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例1 22岁。由患者丈夫及其生母供史。因发现外阴部肿块4月余入院。患者结婚已4个多月,婚后其丈夫发现患者外阴部有一个隆起肿块,阴道口窄小,无法性交,故婚后一直分居,现患者家属要求治疗外阴肿块而收住院。既往史:4岁时患“小儿麻痹症”,并诊断“大脑发育不全”。月经史:16 7/(28～30),末次月经1988年8月27日。查体:营养中等,发育差,表情呆板,对答反应迟钝,言语口齿不清,检查合作。全身皮肤色泽正常,头颅外形无异常,浅表淋巴结未扪及。胸廓对称,两乳房发育欠佳。心肺(-),腹部平坦柔软,肝脾(-),左上肢呈内收状态。神经系统未查。妇科检查:阴蒂肥大,直径2cm,在阴蒂右侧方及右侧大阴唇部位有一8cm×7cm×7cm大小肿块,表面高低不平,形状不规则,质地中等。阴道口窄,仅容1指。子宫前位正常大小,附件(-)。1988年10月4
Example 1 22 years old. By the patient husband and his mother for history. Due to the genital mass found in more than 4 months admission. Patient married more than 4 months after marriage, her husband found that the patient has a bulge in the vulva, vaginal opening narrow, unable to intercourse, so the marriage has been separated, the patient’s family members are required to treat the vulva mass and admitted to hospital. Past history: 4 years old suffering from “polio” and diagnosed “brain hypoplasia.” Menstrual history: 16 7 / (28 ~ 30), the last menstrual August 27, 1988. Physical examination: moderate nutrition, poor development, dull expression, unresponsive response, speech slurred speech, check cooperation. Normal skin color, no abnormal skull appearance, superficial lymph nodes not palpable. Thorax symmetry, poor development of the two breasts. Heart and lung (-), flat and tender abdomen, liver and spleen (-), left upper limb adduction state. Nervous system not checked. Gynecological examination: clitoris hypertrophy, diameter 2cm, in the right side of the clitoris and the right labia minora 8cm × 7cm × 7cm size of the tumor mass, uneven surface, irregular shape, medium texture. Vaginal mouth narrow, only for 1 means. Normal uterine size, attachment (-). October 1988 4