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Cheat Sheet / Daily Progress / Electrolytes / ICU Note / ACLS

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• Don't leave any loose ends!! Costa

Medical Calc :
Fluids | Corrected Ca | Corrected Na
- Neuro:
GCS
- Pulm:
PERC | Wells PE | CURB65
- CV:
TIMI UA/NSTEMI | TIMI STEMI | Wells DVT | CHADSVASc
- GI:
MELD | RANSON | NAFLD Fibrosis Score | ANI Score (NAFLD vs Etoh)
- Addiction:
Opiate Risk / ORT |
- Misc:
Sepsis | CT Head/Trauma



Daily Notes

Interval HPI

#. CC / baseline problem progression; consults / surgeries
#. Pain
#. ADLs? Eating / Drinking, ambulating, ready for home?
#. GI? Peeing / Pooping : diarrhea/constipation, nausea/vomiting
#. Infection? F/C
#. Other baseline medical issues

ROS:
General: no fever/chills, no fatigue, no abnormal weight changes
ENT: no vision changes, no hearing loss, no sore throat
CV: no palpitations, no chest pain, no swelling in extremities
Pulm: no cough, no SOB / difficulty breathing, no wheezing
GI: no nausea/vomiting, no diarrhea/constipation, no abdo pain
GU: no dysuria, no urgency, no flank pain, no blood in urine
Neuro: no headaches, no tremors
MSK: no weakness / numbness / tingling, no joint / muscle pain
Skin: no new rashes or lesions.


VS:

PE:
General : alert & oriented, ø acute distress, well-nourished, well-dressed
Neuro : CN2-12 grossly intact, sensation intact & strength 5/5 all extremities
Psych: cooperative, affect appropriate, good judgement & reason, non-suicidal
Head: NCAT
Eyes: PERRL, EOMI. visiongrossly intact.
ENT: trachea midline, neck supple, no cervical LAD
Cardio: RRR w/o murmurs, +S1, +S2, no heave.
Pulm: CTAB w/o WRR, good air movement, >6 word sentences.
Abdo: +bowel sounds, soft & non-distended, non-tender, no CVA tenderness, no HSM
MSK: 5/5 strength all extremities, full ROM grossly, normal gait. no edema.
Skin: intact w/o lesions, warm & dry

Labs:
Imaging:

A&P:
Pt -

#.
#.


#. PPx:
#. FEN:
#. PRN:
#. Social:
SW / case management, family - contact
#. Code:

#. Consults:

Dispo:
------------------------------------------
Quick Orders:

PPx/PRN
• DVT/PE: heparin 5000mg BID. enoxaparin 40 mg SC qday (c/i if renal dz; better for CA pts), SCD, ambulate; PADUA score? make sure not bleeding
• GERD: pantoprazole PO/IV 40 mg qday, famotidine 20mg BID; risks?
• N/V: ondansetron 4 mg (2mL) IV q6hr PRN, promethazine 12.5-25 mg IV q6hr PRN
•  Sleep: sleep hygiene -> zolpidem 5-10 mg PO qHS, diphenhydramine 50 mg PO 30 min before sleep
•  Bowel Protocol: Docusate Na 100 mg PO BID: Bisacodyl 5 mg PO or 10 mg PR QHS PRN no BM for 24 : MOM 30 mL PO QHS PRN no BM for 48°

Post-op / Ortho
The duration of risk of VTE must also be considered. The risk after knee replacement is around 2 weeks and for hip replacement 4 to 6 weeks. The risk may be longer in some individuals with extra risk factors. Prophylaxis should be continued until the risk has diminished (Figure 2


Warfarin Bridge Protocol:
Intermountain Health Protocol


Pain Management
•  dilaudid: hydromorphone: 0.5-1 mg IV q3hr
•  vicodin: hydrocodone-acetaminophen 5/325
•  oxycodone
•  codeine
- consider PRN on top of daily baseline
• if hypotensive:
• if social high risk:

Insulin
• Baseline: start home lantus dose; if NPO 1/2 home dose.
• SSI: regular or humalog; low/mid/high.
• Accuchecks: TID + ACS; NPO q4-6hrs

BPs
• PRN Hydralazine 10mg PRN SBP >160 / DBP >100
• PRN Labetalol
• amlodipine 5-10mg qd
• Nicardipine GGT

GI
• Metoclopramide
• Colace 100 BID


RT:
• CPAP 10 cm H20, titrate to pt comfort per RT
• BiPAP 10/5 cm H20, titrate to pt comfort per RT


Labs/Imaging :
1. Data : vitals (BP/Tº) / metabolic (K? acid-base?) / cbc (infxn?) / ins+outs (renal fxn?) / O2 sat (pulm fxn?)
2. Imaging : XR/CT/MRI/US
3. Micro: urine / blood / sputum
4. UA: leuk/nitrates/CFUs/Nø
5. Coag studies : PT/PTT/INR (2.5)
6. Renal: BUN/Cr/CrCl/output
7. Hep: AST/ALT/GGT/alk phos/hep panel
8. CBC: Hg/Hct/WBC/plates/L-shift
9. Card: EKG/echo/troponin/BNP
10. Pancreas: amylase/lipase
11. Lipids: TG/TC/HDL/LDL
12. Pulm: ABGs/POx/CXR
13. Other: glucose/A1C

#. Elevated LFTs
#. Hyponatremia
#. Hypernatremia
#. Cardiac: Mg,




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Abx Coverage


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ACLS

ACLS Notes
Bradycardia:
stable:
-atropine: .5mg q3-5min, up to 3mg max
-dopamine: 2-10 mcg/kg/min
-epinephrine: 2-10 mcg/min
unstable:
-pacing: need 5 leads, PB<90, set HR to 70-80, sedation? hit sync and ^amps until capture

SVT:
stable: vagal,
Adenosine 6mg > 12mg > 12mg push and flush
unstable: sedate & sync cardiovert 50j

A-fib rvr:
stable: vagal,
Diltiazem .25mg/kg (max 20mg) rpt: .35mg/kg (max25mg) over 2-5min
unstable: sync cardiovert 120j
*if becomes hypotensive CaCl 250mg

A-flutter rvr:
stable: vagal
Diltiazem .25mg/kg (max 20mg) rpt: .35mg/kg (max25mg) over 2-5min
unstable: sync cardiovert 50j

V-tach w Pulse
stable: amiodarone 150mg over 10min in 250cc D5W
lidocaine 1-1.5mg/kg, rpt: 0.5mg/kg (max 3mg/kg or 3 doses)
unstable: sync cardiovert 100j
*consider adenosine to see underlying rhythm

V-fib & PulseLESS V-tach
unwitnessed: CPR 2min > DFIB…
witnessed: DFIB > CPR / Epi 1mg > DFIB > CPR / Amiodarone 300 IVP > dfib 200j > CPR / Epi 1mg > DFIB > Amiodarone 150mg IVP > DFIB > CPR / Epi 1mg…
*can use Vasopressin instead of Epi during first 2 doses
*2 min pulse checks after CPR/meds

Torsades de Pointes:
Mag: 1-2g IV in 50-100 NS or D5W over 1-2min
if lose pulse DFIB 200j

Asystole & PEA
CPR / Epi 1mg 1:10,000 q 3-5m or Vaso 40 U IVP > CPR / Epi 1mg 1:10,000 q 3-5m or Vaso 40 U IVP > CPR / Epi > CPR/Epi > CPR/Epi > CPR/Epi >…
*2 min pulse checks after CPR/meds
------------------------------


EKGs : rate-rhythm-axis-hypertrophy-ischemia
Blocks : 1 small block = 0.04 sec; 1 big block = 0.2 sec; 5 big block 1sec.

1. Rate : 
     • 300/150/100/75/60/50. 
     • if arrhythmic/brady: 6 sec (0.2 sec big blocks x 5 = 1 sec) of QRS x 10    
2. Rhythm:
     • Best friends: P to each QRS, vice-versa? 
     • PR interval? (>0.2 sec / 1 big-block : AV delay or block?) 
     • QRS width? (if >0.12 / 3 small blocks : BBB?
• QT interval (<2 big block or 450ms; or 1/2 of previous RR)
     • Irregular:  P's not identical? =  Irregular : 
               • Wandering Pacer (irregular w/ variable P shapes P<100); MAT (if P>100)
     > P's identical but Irregular non-tach? Sinus arrhythmia. 
     > ø P-waves + Irregularly Irregular? A-fib (multi-foci pacing, lost P) see below. 
          
     • Escape : sinus forgot to work => other focus covers. 
     • Premature : premature atrial / junctional / ventricular (PVCs)
     • P >100? Tachyarrythmias
          note: fib = multi-foci (multi shaped P) vs. flutter = single foci (single shape P, slower)
          • Paroxysmal = sudden!
               > Supraventricular Tach: paroxysmal atrial tach +/- block; paroxysmal junction tach
               > non-SVT: paroxysmal ventircular tach. 

          • Atrial complexes sparking QRS? = Atrial Tach. won't see P's. 
               > A-flutter: saw-tooth (single focus identical regular P P P -> pow! QRS -> P P P)
               > A-fib: irregularly irregular (multi foci varied irregular P pPpp PP p -> pow! QRS -> pp Pp pP)
          • Ventricular (QRS) just poppin off? = Ventricular Tach. No Ps, all pacing from ventricles
               > V-flutter: smooth regular but tach QRS / often punches into V-fifb. 
               > V-fib : m/l foci variable shaped QRS
     • Blocks (sinus, AV, BBB): where's the block? AV vs. bundle!
          • Best friends: P + QRS
               > 1º AV Block: P + QRS need some distance from each other : >0.2 PR interval
               > 2º AV Block: 
                         a. Type I: Wenkebach: P + QRS going opposite ways: PR longer, longer drop!
                         b. Type II: P + QRS: hang every 3rd (whatev) day: some P don't get QRS, but is regular (ex. every 3rd P doesn't get QRS). 
               > 3º AV Block: totally broke up: P going its own rate, QRS its own rate (junctional focus 40-60 rate, ventricular 20-40 rate)
          •  BBB: note: incomplete BBB (QRS <0.12) vs. complete BBB (>0.12)
               > R-BBB (bunny ears RSR' V1 V2)
               > L-BBB (RSR' V5 V6)

3. Axis: 
     • nl axis : +I,II, aVF
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4. Hypertrophy: 
     > note: atrial chamber enlargement ('hypertrophy') best at V1 + II. 
     • Atrial: R: big biphasic P (>2.5 mm ht = 2.5 small boxes) w/ tall initial part
     • Atrial: L: big biphasic P (>2.5 mm ht) w/ wider end part
     • Ventricular: R (V1 usually (-) w/ S>>R; R atrial hypertrophy is R>S at V1), w/ RAD
     • Ventricular: L (tall R V5 (V1 S + V5 R >35mm ht), w/ some LAD
    

5. Ischemia
     • Q-waves (>1/3 R or >0.04 small box) : infarct, will show old infarcts also. 
     • ST elevation (elevated >1 small box) : acute injury
     • ST depression (down >1 small box: sub-endocardial infarction
     • T inversion (mirrored + inverted against R)
     note: 1 small box = 1 mm
     
     •  Locating area of ischemia: 
          > Anterior: V1/V2/V3/V4
          > Lateral: I/avL
          > Inferior: II/III/avF
          > Posterior: V1/V2 ST depression (mirrored of anterior!!!)

6. Other
     • PE: S1Q3T3: slurred wide S at I  / big Q at III / inverted T at III
     • hyper-K: peaked T,  wide QRS
     • hypo-K: flat T, + U-wave (extra T-wave look-alike)
     • hyper-Ca: short QT (T is repolarization (reset); high Ca is easier to restore Ca amounts)
     • hypo-Ca: long QT
     • hypo-Mg: long QT

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Electrolytes

Potassium (goal 4-4.5)-do not replete if pt is on HD
10mEq of K raises serum K by 0.1mmol. For mild renal failure, cut the dose in half. For severe renal failure (CrCl<30) ask resident for help.

PO: tabs (huge) vs. liquid (tastes gross, fast-acting). Equivalent to IV except PO KPhos which does NOT replete K
IV: Can be painful through peripheral IVs. Slow! (takes an hour to get in 10mEq). 30 mmol IV KPhos = 45 mEq IV KCl.


Profoundly low (<3): can cause arrhythmias (less common than high K). Or- der 40mEq PO STAT and 40mEq IV over 4 hours. Will likely need >100 mEq ultimately (depleted K stores) so recheck every 6-8 hours until nml.
High (>5.5): can cause arrhythmias. CHECK EKG STAT and notify your resi- dent!


If EKG changes: give 2g Ca-gluconate (stabilizes myocardium), 1 amp Na -HCO3, 10 units insulin + 1 amp D50, and albuterol neb (intracellular shifts), and 30 g kayexalate. May need to call renal for emergent HD.
If no EKG changes and <6: can hold off on Ca-gluconate. Ask your resi- dent about insulin, albuterol, bicarb. Still give kayexalate.

Magnesium (goal>2)-do not replete in HD 1 g of Mg will raise Mg level by 0.1.

PO: Mag Oxide. Causes diarrhea.
IV: 1-2g Mag Sulfate IV runs (slow but not painful like potassium)


Phosphate (goal 3-4.5, usually replete if <2.5)-do not replete in HD
For chronically low Phos, check for Vit D Deficiency. Acute drop in a pt that was NPO for days-weeks may indicate refeeding syndrome.PO: typically ―2 packets of neutra-phos‖, can also give extra milk with meals IV: NaPO4 (4mEq Na, 3mmol PO4 per mL), KPO4 (4.4mEq K, 3mmol PO4 per mL)High: typically seen in CKD patients. Will require phosphate binders.

Calcium (goal 8.5-10) –don’t replete in HD unless dangerously low and renal fel- low aware. Remember to correct for albumin. Be very cautious when the Calci- um*Phos product is >55 (can precipitate Ca-Phos and cause MI, etc).

PO: Tums, Calcium Carbonate
IV: Calcium Gluconate 1-2g IV runs (1st choice for peripheral IV) or Calcium Chloride 1-2g IV runs (through central IV’s only—about 4-5x as potent!)

IV Fluids: Surgeons use Lactated Ringers—isotonic solution with ―premix‖ of electrolytes. Good for young people without chronic diseases. Bad for medicine patients. Use normal saline for boluses—500mL to 1L. Use NS, 1/2NS or D5- 1/2NS for maintenance.

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What to Do If You’re Called For...
Whenever called for concerning symptoms, ask for recent vitals over the phone. (If not done recently, ask for them to be done while you’re en route). Remember escalation of care: If a pt looks unstable or you don’t know what to do, call your resident and ask for help!
Insomnia: Very common call. Can use Ambien or Benadryl; both can cause AMS in the elderly. Trazodone is an alternative, causes less AMS. Seroquel is good in the elderly but can prolong QT. Always use lowest starting dose.
Fever: If not done in the last 24 hrs, get a chest xray, UA/urine cx, and periph- eral blood cultures. Can give Tylenol PRN. If the patient is neutropenic, start cefepime 2g q8h (adjust for renal failure) empirically after drawing cultures
Nausea/Vomiting: Another common call, and can be due to meds, chemo, underlying illness, reflux. Evaluate at bedside for new-onset vomiting or abd pain, persistent vomiting, or hematemesis. For symptomatic control, you can give Compazine or Zofran first line.

  • AMS: Always evaluate promptly and do a quick exam to determine if the situation is acute (unresponsive, blown pupil, acute change in orientation). Check the airway-if pt can’t maintain their airway, then call the MRICU. If they can maintain their airway, call your resident and check an ABG (for inc CO2) and fingerstick blood glucose. Talk to resident about stat labs: BMP, cultures, CBC, LFTs (ammonia). Decide quickly whether or not the patient needs a noncontrast head CT.
  • Confused Old People (Elderly delirium) – 20% of elderly become delirious in hospital, ~80% if preexisting dementia or ICU stay.
    Delirium: acute, fluctuating AMS, inattention, difficulty concentra- tion, and disorganized thought.(rambling/incoherent language). Causes: MEDS (opioids, sedatives, ANTICHOLINERGICS, ETOH/ drug withdrawal, polypharmacy), Brain (CVA, bleed, meningitis), Illness (Infxn ie: UTI, hypoxia, shock, dehydration, fever, HYPO- GLYCEMIA). Post-Op.
    Work-up: VS including pulse-ox, CHECK GLUCOSE, review meds, neuro/eye exam for focal findings (if present get Head CT). Management: Redirection, then meds, then physical restraints (use last, try to avoid). Haldol 0.5-1.0mg IV, atypical antipsychotics—all prolong QT except aripiprazole.
  • Chest Pain: Always evaluate promptly. If the pt looks unstable, call your resident. ALWAYS get an EKG. If you are even slightly concerned for an MI, send cardiac enzymes. If the EKG or history is suggestive of ischemia, give the pt aspirin 325mg, SL nitroglycerin (up to 3 doses in 15 minutes—can lower BP so call your resident before giving if BP is low), and oxygen. Your goal is to get the pt chest pain free. If the pt is not pain free after 3 doses of SLNG, or has suspicious ECG findings, then the CCU resident should be noti- fied. Your resident should be involved ASAP—definitely before calling CCU, and before giving heparin/lovenox. Remember: time is muscle for cardiac is- chemia/infarct.
  • SOB/Hypoxia: Again, evaluate promptly, especially if vitals (which nurse should have given you on the phone) sound unstable (tachypnea>25/minute, tachycardia>100, hypotensive, sats <90). Assess pt’s breathing (can they speak in complete sentences? Are they maintaining their airway? Do they look like they’re tiring—using accessory muscles, diaphoretic?) If the pt looks un- stable, call your resident. Listen to the lungs and heart; check for edema and JVD. Get an EKG and check an ABG for hypoxia/hypercarbia. If they’re hy- poxic, be sure they’re on enough O2 to keep their sats above 90% (if on a non- rebreather and still hypoxic, is in impending respiratory failure, then call the MRICU immediately. Your resident should be involved by now.) If you’re concerned, get the nurse to make sure the code cart is nearby.
5. Tachycardia/Arrhythmia: Start by asking the nurse for the pt’s BP and sym- proms — if BP is low or pt is symptomatic, call your resident. Ask the nurse to get an ECG while you’re on the way. When you arrive, check for pulse-if they don’t have one, call a code blue. If pt looks unstable, call your resident. Management of tachycardia depends on whether the pt is hypotensive and/or symptomatic—if they are, you should call your resident to bedside, get the code cart ready and follow your ACLS algorithm for unstable tachycardia. For a stable tachycardia (no symptoms, BP normal), you have some options.

For known A fib with RVR, you can use diltiazem or metoprolol IV, but be aware that these can lower BP. If you’re pushing meds IV, your resident should be involved.
For a regular wide complex tachycardia with a pulse, call your resi- dent for assistance immediately. (If no pulse, call a code.)


For a regular narrow complex tachycardia that you can’t identify, call your resident to bedside to see if adenosine is warranted.
Sinus tachycardia IS NEVER treated with AVN blockade, figure out what’s causing it and fix problem.

  • Hypotension: Causes are numerous and include hemorrhage, CHF, sepsis, arrhythmia/tachycardia, PE, MI, tamponade, cirrhosis, and meds. If pt is symptomatic or has had a significant drop in their BP, evaluate at beside im- mediately. If the pt appears unstable, call your resident to come evaluate the pt. Starting a fluid bolus is usually safe, as long as pt isn’t volume over- loaded and is not anuric. Remember-only IVF boluses help blood pressure; a rate of 125cc/hr won’t help acutely. If the pt appears stable, take the time to go through the chart—look at recent meds, trends in vitals, and build a differential dx to discuss with your resident. If pt looks septic, consider adding/broadening antibiotics. If a pt is still hypotensive after 6 L IVF boluses, then they need pressors, and the MRICU resident should be notified.
  • Hypertension: Efforts should be made to acutely correct a pt’s BP if they are symptomatic or their BP is >170/100. If they are symptomatic (CP, SOB, AMS, no UOP), they have hypertensive emergency (end organ damage) and you should call your resident. If not, pt has hypertensive urgency and you can take your time (up to 12-24 hours) to lower BP. You can even check to see when pt’s next antihypertensive medicine is due to be given. If it’s within the next few hours, just ask the nurse to give it early. Rapid onset meds that can be used acutely include nitropaste (venous dilator, not great), IV labetalol, PO/ IV hydralazine, PO clonidine, PO captopril.
  • Low Urine Output – normal > 0.5ml/kg/hr (usually > 30mls). Oliguria < 400mls/day, anuria < 100mls/day. First question: are the numbers accurate? (Sometimes not recorded—ask nurse.) Is the Foley clogged? (Flush it!). Did pt discard urine without telling nurse? (ask them) or is the pt CKD Stage IV-V and only makes 100-200mls a day normally? Can consider bladder scan (>50mL post-void residual abnl, >200mL post-void = need for Foley). Also consider hypovolemia, decreased cardiac output (MI, CHF), sepsis, contrast induced nephropathy. If not volume overloaded, usually safe to try a 500mL saline bolus. LASIX DOES NOT ―TREAT‖ LOW URINE OUTPUT! 
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Criterias

SIRS / Sepsis / Septic Shock :
Tº: <96.8 or >100.4 / P: >90 / R: >20 or PaCO2 <32 / WBC: <4k or >12k or 10% bands : 2/4
Sepsis: SIRS + evidence of infxn
Severe sepsis: w/ organ injury (hypotension / high lactic acid / reduced GFR)
Septic Shock: severe sepsis + hypoTN refractory to IV fluids

Pnuemonia : CURB65 / 1-3-5
Confusion / Uremia / R >30 / BP <90/<60 / >65 yo.
Death Risk in 30 days: 0—0.6%, 1—2.7%, 2—13.0%, 3—6.8%, 4—14.0%, 5—27.8%
Management: 0-1 --> outpt, 2-3 --> in-pt / close watch, 4-5 --> inpt or ICU

Afib: CHADS2VA2Sc / <1 ø or aspirin / >2 warfarin
CHF / HTN / Age >65-75 / DM / Stroke hx 2 / vascular dz / Age >75 / Sc (sex F)

US-A or NSTEMI; TIMI: US-A or non-STEMI pt risk for ischemic events / death
RF: >65 yo / >3 CAD RFs / known CAD >50% stenosis / 2+ episodes severe angina in past 24 hrs / ASA in past 7 days / elevated card-zymes / ST ∆ >0.5 mm
Scoring: 1=5% / 2=8% / 3=13% / 4=20% / 5=26% / >6=41% : risk major adverse cardiac events at 14 days.
CAD (7!) RFs: DM / high LDL / low HDL / HTN / cigarettes / age (M>45/F>55) / fHx

Proteinuria: >150 mg/24 hr
Nephrotic: >3.5g/24hr
Microalbuminuria: 30-300 mg albumin / 24 hr

AG Acidosis: MUDPILES / KUSMALE
a. methanol / uremia / DKA / paraldehyde / iron or INH / lactic acid / ethylene / salicylate
b. ketoacidosis / uremia / salicylate / methylene / aldehyde / lactic / ethylene

PADUA Score :

ESLD : end stage liver disease; MELD Score Calculator
http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/

Glasgow Coma Score;

Screen Shot 2014-07-20 at 6.31.13 PM
Severe, with GCS < 8-9; Less than 8 ? INTUBATE!
Moderate, GCS 8 or 9–12 (controversial)[2]
Minor, GCS ≥ 13.

DVT Wells: (−2 to 9); if score >1 = 28% have DVT; <2 = 6% risk
+1 for each: Active cancer, calf swelling, Swollen u/l, u/l pitting edema, hx DVT, swelling of entire leg, local TTP, recent paralysis/paresis/immobilization of LE,
Recently bedridden ≥ 3 days, or major surgery requiring regional or general anesthetic in the past 12 weeks,
-2 : Alternative diagnosis at least as likely

PE Wells;
clinically suspected DVT — 3.0 points
alternative diagnosis is less likely than PE — 3.0 points
tachycardia (heart rate > 100) — 1.5 points
immobilization (≥ 3d)/surgery in previous four weeks — 1.5 points
history of DVT or PE — 1.5 points
hemoptysis — 1.0 points
malignancy (with treatment within 6 months) or palliative — 1.0 points
Traditional interpretation[9][10][15]

Score >6.0 — High (probability 59% based on pooled data[16])
Score 2.0 to 6.0 — Moderate (probability 29% based on pooled data[16])
Score <2.0 — Low (probability 15% based on pooled data[16])
Alternative interpretation[9][12]

Score > 4 — PE likely. Consider diagnostic imaging.
Score 4 or less — PE unlikely. Consider D-dimer to rule out PE.