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

-I would ask the patient if she has experienced additional symptoms such as fever, palpitations, shortness of breath, weakness and chest pain. Fevers can sometimes trigger a patient’s atrial fibrillation and uncontrolled heart rate, which in this case is a possibility as she’s had a recent case of influenza. 

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

-The most known and reliable method of stratification for dividing AF patients according to their risk of stroke is the CHADS2 score. This patient’s score is 1. Patients diagnosed with atrial fibrillation (AF) and having a CHADS2 score of 0 are in the low risk category, with a stroke rate of 0.5 – 1.7% per year; an intermediate risk score of 2.0% per year is indicated by a score of 1, and a high risk score of 4.0% per year is indicated by a score of ≥2. For patients at low risk (e.g., score < 1), aspirin (81–325 mg) may be used as an alternative to oral anticoagulation. Systemic anticoagulation is advised for those who are susceptible to thromboembolic events. Vitamin K antagonists like warfarin and novel oral anticoagulants (NOAC) are alternatives for oral anticoagulants that don’t require regular blood tests or dose adjustments. As a result, the use of these drugs and the preferences for their prescription have grown. Direct thrombin inhibitors, like dabigatran, are becoming less used in favor of factor Xa inhibitors, such as rivaroxaban, apixaban, and edoxaban. (Furie & Khan 2016)

  • Congestive heart failure: 0
  • Hypertension: 1
  • Age >75 years: 0
  • Diabetes mellitus: 0
  • Stroke/TIA history: 0

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

-Paroxysmal atrial fibrillation may be indicated in the context of atrial fibrillation by symptoms that have been intermittent for the past 48 hours. Even though this kind of atrial fibrillation is sporadic and sometimes goes away on its own, thromboembolism is still a possibility.

4. 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?

-As the nurse practitioner, I would immediately have the patient transferred to the hospital for IV medication to decrease the heart rate as well as receive an anti-coagulant. The patient is considered to be in distress and requires immediate intervention. The patient would most likely be admitted to the hospital as this is considered new onset and should be evaluated by a cardiologist as soon as possible. When the patient is discharged, the patient will be referred back to a primary practice to manage her new medications. 

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

-Considerations that will be needed while providing care in this case includes patient privacy and confidentiality, ensuring the patient receives emergent care at a hospital as it is under federal law to receive emergency care regardless of immigration status, and lastly provide the patient with resources to obtain low cost care for primary care and medication management, such as through community health centers.


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