Bilateral ptosis

Look at this patient’s face and examine him.

This patient’s brother has similar problems, please examine his upper limbs.

This patient has drooping of the eyelids, examine him.

If you see ptosis, always shake the patient’s hands. You will get the answer if it is myotonic dystrophy. If you did not shake the patient’s hand, you may have failed the station already.

This patient has wasting of the temporalis with bilateral ptosis

Go on to examine for myotonia by percussing the thenar eminence

Look at the pupils for cataract

Ask the patient to grip and open the hands (he may open each finger at a time)

Look for evidence of AICD (Automated implantable cardioverter defribillator) insertion (if cardiomyopathy)

Ask to look for testicular atrophy

During CN examination, we have effectively ruled out Horner and CN III palsy(by looking at the pupil size). So, it is likely partial ptosis due to neuromuscular weakness. At this point, there should be at least 6 differential diagnosis in our mind:

1. Myasthenia Gravis/ LEMS (No wasting of temporalis)
2. Gullain Barre Syndrome (Miller-Fisher)
3. Dystrophic Myotonia
4. Fasciomusculoscapular dystrophy
5. Oculopharyngeal Muscular Dystrophy
6. CPEO (Kearn’s Sayre syndrome)

Therefore, at the end of CN examination, we need to do something extra to get the most likely diagnosis. Do as follow:

1. Check for fatiguability (eye lids, upper limbs, nasal speech)
2. Check for thymectomy scar (may be hidden by patient's dress, and it would be fatal for missing the scar)
3. Check for diplopia on extreme gaze
4. Check for opthalmoplegia
5. Check for myotonia, by percussing the thenar muscle, and ask patient to grip hands
6. Check lower limb reflex for areflexia in GBS
7. Check for winged scapula

During presentation, we need to mention about the possibility of medical emergency, in this situation, we should mention:

1. "I would like to complete my examination by requesting a bed side spirometry to assess for respiratory mucle weakness" -for suspected Myasthenia/LEMS/GBS
2. "I would like to examine upper and lower limb for ascending weakness and aflexia" -for GBS