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病历摘要 患者李××,女性,58岁,农民。主因绝经10~+年,阴道间断出血6~+月,经当地卫生院以“老年性阴道炎”口服中药、西药等治疗无效于94年12月7日要求住院平诊入院。入院查:一般情况正常,心肺未见异常。专科情况,外阴、阴道呈老年型。宫颈:轻度糜烂;宫体:前位约6×4cm大小,活动好,质稍硬,压痛(一);附件:双侧附件未见异常。术前考虑:①年令较大无生育功能,可排除妊娠。②绝经10~+年,不规则出血6~+月经保守治疗无效,故子宫内膜病变不能排外。手术过程:无手术
Patient summary Li × ×, female, 58 years old, farmer. Mainly due to menopause 10 ~ + years, intermittent vaginal bleeding 6 ~ + months, the local hospitals to “senile vaginitis” oral Chinese medicine, Western medicine and other ineffective on December 7, 94 request admission hospital. Admission check: the general situation is normal, no abnormal heart and lung. Specialist circumstances, vulva, vagina was elderly. Cervical: mild erosion; Palace: front about 6 × 4cm size, activity is good, the quality of hard, tenderness (a); Accessories: bilateral anomalies were not seen. Preoperative consideration: ① years without a greater reproductive function, pregnancy can be ruled out. ② menopause 10 ~ + years, irregular bleeding 6 ~ + conservative treatment of menstruation is invalid, so endometrial lesions can not be excluded. Surgical procedure: no surgery