Case 2 :

A 70-year-old-female was admitted to the hospital because of hematochezia. She had been relatively well until that morning when after feeling the urge to defecate, she passed a large amount of fresh blood. She denied any abdominal pain but did complain of lightheadedness. Her family brought her to the emergency room.

In the emergency room she appeared pale but was alert and talkative. Her supine blood pressure was 150/70, pulse =110. After sitting up, the blood pressure was 110/60, pulse =140. She complained of dizziness when she sat up.

Physical examination revealed a grade II systolic murmur heard best at the left upper sternal border with radiation into the carotids. A fourth heart sound was appreciated. The abdomen revealed no abnormalities. The bowel sounds were hyperactive. Rectal examination revealed large hemorrhoids and the stool was grossly bloody.

Laboratory evaluation revealed: Hgb-8.1 gm/dl, Hct-24%, WBC-10, 500 (normal differential) Platelets-347, 000, PT/INR/PTT-normal, BUN/Creatinine-12/0.6 mg/dl.