Breathing | 2025–2026 Update
0798555079
Age: 70 years
Height: 5′ 11″ (180 cm)
Weight: 164 lb (74.5 kg)
Reason for encounter: “Difficulty breathing”
Location: Emergency Room with full imaging and laboratory capabilities
i-Human Case Week #9 – 70-Year-Old Male: “Difficulty Breathing”
,Setting: Emergency Room with full imaging and laboratory capabilities
Student Nurse Case Report
Case Overview / Problem Identification
Patient Presentation:
A 70-year-old male arrives in the ER complaining of progressive shortness of
breath and productive cough for five days. He notes increased sputum volume
and thicker consistency with yellowish color, and reports wheezing and fatigue.
He has a 40-pack-year smoking history and was diagnosed with COPD 10 years
ago.
Initial Clinical Impression:
This presentation suggests an acute exacerbation of COPD, but other
respiratory and cardiac causes must be ruled out:
1. COPD Exacerbation – dyspnea + increased sputum + wheezing.
2. Community-Acquired Pneumonia – fever, focal crackles, infiltrate.
3. Congestive Heart Failure – dyspnea + orthopnea + edema.
4. Asthma Exacerbation – episodic wheeze in younger patients.
5. Pulmonary Embolism – sudden dyspnea, pleuritic pain.
, Assessment Questions / History Taking
Question Patient Response
“About five days ago, getting worse
When did the shortness of breath begin?
each day.”
“No fever, just tight chest and
Any fever or chest pain?
wheezing.”
What color is the sputum? “Yellowish and thick.”
“Yes, I still smoke sometimes; no
Do you smoke or use oxygen at home?
oxygen.”
Any swelling in your legs or recent travel? “No swelling or travel.”
Do you wake up at night short of breath? “Yes, sometimes.”
Are you using your inhaler as prescribed? “I ran out last week.”
Any previous hospitalizations for
“Twice in the last two years.”
breathing problems?