The presentation of pulmonary embolism is variable in the elderly as in any age group. Common symptoms such as chest pain, dyspnea, and hemoptysis may be absent. Furthermore, precursors such as phlebitis, malignancy, and recent surgery often may be absent as well. Our intent was to examine the occurrence in a long-term care institution of pulmonary embolism at autopsy and the extent of missed antemortem diagnosis of this condition, and to compare patients with and without pulmonary embolism by chart and autopsy review. The incidence of pulmonary embolism in our study of elderly patients during a six-year period in a teaching nursing home was 12.8%. Although our series is small, consisting of 47 autopsies, our results are in accord with reports from other patient sites. Few autopsies are performed on nursing home patients and even fewer have been studied with regard to the occurrence and characteristics of pulmonary embolism in this population. The diagnosis remains difficult and uncertain, especially so in the elderly, because of the variability of presentation and association, the lesser pursuit of aggressive or invasive diagnostic methods, and the paucity of postmortem documentation.