Alex is a 20-year-old full-time national serviceman. His only past medical history is asthma, presents to A&E with a 4-day history of bilateral finger weakness and numbness, change in voice, and nasal congestion. He was diagnosed with sinusitis and discharged with clarithromycin.
 
Two days later, he comes back with additional symptoms of breathlessness, lethargy, difficulty swallowing, and diplopia. These symptoms had developed over the last two days. His temperature was 38.5 degrees, blood pressure was 145/75, pulse 114, and oxygen saturations 97% on room air.

On examination, he was alert and orientated. First and second heart sounds were heard, lungs were clear, and the abdomen was soft. He was able to walk, with power at least 4+ in all limbs. Cranial nerve examination was remarkable for bilateral abduction impairment and pooling of saliva in the mouth.  Other cranial nerves were intact.

On examination, he was alert and orientated. First and second heart sounds were heard, lungs were clear, and the abdomen was soft. He was able to walk, with power at least 4+ in all limbs. Cranial nerve examination was remarkable for bilateral abduction impairment and pooling of saliva in the mouth.  Other cranial nerves were intact. Reflexes were normal.

He was admitted to GW.