记录


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患者性别:男

患者年龄:58

出院记录

入院日期:2008年05月05日;出院日期:2008年05月27日;住院天数:23天

入院情况（简要病史,体格检查及主要辅助检查）

病人缘于2008年2月无明显诱因下感左侧胸背痛,剑突下胀痛不适,无咳嗽,不发热,4月24日在南大一附院查胸片示胸腰椎S形弯曲,胸椎CT示:胸9锥体前缘轻度压缩性骨折,上腹部CT示胆管细胞癌可能性大,右肾小囊肿,4月30日在江西肿瘤医院胃镜示浅表性胃炎,骨显像T6-7骨转移瘤,AFP44.41ng/ml,CA199 162.70u/l.为进一步诊治入我科.患者自起病来,精神状态一般,食欲正常,大,小便正常,体重下降6公斤.T:36.1 CP:72 次/分R:18次/分BP:110/65 mmHg

发育正常,营养一般,神志清楚,自动体位,应答切题,查体合作.全身皮肤未见黄染,未见皮疹,出血点,蜘蛛痣,肝掌.未触及肿大的浅表淋巴结.头颅未见畸形;眼睑未见浮肿,眼结膜未见充血,巩膜无黄染,双侧瞳孔等大同圆,对光反应灵敏;鼻中隔未见偏曲,双侧鼻旁窦未及压痛;听力正常,处耳道未见溢液,乳突未及压痛;唇未见紫绀,口腔粘膜未见溃疡,牙龈未见出血和溢脓,咽部未见充血,扁桃体未见肿大.颈软,未及压痛;颈静脉未见怒张,颈动脉未见异常搏动;气管居中,甲状腺不大.胸廓未见畸形,双乳未及肿块.呼吸运动两侧对称,语颤未及增强或减弱,两肺呼吸音清,未闻及罗音;心前区未见隆起,心尖搏动位于左锁骨中线第5肋间内0.5cm,心浊音界不扩大,心率72次/分,律齐,各瓣膜听诊区未闻及病理性杂音.腹软,无压痛,反跳痛,右下腹见长约7cm手术疤痕,愈合良好,莫菲氏征阴性,肝脾肋下未触及.肝区叩痛,肠鸣音正常.肛门外生殖器未检.脊柱4肢未见畸形,未及压痛,活动正常,各关节未见红肿.双下肢未见浮肿.生理反射存在,病理反射未引出.

入院诊断:

原发性肝癌第6,7胸椎转移