CASE PRESENTATION: A 38 year-old female with no significant past medical history presented after a syncopal episode followed by dyspnea, chest pain, and dizziness. She had been immobile due to open reduction and internal fixation for right fibular fracture 4 weeks prior to presentation followed by repair of left ankle ligament 3 weeks later due to fall. Patient denied oral contraceptive use or smoking. Patient was hypotensive (76/55mmHg), tachycardic (118beats/min) with oxygen saturation of 97% on room air. Physical examination was remarkable for obesity, loud S2, right lower extremity dressing, and left lower extremity cast. Patient was admitted to medical ICU for close monitoring. Hypotension resolved with intravenous fluids. Blood work was significant for elevated D-dimer (21641ng/ml), pro-BNP (1880pg/mL), and troponin-I (0.225ng/ml). Arterial blood gas analysis failed to reveal any abnormality. Electrocardiogram showed sinus tachycardia with evidence of right ventricular (RV) strain. CT pulmonary angiogram and lower extremity DVT study revealed diffuse bilateral pulmonary emboli (Image 1), and right sided DVT respectively; enoxaparin was started. Transthoracic echocardiogram (TTE) revealed RV dilation and pressure overload, pulmonary artery (PA) pressure of 50mmHg and a large, mobile right atrial (RA) thrombus originating from the deep veins and attached to the tricuspid valve (Image 2). Due to extensive RV thrombus, RV dilation and tachycardia, STT with 100mg of tPA was initiated followed by intravenous heparin without any significant complications. TTE post-thrombolytic therapy showed no evidence of thrombus with marked improvement in PA systolic pressure. Tachycardia improved and patient was discharged home on warfarin.