Author: rlaith Geary / Editor: Jessie Lynch / Codes: / Published: 06/05/2026
A 47-year-old woman presents to the emergency department (ED) with a 2-day history of progressively worsening symptoms. She initially noticed drooping of her eyelids but is now experiencing difficulty with speech and swallowing. This morning, she found it hard to lift her head from the pillow.
She does not report any past medical history, but takes cetirizine as needed for seasonal allergies. She is just back from holidaying in the Lake District last weekend, and 4 days ago, she got anti-wrinkle injections.
On examination, she has bilateral ptosis, vertical diplopia, and dilated pupils that react sluggishly to light. You note her speech is slurred and that she has difficulty with neck flexion. She has normal sensation in all limbs, with full power (5/5) in the lower limbs and reduced strength (3/5) in the upper limbs. Deep tendon reflexes are diminished bilaterally.
