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患者,男,26岁.左上腹包块2月.于1987年8月20日住院.既往体健.查体:一般情况可.肝脏剑下3cm,轻压痛.脾脏上界在左锁骨中线第5肋间,下界甲乙线8cm.甲丙线12cm,质韧.B超检查:肝脾增大.胸部X线片无异常.实验室检查:血色素69g/L,红细胞2×10~4个/L,白细胞6.1×10~9个/L,中性64%.免疫功能检查无异常.骨髓呈贫血性改变.初步诊断:脾功能亢进,行脾切除术.
Patients, male, 26 years old. Left upper quadrant mass in February. In hospital on August 20, 1987. Past physical health. Physical examination: the general situation can be liver under the sword 3cm, mild tenderness. The upper spleen in the middle of the left clavicle 5 intercostal, the lower bound A line B 8cm. A C line 12cm, quality and tough. B-ultrasound: liver and spleen increased. No abnormal chest X-ray. Laboratory tests: hemoglobin 69g / L, red blood cells 2 × 10 ~ 4 / L, white blood cells 6.1 × 10 ~ 9 / L, neutral 64% .No abnormalities in immune function .Bone marrow showed anemic changes .A preliminary diagnosis: hypersplenism, splenectomy.