A client with myasthenia gravis on scheduled pyridostigmine reports increasing weakness, abdominal cramping, excessive salivation, and lacrimation 45 minutes after the last dose. Which assessment finding most strongly supports cholinergic crisis rather than myasthenic crisis?
1Constricted pupils with bradycardia and excess secretions✓ Correct answer
2Symptoms triggered by emotional stress
3Improvement in muscle strength after edrophonium
4Ptosis worsening 4 hours after the dose
Explanation
Cholinergic crisis results from acetylcholinesterase-inhibitor overdose. Muscarinic excess produces SLUDGE (salivation, lacrimation, urination, defecation, GI cramping, emesis) with miosis and bradycardia, typically within 30-60 minutes of a dose. Myasthenic crisis (under-medication) presents with worsening weakness HOURS after a dose and improves with edrophonium. Stress can trigger either crisis and is non-specific.