A 45-year-old patient with myasthenia gravis is brought to the emergency room. Which statement would you assess first in the initial assessment?

• A. Eyelid drooping and double vision
• B. Weakness of muscles of the extremities
• C. Difficulty chewing or swallowing
• D. Bladder and bowel incontinence

Answer: (A)

In myasthenia gravis, weakness is fatigable and the ocular muscles are often affected first. Eyelid drooping (ptosis) and double vision (diplopia) arise early because the extraocular muscles are highly active and particularly susceptible to impaired neuromuscular transmission. These ocular signs are typically the most readily observable and characteristic at the initial assessment, signaling disease activity before more generalized or bulbar symptoms develop. While breathing and airway status are always critical to assess in an emergency, among the given options the earliest and most informative clue to document for a known MG patient is eye movement and eyelid weakness. Later, weakness of the limb muscles or bulbar difficulties like trouble chewing or swallowing may indicate progression, and bladder/bowel incontinence is not a typical MG feature.