CORE CLINICAL CASES

Self-assessment for Medical Students

Anatomy and Physiology
Marjorie E M Allison BSc MD, FRCP
Hon. Senior Research Fellow, Medical Education,
The Medical School, University of Glasgow

Stuart W McDonald BSc MB ChB PhD FRCS

Senior Lecturer in Anatomy, Laboratory of Human Anatomy
University of Glasgow

CONTENTS
1. Cardiology

253

255

Case 2 Down syndrome and congenital cardiac abnormalities 13

265

Case 3 Valvular heart disease and embolism

19

275

Case 4 Myocardial infarction

26

283

Case 5 Heart failure

32

290

Case 6 Venous conditions of the lower limb

39

298

45

305

Case 1 Cystic fibrosis

47

307

Case 2 Tuberculosis

53

317

Case 3 Respiratory tract infection

59

324

Case 4 Asthma

65

331

71

339

Case 1 Epigastric pain

73

341

Case 2 Inflammatory bowel disease

81

350

Case 3 Painless jaundice

87

358

Case 4 Liver disease

93

366

Case 5 Gastro-oesophageal reflux disease

99

375

105

383

107

385

113

395

Case 1 Muscular dystrophy

115

397

Case 2 Wrist fracture

121

404

Case 3 Spine disease

126

409

Case 1 Congenital heart disease

2. Respiratory

3. Gastroenterology

4. Nephrology
Case 1 Chronic renal failure
5. Musculoskeletal

SELF ASSESSMENT FOR MEDICAL STUDENTS ANATOMY AND PHYSIOLOGY

Case 4 Hernia

132

415

Case 5 Hip fracture

137

422

143

429

Case 1 Motor neuron disease

145

431

Case 2 Cerebral artery disease

152

440

Case 3 Multiple sclerosis

158

446

Case 4 Spinal cord compression

164

454

Case 5 Stroke

171

462

177

471

Case 1 Addisons disease

179

473

Case 2 Diabetes mellitus

187

484

Case 3 Thyroid disease

192

492

199

499

Case 1 Fertility

201

501

Case 2 Pregnancy

207

508

Case 3 Prostate disease

212

515

219

523

Case 1 Chronic lymphocytic leukaemia

221

525

Case 2 Iron deficiency anaemia

228

533

Case 3 Lymph nodes and HIV

236

542

243

551

245

553

6. Neurology

7. Endocrinology

8. Reproduction

9. Haematology

10. Dermatology
Case 1 Psoriasis

vi

NEUROLOGY CASE 1

NEUROLOGY

NEUROLOGY CASES:
QUESTIONS

143

NEUROLOGY CASE 1

NEUROLOGY

1. MOTOR NEURON DISEASE

You are on duty at a local hospice. 34-year-old Mr Wilson is
admitted for one week of respite care. It is your duty to clerk him
in. Mr Wilson was diagnosed with motor neuron disease 18 months
ago.

1. What is motor neuron disease?

2. Which components of the central nervous system (CNS) are affected in

motor neuron disease?
1 marks

3. In which pathways from the motor cortex do most motor impulses

descend?
1 mark

4. What is a motor unit?

1 mark

Since motor neuron disease affects motor neurons, the clinical

manifestations are primarily within skeletal muscles rather than in
smooth or cardiac muscle.

145

NEUROLOGY

mark

SELF-ASSESSMENT FOR MEDICAL STUDENTS ANATOMY AND PHYSIOLOGY

5. Complete the following table comparing the three muscle types. 6 marks
Skeletal

Cardiac

Smooth

Striated or non-striated?
Peripheral or central nucleus/nuclei?
Single or multiple nuclei?
Small, large or very large fibre diameter?

After taking a full and detailed history, you examine Mr Wilson.

During the examination of the nervous system, you find that in Mr
Wilsons upper limbs there are muscle wasting, fasciculation and
reduced power in all muscle groups.

6. What do the fasciculations indicate?

1 mark

NEUROLOGY

You continue with the neurological examination and find there is

also reduced power in the lower limbs.

7. Identify the following features on the diagram (Figure 6.1) of the calf
3 marks
muscles of the right lower limb.

A
B
C
D

146

NEUROLOGY CASE 1

NEUROLOGY

Figure 6.1: Anatomy of the calf muscles of the right lower limb.

After examining Mr Wilson you present your findings to the oncall consultant. You note that there was no involvement of the
extraocular muscles. The consultant explains to you that in motor
neuron disease the extraocular muscles are often not involved and,
if they are, it is a very late feature of the disease. She also tells you
that in patients with advanced motor neuron disease, movement
of the eyeball is often the only means of communication. Special
boards are used which allow the patient to spell out words by
looking at letters on the board in order to communicate.

147

SELF-ASSESSMENT FOR MEDICAL STUDENTS ANATOMY AND PHYSIOLOGY

8. List the six muscles responsible for moving the eyeball and give the
nerve supply of each.
3 marks

Mr Wilsons wife explains that a few months ago Mr Wilson lost the
ability to chew and swallow safely. He had lost almost a stone in
weight before a percutaneous endoscopic gastrostomy (PEG) tube
was inserted by the surgical team.

NEUROLOGY

9. What is a PEG tube?

10. Identify the muscles that are shown in this illustration

(Figure 6.2).

1 mark

2 marks

D
C

Figure 6.2: Some muscles of chewing and swallowing

148

NEUROLOGY CASE 1

mark for each of the following:

A
B
C
D

11. What is the innervation of the muscles of mastication?

1 mark

During examination of Mr Wilsons cranial nerves, you find

abnormalities of the facial nerve. You find he can only raise his
eyebrows minimally and not against resistance.

12. Which muscle is responsible for raising the eyebrows?

1 mark

NEUROLOGY

You notice that Mr Wilson is also unable to close his eyes tightly.

13. Which muscle is responsible for this action?

1 mark

On further examination of the facial nerve you notice Mr Wilson has

great difficulty when asked to blow out his cheeks.

14. Which muscle is being used in this part of the examination?

1 mark

149

SELF-ASSESSMENT FOR MEDICAL STUDENTS ANATOMY AND PHYSIOLOGY

As well as supplying the muscles of facial expression, the facial

nerve has sensory and autonomic functions.

15. What are the sensory and autonomic functions of the facial
nerve?

2 marks

Nearing completion of your examination of the cranial nerves you

find that Mr Wilson is unable to shrug his shoulders.

16. Which cranial nerves are responsible for this action?

17. The following diagram (Figure 6.3) shows the attachments of the cranial
nerves to the brain. Identify structures AF.
3 marks

1 mark

NEUROLOGY

B
C

D
E
F

Figure 6.3: Attachments of the cranial nerves to the brain

150

NEUROLOGY CASE 1

mark for each of the following:

A
B
C
D
E
F

& BIBLIOGRAPHY
Hiatt J L, Gartner L P. 2000. Textbook of Head and Neck Anatomy, 3rd edn. New
York: Lippincott, Williams and Wilkins.

NEUROLOGY

Johnson D R, Moore W J. 1997. Anatomy for Dental Students, 3rd edn. Oxford:
Oxford University Press.
Kiernan J A. 2005. Barrs The Human Nervous System: An Anatomical Viewpoint,
8th edn. Philadelphia: Lippincott Williams and Wilkins.
Standring S. 2005. Grays Anatomy, 39th edn. Edinburgh: Elsevier Churchill
Livingstone.
Tortora G J, Grabowski S. 2002. Principles of Anatomy and Physiology, 10th edn.
New York: John Wiley.

151

NEUROLOGY CASE 1

NEUROLOGY

NEUROLOGY CASES:
ANSWERS

429

NEUROLOGY CASE 1

NEUROLOGY

1. MOTOR NEURON DISEASE

You are on duty at a local hospice. 34-year-old Mr Wilson, is
admitted for one week of respite care. It is your duty to clerk him
in. Mr Wilson was diagnosed with motor neuron disease 18 months
ago.

1. What is motor neuron disease?

Motor neuron disease is a degenerative neurological disease.

2. Which components of the central nervous system (CNS) are affected in

motor neuron disease?
1 marks

Neurons in the motor cortex ( mark), cranial nerve nuclei ( mark) and anterior
horn cells/corticospinal tracts ( mark) within the spinal cord.

1 LEARNING POINT
The cause of motor neuron disease is unknown. Oxidative damage,
abnormal protein aggregation and abnormal axonal transport are all
thought to be involved. The incidence is around 2/100 000 per annum
and it is slightly more common in males. The typical age of onset is 3040
years. There is no cure for motor neuron disease and the patients condition
deteriorates progressively. Survival from diagnosis is rarely more than three
years.

3. In which pathways from the motor cortex do most motor impulses

descend?
1 mark

Lateral and anterior corticospinal tracts ( mark) and the corticonuclear

(corticobulbar) tracts ( mark).

431

NEUROLOGY

mark

SELF-ASSESSMENT FOR MEDICAL STUDENTS ANATOMY AND PHYSIOLOGY

1 LEARNING POINT
A small amount of motor activity may be mediated by the vestibulospinal,
rubrospinal and tectospinal tracts.

4. What is a motor unit?

A single somatic (lower) motor neuron ( mark) and all the muscle fibres it
stimulates ( mark).

1 mark

Since motor neuron disease affects motor neurons, the clinical

manifestations are primarily within skeletal muscles rather than in
smooth or cardiac muscle.

5. Complete the following table comparing the three muscle types. 6 marks

NEUROLOGY

Skeletal

Cardiac

Smooth

Striated or nonstriated?

Striated ( mark)

Striated ( mark)

Non-striated ( mark)

Peripheral or central
nucleus/nuclei?

Peripheral ( mark)

Central ( mark)

Central ( mark)

Single or multiple
nuclei?

Multiple ( mark)

Single ( mark)

Single ( mark)

Small, large or very

large fibre diameter?

Very large ( mark)

Large ( mark)

Small ( mark)

After taking a full and detailed history, you examine Mr Wilson.

During the examination of the nervous system, you find that in Mr
Wilsons upper limbs there are muscle wasting, fasciculation and
reduced power in all muscle groups.

6. What do the fasciculations indicate?

That lower motor neurons have been affected.

432

1 mark

NEUROLOGY CASE 1

1 LEARNING POINT
Fasciculations are small involuntary contractions of a motor unit. They are a
feature of lower motor neuron disease. They can only be seen if the muscle
is relaxed.

You continue with the neurological examination and find there is

also reduced power in the lower limbs.

7. Label the following diagram (Figure 6.1) of the calf muscles of the right
3 marks
lower limb.

NEUROLOGY

Figure 6.1: Anatomy of the calf muscles of the right lower limb.

433

SELF-ASSESSMENT FOR MEDICAL STUDENTS ANATOMY AND PHYSIOLOGY

A Lateral head of the gastrocnemius ( mark).

B Medial head of the gastrocnemius ( mark).
C Soleus (1 mark).
D Calcaneal/Achilles tendon (1 mark).

After examining Mr Wilson you present your findings to the oncall consultant. You note that there was no involvement of the
extraocular muscles. The consultant explains to you that in motor
neuron disease the extraocular muscles are often not involved and,
if they are, it is a very late feature of the disease. She also tells you
that in patients with advanced motor neuron disease, movement
of the eyeball is often the only means of communication. Special
boards are used which allow the patient to spell out words by
looking at letters on the board in order to communicate.

8. List the six muscles responsible for moving the eyeball and give the
3 marks
nerve supply of each.

NEUROLOGY

Superior rectus

Oculomotor nerve/CN III

Inferior rectus

Oculomotor nerve/CN III

Medial rectus

Oculomotor nerve/CN III

Lateral rectus

Abducens nerve/CN VI

Superior oblique

Trochlear nerve/CN IV

Inferior oblique

Oculomotor nerve/CN III

mark for each muscle and its innervation.

1 LEARNING POINT
The levator palpebrae superioris muscle also lies in the orbit. It moves the
eyelids rather than the eyeball and is supplied by the oculomotor nerve.

434

NEUROLOGY CASE 1

Mr Wilsons wife explains that a few months ago he lost the ability
to chew and swallow safely. He had lost almost a stone in weight
before a percutaneous endoscopic gastrostomy (PEG) tube was
inserted by the surgical team.

9. What is a PEG tube?

A PEG tube allows a nutrient solution to be passed directly into the stomach (1
mark) alleviating the need to chew or swallow food.

10. Label the muscles that are shown in this illustration

(Figure 6.2).

1 mark

2 marks

NEUROLOGY

Figure 6.2: Some muscles of chewing and swallowing

mark for each of the following:

A Lateral pterygoid.
B Medial pterygoid.
C Buccinator.
D Superior constrictor.

435

SELF-ASSESSMENT FOR MEDICAL STUDENTS ANATOMY AND PHYSIOLOGY

11. What is the innervation of the muscles of mastication?

Mandibular nerve/trigeminal nerve/CN V.

1 mark

During examination of Mr Wilsons cranial nerves, you find

abnormalities of the facial nerve. You find he can only raise his
eyebrows minimally and not against resistance.

12. Which muscle is responsible for raising the eyebrows?

Frontalis/occipto-frontalis muscle.

1 mark

You notice that Mr Wilson is also unable to close his eyes tightly.

13. Which muscle is responsible for this action?

Orbicularis oculi.

1 mark

On further examination of the facial nerve you notice Mr Wilson has

great difficulty when asked to blow out his cheeks.
NEUROLOGY

14. Which muscle is being used in this part of the examination?

Orbicularis oris.

1 mark

1 LEARNING POINT
A common misconception is that asking a patient to blow out his/her
cheeks is testing the buccinator muscles. The test actually relies upon
pursing of the lips to create an airtight seal, which involves the orbicularis
oris.

436

NEUROLOGY CASE 1

As well as supplying the muscles of facial expression, the facial

nerve has sensory and autonomic functions.

15. What are the sensory and autonomic functions of the facial
nerve?

2 marks

Sensory taste ( mark) from the anterior two-thirds of the tongue ( mark).

Autonomic the secretion of saliva ( mark) and tears ( mark).

1 LEARNING POINT
Parasympathetic fibres in the facial nerve stimulate the secretion of saliva
from only the submandibular, sublingual and minor glands. The parotid
gland is innervated by parasympathetic fibres in the glossopharyngeal
nerve.

16. Which cranial nerves are responsible for this action?

The spinal accessory nerves.

1 mark

437

NEUROLOGY

Nearing completion of your examination of the cranial nerves you

find that Mr Wilson is unable to shrug his shoulders.

SELF-ASSESSMENT FOR MEDICAL STUDENTS ANATOMY AND PHYSIOLOGY

17. The following diagram (Figure 6.3) shows the attachments of the cranial
3 marks
nerves to the brain. Identify structures AF.

B
C

D
E
F

Figure 6.3: Attachments of the cranial nerves to the brain.

NEUROLOGY

mark for each of the following:

A Olfactory bulb.
B Optic nerve.
C Optic tract.
D Trigeminal nerve.
E Abducens nerve.
F Hypoglossal nerve.

438

NEUROLOGY CASE 1

& BIBLIOGRAPHY
Hiatt J L, Gartner L P. 2000. Textbook of Head and Neck Anatomy, 3rd edn. New York:
Lippincott, Williams and Wilkins.
Johnson D R, Moore W J. 1997. Anatomy for Dental Students, 3rd edn. Oxford:
Oxford University Press.
Kiernan J A. 2005. Barrs The Human Nervous System: An Anatomical Viewpoint, 8th
edn. Philadelphia: Lippincott Williams and Wilkins.
Standring S. 2005. Grays Anatomy, 39th edn. Edinburgh: Elsevier Churchill
Livingstone.

NEUROLOGY

Tortora G J, Grabowski S. 2002. Principles of Anatomy and Physiology, 10th edn.

New York: John Wiley.

439