Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Evaluation of suspected or established chemotherapy-induced peripheral neuropathy (CIPN), follow-up for CIPN management.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following:
Onset, duration, and progression of symptoms (numbness, tingling, burning pain)
Location and distribution of symptoms (often affects distal extremities – hands and feet – but can be more widespread)
Severity of symptoms and impact on daily activities (sensory disturbances, weakness, gait difficulties)
Recent chemotherapy regimen and cumulative dose of neurotoxic agents
Exacerbating or relieving factors (e.g., cold exposure worsens symptoms)
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying malignancy and current treatment plan
Pre-existing neurological conditions that might contribute to neuropathy (e.g., diabetes, vitamin deficiencies)
History of CIPN with prior chemotherapy
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Neurological Exam:
Assess for:
Sensory function (light touch, pain, vibration) in the extremities, comparing bilateral sides
Muscle strength and coordination
Presence of reflexes (ankle and knee)
Gait abnormalities (balance, coordination)
Assessment (A):
Diagnosis:
Based on the clinical presentation, history of chemotherapy exposure, and physical exam findings, assess the likelihood of CIPN:
Suspected CIPN
Established CIPN
Severity of CIPN:
Consider using a standardized scale (e.g., National Cancer Institute [NCI] CTCAE scale) to grade the severity of CIPN based on symptoms and functional limitations.
Plan (P):
Management Strategies:
Depending on the severity of CIPN, consider:
Dose modification or discontinuation of the offending chemotherapeutic agent: Discuss with the oncologist if feasible.
Pain management: Medications like gabapentin, pregabalin, or duloxetine can help manage neuropathic pain.
Supportive measures:
Physical therapy to improve strength, coordination, and balance.
Occupational therapy to help with daily activities.
Nutritional counseling to optimize vitamin intake (vitamin B12 deficiency can worsen neuropathy).
Nerve stimulation techniques (e.g., transcutaneous electrical nerve stimulation – TENS) for pain relief (consideration in consultation with a pain specialist).
Monitoring:
Schedule regular follow-up visits to monitor symptom progression, response to treatment, and potential complications (e.g., falls due to gait instability).
Patient Education:
Educate the patient about CIPN, risk factors, and potential long-term effects.
Provide information on managing symptoms at home, including pain management strategies and self-care measures (e.g., foot care, avoiding triggers like cold exposure).
Encourage communication with the healthcare team for any worsening of symptoms or concerns.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., oncologist, neurologist, pain specialist)
Consideration of genetic testing for susceptibility to CIPN (may be helpful in future treatment decisions)
Importance of using appropriate footwear to protect the feet and prevent injuries
Prognosis discussion based on the type and severity of CIPN, potential for improvement after chemotherapy completion.