Clinical Reasoning: A 40-Year-Old Woman With Scapular Winging and Dysphonia

A 40-year-old woman presented to the neuromuscular clinic for evaluation of chronic right shoulder weakness of 1-year duration. During that time, she noticed progressive difficulties lifting her right arm overhead and reaching for objects on the back seat of her car. Around 3 months after the onset of shoulder weakness, she started to develop an intermittent achy sensation behind the right ear and hoarseness of her voice. She noted difficulty talking over loud noises and in phone conversations. She denied vision, taste, or hearing changes, dysphagia, dyspnea, numbness, or weakness in other limbs.

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