| Course | NR 511 Differential Diagnosis and Primary Care Practicum |
|---|---|
| Week | 2 |
| Paper type | Focused SOAP note |
| Length | About 1,180 words, 6 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Family Nurse Practitioner (FNP) |
| Updated | September 2026 |
Free sample paper for NR 511 Week 2
Focused SOAP Note: New Flashes and a Cobweb Floater in the Left Eye of a Nearsighted 58-Year-Old, With a Differential That Keeps a Retinal Tear Open Until an Eye Specialist Rules It Out
Student Name
College of Nursing, Chamberlain University
NR 511: Differential Diagnosis and Primary Care Practicum
Instructor Name
Month Day, Year
Focused SOAP Note: New Flashes and a Cobweb Floater in the Left Eye of a Nearsighted 58-Year-Old, With a Differential That Keeps a Retinal Tear Open Until an Eye Specialist Rules It Out
Subjective
CC: "Since Sunday I keep seeing little lightning flashes on the left side, and now there's a cobweb that follows my eye around."
HPI: Mr. K. O., a 58-year-old tax accountant, reports two days of brief flashes of light in the outer, temporal field of his left eye, most noticeable when he moves his eyes in a dim room. Yesterday morning he noticed a single large floater shaped like a cobweb that drifts when he looks around. He has not counted any new small dots or a sudden shower of specks. He denies a dark curtain or shadow coming in from any side, loss of any part of the visual field, and blurred vision; he read spreadsheets at work yesterday without trouble. There was no trauma, and he has had no eye pain, redness or headache. The right eye has no symptoms.
Pertinent history: High myopia since childhood; he wears glasses of about minus five diopters in both eyes. No cataract surgery or other eye surgery. No diabetes. Hypertension treated with amlodipine 5 mg daily. No anticoagulants. Allergies: No known drug allergies. Family history: A brother had a retinal detachment repaired in his fifties.
Pertinent negatives: No eye pain, halos or redness, which would point toward an anterior segment problem. No jagged zigzag lines that spread and fade over 20 to 30 minutes, and no headache following the flashes, which would favor a migraine aura. No weakness, numbness or speech change.
Objective
Vitals: Blood pressure 134/82 mm Hg, heart rate 72, afebrile.
Visual acuity with his glasses at 20 feet: right eye 20/20, left eye 20/20. No change with pinhole.
Confrontation visual fields: Full in all four quadrants in both eyes.
External eye and anterior segment on penlight: Lids and conjunctivae normal; corneas clear; no redness. Pupils: Equal, round, reactive; no relative afferent pupillary defect on swinging-flashlight testing.
Undilated direct ophthalmoscopy: Red reflex present and symmetric. The left optic disc is sharp with a normal cup; a small portion of the posterior pole seen is normal. A mobile shadow is visible in the vitreous of the left eye. The peripheral retina cannot be seen with this instrument through an undilated pupil, so no statement about a tear can be made from this examination.
Neurologic screen: Cranial nerves II through XII intact; no drift; speech normal.
Assessment
Working diagnosis: acute posterior vitreous detachment (PVD), left eye. Supporting findings: new flashes that are brief and positional, a single large floater that moves with eye movement, age 58, high myopia, normal acuity and full fields. Against it: nothing in this visit, though the diagnosis cannot be confirmed without a dilated examination of the periphery.
Alternative kept alive and ranked first by danger: retinal tear, with or without early detachment. In a pooled analysis of patients seen for acute floaters or flashes, about 14% had a retinal tear (Hollands et al., 2009). Supporting findings here are high myopia and a brother with a detachment. Weakening findings are the absence of subjective loss of vision, which Hollands et al. (2009) found to be the symptom most strongly linked to a tear, and the absence of a shower of new floaters. Neither weakens it enough to close it. This is the candidate that sets the plan, because a tear found early can be treated in the office and a detachment found late can cost central vision.
Alternative: vitreous hemorrhage. A hemorrhage would usually produce many small dark floaters or a haze and some fall in acuity. Weakened by 20/20 vision and a single well-defined floater. It is also, when present, one of the findings most strongly associated with a tear, so a specialist's slit-lamp view of the vitreous answers both questions at once.
Alternative: migraine aura without headache. Can cause visual phenomena in a man of this age. Weakened because his flashes are momentary and positional, not a spreading zigzag pattern lasting many minutes, and because aura does not produce a floater.
Alternative considered and set aside: transient ischemic event affecting vision. He has hypertension, but a vascular event causes loss of vision, not flashes and a floater, and his neurologic screen is normal. Set aside for this visit and reconsidered only if the picture changes.
Ranking. By likelihood: PVD, then retinal tear, then vitreous hemorrhage, then migraine aura. By danger: retinal tear first, then vitreous hemorrhage, then PVD. The plan follows the danger ranking.
Plan
Diagnostics. Same-day referral to ophthalmology for a dilated examination of the peripheral retina, with scleral depression, which is the examination the American Academy of Ophthalmology recommends for patients with symptoms of an acute PVD (Flaxel et al., 2020). The result settles the list: a normal periphery confirms uncomplicated PVD; a horseshoe tear or pigment in the anterior vitreous moves a tear to the working diagnosis; blood in the vitreous raises the chance of a tear and shapes follow-up. I called the on-call ophthalmology office and he has an appointment at 3:30 p.m. today. His wife will drive him, since dilation will blur his vision.
Therapeutics. None from this office. There is no medication for PVD, and any treatment of a tear, such as laser or freezing therapy, is the specialist's decision.
Education. Explained that a PVD is a common change as the gel inside the eye separates from the retina with age and that it usually settles on its own over weeks. Explained why he still needs to be seen today: in a minority of people, the gel pulls a small tear in the retina as it separates, and he has two reasons to be more careful than most. Gave him written return precautions.
Return precautions with triggers. Go to the eye emergency service immediately, even after today's examination, if he notices a dark curtain or shadow in any part of the vision of either eye, a sudden shower of many new floaters, or any drop in how clearly he can see. Hollands et al. (2009) found that people first diagnosed with uncomplicated PVD still had a small chance, about 3.4%, of a tear in the following six weeks, and new floaters or reduced vision raised that risk.
Follow-up. Ask ophthalmology to send the examination report; review it by phone tomorrow. If PVD is confirmed without a tear, follow the specialist's recheck interval. Recheck blood pressure at the next routine visit; no change today.
Case Note
The patient described here is an illustrative composite built for teaching, and no part of this note is drawn from a real encounter or a real record.
References
Flaxel, C. J., Adelman, R. A., Bailey, S. T., Fawzi, A., Lim, J. I., Vemulakonda, G. A., & Ying, G.-S. (2020). Posterior vitreous detachment, retinal breaks, and lattice degeneration Preferred Practice Pattern. Ophthalmology, 127(1), P146-P181. https://doi.org/10.1016/j.ophtha.2019.09.027
Hollands, H., Johnson, D., Brox, A. C., Almeida, D., Simel, D. L., & Sharma, S. (2009). Acute-onset floaters and flashes: Is this patient at risk for retinal detachment? JAMA, 302(20), 2243-2249. https://doi.org/10.1001/jama.2009.1714
NR 511 Week 2 instructions, in plain terms
In Week 2 you document a focused encounter, often from an i-Human or similar simulated case, as a SOAP note. The prompt asks for the subjective and objective data that matter for the chief complaint, an assessment with a primary diagnosis and differentials, and a plan that covers diagnostics, treatment, education and follow-up. Focused means limited to the problem at hand, not short on reasoning. Most rubrics expect at least three differential diagnoses with supporting and opposing findings, and a plan backed by current guidelines. Check whether your section wants the note in a template or as an APA paper with a title page, and whether pertinent negatives must be listed separately.
How the NR 511 Week 2 example is put together
The note begins with the patient's own words and a history that already reads like a differential: questions about a shadow or curtain, a shower of floaters, zigzag lines and headache are asked because each one separates candidates. Pertinent history includes high myopia and a brother with a detachment, both risk factors. The objective section records acuity, fields, pupils and what direct ophthalmoscopy could and could not see. The assessment names posterior vitreous detachment as the working diagnosis, keeps a retinal tear first by danger using figures from a JAMA review, and weighs vitreous hemorrhage, migraine aura and a vascular event. The plan answers the danger ranking with a same-day dilated examination.
NR 511 Week 2 rubric: what full points look like
The rubric for a focused SOAP note usually gives the most points to the assessment: a primary diagnosis that fits the data, differentials with reasons, and a clear link between findings and conclusions. Subjective and objective sections are graded for relevance and completeness, including pertinent negatives. The plan criterion rewards orders that follow from the differential, patient education, and follow-up with specific triggers. Many versions also grade evidence, so a guideline or a systematic review should support at least one decision. The final points go to format, organization and APA 7 citations. A note with a single diagnosis and a routine plan loses most of the assessment points even if the history is thorough.
Common NR 511 Week 2 mistakes, and how to avoid them
Students lose the most points with an assessment that lists one diagnosis and no alternatives. A close second is a plan that ignores the differential, ordering the usual tests for the complaint without saying what each result would change. Another common mistake is a history padded with a full review of systems that the problem did not need, which hides the negatives that matter. Keep interpretation out of the objective section; record what you saw and measured. Return precautions are often too vague, such as return if worse. Name the change that would signal the dangerous diagnosis. Finally, make sure every source in the text appears in the reference list.
Get a NR 511 Week 2 example written to your instructions
Send the note template your section uses, the rubric, and the complaint or vignette you have been given. A custom NR 511 Week 2 example is written against those requirements and sent back inside 24-48h, free the first time, formatted the way your classroom expects so the two versions sit side by side.
More NR 511 papers and FNP samples
- NR 511 Week 1: Discussion Post on Facial Pain
- NR 511 Week 3: Differential Write-up
- NR 511 Week 4: Case Analysis
- NR 511 Week 5: SOAP Note
- NR 511 Week 6: Chronic Care Note
- NR 511 Week 7: Case Study Analysis
- NR 511 Week 8: Practice Reflection
NR 511 Week 2 questions, answered
What makes a SOAP note focused rather than complete?
Scope. A focused note stays with the presenting problem and documents only the history and examination that problem reaches. In many sections the difference shows up in the rubric as a limit on the review of systems. The example keeps that discipline, which also makes the assessment easier to defend.
Should alternatives appear in the assessment or the plan?
In the assessment, where they can be weighed. The plan then refers back to them. Splitting the reasoning across both sections is a common way to lose points, because the grader reads the assessment expecting the comparison and finds only a label with tests attached underneath it.
How much detail belongs in the subjective section?
Enough to support the candidates and no more. Every line in the example is there because it raises a possibility, lowers one, or documents something the plan will act on. Length is not rewarded on its own, and a long history often hides the two or three details the assessment actually relies on.
Where can I find a free NR 511 Week 2 sample paper?
A complete NR 511 Week 2 focused SOAP note is on this page, from chief complaint to return precautions, and it is free to read. For a note matched to your own simulated patient, send the case through the request form.
Does the NR 511 Week 2 SOAP note need references?
Most sections expect at least one or two current sources supporting the assessment or plan. The sample cites a JAMA systematic review and an ophthalmology practice pattern, which is enough for a focused note.