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患者男性,52岁,病理号:81204,于1981年5月6日因右上腹肿块入院。半年前患者无意中发现右上腹包块、约鹅蛋大小,无明显不适。体格检查:右上腹可触及一个15×10×10cm~3包块,活动度差,外廓圆滑,压痛不显。超声波检查:右上腹肿块与肝脏可分离,右肾增大,前后径9.5cm,进出波呈较密微小波反射(实质性),体表投影未测清。化验检查:血红蛋白10.5克％,白细胞4900/mm~3,中性57％,淋巴43％。血沉2mm/h。肝功能检查:锌浊度14单位,总蛋白量6.84克％,白/球蛋白比为3.76/3.08,碱性磷酸酶5单位。尿液化验在正常范围内。
Male patient, 52 years old, pathological number: 81204, was admitted to the right upper quadrant on May 6, 1981. Six months ago, the patient inadvertently found the right upper quadrant mass, about the goose’s size, no obvious discomfort. Physical examination: the right upper quadrant can reach a 15 × 10 × 10cm ~ 3 mass, poor activity, smooth outline, tenderness is not significant. Ultrasound examination: the right upper quadrant tumor and liver can be separated, the right kidney increases, anteroposterior diameter 9.5cm, out of the wave was more dense micro-wave reflection (substantial), the body surface projection is not clear. Laboratory tests: 10.5 grams of hemoglobin, white blood cells 4900 / mm ~ 3, 57% neutral, lymphatic 43%. ESR 2mm / h. Liver function tests: zinc turbidity of 14 units, the total amount of 6.84 g protein, white / globulin ratio of 3.76 / 3.08, alkaline phosphatase 5 units. Urine test within the normal range.