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A lack of a history of trauma and frequent severe bruising raises the possibility of a bleeding diathesis. Disorders of platelet function usually cause immediate bleeding after a procedure whereas coagulation defects cause haematomas and haemarthroses usually with a time delay after trauma. The age of onset of bleeding may distinguish between a congenital and an acquired cause of bleeding. The onset of bleeding in later life suggests an acquired condition. Family history may identify a condition such as haemophilia.

The patient’s renal failure may have been due to hypertension or a primary glomerulonephritis such as immunoglobulin A (IgA) nephropathy. African-Caribbeans are more prone to develop hypertensive renal failure than other racial groups. Antihypertensive medications are needed to treat her blood pressure adequately, oral phosphate binders and vitamin D preparations to control her secondary hyperparathyroidism, and erythropoietin injections to treat her anaemia. The case raises the dilemma of whether dialysis is appropriate in this patient.

Tone, coordination, reflexes and sensation are normal. Bilateral ptosis is present and is exacerbated by prolonged upward gaze. Pupillary reflexes, eye movements and fundoscopy are normal. Questions • What is the diagnosis? • What are the major differential diagnoses? • How would you investigate and manage this patient? 37 100 Cases in Clinical Medicine ANSWER 14 This woman’s generalized weakness is caused by myasthenia gravis. Myasthenia gravis is due to the presence of acetylcholine receptor antibodies causing impaired neuromuscular transmission.

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