#eyes becoming smaller in evenings could be a sign of #neurological illness

1. I was seeing the last patient, on what had been a busy Monday. While counselling the patient's attendant (aged 45), I noticed that her left eye was smaller than the right.

#MedTwitter #neurotwitter
2. On enquiry, she confirmed that her eyes were of equal size in mornings, but left eye became smaller as the day progressed. This was the case for the past 4-5 months. She had no other issues. This had been noted by her family members and friends too. An eye check up was normal.
3. I discussed with her that this could be a sign of #myasthenia gravis (MG) and asked for investigations. Repetitive nerve stimulation was normal. However, acetylcholine receptor antibody was high (8; normal value<0.25). The diagnosis of MG was confirmed. CT chest was normal.
4. She was started on appropriate medical treatment, and she responded well.
She was anxious about her illness. I mentioned that @SrBachchan too had MG, diagnosed in 1984 and his life story is an encouragement for all patients living with this disease.
#Neurology
5. Mild asymmetry (1 mm or more) in eye size can be normally seen in about 25% of people. However, eyes becoming smaller in evenings or associated with double vision can be a sign of MG. MG affects only eyes in about 20% of patients. Other symptoms are difficulty in swallowing +
6. difficulty in speaking, chewing food, weakness of arms or legs and breathing difficulty in severe cases. Symptoms get worse in evenings and with repeated muscle activity. MG is an auto-immune disease, affecting the junction of nerve and muscles.
7. Symptoms of MG can also get worse with heat, stress, infections, surgery, certain drugs, menstruation, pregnancy and in post-partum period. The diagnosis may get delayed by up to 5 years in about 13% of patients.
8. Early diagnosis and prompt treatment results in excellent outcome and also prevents myasthenic crisis (severe symptoms such as difficulty in swallowing and breathing difficulty).
Medical treatment suffices in most cases, in some, thymectomy (removal of thymus gland) is needed
9. Take home message
Asymmetry in eye size (palpebral fissure height) between the two eyes or variation in eye size at different times of day can be a sign of myasthenia gravis.
Early diagnosis and treatment of MG can prevent hardships for the sufferer.

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More from @hyderabaddoctor

Nov 28
Case of a man who almost stopped eating and drinking, as the act of swallowing caused severe throat pain

1. 45-year old man presented with intense episodes of pain in throat, back of tongue and tonsils on the right side for three months. The pain radiated to ear.
#MedTwitter
2. #pain was excruciating and was triggered by eating, chewing or swallowing food, drinking water, sneezing or even yawning. Pain lasted for 30-45 seconds and occurred 10-15 times every hour. He was so scared to eat or drink that he lost 15 kg weight in those 3 months.
3. He consulted ENT and dental doctors, and detailed examination by them was normal.
He became depressed and also had suicidal thoughts. He consulted psychiatrist and was started on anti-depressant medications.
On his sister's (a medico) advice, he decided to take my opinion.
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Nov 28
White coat #hypertension (WCH) can not be left alone

1. Patient: My BP is high only in hospital, at home it is normal. So, I don't want to do anything about it.
Me: High BP (whether in hospital or at home) can lead to adverse outcomes, so, you should aim for a normal BP 24/7.
2. A study showed that in untreated cohorts, WCH was associated with a 38% and 20% increased risk of #Cardiovascular disease (CVD) and total #mortality (death) compared with normotension (normal BP), respectively.
3. However, in the treated patients (who received medications to keep BP normal at office as well as at home), neither the risk of CVD, nor total mortality was increased in WCH.
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Nov 27
Calcium supplements increase the risk of dementia inn older people

1. #Calcium tablets are commonly prescribed to older people to lower the risk of #osteoporosis and #fractures. However, calcium tablets may increase the risk of #Dementia.
#neurotwitter #MedTwitter
2. Women (aged 70 or more) taking calcium supplements had a higher risk of all type dementia, vascular and mixed dementia at 5-year follow up.
The risk of dementia was higher in women with previous history of #stroke and those with white matter lesions (WML) on #MRI brain.
3. In another study, higher serum calcium status (even if not hypercalcemia) was associated with increased risk of #Alzheimers disease in elders. Serum calcium is a useful biomarker in predicting clinical progression in nondemented elders.
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Regular #exercise effectively reduces #headache days in patients with #migraine

1. Migraine is a disabling disease that causes repeated episodes of headaches.
Exercise is very effective, however, it is uncommonly prescribed in migraine.
#MedTwitter #neurotwitter
2. In a recent research, strength/resistance training reduced monthly migraine days (MMD) by 3.5 days, followed by high-intensity aerobic exercise (3.1 days) and moderate intensity aerobic exercise (2.2 days).
3. All exercise modalities showed higher efficacy compared to placebo.
The reason for strength/resistance training to rank top could be because of targeted muscular strengthening and reconditioning, particularly involving major muscles in the neck, shoulders and upper limbs.
Read 12 tweets
Nov 25
Cause of coma in a #woman surprised us!

1. 65-year old woman was brought in an #unconscious state to #emergency dept. She sounded normal over phone to her son about 24 hours earlier. She stayed alone, so, further details were not available.
#MedTwitter #internalmedicine
2. Clinical examination revealed an #unconscious patient. She was afebrile; pulse and BP were normal. Pupils were equal and reacting to light. Meningeal signs were absent. She was electively mechanically ventilated in view of her unconscious state.
3. Serum #calcium was high (13 mg/dL). MRI brain was normal. Lumbar puncture was normal. Investigations were done to determine the cause of high calcium. There was no evidence of #endocrine disorder, infection or #Cancer.
#VitaminD level was very high (160 ng/mL).
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Nov 24
Can #drinking excess amount of #water lead to death?

1. Water is life-saving and is essential for survival. However, ingestion of excess amounts of water, especially over a short period of time can lead to serious health hazards, including #death.
#MedTwitter #internalmedicine
2. How much water is needed on daily basis?

The normal daily requirement of water is 2.5 to 3 liters.
The requirement may be higher in summer months. Requirement also increases during #exercise (due to sweating), during fever, diarrhea or vomiting.
3. Why do some people drink excess amounts of water?

There is a misconception that drinking more water is good for #health.
Some people can drink more water due to #psychiatric illnesses.
#athletes can overestimate fluid loss and drink an excess amount of water.
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