澳大利亚John Murtagh 全科病案研究(四十一)——让人困惑的13 岁女孩周期性下腹和耻骨弓上部疼痛

John Murtagh (著)，杨 辉(译)

作(译)者单位:3165 澳大利亚维多利亚州，澳大利亚Monash大学

1 病史

陈爱梅，13 岁的女学生，前来就诊的原因是5 个月来耻骨弓上部不适。病人主诉说，开始的时候疼痛很轻微，1 个月内疼2 次，父母带她去医院检查。医院的检查并没有发现什么异常情况，她的父母也就放心了，认为她也就是有些肠绞痛。

不过，她的下腹部和骨盆区域的疼痛还是不断出现，而且越来越频繁，并且出现了一些新的症状，包括便秘和后背部疼痛。接着又做了一些基本的检查，包括全血检查、尿液分析、普通X 光检查等，不过化验和检查结果都显示的是正常。医生给她开了通便剂，帮助她排便更有规律一些。

3 个星期后，她的疼痛演变成为持续性的，反复出现。她再去看病，这回找了另外一个医生。这个医生让她去做下腹部超声波检查。检查结果还是没有发现任何异常。

在这期间，她不断地找全科医生看病，已经接连去了5 次全科医学诊所。可是她的症状没有一点好转，而且越来越疼。

这次她前来就诊，诉说她的生病过程。她说现在会感到有些排尿困难，说总是感到尿不干净，感到膀胱里总不能被排空。

2 身体检查

现在给陈爱梅做身体检查，结果证实在她的耻骨弓上部有轻微的膨胀，在耻骨联合上方可以触到直径约3 cm 的块状物。

3 要思考的问题

3.1 诊断假设是什么?

3.2 在陈爱梅的病史中，还缺少哪些信息?

4 问题的答案

4.1 根据病人的性别和年龄以及疼痛的部位，应该想到与生殖系统的发育有关。

4.2 陈爱梅的病史中缺少女性月经初潮的有关信息。因此进一步的病史收集应该包括病人第二性征的发育情况，特别是月经初潮的情况，比如经血、小腹胀痛、是否存在经前紧张等情况。

5 病案的发展和结果

在陈爱梅前来就诊之前，她看过5 次病，但只是在最近的一次，医生才发现她没有来月经。很显然，这些医生都没有想到泌尿生殖系统方面的问题，也没有从青少年特有的症状和疾病上考虑问题。

对病人的外生殖器进行检查，结果发现阴道口明显和紧绷的蓝色膨出，提示阴道内充满经血而膨胀。这是典型的处女膜闭锁的体征。

治疗方法是在处女膜上做十字切口，结果排出300 ml 经血。

6 病案讨论

这个案例给医生最重要的提示，是要对处于青春期的女性病人采集泌尿生殖系统的病史。在这个病人早期的看病过程中，医生没有注意到病人没有来月经。因此，医生对这类病人，要注意收集有关信息，比如伴随青春期发育所出现的那些征兆和身体变化。这些信息对诊断是非常有帮助的。处女膜闭锁症是影响经血从阴道排出的最常见原因。

因此，对主诉为腹部或耻骨上疼痛的年轻女性病人，最好要采集以下这些重要的病史:(1)胃肠系统;(2)泌尿系统;(3)生殖系统，包括月经、初潮、性行为等。

译者注:青春期:可以大致分为三个阶段，10 ～14 岁为青春初期，14 ～17 岁为青春中期，17 ～19 岁为青春末期。这些阶段之间最大的区别是躯体发育和性心理发育程度，以及在两性之间的差别。

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.