CASE 14: DOUBLE VISION
History
A 43-year-old woman presents to her general practitioner (GP) 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 qui-
eter. She has lost about 3 kg in weight in the past 6 months. The woman has had no sig-
nificant 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. Bilateral
ptosis is present and is exacerbated by prolonged upward gaze. Pupillary reflexes, eye
movements and funduscopy are normal.
Questions
- What is the diagnosis?
- What are the major differential diagnoses?
- How would you investigate and manage this patient?