bilateral ptosis

If you find bilateral ptosis in the patient examined
3 diagnosis must blink in your brain
1) GBS (guillain barre syndrome) if + complete opthalmoplegia then = Miller fischer
Check for ataxia and opthalmoplegia for miller fischer , areflexia for GBS
2) Myasternia grvis demonstrate eyelid fatigue, proximal myopathy fatigue and verbal fatigue(ask pt to count 1-50 continuously)
3) Dystrophy myotonica-demonstrate percussion myotonia at palmar and tongue.
or rare causes-oculopharyngeal dystrophy,
third nerve palsy caused by oculomotor nucleus lesion (rare), multiple sclerosis also may considered but normally presented with internuclear opthalmoplegia and optic atrophy.

Experience in exam:
a lady presented with weakness of bilateral lower limb. Please examine the lower limb.
surprisingly normal tone and power 5/5, reflex absent on jendrassic maneuver
request for gait , cerebellar sign , sensation and gait.
Examiner not keen.
Request to look at the face.
A lady with eyes closed, ask to open eyes demonstate eyes movement -complte opthalmoplegia
want to demonstrate ataxia. stopped by examiner
ask what else to consider -want to demonstrate fatigue of muscle-proceed no fatigue of muscle.
Final diagnosis- miller fischer
ask about feature of miller fischer?
give the famous three-opthalmoplegia, ataxia and areflexia.