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患者,21岁未婚,病历号281913,于1991年3月29日门诊以“盆腔包块原因待查”收住院。病人1990年2月26日因白带多如水样,有臭味来我院就诊,肛诊未见异常,B 超示增大子宫切面内可见一约2.0×4.7cm~2大小似妊囊的无回声区,后多次复查 B超未见明显改变。1990年5月出现阴道不规则流血一月余,量较少,每日用纸7～8张,在市人民医院诊为“功血”,用乙菧酚、黄体酮、氯菧酚胺行人工周期治疗三月,月经规律。近二月来白带渐增多,水样,有臭味,多时需用纸。查体:T37℃,P84次/分,R21次/分,BP13/9kpa,未触及全身肿大性浅表淋巴结。心肺未见异常。腹平软无压痛,肝脾未触及。
Patients, 21-year-old unmarried, medical record number 281913, in March 29, 1991 out-patient to “pelvic mass due to be checked” admitted to hospital. February 26, 1990 because of leucorrhea more watery, stinking to our hospital, anorectal no abnormalities, B ultrasound showed that the uterus section can be seen in a 2.0 × 4.7cm ~ 2 size similar to the pregnancy sac No echo area, after repeated review of B-no significant change. May 1990 vaginal irregular bloodshed more than a month, the amount of less daily paper 7 to 8, the city People’s Hospital diagnosed as “dysfunctional uterine bleeding”, with acetochlor, progesterone, clopidogrel amine line Labor cycle treatment in March, menstrual regularity. Leucorrhea in recent months to increase, watery, stinking, often need to use paper. Examination: T37 ℃, P84 times / min, R21 beats / min, BP13 / 9kpa, did not touch the body of enlarged superficial lymph nodes. Heart and lung no abnormalities. Abdominal soft tenderness, liver and spleen not touched.