Learning objectives: Imperforate hymen occurs in 0’1% in infant girls and may be detected at the newborn period. Frequently is misdiagnosed in evaluation for primary amenorrhea or abdominal pain due to :
- Incomplete history taking
- reluctance to perform intimate exams
- relying too much on imagenology .
Case information: A 13 years old afroamerican girl consults for recurrent abdominal pain in absence of fever, urinary or digestive symptoms. She is a healthy looking , moderately overweight teen .The abdominal exam is considered normal. A sonogram of the abdomen is ordered that shows a pelvic mass ( tumor probably arising from the ovary). The patient is sent to the Emergency Department to be admitted to the ward. The surgeon in charge signs the admission form without re examining her. Next day the staff ask for consultation to gynecologist and a work out is initiated as a malignant mass is suspected .Fortunately a female resident doctor exams completely the girl and found the she has an imperforated hymen and the mass is nothing but a hematocolpos.
Discussion: 1 Pediatrician
- -Incomplete history taking: , Did he notice puberty signs ?
- ? Did not ask for menses,very important clue to the diagnosis
- -What was the purpose of the sonogram? What did he expect to find? Gallbladder stones? Kidney anomalies? Something else?.
- Patient sent for administrative reason(sign the admission)
- Anchoring to previous diagnosis, patient not in distress
- Crowded, busy, no private room for intimate exams
- Anchoring to the image
- No new interrogation and physical exam Failure of will?
- Reluctance to perform intimate rectal or genital exams even in presence of a pelvic mass
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