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患者张×,女,5岁,住院号34151。1979年12月12日入院。主诉:左眼球进行性向外上方突出伴视力下降5年。 患者出生后1月即发现左眼内眦部下方有一黄豆大小之肿物,以后肿物逐月增大。曾在兰州某医院诊断为“血管瘤”:于两年前肿物已明显增大致眼球向外上方移位,视力下降,并发现肿物随患者哭闹或低头时增大,其家长要求住院手术治疗。 体格检查:发育正常,营养一般,神智清楚,智力正常。除可在肋缘下2Cm触及肝缘外,余无异常。
Patient Zhang ×, female, 5 years old, hospital number 34151. December 12, 1979 admission. Chief Complaint: left eye progressive outward prominent with visual decline 5 years. One month after birth, the patient was found to have a soybean-sized mass under the left eye, and the mass increased month by month. In a hospital in Lanzhou was diagnosed as “hemangioma”: two years ago, the tumor has been significantly increased to the top of the eye shift to the outside, decreased visual acuity, and found that the mass with the patient crying or bow when the increase in their parents asked to hospital Surgical treatment. Physical examination: normal development, general nutrition, clear mind, mental normal. In addition to 2Cm under the edge of the ribs reach the liver edge, I no exception.