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潘××男 16岁住院号841570 20天前右眼球下方长一肿物,逐渐增大,稍红,不痛?曾在当地医院用药点眼治疗无效。于1984年5月30日来院就诊。眼部检查,右眼视力1.2,下睑高起,睑缘离开眼球,但无内外反,睑皮肤无水肿、充血。下睑结膜充血,下方球结膜下有一约13×10×5mm囊状隆起,边界清楚,表面光滑。用灯光照射呈灰白色半透明状,肿物表面球结膜略有充血。局部无明显压痛。上方球结膜及眼球各部未发现异常。左眼视力1.2,检查无异常。
Pan XX male 16-year-old hospital number 841570 20 days ago, a long tumor under the right eye, and gradually increased, a little red, no pain? In the local hospital medication eye treatment is invalid. In May 30, 1984 to the hospital. Eye examination, visual acuity of the right eye 1.2, high eyelid, eyelid away from the eye, but no internal and external anti-edema, edema, congestion. Under the conjunctiva hyperemia, under the bulbar conjunctiva there is a about 13 × 10 × 5mm cystic bulge, the border is clear, the surface is smooth. Shine with a white translucent light, the tumor surface of the conjunctiva slightly hyperemia. Local no significant tenderness. The top of the conjunctiva and eyeball ministries found no abnormalities. Left eye vision 1.2, check no abnormalities.