history of tobacco abuse quit in August 2021, dyspnea ongoing for quite some time, not exactly sure when but definitely at least by the beginning of 2021, who got to the point where she was panting and could not breathe in August 2021, she had a CT scan (I don't have those results avail), and she was treated with antibiotics for possible infection with some spontaneous improvement though on 7 October 2021 she had a CT angiogram showing similar appearance to chronic pulmonary thromboembolic disease chronic and acute, multiple vessels involved showing narrowing and a few with obliteration, most consistent with chronic thromboembolic pulmonary hypertension with evolving left lower lobe pulmonary infarcts with possible old pulmonary infarct sequela.  She began Eliquis on 7 October 2021, dyspnea has improved since then but she still has significant dyspnea on exertion.  Cardiac MRI on 27 October 2021 showed an EF of 61%, right atrial thrombi, with filling defect at left pulmonary artery, suggestive of pulmonary artery thrombosis.  A TEE on 3 November 2021 showed an EF of 60%, 2 large mobile masses, 12 x 14 mm and 21 x 17 mm in or near the right atrium, consistent with thromboses, no interatrial septal defect was noted.  If she is going to get surgery she would need to go to another state or a specialized center for this.  She did have Moderna Covid vaccines on 1 April and 24 June 2021 but feels like the dyspnea did begin prior to this.  And family history includes a maternal grandmother with DVT.  No other risks such as hormone use, plane flights, active Covid, or recent surgery.  Also she has had platelet count up to 609, hematocrit up to 50.8, and white blood cell count up to 14.9, however some of these may have been reactive or related to smoking (quit tobacco in August 2021) or possible iron deficiency from menorrhagia.  Other labs have shown HCV negative, HIV negative, quantitative immunoglobulins normal, coags normal, lymph node EBUS neg October 2021, flow cytometry negative, and CBC on 4 November 2021 showed white count 9.0, hemoglobin 12.2, platelets 447, and MCV of 90.  ANA has been negative, CRP was elevated in September 2021 to 23.96, coags have been normal, platelet count decreased to less than 450,000 by November 2021, and creatinine normal.  Hypercoag work-up negative thus far (however lupus anticoagulant has not yet been checked as she is on a DOAC), including Antithrombin normal, beta-2 glycoprotein antibodies negative, anticardiolipin antibodies negative, JAK2 with NexGen sequencing negative, erythropoietin level normal, factor V Leiden negative, prothrombin gene mutation negative, protein C&S normal.  24 November 2021 CT angio showed possible left lung subacute pulmonary infarcts, and left lower lobe pulmonary arteries with chronic clot consistent with chronic thromboembolic pulmonary hypertension  TTE 24 November 2021 showed EF 62%, no thrombi were noted, with estimated PA pressure of 28  She continues on Eliquis 5 mg twice daily plus aspirin 81 mg daily indefinitely, holding aspirin on days of menstruation as needed  as of 12/9/2021 still has very signif DOE w/ any exertion at all, pending surgery for CTEPH in other state once approved and able, her 2 large R atrial thrombi were gone on f/u echo indicating they were treated or dislodged in her lungs as DOE is a bit worse since dc, she declines to use lovenos