全科警示录｜面对刻意隐瞒的患者，如何做？

SAGA 1: HOT FLUSHES

病例 1：面部潮红的患者

29-year-old married motor mechanic consulted me for the first time, complaining of episodes of facial flushing associated with ‘blotchiness’ of the skin of his trunk and difficulty in breathing. Sometimes he would feel very ill and eventually vomit.

这位患者是29 岁的摩托车技师，第一次就诊是因为面部潮红，伴躯干部“斑疹”， 伴呼吸困难，伴恶心呕吐。

He said the symptoms occurred only when he drank beer, but not every time. When he drank beer he would usually smoke cigarettes.

他说这些症状只在他喝啤酒的时候出现，但不是每次都是。

He said he was taking no medication and had no history of atopic disease.

他又喝酒又抽烟，否认任何用药史和过敏史。

Examination was unremarkable. I told him I thought he had an allergy and considered a possible carcinoid tumour.

体格检查无异常。我认为是过敏或某种良性肿瘤导致这样的症状。

We agreed he would take further note of his episodes and report to me.

我建议先观察病情，告诉患者再次发作时再来就诊。

I next saw him three months later for a ringworm infection. He said the flushing episodes had resolved spontaneously, and so we let the matter rest.

患者第二次来就诊是三个月后，因为癣菌病。他说面部潮红的症状突然消失了，我也不再继续寻找病因。

About two years later he was ‘retrenched’ from his job while on holiday, and his wife came to see me. She said he was drinking heavily.It emerged that he had been abusing alcohol for many years. As she described the effects of his drinking on their marriage and young family, she confided that in her desperation to help him she had on several occasions ‘spiked’ his coffee with disulfiram (Antabuse), obtained when he had once attended an alcohol rehabilitation program.

两年后，这位患者在病假期间丢了工作，她的妻子来访，她告诉我患者常年嗜酒成性，现在还是酒不离手，患者的酗酒问题给他们的婚姻和家庭造成了巨大的影响，为了帮他戒酒，她已心力交瘁，只能偶尔在他的咖啡里放一点戒酒硫（安塔布司），这种药物是患者在一次戒酒互助项目中获得的。

She was aware of the link with his flushing symptoms and was surprised that I had not realised what was causing them.

这位妻子知道患者潮红的症状和咖啡里的戒酒硫有关，但她惊讶的是我这个医生竟然没有发现。

This story is a reminder that alcoholism can present in many ways: in this case, the surreptitious administration of medication by a worried family member.

这个故事提醒了我，酒精中毒的患者会有多种表现，而这个病例的特殊表现是跟家人暗中用药有关。

SAGA 2: EXCHANGING MILK FOR BEER

病例 2：以奶换酒的患者

George, a 49-year-old dairy farmer and former army officer, presented with gouty arthritis and dyspepsia.

George，一名 49 岁的奶农，从前是军官，因为痛风性关节炎和消化不良就诊。

He had a history of hypertension, which had deteriorated in recent years.

他既往有高血压病史，近期血压控制不佳。

His plethoric bloated facies and continued complaints of anxiety and insomnia made me question him carefully about his alcohol intake.

他看起来又红又肿，并且长期焦虑、失眠，因此我特别注意询问他的饮酒史。

‘I have only a glass or two a day, Doc. It’s not a big deal: ask the wife and the boys at the pub and the RSL club’, was George’semphatic reply.

George每次都很肯定地回答我：“医生，我每天只喝一两杯酒，真的没喝太多，不信的话问问我妻子、酒馆和退伍军人俱乐部的人就知道了。”

With time and a steady rise in his blood pressure, plethora and anxiety, and a continuing decline in his general health and libido, I strongly suspected a considerable intake of alcohol.

George的血压不断上升，红细胞增多症和焦虑症也不断恶化，他的整体健康状况包括性欲在内不断下降，我就越加怀疑他可能喝了很多酒。

I checked his story with his wife and the ‘boys’ at the local hotel. They confirmed his relatively sober habits.

我问了他的妻子和跟他一起喝酒的人，他们作证他最近确实没有多喝。

Eventually George developed a cardiac arrhythmia and had to be admitted to hospital.

最后，George 因为心律失常入院。

His convalescence provided his bemused visitors with a somewhat convincing swatting of spiders on his bed with his slippers and description of the non-existent circus parading through the town.

虽说他已慢慢康复，但总有些奇怪的言行让来探望的亲友一头雾水，比如有时候拿拖鞋在床上狂拍苍蝇，有时候说街上有马戏表演（实际上并没有）。

George and his family continued to deny the alcohol problem: ‘Get off the bandwagon for God’s sake—I have only the odd one’, he said.

George和家人们始终不承认他的酗酒问题，他还说“别闹了好不好，我这次来医院就一个毛病——心律失常。”

这段话的备注：

（The above is a poetic description of the family visiting the patient and it's a joke that the family continued to deny that he had an alcohol problem. Nothing serious but the whole scene in the hospital room was descripted using metaphors to make it amusing as in a "laugh" about the denial by the family of his serious drinking problem.---from an English teacher’s explanation

“Get off the bandwagon for God’s sake—I have only the odd one”means It's like when a new song comes out and you hear it everywhere you go, and you're tired or sick of it.

Then when your friend tells you to listen to this song, you're fed up and say "get off the bandwagon")

One day, while treating the milk-tanker driver, I casually asked him how many bottles of beer he delivered to George. After an uncomfortable pause, the expected revelation was made: ‘A dozen large bottles every other morning’.

直到有一天，牧场的送奶工在我这里就诊，我随口问了一句他每天给George送多少啤酒，他愣了一下说道“我每隔一天给他送 12 大瓶啤酒”。

The outcome was eventually positive. With the help of Alcoholics Anonymous, George managed to control his addiction and now enjoys better health but I remain concerned.

果然如此啊，在神不知鬼不觉地情况下George一直有酒喝，因此我根据他酗酒的实情调整了治疗方案，他的病情好转，我也一直关注着他的病情进展。

DISCUSSION AND LESSONS LEARNED

讨论和反思

As general practitioners we have a golden opportunity and considerable responsibility to detect alcohol and other drug abuse.

作为全科医生，我们最容易发现患者酗酒或其他药物滥用的情况，并对此有最大的监督责任。

We should be prepared to back our clinical judgment and diplomatically confront our patients about the problem when it arises.因此我们应该提前了解相关知识，以便当遇到类似问题的时候，能够准确诊断以及巧妙地和患者沟通。

It is difficult if patients use denial or fabrication（伪造物） to hide a drinking problem. They will go to extraordinary lengths—including bribery—to conceal it from their families and friends.

但是当患者有意隐瞒饮酒问题，诊断就变得困难。这些患者想尽千方百去隐瞒病情，比如贿赂亲友，让他们在家庭医生面前保持沉默。