Mr. Sinha, a 44-year-old investment banker, came in complaining of fatigue, clumsiness, and occasional falls. He had been diagnosed with “burnout” by two prior doctors. He was thin, but active. On exam, he had brisk reflexes, fasciculations in his tongue, and subtle weakness in his grip.

I suspected ALS. EMG confirmed it—diffuse denervation and reinnervation patterns. Telling him was the hardest moment of my week. He took it with quiet disbelief, but with courage.

Over the next 18 months, I watched him adapt: a cane, then a wheelchair, then assisted speech. But what stayed constant was his refusal to be defined by it.

The Lesson Learned

Not all fatigue is psychological. Subtle neuromuscular signs often speak louder than patient narratives—examine thoroughly, always.

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