•Afebrile, pulse 98 bpm, BP 142/89mmHg, SaO₂ 98-100% on RA.

•Tired-looking, hydration on the dry side.

•Examination of the hands reveals no clubbing and normal-appearing palmar creases.

•Head and neck examination is unremarkable.

•Cardiovascular: HS dual, no murmur.

•His chest is clear on auscultation.

•Abdominal examination reveals a soft abdomen, mild right upper quadrant tenderness, gross hepatomegaly with a lobulated surface.

•No stigmata of chronic liver disease.

•No signs of oedema.

Investigations

•CBC is normal.

•Liver and renal function tests are normal.

•CRP normal.

•HBsAg, anti-HCV negative.

What is your differential diagnosis?

•Neoplasm:

–primary, i.e. hepatocellular carcinoma, cholangiocarcinoma;

–secondary metastases.

•Liver abscess.

•Liver cysts:

–simple cysts;

–congenital, i.e. polycystic kidney and liver disease or polycystic liver disease.

Structural imaging of the abdomen would be helpful in delineating the various causes of hepatomegaly, i.e. ultrasonography or a computed tomography (CT) scan with contrast of the abdomen.