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1 病历摘要患者28岁,住院号347021。因经期腹痛加重5年,发现盆腔包块3年,以“盆腔包块性质待查”入院。患者平素月经规律,经量中等,无痛经。近5年出现经期下腹疼痛,且逐渐加重,伴头晕、恶心、呕吐。3年前在某中医学院就诊,发现盆腔包块并以“卵巢肿瘤”行剖腹探查术,术中因未能分辨包块来源,仅行“阑尾切除术”(后证实未切除)。术后症状无缓解。既往无腰痛及肾区不适,孕2产2。入院查体:一般情况良好,系统查体未发现明显异常。双肾区无叩击痛。妇科检查:子宫后位,正常大小,质地中等,活动。右附件区可触及一8cm×6cm×6cm大小之实性包块,质硬,欠规则,活动
A medical record Summary Patient 28 years old, hospital number 347021. Abdominal pain due to menstrual aggravate 5 years and found pelvic mass 3 years to “pelvic mass to be checked” admission. Patients usually menstrual regularity, the amount of medium, no dysmenorrhea. Nearly 5 years of menstrual abdominal pain, and gradually increased, with dizziness, nausea and vomiting. Three years ago at a Chinese medicine school, found pelvic mass and “laparotomy” laparotomy, intraoperative because of the source of mass can not be identified, only “appendectomy” (after confirmation of not removed). Postoperative symptoms without remission. Past no back pain and kidney discomfort, 2 pregnant 2. Admission examination: the general condition is good, the system examination found no obvious abnormalities. Kidney zone percussion pain. Gynecological examination: posterior uterus, normal size, medium texture, activity. The right attachment area can reach a solid mass of 8cm × 6cm × 6cm in size, hard and under-rule, activity