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患者王某,38岁,住院号22796。因停经3个月,要求终止妊娠。既往有高血压史,月经周期正常,末次月经1990年3月2日。 体查:血压20/12kPa,体温36.9℃,一般情况好,呈中度贫血貌,心肺(一),肝脾未触及,腹部无压痛,脊柱四肢发育正常。妇科检查:外阴阴道正常,宫颈着色,肥大、轻度糜烂,宫体前位,约3~+月妊娠大,双侧附件正常。B超检查:胎头双顶径可见,诊断:宫内妊娠3个月。
Patient Wang, 38 years old, hospital number 22796. Because of menopause 3 months, termination of pregnancy is required. Past history of hypertension, normal menstrual cycle, the last menstrual March 2, 1990. Physical examination: blood pressure 20 / 12kPa, body temperature 36.9 ℃, generally good, moderately anemic appearance, cardiopulmonary (a), liver and spleen not touched, no tenderness in the abdomen, spine limbs normal development. Gynecological examination: normal vulva and vaginal, cervical coloring, hypertrophy, mild erosion, the anterior palace, about 3 ~ + months of pregnancy, bilateral attachment is normal. B-ultrasound: fetal head biparietal diameter visible, diagnosis: intrauterine pregnancy for 3 months.