Review Question - QID 211023

A 4-year-old boy is brought to the pediatrician by his mother who is concerned about progressive leg weakness. The patient used to play outside with their neighbors for hours, but lately, he has been sitting on the sidewalk after 15 minutes because he’s too tired. The patient says his legs are “sleepy.” The patient’s mother had to remove the rugs from the house because the patient kept tripping over the edges. The patient is shy but cooperates well with his siblings and other children. He can say his first and last name and just started counting. His learned to fully walk by 15 months of age. He was hospitalized for bronchiolitis at 12 months of age. He had an uncomplicated orchiopexy surgery for undescended testes at 7 months of age. He has no other chronic medical conditions and takes no medications. He is up to date on his vaccinations including a flu vaccine 2 weeks ago. The patient’s mother has systemic lupus erythematous and his paternal uncle has dermatomyositis. His temperature is 98.7°F (37°C), blood pressure is 102/62 mmHg, pulse is 98/min, respirations are 18/min, and oxygen saturation is 98% on room air. On physical examination, his bilateral calves are large in circumference compared to the thighs. Strength is 3/5 in bilateral quadriceps and 4/5 in bilateral calves. Sensation is intact. Achilles tendon reflexes are 1+ bilaterally. The patient can hop on 1 leg but gets tired after 10 jumps. He has a slight waddling gait. Which of the following is the most appropriate test to confirm the diagnosis?