Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.   

 The NP is seeing a 35-year-old well-woman for health promotion and physical exam. She has no complaints, is a nonsmoker, a light social drinker with 1 to 2 glasses of wine per month, and exercises about 30 minutes, five days a week. Her BMI is 22, and her vital signs are unremarkable with her blood pressure 110 over 70. Which of the following is an anticipated finding on her fundoscopic exam?  

A. Retinal arteries wider than veins. 

B. Arteriovenous nicking. 

C. Physiologic cup-to-optic disc ratio of less than 0.5. 

D. Blurred optic disc margins. 

 The correct answer is C. Physiologic cup-to-optic disc ratio of less than 0.5. 

Where should you start with this question? First, consider what kind of a question it is. Given we’re provided with the scenario that she is a younger, well-woman with no chronic health problems, the assumption should be that her fundoscopic exam is normal. We'd be provided with data if we were supposed to be looking for an abnormality on the physical exam. Hence, this is an assessment question as part of the objective information about her physical exam is being gathered. 

 Let's take a look at some background information. Fundoscopic exam is an important part of the health evaluation, and I don't believe I've ever met an NP newer to practice that didn't say, “I am having a really tough time with the fundoscopic exam.” And my piece of advice to you with that is practice, practice, practice. I swear the first two years I was in practice, I would invent every single excuse to look in the back of somebody’s eyes. Oh, you come in with a hangnail. Let me do a fundoscopic exam. Oh, you came in with a stubbed toe. Let me do a fundoscopic exam. I think you get the idea. And the more you do it, the better you get at it. Now, consider this: in the ocular fundus, you can actually see arteries and veins directly. This is the only place in the human body. You're really visualizing blood vessels in vivo, as they're working. While age-appropriate evaluation by an eye care specialist, such as an optometrist or an ophthalmologist is advised, the primary care NP is well posed to be the first-line provider in eye health. As you prepare for the NP boards, you're likely be so accustomed to studying disease pathology, its clinical evaluation, and treatment. To now have a question like this focused on a normal exam, might feel really odd. At the same time, you need that baseline of what is normal in order to have a hopping off point for evaluating the alterations in abnormal. Let's take a look again and the possible answers.  

An NP is seeing a 35-year-old woman for a health promotion and physical exam. She has no complaints, is a nonsmoker, a light social drinker with 1 to 2 glasses of wine per month, and exercises about 30 minutes, five days a week. Her BMI is 22, and her vital signs are unremarkable, with a BP of 110 over 70. Which of the following is an anticipated finding on her on her fundoscopic? 

1. Retinal arteries wider than veins. This is incorrect. In health, the retinal arteries are narrower and brighter compared to the veins. Indeed, one of the most commonly encountered abnormalities on the fundoscopic exam is arterial narrowing seen in hypertensive retinopathy, an avoidable condition with appropriate hypertensive treatment. Of course, we’re given her blood pressure, perfectly normal. We're also told she's well, no high blood pressure is mentioned. While the most common forms of hypertensive retinopathy, grade one or grade two, there are no vision changes, but with the higher grade hypertensive retinopathy, grade three, grade four, noted in hypertensive emergency, there usually are visual changes.  
2. Arteriovenous nicking. This is also incorrect. AV nicking, as it's usually called, is an abnormal finding. Chronic, usually poorly controlled, high blood pressure leads to stiffened and thickened arteries. When one of these diseased arterials rests over a vein, the problematic artery then indents and displaces the vein. Again, this is avoidable, with appropriate high blood pressure treatment. There are usually no visual changes with AV nicking.  

C.    Physiologic cup-to-optic disc ratio of less than 0.5. This is the correct answer. The physiologic cup, sometimes called the optic cup, is located within the optic disc. This area in health measures less than one-half to less than 6/10 of the optic disc diameter. You could think of the cup-to-disc ratio as the hole in the middle of a conventional donut, where if the donut hole takes up about half of the donut, then the ratio of the cup-to-disc would be 0.5 or 1:2. What are the most common reasons for an enlarged physiologic cup is open angle glaucoma, a condition that in advanced untreated disease, can result in peripheral visual loss. In other words, option C is a perfectly normal finding in the back of the eye. And that's really the purpose of this question.  

Let's take a look at option D, which we know is incorrect. 

1. Blurred optic disc margins. The optic disc margins are typically quite crisp or sharp, and the overall optic disc is slightly concave like a saucer. Blurring of the optic disc margins is abnormal and could be indicative of increased intracranial pressure and resulting papilledema. Typically, the patients with these findings will report alterations in the visual field, usually starting with peripheral visual loss, progressing later to central visual changes. 

Key takeaway: Strong health assessment skills, knowing the difference between the normal and the abnormal, is key to both practice and or success. 

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