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患者44岁,住院号89-8865。于1989年12月26日入院。月经量增多4年,近半年加重,经血呈暗红色,多为凝血块,持续6～7天,无痛经,周期正常。查体:轻度贫血貌,全身浅表淋巴结无肿大,心肺无异常,腹平软,肝脾未触及。妇科检查:外阴发育正常,阴道通畅,宫颈光滑,宫体孕6周大小,双附件未触及包块。B超示:子宫体稍大,宫体左侧探及4cm×3.1cm大小的实体回声光团,边界清晰,诊断为子宫浆膜下肌瘤。实验室检查:Hb80g/L,WBC8.2×10~9/L,S0.70,L0.30,临床以子宮肌瘤和功血为诊断行子宫及左附件切除术。
Patient 44 years old, hospital number 89-8865. On December 26, 1989 admitted. Menstruation increased 4 years, increased nearly six months, the menstrual blood was dark red, mostly clot, for 6 to 7 days, no dysmenorrhea, the cycle is normal. Physical examination: mild anemia, systemic superficial lymph nodes without swelling, no abnormal heart and lung, abdominal soft, liver and spleen not touched. Gynecological examination: normal vulva development, vaginal patency, cervical smooth, uterine body size of 6 weeks pregnant, double attachment did not touch the mass. B ultrasound showed: the uterus slightly larger, the left side of the uterus and 4cm × 3.1cm exploration of the size of the body echo light mass, the boundary is clear, the diagnosis of uterine fibroids. Laboratory tests: Hb80g / L, WBC8.2 × 10 ~ 9 / L, S0.70, L0.30, clinical diagnosis of uterine fibroids and dysfunctional uterine and left accessory excision.