Oncology Follow up - SOAP note

Oncologic History:
1. Completed chemotherapy for malignancy (specific cancer type and dates not provided).
2. Underwent magnetic resonance imaging and nerve conduction studies as part of post-treatment surveillance.
3. No additional chemotherapy or radiation therapy administered since last visit.

Subjective:
The patient presents for follow-up of neurological symptoms following completion of oncologic treatment. The patient reports recurrence of prior symptoms, including fatigue, numbness in the fingers, and unsteadiness during ambulation. The patient was evaluated by a neurologist last week, who performed a comprehensive neurological examination and ordered magnetic resonance imaging and nerve conduction studies to further assess the etiology of these symptoms. The neurologist indicated that the current symptoms may represent residual effects of prior treatment but sought to exclude new pathology. The patient denies any new neurological deficits beyond those described. There is no report of new pain, seizures, or visual disturbances. The patient expresses concern regarding possible disease progression but is reassured by the absence of new lesions or tumor recurrence on recent imaging. The patient’s blood counts are recovering following chemotherapy, though there is a mild elevation in inflammatory markers, which may correlate with the recent symptom flare. No new medications have been initiated, and the patient has not restarted corticosteroids or neuropathic pain agents since the last visit. The patient is not currently undergoing additional chemotherapy or radiation therapy and is under surveillance for symptom management and recovery.

Objective:
Recent magnetic resonance imaging demonstrates no new lesions or tumor recurrence. There is evidence of post-treatment inflammation near the spinal cord. Laboratory studies reveal recovering blood counts following chemotherapy and mildly elevated inflammatory markers. No other abnormal findings reported.

Diagnosis:
The patient is being followed for neurological symptoms following completion of oncologic treatment. There is no evidence of new lesions or tumor recurrence on recent magnetic resonance imaging. The current neurological symptoms are attributed to post-treatment inflammation near the spinal cord.

Assessment & Plan:
The patient exhibits neurological symptoms, including fatigue, digital numbness, and gait unsteadiness, which are likely sequelae of prior oncologic therapy and associated post-treatment inflammation. There are no signs of disease progression. No additional chemotherapy or radiation therapy is indicated at this time. No restart of medication is planned unless symptoms escalate. The patient will be referred to a physiotherapist with oncology experience for assistance with balance and mobility. Neurological symptoms will be monitored closely, with consideration for repeat imaging in six weeks if symptoms worsen. The neurologist may recommend neuropathic pain medications if clinically indicated.

Follow-up:
A follow-up appointment is scheduled in four weeks. The patient is instructed to maintain a symptom journal to track neurological changes. Referral to physiotherapy is planned. Repeat imaging will be considered if neurological symptoms worsen.