Symptom: Forgetfulness

Initial Grading Reminder

Grade 1: Mild memory impairment
Grade 2: Moderate memory impairment; limiting instrumental ADL
Grade 3: Severe memory impairment; limiting self-care ADLs

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you had any problems with forgetfulness in the past? Is the melanoma known to be in your brain? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly? Are you taking any new medications, supplements, or marijuana?

Grade the symptom

Ask the patient:

How forgetful are you? Is it affecting your ability to take care of yourself?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any severe head pain with vision changes, fever, nausea and vomiting while feeling confused or tired? Do you have a headache plus a stiff neck? Have you had any sleepiness, hallucinations, seizures? Do you have any lumps in the front of your throat/difficulty swallowing?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Patients with severe or worse forgetfulness should be seen.

    Patients with any of the red-flag symptoms should be seen immediately.

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    Nursing Assessment of Potential Causes

    Thyroiditis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
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    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear unwell?
    • Changes in weight since last visit
      • Appear heavier? Thinner?
    • Changes in hair texture/thickness?
    • Appearing hot/cold?
    • Does the patient look fatigued?
    • Appetite/weight changes?
    • Hot or cold intolerance?
    • Change in energy, mood, or behavior?
    • Palpitations?
    • Increased fatigue?
    • Bowel-related changes?
      • Constipation/diarrhea
    • Skin-related changes?
      • Dry/oily
    • Ensure that patient undergoes thyroid function tests prior to first dose, every 12 weeks while on PD-1 therapy and q3 weeks with ipilimumab
    • High TSH with low free T4 consistent with primary hypothyroidism
    • DDX: secondary hypothyroidism due to hypophysitis, low TSH and low free T4
    • Occasionally thyroiditis with transient hyperthyroidism (low TSH and high free T4) may be followed by more longstanding hypothyroidism (high TSH and low free T4)
    • Other immune-related toxicity?
    • Prior thyroid dysfunction?

    Hepatotoxicity - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear fatigued or listless?
    • Does the patient appear jaundiced?
    • Does the patient appear diaphoretic?
    • Does the patient have any ascites?
    • Change in energy level?
    • Change in skin color? Yellowing?
    • Change in stool color (paler)?
    • Change in urine color (darker/tea colored)?
    • Abdominal pain: specifically, right upper quadrant pain?
    • Bruising or bleeding more easily?
    • Fevers?
    • Change in mental status?
    • Increased sweating?
    • Elevation in LFTs
      • AST/SGOT
      • ALT/SGPT
      • Bilirubin (total/direct)
    • Alteration in GI function
    • Symptoms such as abdominal pain, ascites, somnolence, and jaundice
    • Other potential causes (viral, drug toxicity, disease progression)

    Hypophysitis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear fatigued?
    • Does the patient look listless?
    • Does the patient look ill?
    • Does the patient look uncomfortable?
    • Does the patient report:
      • Change in energy?
      • Headache?
      • Dizziness?
      • Nausea/vomiting?
      • Altered mental status?
      • Visual disturbances?
      • Fever?
    • Low levels of hormones produced by pituitary gland (ACTH, TSH, FSH, LH, GH, prolactin)
    • Brain MRI with pituitary cuts: enhancement and swelling of the pituitary gland
    • DDX adrenal insufficiency: low cortisol and high ACTH
    • DDX primary hypothyroidism: low free T4 and high TSH

    Encephalopathy - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient look uncomfortable?
    • Does the patient look ill?
    • Does the patient report headache, fever, tiredness, sleepiness, hallucinations, stiff neck?
    • Signs of infectious cause (lumbar puncture); Obtain brain MRI; Consult neurologist

    Differential Diagnosis

    What do you suspect is the cause of the forgetfulness?