I am a doctor beginning as an Emergency Medicine Resident in a district hospital; please provide a step‑by‑step treatment plan for the patient based on the symptoms I will give.

Emergency Medicine Treatment Protocol Framework

As an Emergency Medicine Resident in a district hospital, you must establish a systematic approach to every patient presentation that prioritizes immediate life threats, obtains accurate clinical information, and initiates evidence-based treatment.

Initial Patient Assessment – The First 5 Minutes

Immediate Vital Sign Stabilization

• Check and correct vital functions immediately upon patient arrival, including airway patency, breathing adequacy, circulation status, and level of consciousness. 1
• Record oxygen saturation as the "fifth vital sign" and obtain a 12-lead ECG within 5 minutes if any concern for acute coronary syndrome exists. 2
• Assess for red-flag features including syncope (which accounts for roughly 30% of non-accidental falls in older adults), hemodynamic instability, altered mental status, or severe respiratory distress. 2

Critical Triage Decisions

• Transport criteria for immediate specialist care: chest discomfort lasting >20 minutes, hemodynamic instability, syncope or presyncope, acute delirium, unexplained falls, or symptoms unresponsive to initial treatment within 5 minutes. 2
• Recognize that elderly patients frequently present atypically—acute coronary syndrome may manifest as breathlessness, delirium, or falls rather than chest pain. 2

Obtaining Accurate Clinical Information

Medication History – A High-Yield, High-Error Process

• Medication histories obtained during triage are inaccurate in 37% of cases, with discontinued medications included (9.8%), current medications omitted (27.9%), and non-prescription medications missed (38%). 3
• Independently verify the medication list beyond the initial triage documentation, as this is a critical error-prevention step. 3
• Specifically ask about: all prescription medications with exact dosages, over-the-counter medications, herbal supplements, recent medication changes, and medication compliance patterns. 1

Symptom-Specific History Taking

For chest pain presentations:

• Obtain risk stratification factors: history of coronary artery disease, hyperlipidemia, diabetes, smoking, hypertension, male sex and age >50 years, female sex and age >60 years, or family history of coronary artery disease. 1
• Assess pain characteristics: onset timing, radiation pattern, associated nausea/sweating, response to nitroglycerin, and factors that worsen or relieve symptoms. 1
• Rule out high-risk features: pain affected by palpation, breathing, or movement suggests musculoskeletal origin; multiple pain sites reduce likelihood of cardiac ischemia. 1

For dyspnea presentations:

• Determine pattern and chronicity: acute versus chronic onset, seasonal variation, relationship to exertion, positional changes, and environmental triggers. 1
• Identify associated symptoms: peripheral edema, audible rales (especially without fever), elevated jugular venous pressure, orthopnea, paroxysmal nocturnal dyspnea. 1
• Screen for anxiety and depression systematically, as severe breathlessness often precipitates anxiety in a self-reinforcing cycle. 2

Physical Examination Priorities

• For suspected heart failure: assess for peripheral edema, audible rales (especially in the absence of fever), elevated jugular venous pressure, and third heart sound. 1
• For respiratory distress: document respiratory rate, use of accessory muscles, ability to speak in full sentences, and oxygen saturation on room air. 1
• For elderly patients: evaluate orthostatic vital signs, cognitive status, frailty indicators, and signs of polypharmacy complications. 2

Diagnostic Testing Strategy

Laboratory Biomarkers

• For dyspnea: BNP is the single most important initial test, with BNP <100 pg/mL providing 96-99% sensitivity for ruling out acute heart failure. 2, 1
• Age-adjusted NT-proBNP thresholds improve accuracy: <75 years use cutoff ≈125 pg/mL (sensitivity 0.94); ≥75 years use cutoff ≈450 pg/mL (sensitivity 0.94). 2
• For severe dyspnea in patients >65 years: BNP ≥250 pg/mL (sensitivity 0.73, specificity 0.91) or NT-proBNP ≥1,500 pg/mL (sensitivity 0.75, specificity 0.76). 2

Mandatory Initial Blood Work

• Obtain on all acute presentations: troponin, BUN/creatinine, electrolytes, glucose, complete blood count. 1
• D-dimer is indicated only when acute pulmonary embolism is suspected. 1
• Arterial blood gas is not routinely needed but obtain when precise oxygen/carbon dioxide measurement is required or in patients with acute pulmonary edema, COPD history, or cardiogenic shock. 1

ECG and Imaging

• Record and interpret ECG within 5 minutes of presentation for chest pain or dyspnea; pre-hospital ECG reduces in-hospital delay time and mortality. 1
• Chest X-ray rules out alternative causes of dyspnea, though it may be normal in nearly 20% of heart failure patients. 1
• Bedside thoracic ultrasound for signs of interstitial edema (B-lines) and abdominal ultrasound for inferior vena cava diameter if expertise is available. 1

Immediate Treatment Protocols

Oxygen Therapy

• Target oxygen saturation 94-98% for most patients without known risk of hypercapnic respiratory failure, using nasal cannula at 2-6 L/min or simple face mask at 5-10 L/min. 2
• For possible COPD, target 88-92% pending blood gas results. 2
• Monitor with pulse oximetry continuously during acute presentations. 1

Acute Chest Pain Management

• Give aspirin 250-500 mg (fast-acting, chewable or water-soluble) immediately when myocardial infarction is suspected. 1
• Pain relief with intravenous morphine is the preferred drug, titrated according to severity; relieve pain even before ECG interpretation as pain causes sympathetic activation and increased blood pressure. 1
• Short-acting nitrate may be given if no bradycardia or low blood pressure is present. 1
• Establish IV access whenever possible and monitor cardiac activity to facilitate rapid defibrillation if needed. 1

Acute Dyspnea/Bronchospasm Management

• For acute severe asthma or COPD exacerbations, immediately administer nebulized albuterol 5 mg (or 2.5 mg for smaller patients) plus ipratropium bromide 0.5 mg via oxygen-driven nebulizer at 6-8 L/min every 20 minutes for three doses. 4, 5
• Add ipratropium to beta-agonist therapy immediately when: moderate-to-severe exacerbation (FEV₁ or PEF <40% predicted), life-threatening features present (silent chest, cyanosis, altered consciousness), or no improvement after 15-30 minutes of initial beta-agonist therapy. 4, 5
• Administer systemic corticosteroids concurrently—oral prednisone provides equivalent efficacy to IV methylprednisolone and is preferred when feasible. 4, 5

Non-Pharmacological Interventions for Breathlessness

• Position patient upright sitting to increase peak ventilation and reduce airway obstruction. 2
• Encourage leaning forward with arms braced on chair or knees to optimize diaphragmatic mechanics. 2
• Teach pursed-lip breathing (inhale through nose, exhale slowly through pursed lips for 4-6 seconds) to lower airway resistance. 2
• Facilitate shoulder relaxation to mitigate hunched posture and improve breathing efficiency. 2

Acute Heart Failure Management

• Non-invasive ventilation (NIV) is indicated in patients with respiratory distress and should be started as soon as possible to decrease respiratory distress and reduce mechanical intubation rates. 1
• Avoid urinary catheterization unless benefits outweigh infection risks and continence complications. 1

Critical Pitfalls to Avoid

• Do not assume breathlessness is "normal aging"—it is a multifactorial geriatric condition requiring full evaluation. 2
• Do not rely solely on triage medication history—independently verify all medications as 37% contain errors. 3
• Do not overlook atypical presentations in elderly patients—acute coronary syndrome frequently presents as breathlessness, delirium, or falls rather than chest pain. 2
• Do not delay aspirin administration while waiting for ECG results in suspected acute coronary syndrome. 1
• Do not use ipratropium as monotherapy—it must be combined with short-acting beta-agonists for acute exacerbations. 4, 5
• Do not nebulize with pure oxygen in severe COPD patients at risk of hypercapnia—use 24% Venturi mask between treatments. 4

Multidisciplinary Coordination

• Communicate effectively with nursing staff regarding objective monitoring for changes in signs/symptoms, anxiety management through clear patient/family information, and prompt reporting of clinical status changes. 1
• Involve specialists early: respiratory for severe asthma/COPD, cardiology for acute coronary syndrome or heart failure with hemodynamic instability, geriatrics for complex elderly patients with frailty and polypharmacy. 2

This framework provides the systematic approach needed for safe, evidence-based emergency care in a district hospital setting. Always prioritize immediate life threats, obtain accurate clinical information independently, and initiate guideline-concordant treatment without delay.