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69-year-old man with shortness of breath
A 69-year-old man was admitted four days ago because of shortness of breath. He complained of leg
and arm weakness for the past month. Since admission, his respiratory symptoms remain unexplained;
he has been treated for a gram negative UTI with gentamicin, due to multiple antibiotic allergies. On
further questioning, he mentions experiencing intermittent double vision, horizontal or diagonal diplopia
and a nasal quality to his voice (as if he “has a cold”). He also has had some swallowing difficulty, but
denies any sensory problems. He says he has been getting worse since admission to the hospital.
On physical examination, he is taking shallow breaths at a rate of 32 per minute. He has bilateral ptosis,
moderate on the left and mild on the right. He has difficulty fully abducting the right eye (accompanied by
diplopia) although the deficit seems inconsistent. He rises from a chair with much effort and is unable to
stand from a squat even with your help. You also note diffuse moderate symmetrical proximal weakness
and milder distal weakness of all limbs. Sensory examination is normal. Deep tendon reflexes are
intact.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these are
less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain? What
laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor his condition and its treatment? What is the prognosis?
Case 45
A 69-year-old man was admitted four days ago because of shortness of breath. He complained of leg
and arm weakness for the past month. Since admission, his respiratory symptoms remain unexplained;
he has been treated for a gram negative UTI with gentamicin, due to multiple antibiotic allergies. On
further questioning, he mentions experiencing intermittent double vision, horizontal or diagonal diplopia
and a nasal quality to his voice (as if he “has a cold”). He also has had some swallowing difficulty, but
denies any sensory problems. He says he has been getting worse since admission to the hospital.
On physical examination, he is taking shallow breaths at a rate of 32 per minute. He has bilateral ptosis,
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