, Week 10 i-Human Case Study: Maria
Rodriguez – 45-Year-Old Female with
Hypoxic Community-Acquired Pneumonia
Week 10: Right Lower Lobe Pneumonia Requiring Hospital Admission (NURS 6531)
Walden University | Fall 2026 | Simulation Encounter
Patient Demographics: Maria Rodriguez, 45-year-old female | Height: 5'4" (163 cm) | Weight:
158 lb (71.7 kg) | BMI: 27.1 (overweight) |
Reason for encounter (ED presentation): “I can’t stop coughing and I feel like I can’t
breathe.”
Setting: Emergency Department (brought by husband). Subsequent admission to medical floor.
1. Case Overview & Learning Objectives
This i-Human case presents Maria Rodriguez, a 45-year-old female with no significant past
medical history, who develops progressive dyspnea, fever, and productive cough over 5 days.
She presents to the emergency department with hypoxia (SpO₂ 88% on room air) and
radiographic evidence of right lower lobe pneumonia. The case challenges the learner to
recognize severity criteria for community-acquired pneumonia (CAP), differentiate from other
causes of hypoxic respiratory failure, calculate CURB-65 and PSI/PORT scores, initiate
appropriate antibiotics and respiratory support, and determine the need for hospital admission.
The primary diagnosis is severe community-acquired pneumonia (CAP), right lower lobe,
with hypoxic respiratory failure. The patient meets criteria for hospital admission (non-ICU).
2. Chief Complaint & History of Present Illness (HPI)
Chief Complaint (CC): “Shortness of breath and a bad cough with green phlegm – getting
worse every day.”
HPI: Maria Rodriguez, a 45-year-old previously healthy female, reports that approximately 5
days ago she developed a dry cough, low-grade fever, and generalized myalgias. Over the past 2
days, her symptoms have significantly worsened. She now has a productive cough with thick,
greenish sputum, subjective fevers (measured temperature 102.5°F at home), and severe
shortness of breath that limits her ability to walk to the bathroom. She experiences pleuritic right-
sided chest pain that worsens with deep inspiration and coughing. She reports chills, night
sweats, and profound fatigue. She has taken over-the-counter acetaminophen and ibuprofen with
minimal relief. Her husband notes that she has been increasingly confused and less responsive
today, though she is oriented to person and place. She denies hemoptysis, nausea, vomiting, or
abdominal pain.
Pertinent positives: Productive cough (green sputum), fever, chills, pleuritic chest pain, dyspnea
at rest, confusion (mild).
Pertinent negatives: No hemoptysis, no travel history, no sick contacts (other than mild URI in
coworker 1 week ago).
Rodriguez – 45-Year-Old Female with
Hypoxic Community-Acquired Pneumonia
Week 10: Right Lower Lobe Pneumonia Requiring Hospital Admission (NURS 6531)
Walden University | Fall 2026 | Simulation Encounter
Patient Demographics: Maria Rodriguez, 45-year-old female | Height: 5'4" (163 cm) | Weight:
158 lb (71.7 kg) | BMI: 27.1 (overweight) |
Reason for encounter (ED presentation): “I can’t stop coughing and I feel like I can’t
breathe.”
Setting: Emergency Department (brought by husband). Subsequent admission to medical floor.
1. Case Overview & Learning Objectives
This i-Human case presents Maria Rodriguez, a 45-year-old female with no significant past
medical history, who develops progressive dyspnea, fever, and productive cough over 5 days.
She presents to the emergency department with hypoxia (SpO₂ 88% on room air) and
radiographic evidence of right lower lobe pneumonia. The case challenges the learner to
recognize severity criteria for community-acquired pneumonia (CAP), differentiate from other
causes of hypoxic respiratory failure, calculate CURB-65 and PSI/PORT scores, initiate
appropriate antibiotics and respiratory support, and determine the need for hospital admission.
The primary diagnosis is severe community-acquired pneumonia (CAP), right lower lobe,
with hypoxic respiratory failure. The patient meets criteria for hospital admission (non-ICU).
2. Chief Complaint & History of Present Illness (HPI)
Chief Complaint (CC): “Shortness of breath and a bad cough with green phlegm – getting
worse every day.”
HPI: Maria Rodriguez, a 45-year-old previously healthy female, reports that approximately 5
days ago she developed a dry cough, low-grade fever, and generalized myalgias. Over the past 2
days, her symptoms have significantly worsened. She now has a productive cough with thick,
greenish sputum, subjective fevers (measured temperature 102.5°F at home), and severe
shortness of breath that limits her ability to walk to the bathroom. She experiences pleuritic right-
sided chest pain that worsens with deep inspiration and coughing. She reports chills, night
sweats, and profound fatigue. She has taken over-the-counter acetaminophen and ibuprofen with
minimal relief. Her husband notes that she has been increasingly confused and less responsive
today, though she is oriented to person and place. She denies hemoptysis, nausea, vomiting, or
abdominal pain.
Pertinent positives: Productive cough (green sputum), fever, chills, pleuritic chest pain, dyspnea
at rest, confusion (mild).
Pertinent negatives: No hemoptysis, no travel history, no sick contacts (other than mild URI in
coworker 1 week ago).
