Oncology New Consultation

History and Physical  
Oncology #  
Date of Consultation: 01/19/2026  
Date of Birth:  
Referring Physician:  

DIAGNOSIS:  
Post-treatment neurological symptoms likely related to residual effects of prior oncologic treatment. No evidence of tumor progression or recurrence.

NARRATIVE:  
The patient presents for follow-up of neurological symptoms following completion of chemotherapy. 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 recommended further diagnostic evaluation with magnetic resonance imaging and nerve conduction studies to assess for potential new pathology. The neurologist indicated that the current symptoms may represent residual effects of prior oncologic treatment but sought to exclude new etiologies. The patient denies any new or worsening neurological deficits beyond the described symptoms. There is no report of new lesions or tumor recurrence on recent magnetic resonance imaging. The patient’s daily activities are affected by fatigue and gait instability. No adverse effects from current medications are reported. The MRI does not show any new lesions or tumor recurrence. However, there is post-treatment inflammation near the spinal cord, which may explain the nerve-related symptoms. Laboratory studies reveal mildly elevated inflammatory markers, and the patient’s blood counts are recovering following chemotherapy.

PAST MEDICAL History:  
- History of chemotherapy for an oncologic condition  
- No history of excessive bleeding, bruising, or thromboembolic events  
- No recent hospitalizations  
- No mention of weight loss, family history of cancer or anemia, or prior transfusions

PAST SURGICAL History:  

PREVIOUS DIAGNOSIS OF CANCER:  
History of chemotherapy for an oncologic condition.

PREVIOUS RADIATION THERAPY:  

PREVIOUS CHEMOTHERAPY:  
History of chemotherapy for an oncologic condition.

PREVIOUS HORMONAL THERAPY:  

FAMILY CANCER History:  

CURRENT MEDICATIONS:  

ALLERGIES TO DRUGS:  

PHARMACY:  

FAMILY History:  

SOCIAL History:  

PHYSICIANS:  

REVIEW OF SYSTEMS:  
Neurological: The patient reports fatigue, numbness in the fingers, and unsteadiness during ambulation. The patient denies any new or worsening neurological deficits beyond the described symptoms.

PAIN LEVEL:  

PERFORMANCE STATUS:  

QUALITY OF LIFE:  

PHYSICAL EXAM:  

LABORATORY STUDIES:  
Laboratory studies reveal mildly elevated inflammatory markers, and the patient’s blood counts are recovering following chemotherapy.

RADIOGRAPHIC STUDIES:  
MRI: No new lesions or tumor recurrence. Post-treatment inflammation near the spinal cord, which may explain the nerve-related symptoms.

PATHOLOGIC STUDIES:

ICD-10:  
R29.818 (Other symptoms and signs involving the nervous system)  
S34.21XS (Injury of nerve root of lumbar spine, sequela)  
R79.82 (Elevated C-reactive protein (CRP))

TUMOR STAGE:  

ASSESSMENT/PLAN:  
The patient will be referred to a physiotherapist with expertise in oncology to support balance and mobility improvement. Neurological symptoms will be closely monitored, and if there is any worsening, repeat imaging will be scheduled in six weeks. The patient is encouraged to maintain a symptom journal to help identify any patterns or changes over time. At this stage, no further chemotherapy or radiation therapy is required.

Thank you for the referral of this pleasant and the opportunity to participate in your patient's care.

Time spent with patient:  

Electronically signed by Alex Chen

Alex Chen, M.D.