12. The Stairs


‘Morning, doctors!’ Dr. Rivers smiled at me and Kate. We were back on the wards after a few weeks in the ICU. ‘I brought muffins for your comeback.’

Besides being an incredible doctor, he was such a nice person. I already knew that but after Mr. Ethan’s case I was even more impressed.

Ethan was a 67-year-old male admitted after he fell off the stairs and hit his head on the ground. He had a brief loss of consciousness and was under observation since his head CT had shown small subdural bleeding. He was otherwise feeling well.

‘Morning, Mr. Ethan.’ Dr. Rivers reached out to shake the patient’s hand. ‘I am Dr. Rivers and I’m one of the doctors responsible for you during your hospital stay. Dr. Diaz and Dr. Anderson will explain to me your case and we’ll talk a little bit about it, is that ok?’ The patient smiled and nodded.

After I presented his case Dr. Rivers asked me a few follow-up questions.

‘Did he lose consciousness before or after the fall?’

‘After. He reported that he fell because he tripped on the stairs.’

‘I see.’ He turned to the patient. ‘‘So where did you fall, Mr. Ethan?’

‘In my house, can you believe it?’ He laughed. ‘I can’t believe it myself.’

‘Where do you live?’

‘In Brooklyn. I have a big three-story townhouse there. Old, but I love it.’

‘Well, that’s the important part.’ Dr. Rivers smirked. ‘And do you stumble a lot?’

‘You know, I usually walk fine. But I have been tripping on my stairs for a while now.’ Ethan looked puzzled like he had just realized that.

‘Is there something wrong with the steps?’ He asked genuinely interested.

‘Not at all, they have been the same way for 30 years.’ He smiled. ‘I don’t know, maybe I am just getting old. My legs just give out when I am climbing the first steps.’

‘Ageing can be tough.’ Dr. Rivers said and I already knew what was coming next. ‘But, better than the alternative, right?’ He winked.

‘For sure.’ Mr. Ethan laughed. Patients loved that joke.

‘Do you want to ask any additional questions, Dr. Diaz?’ By then I had already realized that when Dr. Rivers asked us that, it was because he had something in his mind. I tried to think back on Mr. Ethan’s case but was having a hard time finding what Dr. Rivers could possibly be thinking of. So I decided to explore his stumbling.

‘You said your legs give out. Do you think your muscles feel weak? Or is it your knees?’

‘My muscles. It seems like my thighs are sleeping. It takes a while for them to work when I get up.’

‘So do you think the last steps on the staircase are better than the first ones?’

‘Much better! I struggle with the first ones. I actually fell from the second step.’ He laughed.

It suddenly hit me and Dr. Rivers' look of approval made me sure that I was on the right path.

After we left the patient’s bedside, Dr. Rivers asked me what I was thinking.

‘I am thinking of Lambert-Eaton Myasthenic Syndrome.’

‘Well done, Dr. Diaz. I am thinking that too. He has proximal muscle weakness that improves with exercise.’ He turned to Kate. ‘And what else could be noted while we talked to him, Dr. Anderson?’

‘He was coughing!’ She said after she thought about it for a while. ‘And he is a smoker.’

‘That’s right. We need to investigate if his Lambert-Eaton syndrome is a paraneoplastic syndrome. But before that, for teaching purposes…’ He winked. ‘ What disease could be confused with Lambert-Eaton?’ He pimped Kate.

‘Myasthenia gravis.’ He nodded for her to continue. ‘But usually the weakness worsens after repeated activity, and ocular movement symptoms like ptosis are common.’

‘Well done, Kate. You guys are really deserving these muffins.’ He took a bite of a big blueberry muffin. ‘Last question for you then, Dr. Diaz. There are a few other differences between them. Name another one.’

‘Lambert-Eaton may present with autonomic instability, like dry mouth and orthostatic hypotension.’ Dr. Rivers snapped his fingers in approval.

‘So you got all that just because I tripped on the second step?’ Mr. Ethan laughed after we explained to him our conversation.

However, it wasn’t such happy news. We discovered a mass in his right upper lung a few days later, which turned out to be small cell lung cancer. He underwent treatment for a few months but unfortunately did not respond well and ended in Hospice Care.

He had no family so Kate and I decided to visit him one day after clinic. When we got there we saw Dr. Rivers at his bedside and we found out that he visited Mr. Ethan regularly. He didn’t want him to die with no one around.

Want to know more about Lambert-Eaton Myasthenic Syndrome?


Want to read a real case of Lambert-Eaton Myasthenic Syndrome?


Clinical Board
Ab: antibody; S/S: signs and symptoms; Ortho: orthostatic; SCLL: small cell lung cancer; Dx: diagnosis; EMG: Electromyography.

Bonus Board
Ab: antibody; S/S: signs and symptoms; Dx: diagnosis; EMG: Electromyography; Tt: treatment.

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