ROONK

SUBDIVISION

TAN/EGA/DIM/BEN/WAN
 Mr. P / 37 y.o.
Adm on Des, 3rd 2017
Chief complaint : Mass on his right eyelid
• Mass on his right eyelid since 5 months ago, mass begun from small size and
became larger by time , pain (-), itchy (-), redness (-), bleed (-), tearing (-),
mass in others area of body didn’t find. History of previous mass (-). History of
family with the same disease (-)
• History of trauma : (-)
• History of surgery : (-)
• History of therapy : (-)
• History of wearing spectacle: (-)
• History of previous eye disease : (-)
• History of systemic disease: HT (-), DM (-)
GENERAL CONDITION

BP : 100/70 mmHg
FBG : 107 mg/dL
BG 2 hr after meal : 121 mg/dL
 Summary of Data Base

Right Eye Left Eye

5/5 VA 5/5
Spasm (-),edema (-), mass (+) Ø 10 x 9 Eyelid Spasm (-), edema (-)
mm, solid, Sharp margin, mobile, pain (-),
redness (-),
CI(-), PCI (-) Conj. CI (-), PCI(-)
Clear Cornea Clear
Deep AC Deep
Radline Iris Radline
Round, Ø3 mm, PR (+) Pupil Round, Ø3 mm, PR (+)
Clear Lens Clear
17.3 mmHg IOP 17.3 mmHg
ASSESSMENT

• RE superior palpebra tumor susp lipoma

dd hemangioma

PLANNING THERAPY

• Education and information about the disease and

planning therapy
• Pro RE tumor excision + PA / GA
 Nov 28th, 2017

RE tumor excision + PA / GA
Diff. : -
Comp. : -

Post Op Treatment

• Cefixime tab 2x200 mg (PO)

• Mefenamic acid tab 3x500 mg (PO)
• Ranitidin tan 2x150mg (PO)
• Chloramphenicol cream 4x1 @woundsite
Marking incision on upper Skin incision Wide undermine  release
eyelid tumor from surrounding tissue

Soft tissue suturing Tumor identification 

tumor disection
 Follow up day 1

Right Eye Left Eye

5/5 VA 5/5
Suture @palpebra, bleed (-) secret (-) Eyelid Spasm (-), edema (-)
CI(-), PCI (-) Conj. CI (-), PCI(-)
Clear Cornea Clear
Deep AC Deep
Radline Iris Radline
Round, Ø3 mm, PR (+) Pupil Round, Ø3 mm, PR (+)
Clear Lens Clear
17.3 mmHg IOP 17.3 mmHg
FR (+), detail wnl Fundus FR (+), detail wnl
ASSESSMENT

• LE post tumor excision day 1

PLANNING THERAPY

• Cefixime tab 2x200 mg (PO)

• Mefenamic acid tab 3x500 mg (PO)
• Ranitidin tan 2x150mg (PO)
• Chloramphenicol cream 4x1 @woundsite
 BEFORE

AFTER