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患者杨××女74岁病案号238415 3个月前,无意中在右眼内眦部触及一黄豆大小肿物,红、痛、溢泪。以后肿物逐渐增大至杏核大小,溢泪加重,疼痛。门诊拟诊为右泪囊包块收入院。全身情况良好。眼部情况:视力右0.4,左0.5。右眼内眦泪囊部位有一肿物,可触及2×2cm 大小肿物,压痛,质硬,边界清,活动性欠佳,表面皮肤正常。眼球运动正常,球结膜不充血。内眼无异常。临床诊断:右泪囊肿物(性质待查)。入院后第3天,在局麻下行右泪囊肿物摘除术,术中见肿物呈灰白色,质硬,基底固定,
The patient, Yang X, female 74 years old, case number 238415, 3 months ago, inadvertently touched a soy bean size mass, redness, pain, and tears in the right eye. After the tumor gradually increased to the size of apricot kernel, increased tears, pain. The outpatient department is diagnosed as a right lacrimal sac massage hospital. The whole body is in good condition. Eye condition: 0.4 right and 0.5 left. There was a tumor in the right eye, a palpable area of the lacrimal sac, which could touch a 2×2 cm size tumor, tenderness, stiffness, clear borders, poor mobility, and normal skin surface. The eye movements are normal and the conjunctiva is not filled with blood. There is no abnormality in the inner eye. Clinical diagnosis: right lacrimal cyst (nature). On the third day after admission, the right lacrimal cyst was removed under local anesthesia. During the operation, the tumor was grayish white, hard and fixed.