| Course | NR 667 FNP Capstone Practicum and Intensive |
|---|---|
| Week | 3 |
| Paper type | Case presentation |
| Length | About 1,140 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Family Nurse Practitioner (FNP) |
| Updated | October 2026 |
Free sample paper for NR 667 Week 3
Case Presentation: A 71-Year-Old Man With Two Weeks of Palpitations, an Irregularly Irregular Rhythm and the Decisions Made Before He Left the Clinic
Student Name
College of Nursing, Chamberlain University
NR 667: FNP Capstone Practicum and Intensive
Instructor Name
Month Day, Year
Case Presentation: A 71-Year-Old Man With Two Weeks of Palpitations, an Irregularly Irregular Rhythm and the Decisions Made Before He Left the Clinic
Why This Patient
Not because atrial fibrillation is unusual in family practice, but because I made three decisions in the encounter that a new nurse practitioner has to make alone: whether the patient was safe to stay in clinic, whether to start anticoagulation that day and what to hand to cardiology rather than keep.
Who This Is and Why He Came
A 71-year-old man, retired, seen at a rural family practice for a scheduled hypertension follow-up. He mentioned two weeks of "fluttering" in his chest, worse climbing stairs, with mild breathlessness on exertion. No chest pain, no fainting, no new leg swelling.
History That Mattered
Hypertension for 12 years on lisinopril. Type 2 diabetes on metformin, last A1C 7.2%. No prior heart disease, stroke or bleeding. No alcohol excess. No new medicines or supplements. No symptoms of thyroid disease, though thyroid function had not been checked in three years. He lives 40 minutes from the regional hospital.
Examination and Results
Pulse irregularly irregular at 112. Blood pressure 138/84. Oxygen saturation 96% on room air. No signs of heart failure: no raised jugular venous pressure, clear lungs, no edema. No murmur.
A 12-lead electrocardiogram in clinic showed an irregularly irregular narrow-complex rhythm with no discernible P waves and a ventricular rate of about 110. No ST changes.
What I Thought It Was, and What Else It Could Be
Atrial fibrillation with rapid ventricular response, of uncertain duration but probably two weeks or more.
Atrial flutter with variable block was considered, since flutter can look irregular. No sawtooth flutter waves were visible in the inferior leads, which moved it down.
Multifocal atrial tachycardia was considered. It needs at least three distinct P wave shapes and usually occurs with lung disease; there were no P waves and no lung disease, which ruled it out.
Frequent premature atrial contractions were considered. A continuous strip without any regular underlying rhythm moved it down.
Causes to look for: thyrotoxicosis, given no recent thyroid test; structural heart disease, given hypertension; and sleep apnea, given his body habitus and snoring his spouse reported.
Was He Safe to Stay in Clinic?
He was hemodynamically stable, with no chest pain, no heart failure signs and no fainting. The preceptor and I agreed that outpatient management was appropriate, and he was told, in writing, that chest pain, fainting or breathlessness getting worse meant an emergency department visit that day, not a call to the clinic.
The Plan, With Reasons
Rate control: metoprolol tartrate 25 mg twice daily, because he was symptomatic with a rate above 110 and a beta blocker is a first-line choice without heart failure with reduced ejection fraction. Recheck heart rate in one week.
Stroke risk: his CHA2DS2-VASc score was 3, one point each for age 65 to 74, hypertension and diabetes. The current guideline recommends anticoagulation for patients at this level of risk and prefers a direct oral anticoagulant over warfarin for most eligible patients (Joglar et al., 2024). We started apixaban 5 mg twice daily; he met none of the dose-reduction criteria.
Bleeding risk: his HAS-BLED score was 1. The score was used to look for modifiable risks, such as uncontrolled blood pressure and alcohol, rather than to withhold anticoagulation (Pisters et al., 2010).
Tests: thyroid function, complete blood count, kidney and liver function, to check for a cause and to confirm the anticoagulant dose.
Referral: cardiology for echocardiography and a discussion of rhythm control, sent the same day.
Education: what atrial fibrillation is, why the anticoagulant matters, signs of bleeding and stroke, and when to go to the emergency department.
What Happened Next
At one week, his heart rate was 84 and he felt better. Thyroid function was normal. Cardiology saw him at three weeks; echocardiography showed a mildly enlarged left atrium and normal ejection fraction. Rhythm control was discussed and deferred. At three months, back in primary care, he remained in rate-controlled atrial fibrillation on the same doses, with no bleeding and good adherence; the clinic added him to its anticoagulation follow-up list, which reviews kidney function and adherence twice a year.
What I Would Change
With hindsight I would have asked about sleep apnea symptoms in a structured way and ordered a sleep study sooner; the cardiologist did so. And I would have checked his kidney function before writing the apixaban prescription rather than the same day, since the dose depends on it in some patients.
What the Preceptor Added
The preceptor asked two questions I had not asked. First, whether he drove, since a symptomatic arrhythmia could affect safe driving until rate control was achieved; he agreed not to drive until the one-week visit. Second, whether he understood that the anticoagulant would be long term, not a short course; he had assumed it would stop once the rhythm settled. Both changed the conversation, and both are now part of how I would present a new diagnosis of atrial fibrillation. I have added them to the short checklist I keep for new chronic diagnoses, alongside the questions about work, driving and who at home can help with medicines.
Why the Decisions Belonged in Primary Care
The safety decision, the rate control and the anticoagulation decision are all ones the guideline expects any clinician who diagnoses atrial fibrillation to address, not only cardiologists (Joglar et al., 2024). Sending him to cardiology without starting anticoagulation would have left him unprotected for three weeks. Sending him to the emergency department would have used a scarce resource for a stable patient. Holding those decisions and referring the rest was the right division.
How This Case Fits the Transition to Practice
Knowing when to act and when to refer is a recurring source of strain for nurses moving into the provider role (Barnes, 2015). This case was chosen partly because it is a decision about that boundary, made with a preceptor present, that I will soon make without one.
What the Case Shows About Practice Readiness
A new diagnosis like this one will arrive in a busy clinic day without warning, often during a visit booked for something else, as this one was. The readiness it tests is less about knowing the guideline than about stopping the planned visit, recognizing that the rhythm changes the agenda and making room for the decisions that cannot wait. That I can recognize the rhythm, judge safety and apply the stroke risk decision. That the rhythm control conversation belongs to cardiology for now.
References
Barnes, H. (2015). Nurse practitioner role transition: A concept analysis. Nursing Forum, 50(3), 137-146. https://doi.org/10.1111/nuf.12078
Joglar, J. A., Chung, M. K., Armbruster, A. L., Benjamin, E. J., Chyou, J. Y., Cronin, E. M., Deswal, A., Eckhardt, L. L., Goldberger, Z. D., Gopinathannair, R., Gorenek, B., Hess, P. L., Hlatky, M., Hogan, G., Ibeh, C., Indik, J. H., Kido, K., Kusumoto, F., Link, M. S., . . . Van Wagoner, D. R. (2024). 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 149(1), e1-e156. https://doi.org/10.1161/CIR.0000000000001193
Pisters, R., Lane, D. A., Nieuwlaat, R., de Vos, C. B., Crijns, H. J. G. M., & Lip, G. Y. H. (2010). A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: The Euro Heart Survey. Chest, 138(5), 1093-1100. https://doi.org/10.1378/chest.10-0134
The Chamberlain NR 667 Week 3 instructions
Choose one de-identified patient because of what you did in the encounter, not because the diagnosis was rare. Tell the story in the order a colleague needs it: who this is, why they came, what mattered in the history, what the examination and results added, what you thought it was and what else it could have been, what was done and what happens next. Keep your reasoning visible throughout. Argue the differential rather than listing it, naming the finding that moved each option up or down. Attach a reason to every part of the plan, citing the guideline where it sets the decision. Report what happened next and close with what you would change, since a presentation that changes nothing has taught nothing.
How this NR 667 Week 3 example is built
The sample presents a retired man with hypertension and diabetes, palpitations and exertional breathlessness, a pulse of 112 and an electrocardiogram without P waves. Flutter is moved down by the absence of flutter waves, multifocal atrial tachycardia ruled out by the lack of P waves and lung disease, and ectopy moved down by the continuous strip. He is judged safe for outpatient care with written emergency instructions. Metoprolol, apixaban by a CHA2DS2-VASc score of 3 and HAS-BLED review, laboratory tests and same-day cardiology referral follow. At one week his rate was 84, and the writer would have screened for sleep apnea and checked kidney function first. The preceptor's questions about driving and the long-term nature of anticoagulation are recorded, along with why each decision belonged in primary care.
Where the points sit in the NR 667 Week 3 rubric
Case presentations lose most when the patient is chosen for an exotic diagnosis rather than for a decision the writer made. Next is a history told in the order it was collected, full of details that never matter, instead of the order a colleague needs. Many presentations list a differential without saying what moved each option. Plans often name drugs without reasons or ignore the guideline that sets the key decision. Follow-up is frequently missing, so the reader never learns whether the plan worked. Presentations that end without saying what the writer would change suggest the case taught nothing, which graders read as a missed chance for reflection. Presentations that skip safety, the decision about where the patient should be managed, also miss the first call a provider must make.
NR 667 Week 3 help from the desk
Presenting a case well means leaving out most of what you know about the patient and keeping only what your reasoning needs. A guided draft can help you choose a patient that shows a decision, order the history for a colleague and argue the differential by the findings that moved it. We can also help you attach reasons and sources to each part of the plan and write a short section on what you would change. Practicing the presentation aloud once usually shows which details can go. The case and your reasoning are yours.
Get a NR 667 Week 3 example written to your instructions
Send the Week 3 instructions with the presentation template or slide limit your section sets, plus a de-identified outline of the encounter you want to use, and a custom example is built to that format and returned inside 24 to 48 hours. The first one is free.
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NR 667 Week 3 questions, answered
How do I de-identify a real patient?
Ages become bands, dates become intervals, the setting is given as a type of practice, and anything striking enough to identify somebody gets altered or dropped. A presentation stays perfectly gradeable that way, since the marks are for reasoning rather than for particulars. Where a detail is doing real clinical work and cannot be blurred, most sections accept a composite as long as you flag it.
Should I present a case where I got it wrong?
Often the strongest choice, provided the account shows the correction. A near miss you caught, explained honestly with what tipped you off, demonstrates more judgment than a straightforward case handled correctly. What does not work is a wrong turn presented without acknowledgment, since a marker who spots it before you do reads the rest of the document differently.
How much detail belongs in the examination section?
Whatever changed a decision, and a line for the rest. Full head to toe documentation is a different exercise and it dilutes the presentation. Positive findings, the negatives that ruled something out, and a brief statement that the remaining systems were unremarkable. If a finding appears in your assessment argument later, it has to appear here first.
Where can I find a free NR 667 Week 3 sample paper?
You can read the whole case presentation on new atrial fibrillation in a primary care visit right here.
Why does the NR 667 Week 3 case start anticoagulation in primary care?
His stroke risk score was 3, the guideline recommends anticoagulation at that level, and waiting three weeks for cardiology would have left him unprotected.