
Avoid UV exposure , Use
• Prevention of MM is easier than treating it:
1. Photoprotection
2. Self examination: Especially those at risk (H/o Skin Cancers.)

24. Assesment of Knowledge, Attitude and Practice (KAP) towards
the Disease
Particulars Knowledge
Attitude
(beliefs and
custom)
Practice
Cause
Treatment
Prevention
Health service
Others
Patient had
acknowledge his
condition as his
brother suffered
from the same
condition and
had died.
Patient is
mentally strong
& optimistic yet
with a Happy –
go – lucky
attitude.
This condition
was caused by
the long practice
of drinking
alcohol.

25. MALIGNANT MELANOMA
Melanoma is a type of cancer that arises from pigmented cells called
melanocytes. It most often occurs in melanocytes in the skin’s top layer.

26. Causes & Risk Factors
Risk factors for melanoma include both
intrinsic (genetic and phenotype) and extrinsic (environmental or exposure)
factors:
• Sun exposure.
• Pigmentary characteristics.
• Multiple nevi.
• Family and personal history of melanoma.
• Immunosuppression.
• Environmental exposures.

27. Hidden Melanoma
• Melanoma under a nail: There are three ways in which this may present:
1. The development of pigmented band in the nail, granulation tissue may
appear some year laterat the edge of the nail, and pigment band may
become wider.
2. Chronic paronychia affecting single nail.
3. Development of warty growth of nail bed with shedding of nail.
• Melanoma in the mouth, digestive tract, urinary tract or vagina.
• Melanoma in the eye.

28. A. Asymmetry: One side is not like the other.
B. Border: The edges are irregular or ragged.
C. Color: It has color variations, such as shades of brown or black,
sometimes with patches of pink, red or white
D. Diameter: It’s more than 6 millimeters across (the size of a pencil
eraser),
though it can be smaller.
E. Evolving: The mole may change in size, color or shape.
Clinical Features

29. Stage Information for Melanoma
Tis, N0, M0 Tis = Melanoma in
situ.b,c
N0 = No regional
metastases detected.
M0 = No evidence
of distant
metastasis.
pTNM Stages 0

30. pTNM Stages IA and IB
IA T1a, N0, M0 T1a = <0.8
mm/without
ulceration.
N0 = No regional
metastases detected.
detected.
IB T2a, N0, M0 T2a = >1.0–2.0
mm/without
ulceration.
N0 = No regional
metastases detected.
M0 = No evidence of
distant metastasis.
M0 = No evidence of
distant metastasis.

31. pTNM Stages II
IIA T2b, N0, M0 T2b = >1.0–2.0
mm/with
ulceration.
N0 = No regional
metastases detected.
M0 = No evidence of
distant metastasis.

32. IV Tis = Melanoma in
situ.
T1a = <0.8
mm/with
ulceration.
N1 = 1 Tumor
involved LN
pTNM Stage IV
M1a = Distant
metastasis to skin, soft
tissue including muscle,
and/or nonregional
lymph nodes

33. Treatment Options for Melanoma
Stage 0 melanoma Excision
Stage I melanoma
Excision +/− lymph node
management
Stage II melanoma
Excision +/− lymph node
management
Stage III melanoma
Excision +/− lymph node
management
Stage IV melanoma
Intralesional therapy
Immunotherapy
Signal transduction inhibitors
Chemotherapy
Palliative local therapy

34. Thank You