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What additional symptoms should you ask the patient if she has experienced? 

The physical exam should focus on identifying the cause of atrial fibrillation. Examining the neck of the patient may give some clues regarding carotid artery disease or thyroid problems. The pulmonary examination may reveal signs of heart failure in the form of rales, and the presence of wheezing may indicate antecedent pulmonary diseases such as asthma and chronic obstructive pulmonary disease (COPD). 

Ask if she had the flu vaccine. Viral respiratory infections, including those due to the influenza virus, increase the risk for pneumonia and systemic illness that can precipitate fatal and nonfatal cardiovascular events. Underlying cardiovascular disease is also a risk factor for influenza infection, downstream cardiopulmonary complications, and mortality from respiratory infections (Behrouzi et al., 2022). 

A cardiovascular exam should consist of careful examination of all four cardiac posts and palpation of the apical impulse, as this would be crucial in diagnosing an underlying valvular pathology. An abdominal exam should consist of palpating the aorta and listening for abdominal bruits. Hepatomegaly and abdominal distension may indicate heart failure (Napalkov et al., 2023).  

Using Table 36.1, calculate the patient’s CHADS2 score and determine whether anticoagulation is recommended based on the score. 

Oral anticoagulation (OAC) markedly reduces the risk of cardiovascular event (CVE); however, this treatment is associated with an increased risk of major bleeding. Decision‐making regarding OAC, therefore, needs to balance the risk of CVE against the risk of bleeding (Napalkov et al., 2023). High CHA2DS2-VASC and HAS-BLED scores are linked to increased mortality in structural and nonstructural cardiovascular interventions irrespective of the presence of atrial fibrillation (AF) or oral anticoagulation. The patient’s CHADS2 score is 2. Hypertension =1, and Female =1. In patients with AF, an elevated CHA2DS2-VASc score of 2 or more is considered “high risk”, and oral anticoagulation is recommended (Chugh et al., 2023).  

What is the significance of this condition happening off and on for the last 48 hours?  

0ne of the most serious complications of AF is thromboembolism, in particular stroke, which exists regardless of the presence or absence of symptoms. Cardioembolic stroke is the most concerning complication of atrial fibrillation because of the abnormal blood flow in the left atrium and the chaotic electrical signals (Jame & Barnes, 2019). AF is associated with a higher risk of major events (including stroke and death, but not bleeding) (Botto et al., 2021). Paroxysmal AF, the classification extends the duration of the single AF episode up to 7 days, but the probability of it is low after 48 hrs. In patients presenting at the emergency department (ED) with symptomatic recent-onset AF, immediate restoration of sinus rhythm by pharmacological cardioversion (PCV) or electrical cardioversion (ECV) is frequently performed. 

You, the nurse practitioner, decide the patient needs treatment beyond the walk-in clinic’s resources. What action do you take to ensure that the patient is treated promptly? 

For this patient, I would advise seeking immediate medical attention at the nearest hospital and contacting emergency services by dialing 911. I would transmit patient data, including evaluations and laboratory findings, to the physician located at the hospital. Advocate for patients to receive free or low-cost follow-up care. 

Because the patient is an undocumented immigrant, what considerations will be needed while care is provided? 

Some of the most common obstacles to receiving medical treatment include insufficient funds, no health insurance, difficulty communicating in English, a lack of reliable transportation, an unclear understanding of where to find treatment, worries about not having the proper paperwork to apply for insurance and get treatment and deportation. With these obstacles, the patient may not attend follow-up appointments due to lack of insurance. In 1986, Congress approved the Emergency Medical Treatment and Labor Act (EMTALA), requiring hospitals to provide services for active labor and emergency care regardless of insurance and immigration status. In addition to EMTALA, there is emergency care under Medicaid, which is currently the only federal insurance that is available to undocumented immigrants (UI). Emergency Medicaid covers patients in active labor and those with acute medical emergencies. It may only be used to stabilize patients and may not cover patients for services after the patient has been stabilized (Beck et al., 2019). The health department in North Carolina has organizations that provide â€œCharity Care” for undocumented immigrants with chronic illnesses. 

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