| Course | NR 511 Differential Diagnosis and Primary Care Practicum |
|---|---|
| Week | 5 |
| Paper type | Comprehensive SOAP note |
| Length | About 1,380 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 5
SOAP Note: Six Weeks of Aching Shoulders and Hips and Two Hours of Morning Stiffness in a 69-Year-Old Retired Librarian, Polymyalgia Rheumatica Ranked First, and a Plan That Checks for Arteritis Before the First Dose
Student Name
College of Nursing, Chamberlain University
NR 511: Differential Diagnosis and Primary Care Practicum
Instructor Name
Month Day, Year
SOAP Note: Six Weeks of Aching Shoulders and Hips and Two Hours of Morning Stiffness in a 69-Year-Old Retired Librarian, Polymyalgia Rheumatica Ranked First, and a Plan That Checks for Arteritis Before the First Dose
Subjective
CC: "I feel like I've aged twenty years since August. I have to roll out of bed in the morning."
HPI: Mrs. E. V., a 69-year-old retired librarian, describes about six weeks of aching across both shoulders and upper arms and, for the last four weeks, both hips and thighs. The pain is worst on waking, when she is stiff for about two hours; she cannot lift her arms to brush her hair until mid-morning. It eases through the day and returns if she sits for a long time. She has lost about 4 pounds and feels tired. She denies any injury. She specifically denies new headache, pain in the scalp when brushing her hair, jaw pain on chewing, double vision, blurred or lost vision, fever, night sweats, swollen finger joints and rash. She has not started any new medication.
PMH: Hyperlipidemia; osteopenia on a bone density scan two years ago (lowest T-score of minus 1.8 at the femoral neck); no thyroid disease. Screening colonoscopy and mammogram up to date, both normal this year. Medications: Atorvastatin 40 mg daily for three years, with no dose change; calcium and vitamin D supplement. Allergies: Penicillin (hives). Social: Never smoker; no alcohol. Lives alone; her daughter lives nearby.
ROS: General: fatigue, weight loss as above, no fever. Eyes and head: no visual symptoms, headache or scalp tenderness. Musculoskeletal: as in HPI; no joint swelling in hands or feet. Neurologic: no numbness or true weakness, though she says her arms feel weak because they hurt. Skin: no rash. Endocrine: no cold intolerance, constipation or dry skin. Gastrointestinal and genitourinary: normal.
Objective
Vitals: Temperature 37.1 C, blood pressure 132/78 mm Hg, heart rate 80, respiratory rate 14. Weight 139 lb (143 lb in June).
General: Moves slowly and stiffly getting onto the examination table; otherwise well appearing.
Head and eyes: Temporal arteries soft, nontender, with normal pulses on both sides; no scalp tenderness. Reading glasses on, she reads the 20/25 line with either eye. Fundi: discs sharp on direct ophthalmoscopy.
Musculoskeletal: Active shoulder abduction limited to about 90 degrees on both sides by pain; passive range is fuller once she relaxes. Pain on moving both hips through internal rotation. Tenderness over the upper arms and outer thighs. No swelling, warmth or tenderness of the wrists, knuckles, finger joints, knees or ankles.
Neurologic: Strength 5/5 in all muscle groups tested once she is given time and pain is allowed for; no wasting; reflexes 2+ and symmetric; sensation intact.
Thyroid: Normal size, no nodules.
Laboratory results from two days ago: Erythrocyte sedimentation rate 58 mm/h; C-reactive protein 3.1 mg/dL (reference below 0.5). Hemoglobin 11.6 g/dL, normocytic; white cell and platelet counts normal. Creatine kinase not yet measured.
Assessment
Problem 1: Bilateral shoulder and hip girdle pain with prolonged morning stiffness and raised inflammatory markers. Working diagnosis: polymyalgia rheumatica (PMR).
Supporting findings: age over 50, symmetric aching of both shoulder and hip girdles, morning stiffness lasting well over 45 minutes, painful restriction of active shoulder movement with preserved strength, raised ESR and CRP, and mild anemia of inflammation. These are the core features in the provisional European and American classification criteria (Dasgupta et al., 2012), which also give weight to the absence of rheumatoid factor and anti-citrullinated peptide antibodies, tests not yet done. Buttgereit et al. (2016) note that diagnosis rests on the clinical picture with raised markers and that ultrasound, where available, often shows bursitis beneath the deltoid on both sides. Against it: nothing so far, but PMR is a diagnosis made after the mimics have been considered.
Alternatives, by likelihood:
a. Late-onset rheumatoid arthritis with a polymyalgic start. Raised by age and raised markers. Weakened by no swelling in the hands, wrists or feet. Rheumatoid factor and anti-CCP antibodies will help, and a later appearance of hand synovitis would move it up.
b. Statin-associated muscle symptoms or myopathy. Raised because she takes atorvastatin and describes aching and difficulty lifting. Weakened by three years on a stable dose, stiffness that is worst in the morning, no true weakness and raised inflammatory markers, which a statin does not cause. A creatine kinase will answer this.
c. Hypothyroidism. Can cause aching, stiffness and fatigue. Weakened by no cold intolerance, constipation or dry skin and a normal thyroid examination. Thyroid-stimulating hormone will settle it.
d. Malignancy or infection presenting as polymyalgia. Raised by weight loss and anemia. Weakened by recent normal cancer screening and no fever. Kept on the list and reviewed if she does not respond quickly to treatment, since a poor response is itself a warning sign.
Ranked separately by danger: giant cell arteritis. PMR and giant cell arteritis often occur together. The danger is vision loss, and the treatment dose is very different: Buttgereit et al. (2016) report consensus starting doses of prednisone 12.5 to 25 mg daily for PMR but 40 to 60 mg daily for arteritis. Weakened by no headache, scalp tenderness, jaw pain or visual symptoms and normal temporal arteries. Not excluded, so the plan names the symptoms that would bring it forward.
Problem 2: Osteopenia, now facing months of glucocorticoid treatment.
Problem 3: Hyperlipidemia on atorvastatin, with a statin as one candidate for Problem 1.
Plan
Problem 1: Suspected PMR.
Diagnostics, drawn today before treatment. Rheumatoid factor and anti-CCP antibodies; thyroid-stimulating hormone; creatine kinase; comprehensive metabolic panel with calcium and alkaline phosphatase; serum protein electrophoresis; urinalysis; glucose. These follow the basic workup in the 2015 recommendations, which aim to exclude mimics before steroids change the picture (Dejaco et al., 2015). Each result answers a named alternative: antibodies for rheumatoid arthritis, creatine kinase for statin myopathy, thyroid-stimulating hormone for hypothyroidism, and protein electrophoresis and calcium for myeloma and other malignancy.
Therapeutics. Prednisone 15 mg once each morning, within the 12.5 to 25 mg range recommended for starting PMR treatment (Dejaco et al., 2015). The dose is planned to be held for about four weeks and then tapered slowly under review, since relapse is common with fast tapers.
Response as a test. A dramatic improvement in stiffness within a week or two supports the diagnosis. A partial or slow response is a reason to revisit the alternatives, especially rheumatoid arthritis and malignancy, before simply increasing the dose.
Education and arteritis warning. Explained PMR and its link to giant cell arteritis. Gave her in writing the symptoms that need a same-day call or an emergency visit: a new headache, tenderness of the scalp, pain in the jaw when chewing, and any blurring, double vision or loss of vision, even briefly. These would move arteritis to first place and change the dose to protect her sight.
Follow-up. Phone call in five days for results and response. Office visit at four weeks with ESR and CRP repeated. Rheumatology referral if the response is atypical, if she is younger-appearing on testing than expected, or if she cannot taper below a moderate dose.
Problem 2: Bone protection during steroid treatment.
Diagnostics. Check 25-hydroxyvitamin D with today's labs. Therapeutics. Continue calcium and vitamin D; discuss starting a bisphosphonate at the results call, since she has osteopenia and is likely to need steroids for many months. Education. Weight-bearing walking as the stiffness improves; home fall hazards reviewed.
Problem 3: Hyperlipidemia.
Plan. Continue atorvastatin for now. If creatine kinase is raised or her aching does not improve on prednisone while the inflammatory markers fall, the statin will be held for a trial period and the question reopened. Changing both at once would make the response impossible to interpret, so the statin stays unchanged this week.
About This Case
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
Buttgereit, F., Dejaco, C., Matteson, E. L., & Dasgupta, B. (2016). Polymyalgia rheumatica and giant cell arteritis: A systematic review. JAMA, 315(22), 2442-2458. https://doi.org/10.1001/jama.2016.5444
Dasgupta, B., Cimmino, M. A., Maradit-Kremers, H., Schmidt, W. A., Schirmer, M., Salvarani, C., Bachta, A., Dejaco, C., Duftner, C., Jensen, H. S., Duhaut, P., Poór, G., Kaposi, N. P., Mandl, P., Balint, P. V., Schmidt, Z., Iagnocco, A., Nannini, C., Cantini, F., . . . Matteson, E. L. (2012). 2012 provisional classification criteria for polymyalgia rheumatica: A European League Against Rheumatism/American College of Rheumatology collaborative initiative. Annals of the Rheumatic Diseases, 71(4), 484-492. https://doi.org/10.1136/annrheumdis-2011-200329
Dejaco, C., Singh, Y. P., Perel, P., Hutchings, A., Camellino, D., Mackie, S., Abril, A., Bachta, A., Balint, P., Barraclough, K., Bianconi, L., Buttgereit, F., Carsons, S., Ching, D., Cid, M., Cimmino, M., Diamantopoulos, A., Docken, W., Duftner, C., . . . Dasgupta, B. (2015). 2015 recommendations for the management of polymyalgia rheumatica: A European League Against Rheumatism/American College of Rheumatology collaborative initiative. Annals of the Rheumatic Diseases, 74(10), 1799-1807. https://doi.org/10.1136/annrheumdis-2015-207492
Reading the NR 511 Week 5 instructions
Week 5 asks for a complete SOAP note on a patient case, often from a simulation, covering the full history, a review of systems, a physical examination of the relevant systems, an assessment with a primary diagnosis and at least three differentials, and a plan. The plan usually needs diagnostics, pharmacologic and nonpharmacologic treatment, patient education, referrals and follow-up, each supported by current evidence. Some sections also want health promotion items appropriate to the patient's age. Read the rubric for how many differentials are required and whether each needs a citation. Your section may supply a template; follow it, but keep the reasoning visible inside it.
How the NR 511 Week 5 example is put together
The note is complete but not exhaustive. The history covers the pattern of pain and stiffness, weight loss and a careful check for arteritis symptoms, and the review of systems follows the candidates. The examination separates pain-limited movement from true weakness, which matters for the statin question. The assessment uses the classification criteria and a JAMA systematic review to support the working diagnosis, weighs four alternatives, and explains why arteritis is ranked by danger. The plan is organized by problem: labs drawn before steroids to exclude mimics, prednisone within the recommended range, bone protection for osteopenia, and the statin left unchanged so the response stays readable.
Where the points sit in the NR 511 Week 5 rubric
In the NR 511 SOAP note rubric, the assessment and plan usually carry the most points. Graders check that the primary diagnosis is supported by the subjective and objective data, that differentials are relevant and explained, and that each part of the plan follows from them. Medication orders are expected to be complete and appropriate, and safety issues such as bone health or glucose on steroids earn credit when addressed. Education and follow-up need specifics. Evidence is graded on currency and relevance. Documentation points cover organization, pertinent negatives, and a clear separation of findings from interpretation. APA 7 citations and references make up the rest.
NR 511 Week 5 help from the desk
The most common loss in a complete note is a plan that would be the same whatever the assessment said, which shows the differential did no work. Another is a mismatch between problems and plan, where a listed problem gets no plan or a treatment appears for a problem never listed. Students often copy a full review of systems that the case did not need and skip the questions that matter, such as arteritis symptoms here. Incomplete medication orders, with no dose or duration, cost easy points. Changing two things at once, for example starting a steroid and stopping a statin, makes follow-up impossible to interpret. Write follow-up with a time and a trigger. Finally, if a drug the patient already takes is one of your candidates, say in the plan when and how you would test it.
Get a NR 511 Week 5 example written to your instructions
Send the note template your classroom uses, the rubric, and the patient scenario you were given. We write a custom NR 511 Week 5 example against it and return the finished note in 24-48h, free on a first order. It arrives complete, from subjective through follow-up, so the link between the assessment and the plan is visible.
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NR 511 Week 5 questions, answered
What separates this from the focused note earlier in the term?
Breadth. The complete note covers history, systems and problems beyond the presenting complaint, and it usually carries a numbered problem list. The reasoning requirement does not change: the assessment still ranks candidates and the plan still answers to that ranking, only across more problems than one.
Should pending results be discussed before they exist?
Yes, and this is where notes gain marks. The example states what a pending result would mean for each live candidate before the result arrives. Writing the interpretation in advance shows the order had a purpose, which is exactly what a plan section is graded on.
How are medications documented in a note like this?
With enough detail to be actioned: agent, dose, route, frequency and duration, plus the reason it was selected for this patient. In many sections the rubric asks for a rationale tied to guidance. The example gives one sentence of justification per therapeutic rather than a citation dropped without comment.
Where can I find a free NR 511 Week 5 sample paper?
The complete NR 511 Week 5 SOAP note on this page is free to read in full, from the chief complaint to the plan for each problem. If your simulated patient has a different complaint, request a matching note through the form.
How many differentials does the NR 511 Week 5 SOAP note need?
Most rubrics ask for at least three, each with supporting and opposing findings. The sample weighs four by likelihood and ranks a fifth, giant cell arteritis, by danger, because it would change the treatment.