On physical examination, the patient’s supine BP was 114/74 mm Hg with a pulse of 74 beats/min. Her upright BP was 90/62 mm Hg, with a pulse rate of 85 beats/min. Her temperature was 37.2°C, respiratory rate was 16 breaths/min, and oxygen saturation was 92% on 1 L of oxygen. Generally, the patient appeared cachectic, chronically ill, and older than her stated age. The pupils were accommodating but nearly unreactive to light. There were three to four beats of vertical nystagmus. The patient had marked temporal wasting and tongue fasciculations. There were no oral lesions or cervical, occipital, or supraclavicular lymphadenopathy. A tracheostomy was in place. The lung fields had poor air exchange, and occasional wheezes were heard. The heart examination revealed regular rate and rhythm without murmurs, rubs, or gallops. The abdomen was remarkable for the presence of a gastrostomy tube and was diffusely tender and slightly distended without hepatomegaly. Neurologic examination was remarkable for global proximal muscle weakness (4/5) and pathologically brisk patellar, biceps, and brachioradialis reflexes. The patient had mild dysmetria. She had normal tone, normal sensation to pin prick, and down-going toes bilaterally.