Myasthenia Gravis – DOCEDUCATES

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MYASTHENIA GRAVIS PERFORMA

Neurology Department Ibn-e-Siena Hospital and Research Institute Multan

Serial Number Of Patient*

Patient Name*

UPIN

Age*

Gender

Male

Female

Other

Patient History

Presenting Complaints

Drooping Of Eyelids

Double Vision

Difficulty in speaking

Difficulty in swallowing

Difficulty in Breathing

Proximal muscle weakness (Upper/Lower Limb)

Proximal Muscle Weakness

Present

Absent

Duration Of Symptoms

Write days/months or years of symptoms

Additional Notes (if any specific)

Write if there is anything specific to mention

Examination

Power Upper Limb Proximal

Power Upper Limb Distal

Power Lower Limb Proximal

Power Lower Limb Distal

Single Breath Count

Chest Expansion

Ocular Fatiguability

Present

Absent

Difficulty in speaking & Swallowing

Present

Absent

Additional Notes (if any specific)

Write if there is anything specific to mention

Associations

Co-morbidities & Disease Association:

Diabetes Mellitus

Thyroid Disorders

Rheumatoid Arthritis

SLE

Autoimmune Liver Disease

Thymoma

Thymic Hyperplasia

None

Aggravating Factors

Pregnancy

Menstruation

Infections

Surgery

Autoimmune Liver Disease

Thymoma

Thymic Hyperplasia

None

Drug History

Any drug intake hx in patient that might have aggravated Myasthenia Gravis

Drug Category	Drugs Aggravating Myasthenia
Steroids	Adrenocorticotropic hormones, methyprednisolone, prednisone
Anticonvulsants	Phenytoin, ethosuximide, MgSO4, baribiturates, lithium
Antimalarial	Chloroquine, Quinine
IV Fluids	Sodium lactate solutions
Antibiotics	Aminoglycosides, fluoroquinolones, sulfonamides, clindamycin, tetracyclines, macrolides, metronidazole
Psychotropics	Chlorpromazine, lithium carbonate, amitriptyline, haloperidol, imipramine
Anti Rheumatics	D-penicillamine, colchicine, chloroquine
Cardiovascular	Quinidine, procainamide, beta blockers, lidocaine, trimethaphan, Mg2+, Ca2+ channel blocker (verapamil)
Local Anesthetics	Lidocaine, procaine
Analgesics	Narcotics (morphine, hydromorphone, codeine, pantopon, meperidine)
Endocrine	Thyroid replacement
Eye drops	Timolol, echothiophate
Neuromuscular blocking agents	Tubocurarine, pancurarine, rocuronium, gallamine, dimethyltubocurarinium, succinylcholine, decamethonium
Others	Amantadine, diphenhydramine, emetine, diuretics, muscle relaxants, CNS and respiratory depressants, sedatives, phenothiazines

Drug Category	Safe Drugs
Steroids	Hydrocortisone, dexamethasone
Anticonvulsants	Carbamazepine, valproic acid, gabapentin, pregabalin
Antimalarial	Hydroxychloroquine
IV Fluids	Normal saline, lactated Ringer’s solution
Antibiotics	Cephalosporins, penicillins, macrolides (except azithromycin), clindamycin, linezolid
Psychotropics	SSRIs, SNRIs, benzodiazepines, buspirone
Anti Rheumatics	Methotrexate, sulfasalazine
Cardiovascular	ACE inhibitors, angiotensin receptor blockers, diuretics (except furosemide), digoxin
Local Anesthetics	Bupivacaine, ropivacaine, prilocaine
Analgesics	Acetaminophen, NSAIDs (except indomethacin), tramadol
Endocrine	Levothyroxine, liothyronine
Eye drops	Brinzolamide, dorzolamide, latanoprost, timolol (0.25%)
Neuromuscular blocking agents	Vecuronium, atracurium, cisatracurium
Others	Vitamin B12, folate, iron, calcium, magnesium, ranitidine, famotidine, pantoprazole, omeprazole

Drug Intake Hx

Yes

Mention Drugs

Classification

Modified Osserman classification

Osserman Classification

Grade 0 = asymptomatic

Grade I = Ocular MG: involvement restricted to extraocular muscles

Grade IIA = Mild generalized MG: generalized weakness without respiratory muscle involvement

Grade IIB = Moderately generalized MG: more severe generalized involvement, bulbar symptoms common and relative sparing of respiratory muscles

Grade III = Acute fulminating MG: rapid onset (within 6 months) of respiratory muscle involvement

Grade IV = Late severe MG: severe symptoms that have progressed for more than 2 years after onset of ocular or mild generalized MG

Investigations

Stigma Test

Positive

Negative

Anti Ach Receptor Antibody Test

Anti Musk Antibody Test

NCS/EMG with RNS

CT Chest with Contrast

Spirometry

Thyroid Function Tests

HbA1c

ANA Profile

RA Factor

Anti CCP

ENA Profile

Any other Investigation (specify)

Treatment

Drug

Route

Frequency

Patient Record

Google Drive Link

Response To Treatment

Visit Assessment

Visit Date

Power

Ocular Fatiguability

Single Breath Count

Chest Expansion

Difficulty in swallowing

Diplopia

Consent Form

Consent Form/ اجازت نامہ

.میں ریسرچ کے لئے اجازت دیتا/دیتی ہوں

میں________ میڈیکل ریزروچ کے مقصد اپنا میڈیکل ریکارڈ اور رابطہ نمبر شیئر کرنے کی اجازت دیتا/دیتی ہوں مجھے اس عمل کے بارے میں بتایا گیا ہے اور مجھے یہ بھی بتایا گیا ہے . میرا ڈیٹا صرف اس مقصد کے لیے استعمال کیا جائے گا اور اسے خفیہ رکھا جائے گا۔

Patient Contact