NKDA
NSND
previously a cleaner
no family history of myasthenic syndrome
PMH:
– HT / HL
history clarified:
– initially presented in 6/2025 with gradual onset variable left eye ptosis and binocular diplopia 6/2025, diurnal variation present, exacerbated by prolonged reading on his phone or the newspaper, relieved by closing his eyes to rest; PE: non-fatigable LE ptosis, impaired LE abduction; ENT: no NPC
– readmitted 7/2025 for right eye variable ptosis, with interval improvement in left eye ptosis; PE: fatigable right ptosis
– partial clinical response to mestinon, LE ptosis better then RE
no red eye / eye pain
no sensory / bulbar / neck or limb symptoms
no fever / headache / neck pain / OTC meds / constitutional sx
anti-AChR 7.71
RNS 04-Sep-2026
contrast CT thorax performed in china, report TF
contrast MRI brain: no brainstem lesion / extra-ocular muscle enlargement
LP was not suggestive of CNS inflammation
baseline bloods unremarkable
ESR CRP N
antiganglioside ab -ve
A1c 5.7, TFT N
HBsAg 2008 -ve
TPMT NUDT -ve
==================================
– alone, unaided
– BP:125/62mmHg P:69/min BW:81kg
bilateral fatigable ptosis (RE almost complete ptosis, LE partial ptosis), curtain sign / cogan lid twitch +ve, rest test / LE ice pack test +ve
no proptosis / chemosis
PEARL, RE impaired elevation / adduction, LE impaired adduction / abduction, right LMN facial weakness
neck power full
limbs power full
tone / reflex / sensation / coordination / gait normal
imp:
fatigable bilateral ptosis with ophthalmoplegia not confined to the innervation of a single cranial nerve
clinical presentation was compatible with seropositive ocular onset myasthenia gravis
discussed the indications, risks, benefits of mestinon and immunotherapy
patient opted for both mestinon and low dose steroids as he wished for better disease control (laid off from his work as a cleaner due to the visual symptoms caused by the ptosis)
understood the benefits and risks of steroids
FU MNEU 4/52 with bloods, CXR
trace SFI contrast CT thorax report, plan to cancel HA CT appt after report seen
RNS 04-Sep-2026
P10 alternate day with pepcidine, calcichew
continue mestinon with holopon prn
off betaloc (may exacerbate MG), add prazocin for BP control; continue low dose zocor for now