The Real-World Boards: Question #3
A 58-year-old man presents with weakness and dyspnea.
“Right” answers? Maybe sometimes. These are the Real-World Boards.
A 58-year-old man with no past medical history is admitted to your ICU after presenting to the emergency department with shortness of breath.
He describes feeling increasingly fatigued in his arms and legs over recent weeks, and sometimes has trouble even holding his eyelids open in the afternoons. He has also had several choking episodes, and swallowing feels “weird”. He came to the hospital today because of a sensation of shallow breathing and an inability to take a full breath.
On exam, bilateral ptosis is noted. He reports diplopia during an ocular exam.
ABG shows pH 7.35, pCO2 52, paO2 150 mmHg on 2 liters oxygen by nasal cannula.
Maximal inspiratory pressure (negative inspiratory force) is -15 cm H2O. Vital capacity using a portable spirometer is 700 mL (10 mL/kg).
He appears anxious but comfortable, without the use of accessory muscles, and says his symptoms are about the same as when he arrived two hours earlier. He agrees to be intubated only if it is truly necessary.
This man has symptoms and signs strongly suggestive of myasthenic crisis, which occurs as the presenting syndrome of myasthenia gravis in up to 20% of patients with MG.