John Murtagh (著)，楊 輝(譯)

作(譯)者單位:3165 澳大利亞維多利亞州，澳大利亞Monash大學(xué)

1 病史

陳愛梅，13 歲的女學(xué)生，前來就診的原因是5 個月來恥骨弓上部不適。病人主訴說，開始的時候疼痛很輕微，1 個月內(nèi)疼2 次，父母帶她去醫(yī)院檢查。醫(yī)院的檢查并沒有發(fā)現(xiàn)什么異常情況，她的父母也就放心了，認(rèn)為她也就是有些腸絞痛。

不過，她的下腹部和骨盆區(qū)域的疼痛還是不斷出現(xiàn)，而且越來越頻繁，并且出現(xiàn)了一些新的癥狀，包括便秘和后背部疼痛。接著又做了一些基本的檢查，包括全血檢查、尿液分析、普通X 光檢查等，不過化驗和檢查結(jié)果都顯示的是正常。醫(yī)生給她開了通便劑，幫助她排便更有規(guī)律一些。

3 個星期后，她的疼痛演變成為持續(xù)性的，反復(fù)出現(xiàn)。她再去看病，這回找了另外一個醫(yī)生。這個醫(yī)生讓她去做下腹部超聲波檢查。檢查結(jié)果還是沒有發(fā)現(xiàn)任何異常。

在這期間，她不斷地找全科醫(yī)生看病，已經(jīng)接連去了5 次全科醫(yī)學(xué)診所?？墒撬陌Y狀沒有一點好轉(zhuǎn)，而且越來越疼。

這次她前來就診，訴說她的生病過程。她說現(xiàn)在會感到有些排尿困難，說總是感到尿不干凈，感到膀胱里總不能被排空。

2 身體檢查

現(xiàn)在給陳愛梅做身體檢查，結(jié)果證實在她的恥骨弓上部有輕微的膨脹，在恥骨聯(lián)合上方可以觸到直徑約3 cm 的塊狀物。

3 要思考的問題

3.1 診斷假設(shè)是什么?

3.2 在陳愛梅的病史中，還缺少哪些信息?

4 問題的答案

4.1 根據(jù)病人的性別和年齡以及疼痛的部位，應(yīng)該想到與生殖系統(tǒng)的發(fā)育有關(guān)。

4.2 陳愛梅的病史中缺少女性月經(jīng)初潮的有關(guān)信息。因此進一步的病史收集應(yīng)該包括病人第二性征的發(fā)育情況，特別是月經(jīng)初潮的情況，比如經(jīng)血、小腹脹痛、是否存在經(jīng)前緊張等情況。

5 病案的發(fā)展和結(jié)果

在陳愛梅前來就診之前，她看過5 次病，但只是在最近的一次，醫(yī)生才發(fā)現(xiàn)她沒有來月經(jīng)。很顯然，這些醫(yī)生都沒有想到泌尿生殖系統(tǒng)方面的問題，也沒有從青少年特有的癥狀和疾病上考慮問題。

對病人的外生殖器進行檢查，結(jié)果發(fā)現(xiàn)陰道口明顯和緊繃的藍色膨出，提示陰道內(nèi)充滿經(jīng)血而膨脹。這是典型的處女膜閉鎖的體征。

治療方法是在處女膜上做十字切口，結(jié)果排出300 ml 經(jīng)血。

6 病案討論

這個案例給醫(yī)生最重要的提示，是要對處于青春期的女性病人采集泌尿生殖系統(tǒng)的病史。在這個病人早期的看病過程中，醫(yī)生沒有注意到病人沒有來月經(jīng)。因此，醫(yī)生對這類病人，要注意收集有關(guān)信息，比如伴隨青春期發(fā)育所出現(xiàn)的那些征兆和身體變化。這些信息對診斷是非常有幫助的。處女膜閉鎖癥是影響經(jīng)血從陰道排出的最常見原因。

因此，對主訴為腹部或恥骨上疼痛的年輕女性病人，最好要采集以下這些重要的病史:(1)胃腸系統(tǒng);(2)泌尿系統(tǒng);(3)生殖系統(tǒng)，包括月經(jīng)、初潮、性行為等。

譯者注:青春期:可以大致分為三個階段，10 ～14 歲為青春初期，14 ～17 歲為青春中期，17 ～19 歲為青春末期。這些階段之間最大的區(qū)別是軀體發(fā)育和性心理發(fā)育程度，以及在兩性之間的差別。

1 History

Amy Chan，a 13 year schoolgirl，presented with a five month history of suprapubic discomfort. The pain was mild at first and after two episodes about one month apart her parents took her to a hospital. She was examined and no abnormality was found and the family was reassured that it was some form of colic of the lower gut.

The lower abdomino -pelvic pain eventually returned and was more intense. It was now accompanied by mild constipation and low back pain. Basic investigations which included a full blood examination，urine- analysis and a plain X - ray were reported as normal. She was prescribed a laxative to make her bowels more regular.

The pain settled again for about 3 weeks but on recurrence she saw another doctor who ordered ultrasound imaging of her lower abdomen. It did not reveal any abnormality.

At the fifth visit to a private general practitioner for worse pain she complained of some difficulty with urination and felt that emptying of her bladder was incomplete.

2 Physical examination

Your examination now revealed mild distension of the suprapubic area and a palpable mass up to 3 cm above the symphysis pubis.

3 Questions

3.1 What is your diagnostic hypothesis?

3.2 What information is missing in Amy's history?

4 Answers

Up to this point information relevant to the female menarche is missing. It would be useful to know about evidence of secondary sex characteristics and particularly about the onset of periods including bleeding，bloating and evidence of premenstrual tension.

5 Outcome

At the fifth visit it was found that Amy had not commenced menstruation. Apparently the doctors had not thought to ask about this aspect of the genitourinary system or found the topic uncomfortable for the teenager.

On inspection of her external genitalia there was a distinct tense bluish bulging membrane presenting at the introitus-compatible with vaginal distension from menses caused by an imperforate hymen. A further ultrasound indicated a distended vagina and enlarged uterus

A cruciate incision was made in the hymen and 300 ml of blood was drained.

6 Discussion

It was extraordinary that a genitourinary history was omitted in this adolescent female patient. The presence of primary amenorrhoea was missed in the early stages of presentation. Enquires about early pubertal features both symptomatic and physical changes would have clinched the diagnosis. An imperforate hymen is the most common form of vaginal outflow obstruction.

For the young female presenting with abdominal and or pelvic pain it would have been (and is)appropriate to take a history relevant to:(1)Gastrointestinal system，(2)Urinary system，(3)Genital system especially menstruation，menarche，sexuality.