A 68-year-old presents with sudden-onset breathlessness, SpO2 88% on air, HR 122, BP 90/60. Walk me through your assessment and initial management.

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I would approach this using an ABCDE framework while calling for senior help and the resuscitation team. Airway: assess patency and talk to the patient. Breathing: respiratory rate, work of breathing, tracheal position, chest expansion, auscultation; apply 15L non-rebreather aiming SpO2 94-98%. Circulation: two large-bore cannulae, fluid bolus 250-500ml crystalloid reassessing, bloods including ABG, lactate, troponin, D-dimer, group and save. Disability: GCS, glucose. Exposure: calves, rashes. My top differentials given hypoxia, tachycardia and hypotension are massive PE, tension pneumothorax, MI with cardiogenic shock, and sepsis. I would request urgent ECG, portable CXR and bedside echo, and arrange CTPA once stabilised. If massive PE with haemodynamic instability I would discuss thrombolysis with the medical registrar and ICU. Throughout I would communicate clearly with the team, document in real time and update the family.

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