Module 2 Case Presentation: Megan Gallagher

Bob is a 66-year-old white man who has come into the office for a routine checkup.

 Height: 5’9”
 Weight is 220 lb; (BMI is 32.5 kg/m2).
 BP 124/80 mm Hg, HR110 bpm.

Past Medical history and meds

 hyperlipidemia and hypertension.
 He currently takes atorvastatin 10 mg/d and lisinopril 10 mg/d.

Social History
 Frank owns and manages a local business.
 He has never smoked
 Consumes alcoholic beverages only on special occasions.

Physical Exam

 Heart rate is 110-120 bpm and irregular. He denies experiencing fatigue, dizziness,
palpitations, shortness of breath, or chest pains.
 Other physical examination findings include: lungs = normal; abdomen = obese, no
tenderness or masses; neck = negative for thyromegaly; vision = normal; neurologic =
normal reflexes and coordination.

1. What is the best next step in the care of Frank?

A. Obtain an echocardiogram
B. Refer for cardiac stress testing
C. Initiate anticoagulation therapy
D. Start aspirin
E. 12 Lead EKG
An electrocardiogram is performed:

2. What is the CNPs interpretation? _Atrial Fibrillation___

3. What are risk factors for this dysrhythmia? Risk factors include: obesity,
hyperlipidemia, alcohol consumption, hypertension
4. What are common symptoms associated with this dysrhythmia? Irregular heartbeat,
fatigue, shortness of breath, chest pain (Centers for Disease Control and Prevention,
2022)
5. What are complications associated with this dysrhythmia? Number 1 complication is a
stroke. This is because in an irregular heartbeat, the blood can sit in the aorta for
awhile and thus, it will become thicker, and can cause a clot to lodge much quicker
(Tachytutorial, 2020).

The CNP will assess the patients stroke risk at this point using the CHA2DS2VASc Score
Below
6. What is Bobs CHADS score? 3 (Hypertension, Vascular Disease, Age 66)

7. What is the Stroke Risk Stratification Recommendation? Oral anticoagulation therapy

8. Which is your treatment of choice?
A. No anticoagulation therapy is needed at this time
B. Start aspirin
C. Start warfarin
D. Start direct-acting oral anticoagulant (DOAC)

9. Be specific about which medication you chose to prescribe for him and WHY? I would
start him on a DOAC because his score is >2. I would prescribe him apixaban or
rivaroxaban because these DOAC medications would to prevent formation of clots
which is the major cause of a stroke related to afib. Medications like warfarin also
cause more accountability for routine blood work, and will increase the Hasbled risk if
his INR does not stay with a solid range.
 10. After the above is decided, would you prescribe any other medication for him prior to
discharge from the office. If so what would you give him? I could also prescribe him a
baby aspirin as well simply do to his heart history including hypertension and
hyperlipidemia. These increase the risk of developing complications from afib.

Centers for disease and prevention. (2022). Atrial Fibrillation.

https://www.cdc.gov/heartdisease/atrial_fibrillation.htm#print

TachyTutorials. (2020). The CHADS-VASC Score (Atrial Fibrillation). [Video]. Youtube.

https://www.youtube.com/watch?v=s_Lp4oOKgnI