The Third xx Hospital of Central South University
Name: XxxxxWard: Hepatobiliary and pancreatic surgery, ward 31, Bed No.: 23ID No.: xxxxx
Discharge Record
Date of Admission: 2017-xxx
Date of Discharge: 2017xxx
Length of stay: 18 days
Diagnosis of admission: Hepatic occupying lesions，Hepatocellular carcinoma
Xxxxx, Male, 46y, was admitted due to upper abdominal pain more than five months, reoccurred and deteriorated for 10 days. Physical examination: The abdomen was plain, abdominal breathing existed, no varix of the abdominal wall, no gastrointestinal shape and peristaltic waves, the abdomen was soft, left upper quadrant tenderness was remarkable , but had no bounce pain, Murphy syndrome was negative，no masses was palpable, Liver and Spleen were not palpable under the ribs, Liver area had percuss pain , bilateral kidney area had no percuss pain，shifting dullness was negative，the peristaltic sound was normal about 4 times/min. The anus and genitalia had no abnormalities.
In hospital process: After admission, the patient completed the relevant examinations, The three Routines, Liver and Renal function, Electrolyte had no significant abnormal. Tumor Markers :Alpha-Fetoprotein antigen AFP 30.3ng/ml ↑;Antibody to hepatitis B: Hepatitis B (HBV-DNA) 4.20E+004IU/ml，Hepatitis B e antibody (quantitative)>4.5PEIU/mL↑, Hepatitis B core antibody (quantitative) >45PEIU/mL↑, Hepatitis B surface antigen (quantitative) >250.00IU/mL↑. DR/CR (Chest ) examination hinted(2017-02-15 at 17:08) : The right pleural is thickening and adhesion. Three- dimensional CT (upper abdomen) examination hints (2017-02-18 at 10:07): Multiple Liver tumor nodules foci, consider primary liver cancer and intrahepatic metastasis, suspected hilar lymph node metastasis. Cirrhosis, Portal hypertension; Splenomegaly: perihepatic small amount of liquid. Color Doppler Ultrasound biopsy showed: (Liver puncture)Primary hepatocellular carcinoma, GradeII. Immunohistochemistry: Tumor cellsCK19(-),Glypican-3(++), Hepatocyte (-),CD34(Microvascular diffuse distribution ), KI-67(60%). DSA(DSA)examination hinted (2017-03-02 at 16:30): Hepatic occupying lesions after interventional chemotherapy and embolization, suggest review CT in 40 days after surgery. Reviewed postoperative blood count, electrolytes, liver and renal functions of patient had no significant abnormal, detailed explaining the situation of the patient to patient and family, and the patient is discharged today.
Discharge situations: The spirit and appetite of the patient are regular,
Diagnosis of discharge: 1. Hepatocellular carcinoma 2. Hepatitis B
Discharge instructions:
1. Pay attention to the rest, strengthen nutrition.
2. Remember to review liver and kidney function and blood routine test, if there are nausea, vomiting, weakness, severe symptoms, the patient should go to a local hospital for treatment.
3. Review CT in 40 days later.
4. Feel free to visit when discomfort.
Signature of physician: xxx
The Second hospital in xxx City of Hunan Province
CT diagnosis Report
Date of examination: 2017-05-16CT No.: xxxx
Name: XxxxxGender: MaleAge: 47yInpatient No.: xxxx
Application Dept.: Emergency outpatient,Application physician: Qiong Wang, Bed No.:
Clinical diagnosis: 1.Medical history No.: xxx
Check item: Upper abdominal CT scan
Image description:
Primary liver cirrhosis, review check after the treatment of liver tumor foci, Current film displayed the loss of volume in liver, the ratio of the liver is disproportion, Liver surface is less smooth,there are small nodules protuberant. Liver parenchymal density is uneven with multiple low density foci. There is a about 91X65mm tumor foci in the right lobe of the liver, the density is not homogeneous, within the perfusion changes after operation. No significant dilatation of Intrahepatic and extra hepatic bile duct, the gallbladder is enlarged, and the surrounding structure is fuzzy. Pancreatic morphology and density have no abnormalities. The spleen is still enlarged and thickened.，there is no exactly enlarged lymph nodes shadow in retroperitoneal.
Diagnosis:
1.Liver Cirrhosis, review check after the treatment of liver tumor foci, current film displayed multiple nodules in the liver and right lobe of the liver tumor foci still existed with the changes after treatment, splenomegaly.
2.Changes of the gallbladder, consider cholecystitis
Reported by: xxx Yang Reviewed by:xxxxZhang Date of report: 2017-05-16 at 09:
Remarks:
1.The report only reflects the patient’s situation at examination time, for clinician reference only, not as a certificate.
2.The report is valid with the signature of reviews physician, when you visit us, please take this report , wish you have good health. |
