“Case Study: 70-Year-Old Male – Week 9 i Human Simulation | Reason for Encounter: Dyspnea (Updated 2025–2026)”

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 When did the shortness of breath begin? “About five days ago, getting worse each day.” Any fever or chest pain? “No fever, just tight chest and wheezing.” What color is the sputum? “Yellowish and thick.” Do you smoke or use oxygen at home? “Yes, I still smoke sometimes; no 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 breathing problems? “Twice in the last two years.”