Formative 4

Question 1

A 48 year old man has 1 day of severe right upper quadrant pain. He has vomited five times. He smokes 10 cigarettes per day and drinks 31 units of alcohol per week. He is tender in the epigastrium and right upper quadrant, and there is voluntary guarding.
His temperature is 37.8°C, pulse rate 90 bpm and BP 140/84 mmHg. He is tender in the epigastrium and right upper quadrant, and there is voluntary guarding.
Investigations:
White cell count 15 × 10^9/L (3.8–10.0)
ALT 41 IU/L (10–50)
Alkaline phosphatase 125 IU/L (25–115)
Bilirubin 14 μmol/L (<17)
Amylase 222U/L (<220)
CRP 42 mg/L (<5)
Which is the most likely diagnosis?
A. Acute cholangitis
B. Acute cholecystitis
C. Acute hepatitis
D. Acute pancreatitis
E. Biliary colic

Answer 1

B. Acute cholecystitis

History and investigations fit with acute cholecystitis. amylase not high enough for acute pancreatitis. would expect higher bilirubin with cholangitis. biliary colic would not have inflammatory response. LFTs do not fit with hepatitis.

Question 2

A 65 year old woman has a week of disorientation and dizziness. She also has headaches that are worse when bending over and associated with vomiting. She had a non-small cell lung cancer that was treated with radical radiotherapy
two years ago.
BP is 178/95 mmHg. She has no focal neurological signs. Which is the most likely diagnosis?
A. Cerebral metastases
B. Hypercalcaemia
C. Hyponatraemia
D. Paraneoplastic encephalitis
E. Severe hypertension

Answer 2

A. Cerebral metastases

Typical Observations due to intracanial hypertension secondary to cerebral metastases

Question 3

A 24 year old man develops low back pain the day after falling while playing tennis. He is usually well and takes no regular medication. He is a laboratory technician.
Which is the most appropriate advice?
A. Avoid work until the pain has completely settled
B. Back strengthening exercises
C. Bed rest until pain improves, then gradual mobilisation
D. Continue usual activity
E. Self referral for physiotherapy

Answer 3

D. Continue usual activity

Short duration acute low back pain in fit person. Therefore most appropriate response would be to continue usual activity and to provide appropriate safety netting advice. NICE Clinical Knowledge Summaries - back pain

Question 4

A 67 year old woman has right-sided pleuritic chest pain and breathlessness of sudden onset. She had a bleeding peptic ulcer secondary to NSAID use 4 weeks ago requiring a 2-unit blood transfusion. She has a history of osteoarthritis. She is taking lansoprazole and co-codamol.
Her pulse rate is 112 bpm, BP 114/74 mmHg, respiratory rate 26 breaths per minute and oxygen saturation 94% breathing 40% oxygen. Her chest is clear.
Investigations:
Haemoglobin 93 g/L (115–150)
Creatinine 81 μmol/L (60–120)
CT pulmonary angiogram: thrombus in both pulmonary arteries.
Which is the most appropriate initial treatment?
A. Insertion of vena cava filter
B. Intravenous alteplase
C. Intravenous heparin
D. Oral apixaban
E. Subcutaneous dalteparin sodium

Answer 4

C. Intravenous heparin

The patient has a sub-massive pulmonary embolus but is also at risk of haemorrhage. In this setting IV unfractionated heparin is best option as it can be stopped and reversed in event of recurrent bleeding.

Question 5

A 63 year old woman has episodes of irregular palpitations, lasting several days and occurring once a month. She has a history of ischaemic heart disease and type 2 diabetes.
Her ECG confirms atrial fibrillation. The patient wants to discuss the risks before starting anticoagulation. Her CHADsVasc score is 3.

Which is her lifetime risk of having a stroke related to her atrial fibrillation?

A. 3%
B. 15%
C. 20%
D. 30%
E. 60%

Answer 5

D. 30%

60% as the her CHADsVasc score is 3 (one point each for sex, hypertension and DM) so 3% per year with life expectancy from 63 years to be about 20 years (83) (2020: life expectancy is 82 years). 3 x 20 is 60%. When discussing this with patients it puts it into perspective more if its lifetime rather than annual risk. Patients more likely to choose anticoagulation.

Question 6

A 33 year old man has 12 hours of severe, constant pain of sudden onset radiating from the right flank to the groin. He has no significant past medical history.
Urinalysis shows blood 2+, protein negative and leucocytes 1+. Which is the most appropriate initial investigation?

A. Contrast CT of abdomen and pelvis
B. Intravenous urography
C. Non-contrast CT of renal tract
D. Plain X-ray of renal tract
E. Ultrasonography of renal tract

Answer 6

C. Non-contrast CT of renal tract

An unenhanced CTKUB is the recommended first investigation of renal stones. NICE guideline NG118- 8/1/19

Question 7

A 63 year old man presents to his GP for review following addition of chlortalidone to maximal-dose ramipril for BP control. He also has type 2 diabetes mellitus and chronic kidney disease and takes metformin. His creatinine 1 month ago was 115 μmol/L (60–120).
His BP is 133/85 mmHg. Investigations:
Sodium 135 mmol/L (135–146)
Potassium 4.6 mmol/L (3.5–5.3)
Urea 9.0 mmol/L (2.5–7.8)
Creatinine 150 μmol/L (60–120)
eGFR 44 mL/min/1.73 m2 (>60)

Which is the most appropriate management?
A. Stop metformin
B. Repeat urea and electrolytes in 2 weeks
C. Stop chlortalidone
D. Stop ramipril
E. Switch chlortalidone to amlodipine

Answer 7

B. Repeat urea and electrolytes in 2 weeks

The patient has had a <30% increase in serum creatinine. At this level there is no indication to change treatment, repeat of renal function in 2-4 weeks is reasonable.

Question 8

A 40 year old woman has 1 day of a painful, swollen left elbow and fever. She has a history of rheumatoid arthritis and takes methotrexate and infliximab.
Her temperature is 38.2°C, pulse rate 100 bpm and BP 119/83 mmHg. The left elbow is swollen and erythematous.
Investigations:
White cell count 16.4 × 109/L (3.8–10.0)
Urea 6.7 mmol/L (2.5–7.8)
Creatinine 98 μmol/L (60–120)
CRP 171 mg/L(<5)

Joint aspiration: no organisms on Gram stain, white cell count 2043/μL (<200), mostly neutrophils, no crystals.
She is advised to take oral paracetamol.

Which is the most appropriate additional management?
A. Inject methylprednisolone into the joint
B. No further treatment pending culture results
C. Start intravenous flucloxacillin
D. Start oral colchicine
E. Start oral prednisolone

Answer 8

C. Start intravenous flucloxacillin

The patient should be considered to have septic arthritis. The patient is septic and is immunocompromised. The gram stain is positive in about 50% of cases, so a negative gram stain does not mean there is no infection. Intravenous antibiotics should be started pending culture results.

Question 9

A 33 year old man is found collapsed on the medical ward. He was admitted 3 days ago with urosepsis and is being treated with intravenous antibiotics. He has a history of type 1 diabetes and has been taking his usual doses of subcutaneous insulin.
He is unrousable and is clammy. His capillary blood glucose is 2.1 mmol/L.
Which is the most appropriate immediate treatment?
A. 20 mL of 50% glucose by slow intravenous injection
B. 75 mL of 20% glucose by intravenous infusion
C. 150 mL of 5% glucose by intravenous infusion
D. Glucagon 1 mg by intramuscular injection
E. Glucose gel 25 g (contains 10 g glucose) applied to buccal mucosa

Answer 9

B. 75 mL of 20% glucose by intravenous infusion

20% glucose is first choice treatment. 50% glucose too hyperosmolar with risk of local tissue necrosis. Glucagon has unpleasant effects (nausea and flushing) but is reasonable second choice if no venous access available. 5% glucose will not reverse hypo effectively. Risk of aspiration with glucose gel in unconscious patient. Joint British Diabetes Society Guidelines: Hospital management of hypoglycaemia in adults with diabetes mellitus (3rd edition Feb 2018)

Question 10

A 75 year old woman with type 2 diabetes mellitus attends the clinic for review. Her metformin treatment was stopped during a recent hospital admission with a hip fracture, in view of worsening chronic kidney disease [eGFR 28 mL/min/1.73 m2(>60)]. She has a history of osteoarthritis. She is currently taking the maximum dose of gliclazide.
Investigations:
Glycated haemoglobin 79 mmol/mol (20–42)
She is keen to avoid giving herself injections.

Which is the most appropriate additional treatment?
A. Acarbose (α-glucosidase inhibitor)
B. Dulaglutide (GLP-1 agonist)
C. Empagliflozin (SGLT2 inhibitor)
D. Pioglitazone (thiazolidinedione)
E. Sitagliptin (DPP4 inhibitor)

Answer 10

E. Sitagliptin (DPP4 inhibitor)

Sitagliptin approved for use in CKD. Dulaglutide is sc injection. Empagliflozin currently not licensed for CKD. Pioglitazone is contra- indicated in heart failure, bladder cancer and can cause fractures. Acarbose unlikely to be tolerated due to GI adverse effects.

Question 11

A 53 year old woman has 6 days of worsening abdominal pain. She has also had recent constipation . There is no rectal bleeding.
Her temperature is 37.8°C, pulse rate 105 bpm and BP 140/85 mmHg. She has tenderness in the left iliac fossa with some guarding . Bowel sounds are normal. Rectal examination shows hard stools only.

Which is the most likely diagnosis?
A. Ischaemic colitis
B. Meckel’s diverticulitis
C. Proctocolitis
D. Rectal carcinoma
E. Sigmoid diverticulitis

Answer 11

E. Sigmoid diverticulitis

The classical presentation of diverticulitis includes change in bowel habit, left iliac fosa pain and features of infection (ie pyrexia).

Question 12

A 76 year old man has nausea, fever and rigors. He has foul smelling urine . He was discharged 3 days ago after being treated for a PE. He has been having low molecular weight heparin injections twice daily since the diagnosis. He had a cholecystectomy 12 years ago.
His temperature is 39.7°C, pulse rate 100 bpm and BP 92/41 mmHg.
Investigations:
APTT 43 seconds (22–41) PT 18 seconds (10–12)
Which is the most likely cause of the prolonged prothrombin time?
A. Disseminated intravascular coagulation
B. Liver disease
C. Low molecular weight heparin
D. Lupus anticoagulant
E. Vitamin K deficiency

Answer 12

A. Disseminated intravascular coagulation

Diagnosis of DIC is based on presenceof ≥1 known underlying condition causing DIC plus abnormal global coagulation tests: decreased platelet count, increased prothrombin time, elevated fibrin-related marker (D-dimer/fibrin degradation products) and deccreased fibrinogen level. In this patient the underlying condition triggering DIC is sepsis and it is likely that further blood tests would show abnormalities in the above markers.

Question 13

A 62 year old man has a right-sided hearing loss. There has been slow deterioration over the previous two years, and he is now also troubled by non- pulsatile, right-sided tinnitus that prevents him from sleeping.
A pure-tone audiogram shows a right-sided high-frequency hearing loss. He has normal tympanometry bilaterally.
Which is the most appropriate diagnostic investigation?
A. Cerebral angiography
B. CT of head
C. CT of petrous temporal bones
D. MR imaging of internal acoustic meatus
E. PET–CT of brain

Answer 13

D. MR imaging of internal acoustic meatus

Where there is a unilateral sensorineural hearing loss, it is vital to exclude the presence of a vestibular schwannoma or other neoplasm of VIII nerve or brainstem. This is done via an MRI scan.

Question 14

A 28 year old man presents to his GP with 7 weeks of right iliac fossa pain, weight loss of 3 kg and diarrhoea five times a day. He previously opened his bowels once daily. He has not travelled abroad. He lives with his partner, who is well.
Rectal examination is normal.
Investigations:
Haemoglobin 129 g/L (Men: 135-180 g/l Women: 115-160 g/l)
Albumin 32 g/L (35–50)
White cell count 11.4 × 10^9/L (3.8–10.0)
Platelets 450 × 10^9/L (150–400)
Erythrocyte sedimentation rate 60 mm/hr (<20)
ALT 10 IU/L (10–50)
ALP 110 IU/L (25–115)
Bilirubin 15 μmol/L (<17)

Which is the most appropriate next investigation?
A. Antimitochondrial antibodies
B. Anti-tissue transglutaminase antibodies
C. Faecal calprotectin
D. Faecal occult blood testing
E. Stool cultures

Answer 14

E. Stool cultures

NICE CKS suggest stool cultures as part of work up in primary care before referral. Most likely diagnosis is IBD

NICE suggests stool culture and other tests before faecal calprotectin to rule out other causes first

https://www.nice.org.uk/guidance/dg11/resources/endorsed-resource-consensus-paper-pdf-4595859614

Question 15

A 36 year old man has recurrent episodes of collapse over 4 months. When laughing, his muscles feel limp and he falls to the floor, but remains conscious. He has a history of anxiety and depression and takes citalopram. His father died from an ischaemic stroke aged 59 years.
Which is the most likely diagnosis?
A. Cardiogenic syncope
B. Cataplexy
C. Cough syncope
D. Dissociative (non-epileptic) seizures
E. Epilepsy

Answer 15

B. Cataplexy

Cataplexy classically presents with loss of skeletal muscle tone with strong (usually postive) emotions

Question 16

A 37 year old man has 4 weeks of pain on the radial side of his left wrist. The pain is worse when he plays the piano. He has no history of trauma.
He has swelling and tenderness over the distal end of the left radial styloid. The pain is exacerbated by ulnar deviation of the wrist when the thumb is clasped in the palm.
Which is the most likely diagnosis?
A. de Quervain tendinopathy
B. Ganglion cyst
C. Intersection syndrome
D. Osteoarthritis of the trapeziometacarpal joint
E. Scaphoid fracture

Answer 16

A. de Quervain tendinopathy

The diagnosis of de Quervain tendinopathy usually has a history of atraumatic radial wrist pain with tenderness and enlargement at the first dorsal compartment over the radial styloid and pain at the radial styloid with active or passive stretch the thumb tendons over the radial styloid in thumb flexion (the Finkelstein test).

Question 17

A 41 year old woman is admitted following a significant overdose of amitriptyline and propranolol taken 30 minutes ago.
Her GCS is 15. Her pulse rate is 80 bpm, BP 134/90 mmHg, respiratory rate 14 breaths per minute and oxygen saturation 98% breathing air.
Investigations:
Arterial blood gas breathing air
pH 7.42 (7.35–7.45)
PO2 11.7 kPa (11–15)
PCO2 4.9 kPa (4.6–6.4)
Bicarbonate 24 mmol/L (22–30)
ECG: sinus rhythm, QRS duration 100 ms (80–120) Which is the most appropriate next step in management?
A. Arrange gastric lavage
B. Give oral activated charcoal
C. Give oral ipecacuanha
D. Start IV 1.26% sodium bicarbonate
E. Start IV acetylcysteine

Answer 17

B. Give oral activated charcoal

Activated charcoal should be considered for people who have self harmed by poisoning, who present early (within one hour of ingestion), are fully conscious with a protected airway, and are at risk of significant harm as a result of poisoning.

Question 18

A 48 year old man has 8 months of a painful, stiff left shoulder. The pain is dull and worse at night. There is no history of trauma. He has type 1 diabetes mellitus.
He has reduced passive and active range of movement in the left shoulder with pain at extremes of range of motion. Neck movements are normal. Power and sensation are normal.
Investigations: CRP 6
Which is the most likely diagnosis?
A. Adhesive capsulitis
B. Glenohumeral osteoarthritis
C. Polymyalgia rheumatica
D. Rotator cuff tear
E. Subacromial bursitis

Answer 18

A. Adhesive capsulitis

Adhesive capsulitis (frozen shoulder) presents with dull shoulder pain, that often disturbs sleep, followed by stiffness and loss of shoulder mobility. Adhesive capsulitis is unlikely in patients younger than 40 years of age, and patients older than 70 are more likely to have rotator cuff tears or glenohumeral osteoarthritis. Patients with subacromial pathology often give an occupational or athletic history of heavy lifting or repetitive movements, especially above shoulder level. Patients with rotator cuff tendinopathy and subacromial bursitis often complain of activity-related pain and problems performing usual activities. Adhesive capsulitis is more common is diabetics.

Question 19

A 38 year old woman has abdominal pain 7 days after a laparoscopic sleeve gastrectomy for weight loss.
Her temperature is 36.5°C, pulse rate 110 bpm, BP 120/72 mmHg and oxygen saturation 96% breathing oxygen 4 L/min via nasal prongs. She has reduced breath sounds in both bases. She has abdominal tenderness with guarding and reduced bowel sounds.
Which is the most appropriate diagnostic investigation?
A. Abdominal X-ray
B. Barium enema
C. CT of abdomen
D. Erect chest X-ray
E. Point-of-care FAST scan

Answer 19

C. CT of abdomen

The question aims to assess investigation of an acute abdomen following abdominal surgery. A CT scan (usually with intravenous contrast) is most likely to provide diagnostic information to plan further management. None of the other investigations are likely to be useful in this setting.

Question 20

A 59 year old man presents to the GP for review. He has type 1 diabetes mellitus, hypertension, ischaemic heart disease and CKD stage 4 [recent eGFR 25 mL/min/1.73 m2(> 60)]. He is taking insulin, lisinopril, metoprolol tartrate and aspirin.
His BP is 160/96 mmHg. He has pitting oedema to the mid shin. Investigations:
Sodium 144 mmol/L (135–146)
Potassium 5.4 mmol/L (3.5–5.3)
Urea 19.2 mmol/L (2.5–7.8)
Creatinine 237 μmol/L (60–120)
eGFR 26 mL/min/1.73 m2 (>60)
Urinalysis: protein 2+
Which is the most appropriate therapeutic change?
A. Add indapamide
B. Add furosemide
C. Add spironolactone
D. Stop lisinopril
E. Switch lisinopril to losartan

Answer 20

B. Add furosemide

The patient has hypertension outside of target (130/80 mmHg), with evidence of peripheral oedema. Furosemide will reduce peripheral oedema, lower BP and help with hyperkalaemia. Bendroflumethiazide is less effective when compared to furosemide when the creatinine clearance is below 30. Although the potassium is elevated this is not an indication to stop lisinopril. Spironolactone is relatively contraindicated by hyperkalaemia and not as effective as furosemide. There is no benefit in switching to an angiotensin receptor blocker.

Question 21

A 30 year old woman is brought to the resuscitation room of the Emergency Department after after being kicked by a horse . She is 28 weeks pregnant. Her cervical spine is immobilised.
She is conscious and asks about her baby. Her temperature is 37°C, pulse rate 100 bpm, BP 78/56 mmHg and oxygen saturation 99% breathing 40% oxygen . Fluid resuscitation has been started and bloods have been sent.
Which is the most appropriate next step?
A. Image the long bones and pelvis, and orthopaedic review
B. Perform a full primary survey
C. Scan the baby and arrange fetal monitoring
D. Transfer to theatre for immediate delivery of baby
E. X-ray cervical spine

Answer 21

B. Perform a full primary survey

The patient is tachycardic and hypotensive. It is likely that they are bleeding. They need a full primary survey to identify any potential life threatening injuries and commence treatment. The resuscitation efforts are mainly focused on the mother not the fetus. Delivery of the fetus at this point would only be indicated to aid resuscitation of the mother.

Question 22

A 55 year old man is brought to the Emergency Department with 2 hours of severe left sided chest pain. A pre-hospital ECG shows left bundle branch block, for which paramedics gave aspirin and glyceryl trinitrate spray.
On arrival at hospital, he is sweating and distressed . His pulse rate is 85 bpm, BP 99/54 mmHg, respiratory rate 22 breaths per minute and oxygen saturation 96% breathing air. His GCS score is 15/15.
Which is the most appropriate management?
A. Continue breathing air
B. Start 28% oxygen via a Venturi mask
C. Start 40% oxygen via a Venturi mask
D. Start oxygen 2 L/min via nasal cannulae
E. Start oxygen 15 L/min via a non-rebreathe mask

Answer 22

A. Continue breathing air

Airway is patent and does not require intervention. Oxygen will increase mortality for STEMI with sats of >94%. (BMJ Nov 2018)

Question 23

A 75 year old woman attends her GP surgery with breathlessness on exertion and a cough productive of white sputum throughout the day. She has never had haemoptysis and has lost 2kg in weight . She describes two chest infections in the past year treated with a short course of steroids and antibiotics. She has a 15 pack-year smoking history.
Her heart rate is 82. Chest X-ray is normal.
Which is the most appropriate investigation to establish the diagnosis?
A. Cardiopulmonary exercise test
B. Echocardiography
C. High resolution CT scan of thorax
D. Spirometry
E. Sputum cytology

Answer 23

D. Spirometry

COPD is the most likely diagnosis and basic spirometry most appropriate

Question 24

A 82 year old woman is oliguric 8 hours after an emergency sigmoid colectomy for a perforated diverticulum. She has a history of chronic kidney disease stage 3, peripheral vascular disease and type 2 diabetes mellitus. She takes metformin and ramipril.
Her pulse rate is 110 bpm, BP 94/60 mmHg and JVP not visible. Her urine output has been 10 mL per hour for the past 4 hours. She has been given 2 L of hartmann’s solution since returning from theatre.
Investigations:
Urea 14.9 mmol/L (2.5–7.8) Creatinine 188 μmol/L (60–120)
Which is the most likely cause of her oliguria?
A. Acute tubular necrosis
B. Catheter obstruction
C. Intraoperative ureteric injury
D. Prerenal hypovolaemia
E. Renal artery occlusion

Answer 24

D. Prerenal hypovolaemia

The patient continues to show signs of hypovolaemia so a pre-renal cause for the oliguria is most likely. ATN usually takes longer to develop and would need to ensure adequate fluid resuscitation. Ureteric injury is unlikely and would need to be bilateral to cause AKI. Catheter blockage would cause anuria. Renal artery occlusion is rare and would cause loin pain and more severe clinical picture.

Question 25

A 39 year old man is brought to the Emergency Department having hit his head on a tree trunk when he lost control of his bicycle.
He has a minor scalp abrasion. His GCS is 15/15 and there are no focal neurological signs.
Seven hours later he collapses, at which point his GCS is 6/15. A CT scan of brain reveals a lens-shaped haemorrhage in the right parietal region.
Which is the most likely vessel to be injured?
A. Anterior communicating artery
B. Basilar artery
C. Bridging veins
D. Middle meningeal artery
E. Vertebral artery

Answer 25

D. Middle meningeal artery

The middle meningeal sits beneath temporal bone and is fragile

Question 26

Researchers compare the diagnostic accuracy of a new serological test for SARS-Cov-2 against the nose and throat swab currently being used for clinical diagnosis in the UK. The new test detects all 23 confirmed cases of the disease that were positive by the current test. 92% (230/250) of patients who tested negative with the current test are also negative by the new rapid diagnostic test.
Which statement is correct?
A. The false negative rate of the new test is 0%
B. The false positive rate of the new test is 92%
C. The sensitivity of the new test is 92%
D. The specificity of the new test is 8%
E. The specificity of the new test is 100%

Answer 26

A. The false negative rate of the new test is 0%

All those who had the condition were identified by the test

Question 27

A 24 year old man has 12 hours of a severe headache of sudden onset. When the headache started, he lost consciousness briefly and vomited; he also reports photophobia . He has a past history of severe hypertension .
Neurological examination is normal. A non-contrast CT scan of brain is normal. What is the most appropriate next step in management?
A. Carotid Doppler studies
B. Lumbar puncture
C. MR scan of brain
D. MR imaging of brain with MR venography
E. No future investigations required

Answer 27

B. Lumbar puncture

This is a case of a possible subarachnoid haemorrhage. A normal CT brain scan does not rule out haemorrhage although the earlier it is done the more likely it is that haemorrhage will be detected on the scan. When the CT is unhelpful a lumbar puncture should be performed to look for presence of xanthochromia (haem breakdown products)

Question 28

Six students living in the same hall of residence have developed diarrhoea and vomiting within 48 hours of each other. There is no blood in the stool, they have not eaten similar foods and have no history of foreign travel.
A doctor requests stool samples from each to confirm the likely diagnosis. Which test is most likely to confirm the diagnosis?
A. Clostridium difficile enzyme assay and toxin detection
B. Faecal elastase test
C. Stool for culture and sensitivity
D. Stool for viral PCR
E. Stool microscopy for ova, cysts and parasites

Answer 28

D. Stool for viral PCR

PCR is the current method for confirming norovirus

Question 29

A 60 year old man reports increasing fatigue. He has noticed intermittent difficulty swallowing, usually in the evening. He is a smoker. His only regular medication is levothyroxine.
There is bilateral mild ptosis. The rest of the neurological examination is normal. Which is the most likely diagnosis?
A. Guillain–Barré syndrome
B. Migraine
C. Multiple sclerosis
D. Myasthenia gravis
E. Stroke

Answer 29

D. Myasthenia gravis

Myasthenia Gravis is an autoimmune disorder characterised by muscle weakness that worsens with exercise (fatiguability) and improves with rest. Double vision, ptosis, difficulty chewing and swallowing, and slurring of speech that worsen throughout the day are characteristic symptoms.