Thrombosis and Anemia

Alvin H. Schmaier, MD

Case Western Reserve University, Cleveland, OH

Copyright of the American Society of Hematology, 2012. ISSN: 1931-6860.



Vital signs The patient was sitting up in bed wearing nasal oxygen. She was breathing fast, but not labored. Temp 37.6o, Pulse 96/min, Respiratory rate 18/min, BP 124/84. By the time you are asked to see the patient, she has not deteriorated from admission.
Chest exam Symmetric expansion with clear breath sounds. No rales, rhonchi. A scratchy sound was heard in the upper posterior right lung.
Heart Regular rate and rhythm. Palpable P2. Loud P2 heart sound. No gallop rhythm. No heaves. No murmurs.
Abdominal No evidence of hepatosplenomegaly.
Extremities There is no peripheral edema and both leg sizes were the same size in circumference (10 cm below the lower end of the patellas).
Neurological Cranial nerves II through XII are intact. She has symmetric deep tendon reflexes and a negative Babinski sign. Her sensation to light touch and vibration are intact, but she has some mild proprioceptive defects on the left. Her Rhomberg sign was slightly tilted to the left. She had some pronator drift on examination.


There appears to be evidence of an acute pulmonary problem with sudden onset of shortness of breath (SOB). On exam, the patient has a scratchy sound in the upper posterior right lung that may be interpreted as a pleural rub. She also has physical findings consistent with pulmonary hypertension such as a palpable and loud P2.

Secondarily, the patient has some soft neurologic findings with an abnormal Rhomberg test, proprioception changes and pronator drift.

Have a question or comment about the ASH Teaching Cases? Please e-mail