6/16/21:  3 circular lesions.  The most distal one in particular has an erythematous, raised, crusted border with some central clearing.  The others are more diffusely erythematous with an irregular border and satellite lesions.  He has 1 main lesion on the proximal right lower leg as well with similar appearance.  The lesions are not blanchable. Prescribed antifungal cream - ketoconazole (NIZORAL) 2 % cream . Did not work. Returned to clinic 1 week later.   6/25/21:  Patient was seen by Dr. on 6/16, at which time he presented for evaluation of new lesions emerging on his lower legs.  He had some associated pruritus and discomfort with these spots.  No provoking factors were identified.  On exam, he was noted to be mildly hypertensive to 143/94, with 3 circular lesions on the left lower leg which had central clearing and raised, crusted borders.  Plan was put in place for the patient to be treated with topical antifungal cream, with baseline labs obtained including a CBC, creatinine and urinalysis.  All of this was overall unremarkable.  Plans were then made for him to return today for follow-up of his blood pressure and assessment of the rash after a short course of topical antifungals.   Today, patient reports that the rash on his anterior shins is largely unchanged and continues to be pruritic from time to time, worsened with contact with hot water.  No improvement has been noted since starting the antifungal cream.     His blood pressure continues to be elevated today.  In speaking with him, he actually does have some exertional shortness of breath from time to time, though no associated diaphoresis or chest pain.  He endorses no exertional headaches or vision changes.  6/25/21:  66-year-old male presenting with EMS from home for chest pain.  Onset of pain was around 6:00 p.m. after he had finished eating dinner.  His pain is severe, sharp, located in the right lower chest, pleuritic and not associated with exertion.  He has never had a pain like this before.  It does not radiate.  He denies cough or significant shortness of breath but states that he is not taking deep breath because it exacerbates the pain.  No fever.  No known recent trauma.  He has been found to have elevated blood pressure recently but has not been started on medications.  He states he has also had elevated cholesterol.  His father had a heart attack when he was in his 40s.  The patient does not have any known coronary artery disease.  He is a current smoker.  No history of PE or DVT.  No cancer.  No recent surgery or immobilization.  No hemoptysis.  No leg swelling or pain.  He is not anticoagulated.  He has had a rash on his shins since April. Regular rhythm and normal heart sounds.  Tachycardia present.  Pulses are strong.  Capillary refill: takes less than 3 seconds, Pulmonary/Chest: Breath sounds normal. Tachypnea noted. He has no wheezes. He has no rales. Abdominal: Soft. There is no abdominal tenderness. Musculoskeletal:        General: No edema (No lower extremity edema).     Cervical back: Normal range of motion. Neurological: Alert. He is not disoriented. Skin: Skin is warm and dry.  He has erythematous nonblanching rash on bilateral shins.  Psychiatric: Behavior is normal.   Multiple Subsegmental Pulmonary Embolism Without Acute Cor Pulmonale