You ask to talk with him directly, but he is having difficulty speaking. He was previously healthy. You meet them in the local emergency department. He has a hoarse voice, bilateral ptosis, a weak gag reflex, and bilateral proximal upper extremity weakness. He has no lower extremity weakness.
Sensation is intact in all extremities.
His mental status is normal. The patient denies having a flu-like illness within the last month. Neither he nor his family members have had similar symptoms. There is no family history of stroke or other neurological disorders, and he does not have hypertension or hypercholesterolemia. He has not discovered any ticks on himself or in his environment, and he has not been camping, hiking, or in any tick-infested area within the last week.