A 43-year-old woman presents to her general practitioner complaining of diplopia, more marked in the evenings, for the last 3 months. She has noticed difficulty holding her head up, again especially in the evenings. She has problems finishing a meal because of difficulty chewing. Her husband and friends have noticed that her voice has become quieter. She has lost about 3 kg in weight in the past 6 months. The woman has had no significant previous medical illnesses.
She lives with her husband and three children. She is a non-smoker and drinks about 15 units of alcohol per week. She is taking no regular medication. Examination She looks well, and examination of the cardiovascular, respiratory and abdominal systems is normal. Power in all muscle groups is grossly normal but seems to decrease after testing a movement repetitively. Tone, coordination, reflexes, and sensation are normal.…
