# 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?

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> language: en  
> subject: NCLEX-RN  
> category: PA

## Question

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?

## Option

1. Ptosis worsening 4 hours after the dose
2. Constricted pupils with bradycardia and excess secretions **✔ Correct answer**
3. Improvement in muscle strength after edrophonium
4. Symptoms triggered by emotional stress

**Correct answer: 2**

## 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.

## In-depth explanation

Distinguishing feature: timing (within 1 hour vs hours later) plus muscarinic SLUDGE pattern. Atropine reverses muscarinic effects in cholinergic crisis; pyridostigmine is HELD.

## Clinical scenario

Hospitalized with worsening dysphagia. Pyridostigmine 60 mg PO every 4 hours. Pupils 2 mm bilaterally, HR 54, BP 102/64.

## Key concepts

- **cholinergic crisis** — Acetylcholine excess from anticholinesterase overdose causing SLUDGE and weakness.
- **SLUDGE** — Mnemonic for muscarinic toxicity: Salivation, Lacrimation, Urination, Defecation, GI cramping, Emesis.
- **edrophonium** — Short-acting cholinesterase inhibitor used historically to differentiate the two crises.

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