Module 2 Assignment Case Study: Integumentary System
Module 2 Assignment Case Study: Integumentary System
Module 2 assignment
Case Study: Integumentary System
Part I—”Soaking Up the Sun”
Judy sat up, took a swig from her water bottle, and wiped the sweat off of her face. She glanced at her watch and frowned. Had they only been out here for half an hour? Man, trying to get a good tan was way too much work. She glanced over at Mariah who was sleeping peacefully in her lounge chair. No wonder she looked like a Greek goddess every summer—she enjoyed lying in the sun. Judy decided that her normally pasty-?white skin was tan enough, getting a little red again in fact, and she started to gather her things. Anyway, she reasoned, a dark tan might clash with her red hair.
Judy stopped for a second to scratch her calf. It had been itching for several days now, and she figured that the mosquitoes had really gotten her at the barbecue the other night. Since she was on the ground, she bent her neck to look at it and was surprised to see that it wasn’t a mosquito bite but a mole. She’d had this mole ever since she could remember, but it had never itched before. She looked a little more closely and noticed that the mole looked kind of different than she remembered. It was a little bigger and the edges were sort of jagged. One edge was a bit darker than the other and in the middle was a raised purplish-?black dot that she tried to wipe away but couldn’t. As she was staring at her leg, Mariah woke up. Module 2 Assignment Case Study: Integumentary System
“What are you day dreaming about, your hot date with Tim tomorrow night?” Mariah teased as she rolled on her side, her black hair falling into her eyes.
Judy shook her head, “Ha, ha, I do have more things in my life to ponder. Anyway, I just noticed that a mole on my leg looks kind of weird and it keeps itching.”
Mariah sat up with a concerned look on her face. “Let me see it.” As she looked at Judy’s leg, she said quietly, “Maybe you should go to the clinic.” As Judy stared at her, she continued. “My mom sent me a pamphlet on skin cancer last year. You know, trying to convince me to stop lying in the sun so much. I glanced through it before I tossed it into the garbage. I remember some of the pictures of skin cancer and they kind of looked like your mole.”
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“What are you talking about?” Judy said defensively. “How could I have skin cancer? I’m barely in the sun compared to you.”
“Alright, alright. It’s not like I’m a doctor or something. I just remember those pictures. Come on, let’s just call the clinic so they can check you out. I’m sure they’ll tell you I’m crazy.”
Part II—”The Basics of Cancer”
Judy did a little research about skin cancer on the Internet before her doctor’s appointment the next morning. She learned that most cases occurred in people who were significantly older than she was. It didn’t make sense that it would happen to her—she was only 20 years old!
The articles talked about how UV light from the sun causes mutations in your DNA. Accumulation of DNA mutations over many years can cause certain cell cycle genes called “proto-?oncogenes” to become super-?active. Judy actually felt thankful for the college biology course she had been forced to take. She knew that DNA was the hereditary material that acted as a “blueprint” for everything our cells make and that a gene is a piece of DNA that contains the instructions for making a single protein. However, she would have to ask the doctor about these proto-?oncogenes.
In the examining room, Dr. O’Brien was silent as he looked at the mole on her leg. Finally, he said kindly, “I want to do a biopsy. All that means is we’ll remove your mole and look at the cells under a microscope and see if they look abnormal.” Module 2 Assignment Case Study: Integumentary System
Judy could feel the tears welling up in her eyes. “You mean you can tell if I have a tumor by just looking at some cells?”
“Whoa, slow down a minute,” Dr. O’Brien replied calmly. “It’s very possible that your cells will look completely normal. And to clarify something, a tumor is not necessarily the same thing as cancer.” She looked confused, so he continued. “A tumor means that cells have divided and piled up on one another in a single mass. But not all tumors are automatically cancerous and life threatening. A benign tumor is a mass of normal-?looking cells. These tumors are not considered cancer and they’re usually relatively easy to treat—we just remove them. On the other hand, a malignant tumor is a mass of abnormal cells whose growth cannot be controlled by the regular mechanisms. In addition, malignant tumors often spread to other parts of the body instead of just staying in one spot. We call this process metastasis. Malignant tumors are cancerous and, therefore, a very serious condition. To treat them, we have to remove the cancerous cells that we find and then do chemotherapy treatments to be sure to kill all the cancer cells that we may have missed surgically.”
“So, if I have cancer, is it from these proto-?oncogenes that I read about on the Internet?”
The doctor smiled and seemed pleased that Judy had been reading about this on her own. “Let’s back up for a minute. You see, we have tens of thousands of genes in our cells, but it’s not like mutations in just any of them will lead to cancer. The genes that get mutated and can cause cancer are of a specific type called cell cycle genes. Everyone has a set of cell cycle genes in each of their cells that code for cell cycle proteins. Cell cycle proteins control if and when cells divide. Sometimes we need to make more cells in our bodies, and some of these cell cycle proteins allow that normal process of cell division to occur. At other times we don’t want the cells to divide, so different cell cycle proteins inhibit cell division then. In normal, healthy cells, the formation of the cell cycle proteins is tightly controlled so the activating proteins are only made when we really need more cells and the inhibitory proteins are only made when we don’t need more cells. However, mutations (or alterations) in these genes can eliminate this tight regulation and lead to uncontrolled cell division. This is what happens in many types of cancer: a normal cellular process, cell division, is no longer properly controlled.” Module 2 Assignment Case Study: Integumentary System
Judy thought for a second. “Okay, but you still didn’t say what these proto-? oncogenes are.”
“Oh yes, sorry. The activating class of these cell cycle genes consists of the proto-? oncogenes. The normal job of these genes is to code for proteins that promote cell division. Certain mutations in proto-? oncogenes result in proteins that are active all the time, causing cells to divide continuously. But let’s not get ahead of ourselves— we won’t know if your mole is even cancerous until we do the biopsy.”
When Judy didn’t say anything in response right away, Dr. O’Brien continued, “I know this is all a bit confusing, but it’s good that you’re asking these questions. We’ll make sure that you understand this a little better before you leave today.”
Just then a nurse knocked and entered the room. He needed Dr. O’Brien for a minute. At least Judy would have a minute to gather her thoughts.
Part III—”Like Mother, Like Daughter?”
Dr. O’Brien had handed Judy a pamphlet on melanoma before he left the room.
As she started reading it, Judy realized that this is what they were going to test her for. Melanoma is a type of skin cancer that starts in your melanocyte cells, or the pigment cells of your skin. Actually, a mole is just a clump of melanocytes. There were pictures of cancerous moles in the pamphlet and one of them looked a little like hers, only bigger. She was starting to get worried. Below is part of what she saw:
“Images retrieved from the National Cancer Institute at the National Institute of Health”
Dr. O’Brien returned just then and apologized for the disruption. “Do you have any more questions?”
“Well, I just don’t understand how it’s possible for a 20-year-old to get cancer. Isn’t cancer an old person’s disease?”
“You’re right that most cancer patients are older. That’s because you accumulate mutations in your genes over time. UV light, cigarette, smoke, other chemicals, and even aging itself can cause mutations in genes. The kind of cancer that we’re checking your mole for is melanoma. This is the most common cancer in people aged 25 to 29 and is the fastest- growing category of cancer, increasing four percent each year. You are a bit young, but you may be genetically predisposed to melanoma.”
“What does that mean?” Judy asked.
“Well, remember the cell cycle genes that we were talking about earlier? I described the proto-oncogenes as being needed for activating cell division. Well, remember that I also mentioned a class of cell cycle genes that prevent cell division. These genes are called tumor suppressors. You usually have two good copies of each of these tumor suppressor genes, but sometimes you inherit one good copy and one mutated copy. Basically it means that, along with inheriting genes for your red hair or blue eyes, you may have inherited a mutated cell cycle gene. You had it when you were born, so it’s not the result of lying in the sun too much or anything like that. But for these types of genes to lead to cancer, you need to have both copies of the gene mutated. One good copy is sufficient to prevent your cells from dividing aberrantly. So you can be born with one mutated copy, but not actually get cancer unless the other copy accidentally gets mutated sometime during your life. Mutations in the second copy could be the result of UV light from the sun, like in the case of melanoma. Since you may have been born with one mutated copy already, you are “predisposed” to getting cancer. You are one step closer to getting cancer compared to someone who doesn’t have a mutation. We see a genetic, or hereditary, component in about five to 10 percent of melanoma cases. Do you know if anyone in your family has had melanoma?”
Judy shook her head, “I’m pretty sure that my dad hasn’t, but my parents split up when I was young and I haven’t really talked to my mom in the last 10 years. I thought I heard that she had some mole thing removed a long time ago, but I didn’t think that it was cancer. Module 2 Assignment Case Study: Integumentary System
The doctor said, “You might want to call her. Now, let’s get this biopsy done and hopefully prove that all this talk about cancer is unnecessary.”
Part I—”Soaking Up the Sun” Questions
1. What are some differences between Judy and Mariah that might make Judy more “at risk” for skin cancer than Mariah? (2 points)
2. What observations did Judy make concerning her mole? How could they have used the ABCDE’s of skin cancer assessment to further assist their observations? (2 points)
3. Should Judy be concerned? Why or why not? (2 points)
Part II—”The Basics of Cancer” Questions
1. Considering the differences between a benign tumor and a malignant tumor, why might a benign tumor be easier to treat? (3 points)
2. Judy learned that every single person has these cell cycle genes so cells in our body can divide when necessary. What are some normal circumstances where our bodies might need to make more cells? Why is the skin continuously replacing its main cell and what specific damages to the skin would there be a need to make more cells? (3 points)
3. Every person has these cell cycle proto-oncogenes, but not every person has cancer. Why might this be the case? (3 points)
Part III—”Like Mother, Like Daughter?” Questions
1. Now that you know a little more, what are the risk factors that increase a person’s chances of having melanoma? Besides the ABCDE’s, what other signs/symptoms can melanoma present with on a patient? (2 points)
2. How does sunlight contribute to the development of melanoma? (2 points)
3. What does it mean to be predisposed to getting cancer? If you inherit a mutated cell cycle gene, does that automatically mean that you will get cancer some day? If you inherit a mutated cell cycle gene and participate in risky behaviors such as sunbathing, does that mean that you will automatically get cancer some day? (4 points)
4. What is the prevalence and occurrence for Melanoma? What are the treatment options and success rates for melanoma? (2 points)
Module 4 assignment
Case Study: Bone Tissue
Part I—“Marissa”
Marisa, a petite, Caucasian, 15-year-old, just learned this morning that her 55-year-old grandmother, with whom she has lived since the death of her parents, was diagnosed with osteoporosis after visiting her doctor because of chronic hip and wrist pain. For the past year, Marisa’s life has been one tragedy after another. Her happily married parents were killed in a car crash nine months earlier on the way home from their 16th anniversary surprise party. Her boyfriend of two years moved to a different state a few months back and ended their relationship shortly after. To make things worse, her first year in high school was disastrous. Not only did she fail algebra, she didn’t make the soccer team, as she had hoped.
Marisa’s grandmother lives far from where Marisa used to, and because she is an only child, Marisa often finds herself feeling lonely and on the brink of depression. The only person she feels she can count on besides her grandmother is her best friend, Tara. She told Tara about her grandmother’s disease as soon as she found out. Marisa has no idea what osteoporosis is or what it does to the body. All she knows is that her grandmother is the only close living relative she has and she can’t fathom losing another loved one. Module 2 Assignment Case Study: Integumentary System
Part II—“Jeremy”
Jeremy, a lanky, 19-year-old college sophomore, has recently become interested in weightlifting thanks to his friend, Sebastian. He wants to improve his physique, strength, and self-esteem, and impress his girlfriend. Jeremy has been taking asthma medication since the age of seven and he hopes the exercise will also help to improve his condition, which seems to have slightly worsened over the years. Throughout high school, Jeremy was always teased for being scrawny. Once he entered college, he wanted to put the past behind him. He soon discovered alcohol and its ability to bring people together. Jeremy drank more than his share freshmen year and had a belly to show for it.
Over the summer, he met Sebastian at his restaurant-catering job. Jeremy immediately noticed how muscular Sebastian was and asked him if he lifted weights. The two soon developed a friendship and became gym buddies, and Sebastian recommended a personal trainer for Jeremy.
Jeremy returned to school in the fall in better shape and promised himself to cut down on the drinking. His personal trainer had told Jeremy that he had small bones for a guy and alcohol would only aggravate the problem. Perhaps he should follow his lead and start taking steroids to bulk up. Jeremy wondered what he meant and intended to ask his biology professor.
Part III—“Eleanor”
Eleanor, a 45-year-old perimenopausal (aka: premenopause) woman, is considering hormone replacement therapy mainly to prevent osteoporosis. Lately, she has been experiencing severe hot flashes and nausea. In addition, her back has been sore on and off. Eleanor has smoked for the past 20 years and has a family history of breast cancer and heart disease. Although she vows every New Year to quit her costly habit, she has yet to follow through completely.
Two years ago, Eleanor’s mother underwent a double mastectomy after her struggle with breast cancer. The experience was a slap in the face for Eleanor and she vowed to take better care of herself. Aside from smoking, she eats healthier now and doesn’t drink. Her husband is an avid walker, and every morning before work they both walk around the park with Tosha, the family Labrador. Everywhere she turns, Eleanor is reading about hormone replacement therapy (HRT) and women’s health. Although she worries how her body will respond to HRT, she doesn’t want to risk her bone health like her 58-year-old neighbor, Janice.
Janice refused her doctor’s advice about taking HRT a few years back and now walks with a cane. Eleanor has lately felt the pressure building to make a decision about HRT. She wants to stay healthy for her husband and 25-year-old son, Chad, but is unsure of the consequences of HRT. She’s heard that it might have some bad effects.
Module 04Case Study: Bone Tissue
Part I— “Marissa” Questions
1. Describe bone tissue and the role each component plays in bone physiology and remodeling. What is the difference between compact and spongy bone? (2 points)
2. Explain the relationship between calcium and bones. (1 point)
3. Explain how the body controls calcium levels in the bones and blood. Be sure to describe the roles of parathyroid hormone (PTH) and calcitonin in detail. (2 points)
4. Explain specifically how osteoporosis affects the bone matrix and the normal bone remodeling cycle. (1 point)
5. Discuss what scientists know about the genetics behind osteoporosis.(1 point)
6. List at least 5 controllable and 3 uncontrollable risk factors for this disease. (1 point)
7. What are the symptoms or telltale signs of osteoporosis? (1 point)
Part II— “Jeremy” Questions
1. What foods are good sources of calcium? (1 point)
2. Discuss the importance of Vitamin D to calcium absorption. (1 point)
3. Discuss calcium supplementation and the recommended daily dosages. (1 point)
4. Discuss the effects of sodium, caffeine, and alcohol on calcium levels in the body. (1 point)
5. Explain what peak bone mass is and its relationship to osteoporosis. (1 point)
6. Describe the types of exercise that help prevent osteoporosis. Why? (1 point)
7. What are steroids? What are some examples of steroid prescription medications? What are they used for? (1 point)
8. Explain how long-term use of steroids may increase risk for osteoporosis. (1 point)
Part III— “Eleanor” Questions
1. Define “perimenopausal” and explain how menopause affects a woman’s hormonal levels of estrogen and progesterone. (1 point)
2. Explain how estrogen affects calcium levels in bones.(2 points)
3. Explain how smoking affects estrogen levels. How does this in turn affect calcium levels? (1 point)
4. What is HRT? Who is it intended for? (1 point)
5. In general, and based on medical studies, what are the pros and cons of HRT? (2 points)
6. Describe at least two other drug options available to men and women to help prevent and/or treat osteoporosis. (1 point)
Module 6 assignment
Case Study: Articulation and Nerve Tissue
Part I—“Jill”
Jill was a senior and the star player on her high school basketball team, the Cardinals. It was the last game of the season and not only were the Cardinals playing their rivals, the Spartans, their undefeated record for the season was on the line. Also, Jill was only 23 points away from becoming the girl’s basketball all-time scorer for the Cardinals. She was needless to say excited, but yet very nervous about the game.
It was only a minute left in the 2rd period, Jill was dribbling the ball down the court when at about mid-court she made a move on the defensive player and ultimately tripped over The Spartans’ defender. As Jill fell she twisted her left ankle and stayed down clutching that ankle. At this point the Cardinals were up by 6 points and Jill had 14 points. As the team trainer ran out on the court to examine Jill’s ankle she was already trying to get up. The team trainer helped Jill to the Cardinals’ bench. Jill sat out the rest of the period and had some work done on her ankle at halftime. Module 2 Assignment Case Study: Integumentary System
Jill returned to the game at the beginning of the 3rd period with her ankle wrapped but still had a noticeably slight limp. She was still an effective basketball player even with her injured ankle and with the undefeated season plus the all time scorer record on the line, it would have taken much more to have her sit out the rest of the game.
One minute into the 4th period, Jill got a quick rebound and made a fast break to their hoop. As she jumped up for what she thought was an easy lay-up a Spartan defender came rushing in and bumped into her and because of it Jill landed awkwardly on her left side again. She instantly fell to the ground and was obviously in a lot of pain. Everyone in the stands held their breath thinking she re-aggravated her left ankle but everyone watching the game realized it was much worse.
By the time the team trainer got to Jill, he could see that the left knee was completely swollen and knew this wasn’t good. The trainer had a good sense of what happened but didn’t want to upset Jill any further by telling her. He and a few others helped her up and took her back to the locker room.
In the locker room, they instantly got ice on Jill’s left knee and informed her she would have to schedule an appointment with her doctor as soon as possible and to continue icing her knee all weekend long (it was Friday night). The trainers got Jill some crutches to use and she knew this was bad; it was just a matter of how bad was it.
At her doctor’s visit on Monday, Jill’s left knee was still swollen and in a lot of pain. The doctor performed a few knee orthopedic tests and had a positive Lachman’s test. She also took an X-ray, which was negative for any fractures or pathology. The doctor referred Jill out to have an MRI of her left knee in one week, to continue using crutches and take ibuprofen for the pain and swelling.
Jill asked her doctor why she had to wait a week to have the MRI and what she thought was wrong with her knee.
Part II—“Kathy”
Kathy, a 30-year-old woman, awakens one morning to a tingling, numb sensation covering both of her feet. This has happened to her a number of times throughout the year. In the past, when experiencing this sensation, within a couple of days to a week the numbness would subside, and so she is not too concerned. About a week later, she notices that the numbness and tingling not only persists, but has also spread up to her knees. Again, she ignores the abnormal sensation. By the end of a month’s time, the numbness spreads to the midline of her body. At this point, she becomes alarmed.
Kathy sees the nurse at her college who tells her that she should see a doctor. Kathy calls her doctor’s office to schedule an appointment, but the soonest slot is in two weeks. She makes the appointment and goes about her daily routine.
The next morning, Kathy wakes, but when she attempts to get out of bed, she comes crashing to the floor. Because she is still groggy from sleep, she doesn’t really understand what has just happened. As she tries to stand up, the muscles of her left leg engage, but as she also attempts pushing up with her right leg, she again falls to the floor. She sits in bewilderment as she tries to make sense of what has just happened and realizes that she has seriously scraped her knee in her fall. She does not feel the pain from her wound. She also notices that she has blurry vision in her right eye and thinks that’s the reason she has fallen twice.
Sitting there, trying to focus on something that can help her stand up, she realizes that isn’t the first time she has had blurry vision. About two months ago, it was her left eye that she had trouble seeing out of it and thought it was because of eye strain from staring at her computer screen so much as she was trying to finish up a project for work. Now she doesn’t know what to think.
Kathy thinks about how odd this year has been. She also remembers another medical issue she had earlier in the year when she had lost hearing in her right ear and wonders if there is a connection to her current condition. At that time, Kathy
underwent extensive testing, but the ear, nose, and throat specialist remained baffled. He thought that a severe inner ear infection could have destroyed her ability to hear on that side, but there was no conclusive evidence to support this. In an attempt to recover any hearing he could, the doctor prescribed very high dosages of steroids; he told Kathy that she probably wouldn’t see a change, but there were rare occurrences where steroids helped. To both Kathy and her doctor’s surprise, after about a week of steroids, she completely regained hearing in her right ear. It was a “miracle.”
Kathy wonders whether she can count on a new miracle to heal her current medical issues.
Module 06 Case Study: Articulations and Nerve Tissue
Part I— “Jill” Questions
1. What is the difference between a tendon and ligament? (1 point)
2. What bones form the articulation (joint) of the ankle? Did Jill most likely sprain or strain her ankle? Explain your reasoning and the difference between the two? (1 point)
3. What are the four major ligaments of the knee along with their individual function in respect to the femur? (1 point)
4. If you were the trainer that initially saw Jill after her fall, describe what her knee probable looked at (Hint-inflammation). Why did the trainers put ice on her knee right away? (1 point)
5. What did a positive Lachman’s test signify? What are some of the other orthopedic tests the doctor most likely perform on Jill’s knee? (1 point)
6. Why didn’t the X-ray demonstrate (show) anything wrong with Jill’s knee? Why did the doctor order an MRI and what was the doctor’s reasoningto wait a week before doing the MRI? (1 point)
7. Besides damage to the ligament(s), what other anatomical structures could the MRI demonstrate (show) damage to? (1 point)
8. Describe the procedure of arthroscopic knee surgery. What should a patient expect after arthroscopic reconstructive ligament surgery- recovery time, strength/stability of knee, long-term complications? (1 point)
Part II— “Kathy” Questions
1. What components of the nervous system are involved in physical sensation? How does sensory impulse move throughout the body? (1 point) Module 2 Assignment Case Study: Integumentary System
2. What components of the nervous system are involved in skeletal muscle movement? How does motor impulse move throughout the body? What is a “motor unit”? (1 point)
3. What movements are involved in the action of standing up? What muscles need to contract to perform these actions? (1 point)
4. What are the different levels of organization of a muscle down to myofilaments? What is a “sarcomere” and how are its proteins organized? (2 points)
5. Starting from the release of acetylcholine by the motor neuron, what are the steps in muscle contraction? How is contraction ended? (2 points)
6. Are Kathy’s medical problems related to her sensory neurons, motor neurons, or both? What in Kathy’s medical history supports your answer? (1 point)
7. What is the diagnosis to Kathy’s condition, it’s prevalence, the prognosis and how is it treated? What other conditions/diseases could it have been? (1 point)
8. What is myelin and how does it affect the transmission of nerve impulses? Identify the cells responsible for the formation of myelin. (2 points)
9. What happens to the myelin in Multiple Sclerosis? (1 point)
10. How does an MRI and spinal tap help confirm the diagnosis of Multiple Sclerosis? (1 point)
11. Why would steroids help alleviate Kathy’s symptoms? (1 point)
12. Why did Kathy experience the altered sensation in her lower body? Was there something wrong with her skin? Why couldn’t she stand? Was there something wrong with the muscles of her right leg? (2 points)
13. Could Kathy’s blurred vision and hearing loss be related to Multiple Sclerosis? (1 point)
Module 8 assignment
Case Study: CNS Movement
Disorders
Part I—”Harry”
Harry is in his mid-40’s. He has come to his doctor reporting general weakness, particularly in his lower extremities. When he enters the doctor’s office, he is obviously clumsy “Gee, I guess I shouldn’t have that third martini at lunch,” he jokes. However, the physician’s assistant (PA) who takes him back to the examination room notices that his speech is slurred.
In taking his medical history, the PA notes that Harry has had a six-month-long problem with extreme fatigue and he has lost significant weight. In fact, his upper body appears to have nearly wasted away. When asked why he came in, Harry tells the PA that he has had difficulty in combing his hair, writing, climbing stairs, and climbing up and down out of his truck. His arms have become increasingly weak, and he has also experienced increasing trouble getting dressed (zipping and buttoning his jeans is beyond him).
As the PA speaks with Harry, he notices that Harry’s tongue is moving strangely; it keeps writhing and twitching. During the physical examination, Harry gags on the tongue depressor (when it is only touching his lips!) and he has difficulty swallowing. He also shows an abnormal Babinski reflex: his toes fan out when the bottom of his foot is stroked. While the remainder of his reflexes is normal, Harry shows pronounced muscle weakness and abnormal spasticity—mostly in his legs, but also in his arms, though to a lesser degree.
Based on the report from his PA, the doctor decides to order a series of tests, including an MRI and EMG. While the MRI comes back normal, the EMG is quite abnormal; it indicates denervation. A blood test indicates an abnormally high level of glutamate.
Part II—”Keith”
Keith is a 35-year-old male Caucasian. While he had had a seemingly normal childhood and graduated high school with a 3.9 GPA, things began to slide downhill after that. His grades began slipping in college and he barely graduated with a 2.0 GPA. It was at that time that he began to experience strange finger twitches, facial contortions, and random jerks of his arms. His doctors tried various treatments.
Surprisingly enough, antipsychotics seemed to help with the odd movements for a while.
After graduation, Keith’s personality changed completely. He became nearly a hermit, had significant difficulty making eye contact, and barely answered when spoken to. He started working at McDonald’s at the age of 24. During that year his coworkers noticed that he became steadily more and more uncoordinated.
He began dropping things with regularity, and seemed to have difficulty walking smoothly. He eventually was fired from his job, apparently for failing to appear at work as needed and being totally ineffective when he did appear.
By the age of 28, he was in a doctor’s steady care, exhibiting a host of symptoms including dysarthia, stiffness, and ataxic gait. By the age of 30 he had developed dementia of a type typically expected in much older men. Regrettably, this required that he be placed in a nursing home.
A wide battery of tests yielded the following results:
• No indications of cancer, tumor, or other such conditions.
• He scored quote low on a mini-mental status exam.
• He continued to show dysarthria, combined with an increased muscle tone in all extremities and a wide-based ataxic gait.
• A DNA test yielded a positive result for an inheritable disease, although his one sister was found to be negative on the same test.
• Antipsychotics seem to control some of his dementia symptoms while botulinum toxin helps with some of Keith’s dystonia.
Part III—”Jim”
Jim is 70 years old and still working as a university professor. A few years ago, he started to notice uncontrollable hand and arm shaking after taking a new antihypertensive drug called Serpalan®. His physician put him on another regimen to control his hypertension, but he continued to have subtle movement problems. While his hands and arms no longer shook, he did notice an odd twitch in his shoulder, which eventually progressed to a noticeable tremor in his right arm and leg. Jim’s doctor diagnosed this as being due to the stress of his job, and advised that he take a vacation. Luckily, it was the end of spring term and Jim had no commitments for the summer.
Jim took a long, relaxing summer off, but after returning to work both he and his students noticed that his handwriting had become nearly illegible. He also began having problems cutting his food at dinner, and getting his morning cup of coffee to his lips was a trial. However, he insisted that this was due to stress and that “shakiness has always run in my family.”
His doctor insisted on a neurological exam, which yielded the following results:
• Normal gait
• Mild voice tremor and mild bradykinesia
• Mild intention tremor of the arm
• Rigidity of his limbs and trunk (intermittent)
• Normal MRI and EEG
Part IV—”Mike”
Dr. Green and Dr. Carter were nearing the end of the first year of their medical residency in the emergency department of County General Hospital. It had been a long year and a long week. They had been on duty for the last 12 hours and things were not slowing down.
“What are your plans for the weekend, Ken?” Dr. Green asked.
“Sleep, what else?” Dr. Carter replied.
“I hope things slow down a bit,” Dr. Green said to himself.
Suddenly, a call came over the radio. Paramedics were bringing in a young man with injuries sustained in a diving accident. A minute later, the doors to the department burst open and the paramedics wheeled in a young man.
“What gives?” Dr. Green asked.
The senior paramedic, Jim Morrison, reported that the patient was swimming at the local quarry and did a forward flip into the water, striking some submerged rocks.
“Which part of his body struck the rocks?” asked Dr. Carter.
“He was in a hyperflexed-tucked-position when he hit the rocks, lacerating the right side of his head and neck and upper back. The patient indicated he had severe pain upon impact and loss of sensation and movement in his arm and leg.
He may have lost consciousness, but he’s not sure. He also complains of a severe headache, dizziness, and nausea. When we arrived at the scene we immobilized, stabilized and transported him immediately,” Jim explained.
Looking at the patient, Jim continued. “His name is Mike Smith, and he’s 22 years of age. His vital signs include slightly lowered blood pressure (100/70), heart rate of 75 beats per minute, respiration normal, and he is conscious and alert.”
As the patient was being prepped for examination, Dr. Carter and Dr. Green discussed how they should approach their evaluation. Dr. Carter started by saying, “After seeing the head wound and the amount of blood loss, and hearing his complaints, I want to confirm my suspicion that this patient has a brain injury.”
Dr. Green disagreed: “I think that the other signs and symptoms indicate a spinal cord injury, and that’s what we should investigate.”
The following table summarizes the findings of the evaluation, which included a physical exam, x-rays, magnetic resonance imaging (MRI), and neurological test:
(see next page)
Summary of Diagnostic Testing on Mike Smith
Sensory Testing
• Decreased sensation to touch, pressure, and vibration in the right upper/lower extremities
• Decreased temperature discrimination (cold vs. warm) in the left upper/lower extremities
Motor Testing
• Decreased strength and movement of the right upper/lower extremities during muscle testing
• Decreased strength and movement of left abdominal muscles
• Absence of triceps and biceps reflexes in the right upper extremity
• Abnormal response of patellar, Achilles (hyper) reflexes in the right lower extremity
• Positive Babinski sign on the right foot
• Abnormal cremasteric reflex in the right groin region
General Examination
• Abnormal pupil response of right eye (constriction)
• Other vital signs within normal limits
• Cognitive testing normal (counts backward from 100 by 7s; knows name, date, place)
X-ray and MRI Examination
• No fractures present in the skull
• Fracture in the 7th cervical vertebra
• Significant swelling present in the spinal canal in the C7-T2 region
• Spinal cord appears to be intact
Module 08 Case Study: CNS Movement Disorders
Part I—”Harry” Questions
1. What condition or conditions (disease/diseases) could Harry have as described in this case? Which one would be your primary diagnosis?In a very general explanation, describe this condition/disease. (1 point)
2. Which patient findings/observations lead you to your primary diagnosis? How do they relate to the primary diagnosis? (1 point)
3. How does this condition (pathophysiology) affect the body and lead to the observable symptoms and dysfunction? Be specific in the areas of the CNS it affects. (1 point)
4. What treatment options are available for this condition?(1 point)
5. What is the prevalence and prognosis of this condition?Is it an inheritable (genetic) condition/disease? (1 point)
6. What types of care and health care support will Harry have to possibly depend upon in the future? What preparations should Harry make? (1 point) Module 2 Assignment Case Study: Integumentary System
Part II—”Keith” Questions
1. What condition or conditions (disease/diseases) could Keith have as described in this case? Which one would be your primary diagnosis?In a very general explanation, describe this condition/disease. (1 point)
2. Which patient findings/observations lead you to your primary diagnosis? How do they relate to the primary diagnosis? (1 point)
3. How does this condition (pathophysiology) affect the body and lead to the observable symptoms and dysfunction? Be specific in the areas of the CNS it affects. (1 point)
4. What treatment options are available for this condition?(1 point)
5. What is the prevalence and prognosis of this condition?Is it an inheritable (genetic) condition/disease? (1 point)
6. What types of care and health care support will Keith have to possibly depend upon in the future? What preparations should Keith make? (1 point)
Part III—”Jim” Questions
1. What condition or conditions (disease/diseases) could Jim have as described in this case? Which one would be your primary diagnosis? In a very general explanation, describe this condition/disease. (1 point)
2. Which patient findings/observations lead you to your primary diagnosis? How do they relate to the primary diagnosis? (1 point)
3. How does this condition (pathophysiology) affect the body and lead to the observable symptoms and dysfunction? Be specific in the areas of the CNS it affects. (1 point)
4. What treatment options are available for this condition?(1 point)
5. What is the prevalence and prognosis of this condition?Is it an inheritable (genetic) condition/disease? (1 point)
6. What types of care and health care support will Jim have to possibly depend upon in the future? What preparations should Jim make? (1 point)
Part IV—”Mike” Questions
1. Based upon the findings presented, which doctor made the correct initial prediction? (1 point)
2. Based upon previous knowledge of brain function, what results from the testing were consistent with a brain injury? (2 points)
3. Based upon previous knowledge of spinal cord function, what results from the testing were consistent with a spinal cord injury?(2 points)
4. Based upon previous knowledge of CNS function, what results could be consistent with both types of injury? (2 points)
Module 10 assignment
Case Study: Endocrine System
Part I—”Frustration”
Ellie dropped her backpack beside the chair in Dr. Kern’s office and sat down with a sigh. Her hands trembled as she glanced again at the graded exam in her hand.
“It’s no better than the last one,” she mumbled. “I really, really tried this time, Dr. Kern. I did all the reading assignments before and again after class. I completed all of the study guide questions and rewrote my notes and made flash cards and studied with straight-A Cassie every week. But it didn’t make any difference. I still failed it.” She sniffled loudly and reached for the box of tissues on Dr. Kern’s desk.
Dr. Kern sat back and thought for a moment while Ellie made use of several tissues. Ellie was a junior in Dr. Kern’s physiology course and had struggled from the start of the semester. One-on-one help sessions and different study strategies hadn’t seemed to help. “I know how discouraged you must be, Ellie. Tell me again what you do when you sit down to study.”
“I read and review my class notes and reread the assigned sections in the book. But for some reason I can’t concentrate on much of anything for very long and, even when I can, I don’t remember what I’ve studied by the next day. It’s so frustrating to spend so much time studying and not retain anything. If I fail this class, my GPA might drop enough that I’ll lose my scholarships. I’m so stressed that I can’t sleep, even when I try.”
Ellie broke off, and Dr. Kern gently tried to encourage her. “Let’s not give up hope yet. Sometimes you have to use new study methods for a while until you start to see some benefits. Let’s also take a look at your exam and see if there’s a pattern in the questions you missed.”
Ellie sniffled again. “OK, but I’m not very hopeful. I’ve been thinking about changing my major. All these upper-level courses seem so hard … there’s so much to learn in such a short time and I just don’t seem to get it even though everyone else does. I can’t stand the stress anymore.”
“Perhaps talking this over with your parents or a trusted friend would help,” Dr. Kern suggested. She noted Ellie’s strikingly large blue eyes that gave her a permanent look of surprise. Ellie was also quite thin, almost to the point of being too thin. Dr. Kern paused and chose her words with care. “I also know there are terrific folks over at the health center who are experts in how to deal with stress.”
Ellie gave a small, noncommittal smile and pushed a shaking hand through her hair. “Thanks, I’ll think about it. See you in class on Monday.”
However, Ellie didn’t come to class on Monday or Wednesday. She emailed Dr. Kern that she most likely had a sinus infection and would miss class on Friday to see a doctor. Dr. Kern shook her head at Ellie’s misfortune; missing a week of class was not going to make it any easier for Ellie to pull up her grade.
Part II—”Health Center”
Ellie sat in a small exam room of the student health center, feverish and with a throbbing headache. A sinus infection right before midterms was not what she needed.
Dr. Simmons entered in a rush and took a quick look at her chart. “Hmm … fever, headache, green nasal discharge that you’ve had for two weeks. Sounds like your sinuses have been invaded by something nasty. Does this hurt?” He pressed his thumbs on Ellie’s cheeks, which nearly sent her through the ceiling. “Yep. Let’s try some antibiotics to clear that up.”
He reached for his prescription pad, but stopped and glanced at Ellie’s face again. “Your eyes protrude a bit. Have they always been that way?” He turned her face to look at her profile and frowned slightly.
Ellie had no idea what her eyes had to do with her sinus infection. “I haven’t noticed. But I’ve been so stressed lately that I don’t notice a lot of things.” She paused and then continued, “My little brother did start calling me ‘Bug Eyes’ this summer, but he’s just an annoying 10-year-old.”
Dr. Simmons nodded and then gently palpated her neck. He looked at her chart again. “Your blood pressure and pulse are elevated. Your fever might account for that, but there could be something else going on here.” Ellie felt a small knot form in her stomach. This was supposed to be a simple sinus infection, nothing more.
Dr. Simmons began to fire questions at her. Did she have trouble sleeping? Did she often feel nervous or “jittery”? Had she lost weight recently? Did she often feel like the room was too warm? Did she have frequent bowel movements or diarrhea?
Ellie’s head spun. “Uh, y-yeah, but I’m just stressed, you know, with classes. Aren’t all those things just signs of stress?”
“They certainly can result from stress, and I see a lot of students where that is the case. However, there is a slight swelling in the front of your neck. That combined with your other symptoms suggests that perhaps your thyroid gland isn’t functioning quite the way it should. I’d like to take a look before we assume your symptoms are all due to stress. Let’s start with some simple blood tests and see what we find.”
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He scribbled a lab order and smiled kindly. Ellie grabbed the papers and left, feeling worse than when she first came in.
Part III—”Thyroid Trouble”
Once again, Ellie sat in the exam room waiting on Dr. Simmons. He flew in the door, grabbed a stool and, to Ellie’s relief, got right to the point. “Well, your blood work does show some problems with your thyroid. Your TSH levels are lower than they should be, your T4 levels are a bit high and your T3 levels are very high.
Those results suggest that you might have Graves’ disease, which means that your thyroid is releasing too much thyroid hormone. Since thyroid hormones are responsible for your metabolic rate, that explains why your heart rate and blood pressure are elevated, why you’ve felt nervous and can’t sleep, and why you’ve lost weight even though you aren’t dieting.”
Ellie’s mind whirled. “Sooooo, could this also be why I can’t concentrate when I try to study and why I can’t seem to remember anything?” Maybe there was still some hope for her in Dr. Kern’s physiology class.
“Well, maybe,” Dr. Simmons answered. “Some studies suggest that excess thyroid hormone is correlated with decreased attention, concentration, and working memory. In other words, your thinking might not be as clear as it should be. However, other experts argue that it’s the anxiety and nervousness that cause patients to feel their thinking is impaired, even though there is no actual impairment. The good news is that with treatment patients report an improvement in their cognitive abilities, regardless of the underlying cause.”
Ellie felt a twinge of relief. “Oh, good! That will certainly help my grades. But why is my thyroid releasing too much hormone? And you said my TSH levels were low. Isn’t TSH a thyroid hormone? If my thyroid is too active, shouldn’t it be high instead of low?”
Ellie has just asked some very good questions. If you were Dr. Simmons, how would you answer her?
Part IV—”Options”
Dr. Simmons continued. “I’m going to refer you to a local endocrinologist, someone who specializes in disorders like this. She will probably order a radioactive iodine uptake test and a thyroid scan to confirm that you have Graves’ disease and determine the best way to treat it.”
At Ellie’s look of alarm, he explained. “Don’t worry … the amount of radioactivity is very small and not harmful, so you won’t start to glow. The thyroid gland incorporates iodine into its hormones, and if we tag the iodine with radioactivity, we can measure the amount of iodine taken up by the thyroid.”
Ellie jumped in. “And if my thyroid is overactive, it will use more iodine than it should, right?”
“Exactly,” responded the doctor. “Assuming that your uptake is elevated, there are several ways to treat your condition. Unfortunately, we can’t cure it. However, there are some medications that can help, and another procedure that involves radioactive iodine. Surgery to remove the thyroid is also an option, although not a common one anymore. The endocrinologist will evaluate your test results and help you choose the best treatment. Until then, I’m going to prescribe a beta-blocker that should help lower your heart rate and reduce that nervous feeling you’ve had.”
Several weeks later, Ellie dropped her backpack beside the chair in Dr. Kern’s office and sat down with her latest physiology exam and a smile. “I think there’s hope!” “I agree. Tell me about this dramatic turn-around,” Dr. Kern smiled in return. Ellie was still very thin and her blue eyes startlingly wide. However, the fidgeting and shakiness were gone and the overall impression was one of calmness and purpose.
Ellie explained how a sinus infection led to discovery of her thyroid disorder. “I’m taking some medication now until the radioactive iodine treatment becomes effective, and I feel so much better. I can sleep, I can concentrate, and I think I can pull up my grade enough to pass the course!”
Dr. Kern smiled again. “So often signs of stress are just that, but occasionally there is another explanation. I’m so glad you found out what was going on sooner rather than later, and I’m sure this will reduce your stress levels even further. We’ll look for even better results on the next exam.”
Ellie laughed. “Oh, it covers the thyroid gland. I think I can ace that part!”
Module 10 Case Study: Endocrine System
Part I—”Frustrated” Questions
1. Please note anything unusual about Ellie’s behavior or appearance. (1 point)
2. What do you think might be going on with Ellie that could cause her difficulties? Consider both physical and psychological causes. (1 point)
Part II—”Health Center” Questions
1. Where is the thyroid gland located? (1 point)
2. List the hormones secreted by the thyroid and describe their general actions. (2 points)
3. Protrusion of the eyes is called exophthalmos. How is it related to thyroid dysfunction? What causes it? (2 points)
4. What is the significance of the slight swelling in Ellie’s neck? (1 point)
5. Based on the information you have at this point, do you think Ellie’s thyroid gland is hyperactive or hypoactive? Explain your answer. (2 points)
6. Dr. Simmons ordered blood tests to measure Ellie’s levels of thyroid hormone and thyroid-stimulating hormone (TSH or thyrotropin). If Ellie has a hyperactive thyroid, what are the expected results? What are the anticipated results if she has a hypoactive thyroid? (3 points)
7. Compare and contrast the symptoms of hyperthyroidism and hypothyroidism. (1 point)
Part III—”Thyroid Trouble” Questions
1. What is causing Ellie’s thyroid to secrete too much hormone?(2 points)
2. Is Ellie correct in thinking that TSH is a thyroid hormone? Why is her TSH level low instead of high? (2 points)
Part IV—”Options” Questions
1. Ellie is a 22-year-old female. Do some research on the average age of onset and any gender differences in Graves’ disease to see if Ellie’s diagnosis is unusual. (2 points)
2. How are beta-blockers like propranolol helpful as an initial treatment for Graves’ disease? Do they have any effect in reducing thyroid hormone levels or do they counter the effects of the hormones? (2 points)
3. After Ellie’s diagnosis of Graves’ disease was confirmed by the uptake test, her endocrinologist explained several options for long-term treatment, which are listed below. For each treatment, describe the major advantages and disadvantages. (3 points)
a. Anti-thyroid medications (methimazole, propylthiouracil)—these medications slow the production of thyroid hormones.
b. Radioactive iodine—a stronger dose of radioactive iodine is given to gradually destroy the thyroid gland. Module 2 Assignment Case Study: Integumentary System
