Bilateral pulmonary embolisms Chief Complaint   Severe chest pain for several hours, positional, tenderness to L rib cage.  History of Present Illness     The patient is here with complaints of left sided lower chest pain.  He stated that its been going off and on since yesterday afternoon.  He stated that he was able to go to sleep last night but then he woke up with severe left-sided chest pain.  He stated feels pretty positional and occasionally gets short of breath with it.  He denies any cough or cold symptoms.  Denies any injury to the left flank area.  Denies any burning or frequency with urination.  Denies any hematuria.  Denies fevers.  Denies any history of blood clots.  Denies any recent travels or surgeries or traumas.  Review of Systems     Constitutional: No fevers, chills, sweats, weakness, or fatigue  Eye: No recent visual problems  ENT: No ear pain, no ear drainage, nasal congestion,or  sore throat  Respiratory: Occasional shortness of breath, no cough, no wheezing  Cardiovascular: Left lateral lower Chest pain, no palpitations, no syncope  Gastrointestinal: No nausea, vomiting, diarrhea, abdominal pain, or abdominal distention  Genitourinary: No hematuria, no dysuria, no frequency, left flank pain, no incontinence  Musculoskeletal: No back pain, neck pain, joint pain, or muscle pain  Integumentary: No rash, pruritus, or abrasions  Neurologic: Alert & oriented X 4, no headache, no dizziness, no numbness or tingling  Physical Exam  Vitals & Measurements  T: 36.6  °C (Oral)  HR: 71(Monitored)  RR: 17  BP: 148/80  SpO2: 97%  HT: 180.000 cm  WT: 82.000 kg  BMI: 25.310  O2 Therapy: Room air      General: Alert and oriented, well nourished, no acute distress.  Eye: PERRL, EOMI, normal conjunctiva.  HENT: Normocephalic, clear tympanic membranes, normal hearing, moist oral mucosa.  Neck: Supple, non-tender, no lymphadenopathy.  Lungs: Clear to auscultation all lung fields, non-labored respiration.  Heart: Normal rate, regular rhythm, no murmur, gallop or edema.  Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no masses, left sided flank pain with palpation, positive left sided CVA tenderness.  Musculoskeletal: Normal range of motion and strength, left lateral distal chest wall pain with palpation, no deformities.  Skin: Skin is warm, dry and pink, no rashes or lesions.  Neurologic: Awake, alert and oriented X4.  Psychiatric: Cooperative, appropriate mood and affect.     Assessment/Plan      1. Bilateral pulmonary embolism I26.99  The patient is not ill-appearing or toxic upon arrival to the emergency room.  He has quite a bit of pain in the left flank area.  Initially it appeared to be kidney stone type of pain.  The patient has no blood in his urine though.  His urine does not show any infection.  His renal function is within normal limits.  We did do a D-dimer and it came back elevated.  He does not have any troponin leaks.  CT she does show bilateral pulmonary embolisms as well as a possible thrombus in the posterior distal ascending aorta.  These results were discussed with Dr. from Facility.  He did review the scans as well.  He does think that this is a acute versus chronic thrombus in the ascending aorta.  He did recommend getting a CT of the abdomen tomorrow morning to rule out any lesions or tumors as well as any infarcts.  The patient will be put on a heparin drip and admitted observation.  We did have to give him multiple doses of IV pain medication.  Again with certain positions he has quite a bit of pain in that left flank area or distal left lateral chest.  The patient was agreeable with this plan of care.  Dr. was notified plan of care and is agreeable.  We will keep the patient on telemetry and they will adjust the weight-based heparin per protocol.   2. Thrombus of aorta I74.10    Orders:   aspirin, 324 mg = 4 tab(s), Tab-Chew, Oral, Daily, Routine, Start date 06/10/22 9:00:00 CDT, 06/10/22 6:14:00 CDT  heparin additive 25,000 unit(s) + premix diluent 250 mL, 250, mL, IV, Routine, Start date 06/10/22 11:16:00 CDT, titrate see comments, Total volume (mL): 250, 82 kg, 2.02, m2, 06/10/22 11:16:00 CDT  Consult to Pharmacy, Pharmacy Consult, Misc, N/A, On Call, Routine, Start date 06/10/22 11:16:00 CDT, 06/10/22 11:16:00 CDT  PTT, Blood, Routine collect, 06/10/22 11:16:00 CDT, q6hr (interval), Lab Collect  Pulse Oximetry Check - Nursing, 06/10/22 11:16:00 CDT, q4hr (scheduled), to be monitored continuously  Telemetry, 06/10/22 11:16:00 CDT, q4hr (scheduled)  Images   obs profee: medium  Problem List/Past Medical History   Ongoing  Bilateral pulmonary embolism  Thrombus of aorta  Historical  No qualifying data  Procedure/Surgical History  ?None  Medications   Inpatient  aspirin, 324 mg= 4 tab(s), Oral, Daily, PMC  Consult to Pharmacy, Pharmacy Consult, N/A, On Call  heparin additive 25,000 unit(s) + premix diluent 250 mL  Home  omeprazole 20 mg oral delayed release capsule, 20 mg= 1 cap(s), Oral, Daily  Allergies   No Known Medication Allergies  Social History    Electronic Cigarette/Vaping   Electronic Cigarette Use: Never.   Tobacco   Current some day tobacco user Tobacco Use:.  Family History     Deceased Family Member(s):