Symptom: Clumsiness

Initial Grading Reminder

CTCAE grading of Clumsiness:

Grade 1: Mild, Asymptomatic; clinical or diagnostic observations only; intervention not indicated
Grade 2: Moderate symptoms; limiting instrumental ADLs
Grade 3: Severe symptoms; limiting self-care ADLs; mechanical assistance indicated

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you had any issues with clumsiness 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 bad is your clumsiness? Do you feel disoriented? Please give examples of things you can’t do now that you could before.

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Are you afraid you are going to fall? Are you also having any difficulty breathing?

Is your speech slurred? Do you have any new or increased fatigue? Is the clumsiness associated with any numbness, and is it more predominant on one side of the body or the other?

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 new onset moderate or worse (or worsening) clumsiness should be seen.

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

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    Nursing Assessment of Potential Causes

    Neuropathy - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear weak?
    • Does the patient appear uncomfortable?
    • Altered ambulation or general movement?
    • If muscular weakness is present, any respiratory difficulties apparent?
    • Does the patient report weakness (unilateral or bilateral)?
    • Does the patient report new or worsened pain, numbness, or tingling?
    • Does the patient report difficulty walking or holding items?
    • Motor deficits
    • Sensory deficits
    • Mental status changes
    • Paresthesias
    • Laboratory values
    • Does the patient have diabetes mellitus?
    • Are there neurologic signs and symptoms?
    • Results of prior imaging
      • Metastases to spinal cord
      • Other metastases that may cause symptoms

    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

    Differential Diagnosis

    What do you suspect is the cause of the clumsiness?