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患者男性,38岁,汉族,已婚,军队文职干部,病案号68546,于88年5月发现右上腹包块,同年9月23日入本院。检查:营养良好,巩膜无黄染,心肺无异常。腹软,肝肋下约10cm,质硬,表面结节,触痛。脾未触及,腹水征(-),肠鸣音正常。化验肝功正常。AFP>1000ng/ml。B超,原发性肝癌。胸片,双肺转移性癌。CT,原发性肝癌,门脉内癌栓形成,腹腔内转移。最后诊断:原发性肝癌并广泛转移。
The patient was male, 38 years old, Han nationality, married, civilian cadre of the army, medical record number 68546. In May of the same year, he discovered the mass of right upper quadrant and entered the hospital on September 23 of the same year. Check: good nutrition, no sclera yellow stain, no abnormal heart and lung. Soft abdomen, liver about 10cm under the ribs, hard, nodules on the surface, tenderness. The spleen did not touch, ascites sign (-), bowel sounds were normal. The liver function was normal. AFP> 1000ng/ml. B ultrasound, primary liver cancer. Chest radiograph, metastatic lung cancer. CT, primary liver cancer, portal thrombus formation, intra-abdominal metastasis. Final diagnosis: Primary liver cancer and extensive metastasis.