Symptom: Irritability

Initial Grading Reminder

Grade 1: Mild; easily consolable
Grade 2: Moderate; limiting instrumental ADLs; increased attention indicated
Grade 3: Severe abnormal or excessive response; limiting self-care ADLs; inconsolable

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you (or he/she) ever been overly irritable 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?

Grade the symptom

Ask the patient:

How irritable are you (or he/she)? Can you be consoled? Are you able to function?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Have/has you (or he/she) fainted? Are you short of breath? Does your heart seem to be racing? Do you have chest pain? A headache or a stiff neck? Are there other personality changes? Any inappropriate language?

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?

  • Click Here for Telephone Triage

    Suggested Intervention

    Patients with new-onset moderate or worse (or worsening) irritability should be seen. Patients with any of the red-flag symptoms should be seen immediately.

  • Click Here for In-Office Triage

    Nursing Assessment of Potential Causes

    Thyroiditis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • 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?

    Pneumonitis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Did the patient have difficulty walking to the exam room? Or going up stairs?
    • Does the patient appear short of breath?
    • Is the patient tachypneic?
    • Does the patient appear to be in respiratory distress?
    • Has the patient noted any change in breathing?
    • Does the patient feel short of breath?
    • Does the patient note new dyspnea on exertion?
    • Does the patient notice a new cough? Or a change in an existing cough?
    • Have symptoms worsened?
    • Are symptoms limiting ADLs?
    • Associated symptoms?
      • Fatigue
      • Wheezing
    • Is the pulse oximetry low? Is it lower than baseline or compared with last visit? Is it low on exertion?
    • Is there a pre-existing pulmonary autoimmune condition (i.e., sarcoidosis)?
    • Is there a history of prior respiratory compromise (e.g., asthma, COPD, congestive heart failure)?
    • Has the patient experienced other immune-related adverse effects?

    Cardiotoxicity - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient look unwell?
    • Fatigued?
    • Diaphoretic?
    • SOB or in respiratory distress?
    • Is there leg edema?
    • Change in energy level?
    • SOB or DOE?
    • Leg edema?
    • Palpitations?
    • Changes in BP?
    • Dizziness or syncope?
    • What exacerbates or improves symptoms?
    • Any new prescribed or OTC meds? Illicit substances?
    • Any underlying cardiac disease (CAD, MI, or other)?
    • What exacerbates or improves symptoms?
    • Prior radiation therapy?
    • Determine specific toxicity and related grade (if applicable)
    • Other related symptoms: hypotension, syncope, chest pain, DOE, SOB, palpitations, edema, etc.
    • Impact of symptoms on QOL/performance status
    • Changes in cardiac function: ECG changes, decreased EF, elevated cardiac enzymes (troponin, CK)
    • Assess other changes in oxygen saturation, BP, lung function

    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 irritability?