Group​ ​Names:_________________________________________________________________

JennaCammin mares and Kyla

The​ ​Tired​ ​Swimmer:​ ​A​ ​Case​ ​Study
​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​Modified​ ​from:​ ​http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=202&id=202​​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​~45-60​ ​min

Part​ ​I—Meet​ ​Annie

Annie​ ​felt​ ​despondent​.​ ​Her​ ​teammates​ ​were​ ​being​ ​kind​ ​to​ ​her,​ ​but​ ​she​ ​knew​ ​that​ ​she
was​ ​the​ ​reason​ ​that​ ​her​ ​team​ ​lost​ ​the​ ​swim​ ​meet​ ​against​ ​the​ ​neighboring​ ​college.​ ​How
many​ ​people​ ​could​ ​lose​ ​with​ ​a​ ​four-second​ ​lead​ ​against​ ​someone​ ​they​ ​had​ ​beaten​ ​so despondent

easily​ ​last​ ​year?​ ​As​ ​she​ ​walked​ ​out​ ​of​ ​the​ ​locker​ ​room​ ​she​ ​noticed​ ​that​ ​the​ ​blurred​ ​vision​ ​and​ ​eye inlowspiritsfrom
strain​ ​had​ ​returned,​ ​even​ ​though​ ​she​ ​was​ ​wearing​ ​glasses​ ​instead​ ​of​ ​her​ ​usual​ ​contacts.​ ​Her​ ​eye lossofhopeor
courage
strain​ ​had​ ​become​ ​worse​ ​over​ ​the​ ​past​ ​month.​ ​Over​ ​the​ ​last​ ​week​ ​she​ ​had​ ​had​ ​mid-term​ ​exams​ ​and
papers​ ​to​ ​write​ ​and​ ​recently​ ​typing​ ​made​ ​her​ ​hands​ ​and​ ​fingers​ ​ache​ ​and​ ​they​ ​felt​ ​weak.​ ​Even​ ​swim
practice,​ ​which​ ​helped​ ​relieve​ ​her​ ​stress​ ​in​ ​the​ ​past,​ ​had​ ​become​ ​taxing.​ ​Her​ ​coach​ ​noticed​ ​that​ ​her
times​ ​were​ ​getting​ ​worse,​ ​even​ ​though​ ​he​ ​could​ ​see​ ​that​ ​she​ ​was​ ​working​ ​hard​ ​in​ ​practice.
fatigue
As​ ​Annie​ ​walked​ ​out​ ​of​ ​the​ ​locker​ ​room​ ​she​ ​looked​ ​up​ ​and​ ​she​ ​saw​ ​her​ ​boyfriend,​ ​Matt,​ ​waiting​ ​for extremetiredness
her.​ ​ ​As​ ​they​ ​walked​ ​back​ ​to​ ​her​ ​dorm,​ ​Annie​ ​thought​ ​how​ ​nice​ ​it​ ​was​ ​to​ ​have​ ​Matt​ ​to​ ​support​ ​her
during​ ​such​ ​a​ ​tough​ ​time.​ ​Annie​ ​was​ ​gasping​ ​for​ ​air​ ​and​ ​felt​ ​weaker​ ​than​ ​ever​ ​after​ ​they​ ​had​ ​walked
up​ ​the​ ​two​ ​flights​ ​of​ ​stairs​ ​to​ ​her​ ​floor.​ ​She​ ​told​ ​herself​ ​that​ ​she​ ​must​ ​set​ ​some​ ​time​ ​aside​ ​next​ ​week
to​ ​do​ ​something​ ​about​ ​this​ ​constant​ ​fatigue​. reclining
lyingbackin a
Annie​ ​had​ ​already​ ​packed​ ​her​ ​bags​ ​for​ ​the​ ​trip​ ​home​ ​and​ ​Matt​ ​was​ ​able​ ​to​ ​carry​ ​all​ ​of​ ​her​ ​stuff​ ​to​ ​his relaxedposition
car​ ​in​ ​one​ ​trip.​ ​When​ ​he​ ​returned​ ​to​ ​the​ ​room​ ​he​ ​found​ ​Annie​ ​reclining​​ ​on​ ​the​ ​bed​ ​with​ ​her​ ​eyes
closed.​ ​He​ ​asked​ ​her​ ​if​ ​she​ ​was​ ​ready​ ​to​ ​go.​ ​“Sure,​ ​just​ ​can’t​ ​keep​ ​my​ ​eyes​ ​open​ ​these​ ​days.​ ​I​ ​am
sure​ ​I’ll​ ​be​ ​better​ ​when​ ​we’re​ ​home.”

Matt​ ​knew​ ​that​ ​Annie​ ​liked​ ​to​ ​drive,​ ​so​ ​when​ ​they​ ​got​ ​to​ ​the​ ​car​ ​he​ ​handed​ ​her​ ​the​ ​keys.​ ​She​ ​tried​ ​to​ ​take​ ​them,​ ​but​ ​her
fingers​ ​didn’t​ ​seem​ ​to​ ​work​ ​and​ ​she​ ​dropped​ ​his​ ​keys​ ​on​ ​the​ ​ground.​ ​Matt​ ​grabbed​ ​the​ ​keys​ ​and​ ​opened​ ​the​ ​passenger
door​ ​for​ ​Annie.​ ​As​ ​they​ ​set​ ​off​ ​for​ ​home,​ ​Matt​ ​asked,​ ​“Are​ ​you​ ​feeling​ ​okay?​ ​You’re​ ​not​ ​usually​ ​so​ ​exhausted​ ​after​ ​a​ ​swim
meet,​ ​and​ ​you​ ​seem​ ​to​ ​be​ ​having​ ​trouble​ ​catching​ ​your​ ​breath.​ ​I​ ​am​ ​worried​ ​about​ ​you.”​ ​ ​Matt​ ​thought​ ​that​ ​this​ ​was
probably​ ​ ​the​ ​best​ ​time​ ​to​ ​suggest​ ​that​ ​she​ ​see​ ​a​ ​doctor.

1.​ ​Summarize​ ​the​ ​setting​ ​(background)​ ​for​ ​this​ ​case.

The setting is a collage campus. There was a swim meet and then they went to a dorm.

2.​ ​What​ ​symptoms​ ​does​ ​Annie​ ​exhibit?​ ​ ​Prioritize​​ ​these​ ​symptoms​ ​in​ ​order​ ​of​ ​what​ ​you​ ​think​ ​is​ ​the​ ​most​ ​concerning​ ​and

the​ ​least​ ​concerning.

Blurred vision and eye strain, weakness, fatigue, swim performance decreased.

3.​ ​What​ ​is​ ​the​ ​one​ ​common​ ​feature​ ​of​ ​all​ ​of​ ​her​ ​symptoms?
Loss of strength.

4.​ ​ ​When​ ​did​ ​Matt​ ​notice​ ​that​ ​Annie​ ​was​ ​having​ ​trouble​ ​breathing?

When they were walking up the stairs.

5.​ ​ ​List​ ​any​ ​diseases,​ ​disorders,​ ​or​ ​health​ ​problems​ ​that​ ​you​ ​can​ ​think​ ​of​ ​that​ ​might​ ​cause​ ​these​ ​symptoms.​ ​(Brainstorm)

It is possible Annie could have high blood pressure or a serious migraine.

Part​ ​II—The​ ​Doctor’s​ ​Office

On​ ​Monday​ ​afternoon,​ ​Matt​ ​drove​ ​Annie​ ​to​ ​her​ ​family​ ​doctor.​ ​She​ ​seemed​ ​to​ ​have​ ​slept​ ​for​ ​most​ ​of​ ​the
weekend,​ ​and​ ​Matt​ ​thought​ ​that​ ​she​ ​looked​ ​much​ ​better​ ​than​ ​last​ ​Friday​ ​after​ ​the​ ​meet.​ ​In​ ​fact,​ ​she​ ​told
him​ ​that​ ​she​ ​felt​ ​so​ ​much​ ​better​ ​that​ ​she​ ​really​ ​didn’t​ ​need​ ​to​ ​go​ ​to​ ​the​ ​doctor.

“Seriously,​ ​this​ ​is​ ​stupid.​ ​I’ve​ ​been​ ​feeling​ ​much​ ​better​ ​in​ ​the​ ​past​ ​few​ ​days.​ ​It’s​ ​amazing​ ​what periodically
some​ ​rest​ ​can​ ​do.​ ​That’s​ ​all​ ​I​ ​need;​ ​I​ ​really​ ​don’t​ ​need​ ​a​ ​doctor​ ​as​ ​long​ ​as​ ​I​ ​take​ ​a​ ​nap
periodically​.​ ​Let’s​ ​not​ ​waste​ ​his​ ​time;​ ​let’s​ ​just​ ​go​ ​home.”​ ​ ​Matt​ ​looked​ ​at​ ​her​ ​with​ ​his​ ​eyebrows
timetotime
from
raised,​ ​“Let’s​ ​just​ ​hear​ ​what​ ​he​ ​has​ ​to​ ​say;​ ​better​ ​safe​ ​than​ ​sorry.”

Matt​ ​sat​ ​in​ ​the​ ​waiting​ ​room​ ​and​ ​Annie​ ​went​ ​with​ ​the​ ​nurse.​ ​After​ ​a​ ​few​ ​minutes​ ​Dr.​ ​Jones​ ​entered
the​ ​cubicle,​ ​“Well,​ ​Annie,​ ​what​ ​seems​ ​to​ ​be​ ​the​ ​problem?”

“It’s​ ​nothing,​ ​really.​ ​I​ ​have​ ​just​ ​been​ ​tired​ ​lately.​ ​You​ ​know​ ​I’m​ ​going​ ​to​ ​college​ ​on​ ​a​ ​swimming​ ​scholarship,
but​ ​my​ ​times​ ​have​ ​been​ ​getting​ ​worse​ ​this​ ​season,​ ​and​ ​I’ve​ ​been​ ​short​ ​of​ ​breath​ ​more​ ​than​ ​usual​ ​after​ ​my
workouts.​ ​I​ ​think​ ​it’s​ ​just​ ​because​ ​I​ ​was​ ​stressed​ ​out​ ​over​ ​school;​ ​I​ ​have​ ​been​ ​feeling​ ​much​ ​better​ ​since​ ​I
came​ ​home​ ​last​ ​Friday.​ ​ ​“I​ ​see,”​ ​said​ ​the​ ​doctor.​ ​“Have​ ​you​ ​had​ ​any​ ​other​ ​problems?”

“Well,​ ​yes.​ ​My​ ​hands​ ​and​ ​fingers​ ​seem​ ​to​ ​get​ ​tired​ ​when​ ​I​ ​type,​ ​and​ ​a​ ​few​ ​days​ ​ago,​ ​after​ ​a​ ​swim pensive
meet,​ ​my​ ​fingers​ ​felt​ ​too​ ​weak​ ​to​ ​grab​ ​my​ ​boyfriend’s​ ​car​ ​keys​ ​when​ ​he​ ​offered​ ​them​ ​to​ ​me;​ ​but​ ​I
was​ ​tired​ ​after​ ​a​ ​really​ ​hectic​ ​week.” engaged inserious
thought
Dr.​ ​Jones​ ​looked​ ​pensive​​ ​and​ ​asked,​ ​“Have​ ​you​ ​had​ ​any​ ​trouble​ ​with​ ​your​ ​eyes?​ ​ ​Like​ ​have​ ​they
been​ ​drooping?”

Annie​ ​looked​ ​confused.​ ​“I​ ​have​ ​had​ ​a​ ​lot​ ​of​ ​eye​ ​strain​ ​and​ ​double​ ​vision​ ​recently.​ ​It​ ​gets​ ​blurry​ ​when​ ​I​ ​stare
at​ ​the​ ​computer​ ​screen​ ​too​ ​long;​ ​I​ ​seem​ ​to​ ​get​ ​a​ ​zillion​ ​papers​ ​every​ ​week.​ ​I​ ​also​ ​think​ ​the​ ​chlorine​ ​level​ ​in
the​ ​pool​ ​is​ ​too​ ​high.​ ​Everyone​ ​on​ ​the​ ​team​ ​complains​ ​about​ ​it​ ​because,​ ​if​ ​your​ ​goggles​ ​come​ ​off​ ​,​ ​your​ ​eyes
sting​ ​like​ ​mad.

The​ ​doctor​ ​smiled,​ ​“I​ ​swam​ ​before​ ​those​ ​goggles​ ​were​ ​even​ ​invented,​ ​so​ ​I​ ​know​ ​what​ ​you​ ​mean​ ​about
stinging​ ​eyes.​ ​But,​ ​I​ ​think​ ​what​ ​you’re​ ​telling​ ​me​ ​goes​ ​beyond​ ​simple​ ​fatigue.​ ​I’m​ ​going​ ​to​ ​refer​ ​you​ ​to​ ​a
neurologist​ ​at​ ​the​ ​hospital.”

5.​ ​ ​What​ ​specific​ ​question​ ​does​ ​the​ ​doctor​ ​ask​ ​Annie?

Have you had any trouble with your eyes, like have they been drooping?

6.​ ​ ​What​ ​excuse​ ​does​ ​Annie​ ​give​ ​about​ ​her​ ​eye​ ​strain?
The chlorine level in the pool.

7.​ ​ ​What​ ​is​ ​a​ ​neurologist?​ ​ ​ ​(you​ ​may​ ​need​ ​to​ ​look​ ​this​ ​one​ ​up)

They deal with disorders of the nervous system.

Based​ ​on​ ​how​ ​the​ ​doctor​ ​responded,​ ​do​ ​you​ ​think​ ​he​ ​believes​ ​that​ ​Annie’s​ ​problems​ ​are​ ​caused​ ​by​ ​not
getting​ ​enough​ ​sleep?

Negative
Part​ ​III—The​ ​Neurologist

Annie​ ​returned​ ​to​ ​the​ ​neurologist’s​ ​office​ ​with​ ​her​ ​mother.​ ​ ​That​ ​morning​ ​Annie​ ​had
subjected
been​ ​subjected​​ ​to​ ​several​ ​different​ ​tests​ ​and​ ​she​ ​had​ ​been​ ​asked​ ​to​ ​return​ ​after​ ​lunch
causeIforce to
when​ ​the​ ​results​ ​would​ ​be​ ​in.​ ​The​ ​nurse​ ​ ​told​ ​her​ ​that​ ​they​ ​were​ ​rushing​ ​this​ ​through undergo
because​ ​they​ ​knew​ ​that​ ​Annie​ ​was​ ​only​ ​home​ ​for​ ​a​ ​week.​ ​Annie​ ​ ​and​ ​her​ ​mother​ ​sat
in​ ​the​ ​waiting​ ​room​ ​for​ ​what​ ​seemed​ ​to​ ​be​ ​hours.​ ​At​ ​last​ ​the​ ​nurse​ ​came​ ​for​ ​them.

“Some​ ​of​ ​the​ ​results​ ​are​ ​here,​ ​and​ ​the​ ​rest​ ​are​ ​on​ ​their​ ​way,”​ ​she​ ​explained.​ ​“So​ ​the
doctor​ ​will​ ​see​ ​you​ ​now.”​ ​ ​Annie​ ​and​ ​her​ ​mother​ ​went​ ​into​ ​the​ ​doctor’s​ ​office​ ​and​ ​sat​ ​down.

“Well,​ ​Annie,​ ​I​ ​have​ ​read​ ​your​ ​family​ ​doctor’s​ ​notes,​ ​and​ ​we​ ​put​ ​you​ ​through​ ​a​ ​battery​ ​of​ ​tests​ ​this​ ​morning.”
the​ ​neurologist​ ​skimmed​ ​through​ ​the​ ​chart,​ ​“Hmm,​ ​blurred​ ​vision,​ ​weak​ ​ ngers,​ ​and​ ​decline​ ​in​ ​swimming
performance.​ ​OK,​ ​let’s​ ​see​ ​what​ ​we​ ​found​ ​out​ ​today.​ ​First,​ ​the​ ​nerve​ ​conduction​ ​and
the​ ​electromyography​ ​(emg)​ ​tests;​ ​these​ ​are​ ​the​ ​only​ ​results​ ​we​ ​have​ ​right​ ​now.​ ​his
was​ ​the​ ​test​ ​when​ ​they​ ​put​ ​sticky​ ​electrodes​ ​on​ ​ ​your​ ​skin,​ ​remember?”​ ​ ​Annie Velocity
nodded.
speedofsomething
in agivendirection
“Well,​ ​for​ ​the​ ​nerve​ ​conduction​ ​tests​ ​one​ ​set​ ​of​ ​electrodes​ ​stimulated​ ​the​ ​nerve​ ​and
another​ ​recorded​ ​its​ ​response​ ​a​ ​little​ ​way​ ​down​ ​the​ ​nerve.​ ​ ​The​ ​nerve​ ​conduction
results​ ​are​ ​normal.​ ​ ​There​ ​is​ ​no​ ​nerve​ ​fatigue​ ​and​ ​ ​the​ ​conduction​ v​ elocity​​ ​is​ ​ ne;
nothing​ ​wrong​ ​with​ ​your​ ​nerves.”

Annie​ ​and​ ​her​ ​mother​ ​looked​ ​at​ ​each​ ​other​ ​and​ ​smiled​ ​with​ ​relief.

“Now,​ ​the​ ​electromyography​ ​test​ ​involves​ ​recording​ ​from​ ​a​ ​muscle;​ ​it
was​ ​done​ ​in​ ​two​ ​stages.​ ​The​ ​ rst​ ​stimulated​ ​the​ ​muscle​ ​directly,​ ​and
there​ ​isn’t​ ​too​ ​much​ ​out​ ​of​ ​the​ ​ordinary​ ​there.​ ​ ​The​ ​second​ ​stage​ ​is
when​ ​ ​the​ ​nerves​ ​were​ ​stimulated​ ​and​ ​the​ ​muscle​ ​response​ ​was
recorded.​ ​ ​These​ ​results​ ​concern​ ​me​ ​because​ ​the​ ​muscle​ ​response
decreased​ ​quickly​ ​during​ ​repeated​ ​nerve​ ​stimulation,​ ​indicating​ ​that
your​ ​muscle​ ​response
fatigued​ ​over​ ​time.”

8.​ ​Summarize​ ​the​ ​results​ ​of​ ​the​ ​nerve​ ​conduction​ ​test?

There was no nerve fatigue and the conduction velocity is normal,

meaning there is nothing wrong with her nerves.

9.​ ​ ​What​ ​is​ ​the​ ​EMG​ ​test?​ ​ ​What​ ​did​ ​this​ ​test​ ​reveal​ ​about​ ​Annie’s​ ​muscles?
The EMG test involves recording from a muscle. It revealed Annie’s
muscle response fatigued over time.

10.​ ​ ​Based​ ​on​ ​these​ ​two​ ​tests,​ ​does​ ​Annie​ ​have​ ​a​ ​nerve​ ​problem​ ​or​ ​a​ ​muscle​ ​problem?
Muscle.
Part​ ​IV—The​ ​Neurologist​ ​Makes​ ​a​ ​Diagnosis

They​ ​heard​ ​a​ ​knock​ ​at​ ​the​ ​door​ ​and​ ​turned​ ​to​ ​see​ ​the​ ​nurse​ ​enter;​ ​she​ ​was​ ​holding​ ​a​ ​folder​ ​with​ ​the​ ​hospital’s
stamp.​ ​ ​The​ ​doctor​ ​looked​ ​over​ ​the​ ​lab​ ​results​ ​and​ ​then​ ​continued.

“I’m​ ​afraid​ ​I​ ​don’t​ ​have​ ​very​ ​good​ ​news.​ ​Do​ ​you​ ​remember​ ​when​ ​the​ ​nurse​ ​injected​ ​that​ ​solution​ ​into​ ​your
arm​ ​and​ ​you​ ​said​ ​that​ ​suddenly​ ​you​ ​felt​ ​much​ ​stronger?”​ ​ ​ ​ ​Annie​ ​nodded.

“That​ ​was​ ​the​ ​edrophonium​​ ​test.​ ​ ​It​ ​temporarily​ ​relieves​ ​symptoms​ ​of​ ​ ​people​ ​who​ ​suffer​ ​from​ ​myasthenia
gravis.​ ​I​ ​am​ ​afraid​ ​that​ ​the​ ​diagnosis​ ​is​ ​confirmed​ ​by​ ​these​ ​lab​ ​results,​ ​which​ ​show​ ​ ​the​ ​disease.

The​ ​nurse​ ​handed​ ​Annie​ ​and​ ​her​ ​mother​ ​a​ ​pamphlet​ ​about​ ​myasthenia​ ​gravis​ ​while​ ​the​ ​doctor​ ​explained.
“Myasthenia​ ​gravis​ ​causes​ ​your​ ​immune​ ​system​ ​to​ ​attack​ ​the​ ​acetylcholine​ ​receptors​ ​on​ ​your​ ​muscles.​ ​ ​As
these​ ​receptors​ ​stop​ ​working,​ ​the​ ​muscles​ ​fatigues​ ​easily.​ ​ ​Often​ ​the​ ​first​ ​symptom​ ​is​ ​weakness​ ​of​ ​the​ ​eye
muscle.”​ ​ ​ ​The​ ​doctor​ ​held​ ​a​ ​chart​ ​up​ ​showing​ ​the​ ​neuromuscular​ ​junction.

11.​ ​ ​Label​ ​ ​the​ ​image​​ ​ ​below​ ​that​ ​shows​ ​the​ ​neuromuscular​ ​junction:​ ​ ​ ​Sarcomere​ ​|​ ​ ​Sarcolemma​ ​|​ ​Synapse​ ​|
Motor​ ​End​ ​Plate​ ​|​ ​ ​Nerve​ ​|​ ​Vesicles​ ​|​ ​Sarcoplasmic​ ​Reticulum​ ​|​ ​T-​ ​Tubules​ ​|​ ​ ​ ​ ​ ​*You​ ​may​ ​need​ ​to​ ​google​ ​this!

MotorNeuron Ax
on
synapticcleft
synapticresides
Sarcolemma

T tubule
MotorEnd Plate

Nerve

12.​ ​ ​Add​ ​to​ ​the​ ​drawing​ ​by​ ​placing​​ ​stars​​ ​where​ ​the​ ​acetylcholine​ ​receptors​ ​would​ ​be​ ​located.​ ​⭐
insidebluedots
13.​ ​ ​Edrophonium​​ ​is​ ​a​ ​drug​ ​the​ ​blocks​ ​cholinesterase​ ​from​ ​breaking​ ​down​ ​acetylcholine​ ​in​ ​the​ ​muscles.​ ​ ​ ​Why
does​ ​this​ ​improve​ ​Annie’s​ ​muscle​ ​function?

It stops the body from attacking itself.

14.​ ​Why​ ​is​ ​myasthenia​ ​gravis​ ​called​ ​an​ ​AUTOIMMUNE​ ​DISEASE​?​ ​ ​ ​(you​ ​may​ ​need​ ​to​ ​look​ ​up​ ​the​ ​definition)

It is an autoimmune disease because cholinesterase breaks down acetylcholine in the muscles.