A 33-year-old female complains of episodes of weakness of the left side of the face. Drooping of the left eyelid and weakness of the jaw muscle develops gradually throughout the day, and it is worse at night than the morning
The patient has a medical-surgical history of cholecystectomy at age 30. Otherwise, patient has no history of illness and takes no medications. Denies use of tobacco or alcohol. On physical examination, vital signs are T 98 degrees, 18 resps/min, pulse 66, and BP 110/60. Ptosis of the left eyelid is noted. Vision: 20/20 os, 20/20 od, and 20/20 ou. Heart: regular rate and rhythm, no murmurs. Lungs are clear to auscultation. Abdomen is non-tender with no organomegaly. Extremities: Skin is pink, cool to touch, and intact bilaterally. Left and right quadriceps muscle strength 5/5. DTRs left and right + 2/4. No clonus. Negative Homan's and Babinski's sign. Sensation to pinprick and cotton ball intact in extremities and equal bilaterally. Dorsalis pedis pulses +1/4 bilaterally. Eyelids: left-sided ptosis. No facial droop. Left and right cheek sensation to pinprick and cotton ball intact. Masseter muscle: 2/5 left versus 5/5 on right. EOMs intact. Gag reflex: uvula midline gag intact. Shrug and sternocleidomastoid muscle strength 5/5 bilaterally. Tongue: midline and strength 5/5 bilaterally. The following disorder(s) should be considered in the diagnosis:
A. Bell's palsy
B. Stroke
C. Myasthenia gravis
D. Multiple sclerosis
ANS: C
Myasthenia can occur at any age and may be associated with other autoimmune diseases. Limb weakness and fatigability of the affected muscles is a diagnostic sign. Symptoms are due to a variable blocking of neuromuscular transmission by autoantibodies that bind to acetylcholine receptors. Ocular, facial, masticatory, and pharyngeal muscles are most often affected. The eye symptoms of diplopia and ptosis are common early signs. Other symptoms include dysphagia, weakness in the extremities, and respiratory difficulties. Symptoms fluctuate during the day and the symptoms often relapse or remit over long periods of time, but ultimately the disease is progressive. Sustained activity of the affected muscles increases the weakness, and symptoms will improve with rest. Patients may require life support if respiratory effort is significantly affected.
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