HISTORY TAKING

General Data
This is the case of A.G, 28 years old, female, married, Roman Catholic, Filipino, call center agent, from
Betty Go-Belmonte Street, Quezon City, admitted for the second time at St. Luke's Medical Center.

Chief Compliant
“Loss of consciousness”

Reliability: 90%
Informant: The husband, Mr. Armando Gano.

Present Illness
9 months prior to admission A.G started to complain of eye strain and drooping of the eyelids after long
hours of exposure to computer due to her work. No consultation was done.
8 months prior to admission, A.G noticed persistence of symptoms which prompted her to consult to an
ophthalmologist. Eye examination was done which revealed normal results.
7 months prior to admission, A.G. experienced worsening of eye drooping which prompted her to seek
consultation to the nearest hospital. A blood test was ordered to detect the presence of acetylcholine
receptor antibodies. The blood test confirmed a diagnosis of myasthenia gravis, and referred to a
neurologist. Neurologist prescribed pyridostigmine 30 mg TID and order intravenous immunoglobulin.
She completed the 3-month course of medication. The patient tolerates the therapy without any untoward
events.
4 months prior to admission, A.G had recurrence of eye droop and worsening of muscle weakness which
affected patient’s activities of daily living. No consultation was done.
A month prior to admission, he went back to her neurologist for a follow up and she was prescribed with
methylprednisolone 100 mg IV continuous drip.
1 week prior to admission, A.G experienced fever, difficulty in breathing and productive cough thus
prompted her to contact her neurologist and report her concern and also described her eyes as “turned in”.
The neurologist advised to continue her steroid treatment but due to financial constraint, she was not able
to comply.
Few days prior to admission, A.G had worsening of cough and had difficulty of swallowing foods and
stays in bed most of the time.
Few hours prior to admission, husband found his wife in their room unconscious, and was immediately
brought to emergency room of St. Luke's Medical Center and was subsequently admitted.

Allergies. No allergies
Tobacco. Do not smoke.
Alcohol/ drugs. Red wine (Novelino), 1 shot per day before dinner.

Past History
Childhood illnesses: Chicken pox
Surgical: No previous surgeries.
Immunization: Unrecalled

Family History
Informant claimed that her wife’s parents died of old age.
First born brother died at the age of 32 years from a vehicular accident.

Personal and Social History

Patient works as a call center agent while the husband works as an engineer but due to the present
condition of the patient, both decided to stop working.
Review of Systems
General: Unconscious and recent weight changes
Skin: Pale in appearance.
Head, Eyes, Ears, Nose, Throat (HEENT): Head: No history of head injury. Eyes: no discharges Ears:
no use of hearing aids Nose: with nasal yellowish discharges and stuffiness Throat: No sore throat.
Mouth: Incomplete teeth. No dentures.
Neck: No lumps, goiter, No swollen glands.
Breast: No lumps and discharges.
Respiratory: No asthma.
Cardiovascular: No heart disease or high blood pressure. No orthopnea, chest pain or palpitations.
Gastrointestinal: Poor appetite; no vomiting, indigestion diarrhea or bleeding.
Peripheral Vascular: No leg cramps, edema, intermittent claudication.
Urinary: No pain during urination.
Musculoskeletal: No joint pain.
Neurologic: Mood swings, no dizziness, no vertigo.
Hematologic: No anemia, no easy bruising.
Endocrine: No heat or cold intolerance, no excessive sweating, no polyuria.

PHYSICAL EXAMINATION

General Appearance
The patient was received lying on bed, intubated but responsive with GCS of 11. She’s wearing a clean
hospital gown and looks according to age with mesomorphic body built. Body weakness noted and moves
with assistance. She’s placed on moderate high back rest.

Vital Signs
Blood pressure: 90/70
Heart rate: 97 beats per minute
Respiratory rate: 16 cycle/min
Temperature: 36.8°Celsius (axillary)

Skin
Warm to touch with good skin turgor.

Head
Midline and symmetrical.

Eyes
Positive ptosis on both eyes (right and left eyes), positive redness and discharge on both eyes, presence of
red orange reflex, pupils are equally reactive to light.

Ears
Clear external auditory canals. Pinna normal in shape and contour. No pre-auricular pits or skin tags.
Tympanic membrane gray bilaterally. No erythema or bulging.

Nose
Midline with nasal stuffiness and discharges color yellow to green in appearance.

Throat
Positive sore throat with patches.
Chest and Lungs
Symmetrical lung expansion is noted upon respiration. Wheezes noted on both lung fields upon
auscultation. Productive cough noted and able to suction whitish secretions per endotracheal tube. Patient
was asked to say ninety-nine and one, two, three repeatedly and increased fremitus noted upon palpation
on both lower lung fields. Diaphragmatic excursion is 4cms upon percussion. Heart no pulsation or
precordial bulge noted upon inspection. The location of apical beat is at the left midclavicular line 5 th
intercostal space upon auscultation. No murmurs and any unusualties noted.

Abdomen
Soft, non-distended, non-tender. Bowel sounds are present.
Extremities
No clubbing and cyanosis. Upper and lower extremities are symmetric. No signs of atrophy. Normal axial
tone.

NEUROLOGIC EXAMINATION
Patient is unconscious. Gait not assessed.

MOTOR: Grossly reduced power in all the muscles of the four limbs, symmetric upper extremity
weakness with fasciculation.

UPPER EXTREMITY LOWER EXTREMITY

RIGHT 3/5 RIGHT 4/5
LEFT 3/5 LEFT 4/5

SENSORY: Intact on all extremities.

CRANIAL NERVES

CN I: Not assessed
CN II: (+) Direct and consensual light reflex
CN III, IV, VI: Loss of conjugate movements, both eyes have assymetric deviation of movement (+
binocular diplopia), ptosis present
CN V: Temporal and masseter weakness, has difficulty clenching the teeth, facial sensory intact.
CN VIII: Not assessed
CN IX: Not assessed
CN X: Not assessed
CN XI: Not assessed
CN XII: Not assessed

DEEP TENDON REFLEX

Deep tendon reflex is intact.

+ + + +
+ +

+ +

+ +
SPECIAL TESTS
Ice pack test: Positive
Tensilon arm test: Positive
Simpson’s test: Positive
Gorelick’s test: Positive

DIAGNOSTIC EVALUATION
 Complete blood count
Result Normal value
RBC: 4 x 1012 /L 4-5 x 1012 /L
Hgb: 8.5g/dL 11-16 g/dL
Hct: 0.48 .40 - .48
WBC: 15.2 x 109/L 3.8-11 x 109/L
- Neutrophil: 0.59 0.55 – 0.65
- Lymphocyte: 0.67 0.25 – 0.40
- Monocytes: 0.04 0.02 – 0.06
- Eosinophils: 0.03 0.01 – 0.05
- Basophils: 0.02 0.01 – 0.03
MCV: 85fL 80 – 96 fL
MCH: 30pg 27-33 pg
MCHC: 36 g/dL 33-36 g/dL

 Arterial blood gas

pH: 7.46
pCO2: 30 mmHg
pO2: 98 mmHg
HCO3 : 24 mmol
O2 Sat: 89%

 CBG: 4.5 mmol/L

 Serum Electrolyte

Test Result Normal Value

Na+ 143mEq/L 135-145mEq/L
K+ 3.1 mEq/L 135-145 mEq/L
Cl- 100 mEq/L 98-107 mEq/L
Ca2+ 7.6 mg/dL 8.5-10.5 mg/dL
Mg+ 2.6 mg/dL 1.8-3.0 mg/dL
BUN 12 mg/dL 8-20 mg/dL
Crea 1 mg/dL 0.6-1.2 mg/dL

 Chest X-ray
Impression:
- Heart is not enlarge with no mediastinal shift
- Fine demarcation of lung tissues shown from the hilum to periphery. With focal areas of
consolidation of both lung lobes.
- Trachea is visible in the midline
- There are no evidence of plural effusion and pneumothorax

 ECG – Sinus rhythm

Rate: within normal range
Rhythm: R-R interval is regular
P wave: normal
PR interval: Normal
QRS complex: normal

 EMG
Interpretation: Electrical shocks delivered at a rate of 2-3sec with EMG by Repetitive Nerve
Stimulation (RNS) showing a rapid decrement in the muscle groups stimulated.

 CT scan of the Thymus gland

Impression:
- The thymus is of normal size and density for age.
- The AP diameter measures 2cm with each limb measuring <1cm in size.
- No discrete thymus mass is identified.

TREATMENT

 Cholinesterase inhibitors. Pyridostigmine 30 mg TID. Enhances communication between

nerves and muscles and improves muscle contraction and muscle strength.

 Corticosteroids. Methyprednisolone 100 mg IV. Inhibits the immune system, limiting antibody
production.

 Monoclonal antibody. Rituximab. This drug depletes certain white blood cells, altering the
immune system and improving myasthenia gravis.

 Plasmapheresis. This procedure uses a filtering process similar to dialysis. Blood is routed
through a machine that removes the antibodies that block transmission of signals from nerve
endings to muscles' receptor sites.

 Intravenous immunoglobulin (IVIg). This therapy provides body with normal antibodies,
which alters your immune system response.

 SURGERY. Thymectomy Recommended even if no tumor is present because removal of the thymus
improve symptoms in many patients.