A 52 year-old man with a past medical history of an isolated seizure presented to the Veterans Affairs hospital complaining of weakness which was most prominent in the face and upper extremities. About 6 months prior to this admission he developed intermittent episodes of weakness when chewing and swallowing. He would often have to use his hands to close his jaw when eating or talking. He noticed that his voice had developed a nasal quality but he did not have slurred speech. He denied drooling, ptosis, cramping or muscle twitches. He was seen 6 months ago at another VA hospital where a neurologic workup was done. This included a cranial nerve EMG positive for denervation of cranial nerves, R arm and T- and L-spine. MRI and CT scans could not be done because the patient aspirated when supine. He was given a presumptive diagnosis of motor neuron disease, specifically bulbar ALS. At that time he was told he would need a PEG-feeding tube placed due to significant weight loss. The patient refused the feeding tube and did not follow up until 6 months later when the symptoms had worsened.

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