Rules of thumb

Weakness around the eye should raise suspicions of myasthenia (with diplopia) or
ocular myopathy (no diplopia). If the face is also affected, facioscapulohumeral
dystrophy is also a possibility. If neck weakness predominates, myasthenia,
polymyositis, systemic sclerosis, dystrophia myotonica and motor neurone disease
are the most likely diagnoses.
Bulbar weakness may usually be explained by motor neurone disease, myasthenia
or polymyositis. Upper motor neurone signs or fasciculation suggest motor neurone
disease; fatigue, myasthenia; and an elevated CK, polymyositis. Isolated weakness
of chewing is usually due to myasthenia.
In the upper limbs selective weakness of biceps and brachioradialis with sparing of
deltoid and perhaps triceps suggests a dystrophy as does a difference in the two
heads of pectoralis. Distal weakness suggests dystrophia myotonica or, of course,
the weakness of a peripheral neuropathy.
Muscle weakness (not of upper motor neurone pattern) with brisk tendon reflexes
should suggest the myopathy of hypocalcaemia or hypercalcaemia and is seen in
myasthenia gravis. Reflexes are often lost in affected muscles in dystrophies,
though they may paradoxically be preserved in the calves affected by
pseudohypertrophy.
Attacks of flaccid paralysis of trunk and limb muscles and sometimes of respiration
but sparing eye movements suggests one of the familial periodic paralyses. That
associated with high K+ levels is less severe, the attacks are shorter, the onset is
early in life and there may be myotonia. That associated with low potassium levels
is more severe and may be seen in thyrotoxic patients.