Two years earlier, this 53-year-old woman had a left middle cerebral artery territory cardioembolic infarction due to atrial fibrillation/flutter. She was status post-catheter cardiac ablation a week prior to her stroke. She was treated with warfarin and had a good recovery. Subsequently she had a maze atrial procedure and warfarin was discontinued.

She then complained of progressive dysphagia and increased muscle weakness, involving mostly the proximal aspect of her extremities. She also had difficulty getting up from stairs, lifting objects above her shoulders, and brushing her hair. Furthermore, she had trouble climbing stairs and had muscle pain and tenderness when climbing stairs. There was no history of skin disease, lung disease, inflammatory arthritis, or Raynaud phenomenon.

Our patient presented with progressive and severe neuromuscular weakness including dysphagia and dyspnea. The first priority assessing a patient with speech, swallowing, or breathing difficulties is always to establish that their vital neuromuscular functions are secure. If overtly aspirating, choking frequently with meals, or losing weight precipitously, it is best to admit the patient on an urgent basis to formally assess swallowing function more thoroughly and adjust nutritional intake appropriately. Similarly, if any question arises about pulmonary status, it is best to deal with that on an urgent basis before pursuing further diagnostic tests.