Case Number 42
~~-Y E A R -O L D WHITE, widowed, gravidaA VII, para V, aborta 2 was admitted to the gynecology service with a history of postmenopausal bleeding; her last menstrual period had been in 1947. Following menopause, she had no history of vaginal bleeding until 3 weeks before hospitalization. Other complaints included right lower quadrant pain, without associated gastrointestinal symptoms, and easy fatigability. Past history included a fracture of the left femur 2 years before admission, treated by traction and casting. No history of food or drug allergies was obtained. The patient had never received a blood transfusion or a general anesthetic agent.The preanesthetic survey revealed that the patient was afebrile, weight 133 pounds, height 64 inches, systemic blood pressure in recumbent position 130 mm. of mercury systolic, 80 mm. diastolic, and apical pulse rate 60 per minute.The head and neck were normal, with the exception of poor oral hygiene with gross dental caries and several loose teeth. No masses or areas of tenderness were found in either breast. The chest was clear to percussion and auscultation. The heart was not enlarged. The rhythm was normal sinus; a grade I1 out of V I apical systolic murmur was present.On pelvic examination (by the gynecologists), the outlet was parous with fair support. The vault was atrophic with obliterat-ed fornices, and a 2-cm. inclusion cyst was present on the anterior wall. The cervix was small and had an area of central erosion. The corpus was of normal size, retroverted, and mobile. There was an adnexal mass on the right side. Examination of the extremities revealed bilateral varices.Laboratory data were as follows: hemogram 13.7 gm., venous hematocrit 42 per cent, and total leukocyte count 8750 with a normal differential. Urinalysis was within normal limits. The fasting blood sugar value was 73 mg. per 100 ml. The blood urea nitrogen level was 20 mg. per 100 ml. The electrocardiogram was interpreted as normal.During the preanesthetic visit, the possibility of dislodgment of a tooth (or teeth) was discussed with the patient by the anesthesiologist and was noted in the chart. The operative procedures contemplated were pelvic examination under anesthesia, dilatation and curettage, and possibly celiotomy. The patient was considered to be a good risk for anesthesia and surgery. Premedication consisted of 100 mg. of pentobarbital sodium and 0.4 mg. of atropine sulfate administered intramuscularly 55 minutes before induction. The anesthetic agent was PentothaP sodium, 100 mg. intravenously, followed by cyclopropane and oxygen in a closed system.Following dilatation and curettage, the gynecologists informed the anesthesiologist that an abdominal hysterectomy and bilateral salpingeoophorectomy were indicated.
