Stem: Please examine this person's eyes.
- Ptosis – may be asymmetrical. Worse after sustained upward gaze
- Diplopia (+/- ophthalmoplegia) with sustained upward gaze
- Bulbar weakness -> dysarthria (counting back from 20 to 1)
- Neck extensor weakness
- Proximal arm weakness with fatiguability
- Look for thymectomy scar
- Ask for spirometry / RFTs
This patient has clinical features of myaesthenia gravis; evidenced by bilateral ptosis and diplopia on upward gaze; weakness of neck extension and fatiguability of shoulder abductors with a median sternotomy scar that suggests a previous thymectomy.