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1 病历摘要患者35岁,已婚,住院号343080。妇科普查发现盆腔肿物1个月。1990年10月18日入院。平时体健,无腹痛、发热及消瘦,二便正常,月经14(5/27)天,量中,无痛经,末次月经1990年9月21日。1980年足月分娩一男婴。1983年置宫内节育器至今。既往无烟酒嗜好,否认结核史。查体:737℃,P78次/分,Bp16/10.7kPa。全身浅表淋巴结无肿大,心肺正常,腹软,肝脾未触及,腹部未及包块,无移动性浊音。妇科检查:外阴正常,阴道通畅,宫颈轻度糜烂,子宫中位,稍大,质中,活动差,于子宫右前方可及9cm×8cm囊实性包块,与子宫粘连,不活动,无压痛,左附件正常。化验:肝功正常,Hb133g/L,WBC6.6×10~9/L,S 0.7,余正常。胸部摄片未见异常。B超:子宫6.4cm×5.5cm×4.9cm,子宫右上方可见一囊实性肿物9.0cm×8.0cm×8.0cm,壁光滑,左侧无异常。提示:右侧卵巢囊肿,宫内节育器。入
1 medical record Summary of patients 35 years old, married, hospital number 343080. Gynecological census found pelvic mass 1 month. October 18, 1990 admitted to hospital. Normal physical health, no abdominal pain, fever and weight loss, two will be normal, menstrual 14 (5/27) days, the amount of, no dysmenorrhea, the last menstrual September 21, 1990. 1980 Full-term delivery of a baby boy. 1983 IUD device so far. Past non-smoking alcohol hobby, denied a history of tuberculosis. Physical examination: 737 ℃, P78 times / min, Bp16 / 10.7kPa. Systemic superficial lymph nodes without swelling, normal heart and lung, abdominal soft, liver and spleen not touched, the abdomen and mass, no dullness. Gynecological examination: normal vulva, vaginal patency, mild cervical erosion, the uterus, slightly larger, qualitative, poor activity in the right front of the uterus and 9cm × 8cm cystic mass, adhesions with the uterus, inactive, no Tenderness, left attachment normal. Laboratory tests: normal liver function, Hb133g / L, WBC6.6 × 10 ~ 9 / L, S0.7, more than normal. No abnormal chest radiography. B super: uterus 6.4cm × 5.5cm × 4.9cm, the upper right of the uterus can be seen a cystic solid tumor 9.0cm × 8.0cm × 8.0cm, wall smooth, no abnormalities on the left. Tip: Right ovarian cyst, IUD. Into