Funduscopic Exam Findings

Which of the two following findings would be anticipated in the normal funduscopic exam of a healthy 40-year-old woman who is normotensive, generally in good health and without ocular complaint?  

A. Arteriovenous nicking

B. Optic cup to disc ratio < .0.5

C. Retinal arteries are brighter and narrower than veins  

D. Slight bulging of the optic disk

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Transcript

Voiceover: 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. 

Margaret Fitzgerald: Which of the two following findings would be anticipated in the normal funduscopic exam of a healthy 40-year-old woman who is normotensive, generally in good health, and without ocular complaint.  

A: Arterial venous nicking. 

B: Optic cup to disc ratio of less than 0.5.  

C: Retinal arteries brighter and narrower than veins. 

D: Slight bulging of the optic disc. 

The correct answers are B: The optic top to disc ratio of less than 0.5 and C: Retinal arteries brighter and narrower than veins. Where to start first? Determine what kind of a question this is, given that we're provided with a number of physical exam findings and asked to determine what's normal or not, this is an assessment question. 

About one in four questions on boards will be in this assessment category. I advise you to take a look at the certification breakdown for the exam you plan to take to get a better understanding of exam domains. By the way, a question format like this where you're asked to choose two correct questions, the question will very clearly state that. 

And to be honest, there are only a handful of questions like this if you get any at all. And they tend more to be on ANCC than they are on AANP. And as a reminder, there are no all of the above or none of the above questions on the NP boards. And if there's no mention of how many answers to choose, that means it's a single answer question. 

So, first, as always, let's go with some background information. Being able to perform a funduscopic exam is a key component of being a competent primary care provider, I would dare say. Any provider for any setting-and remember, on the NP boards you're going to be tested as if you have these skills that one would expect to find in a competent entry-level primary care NP. 

And I remind you to the only place in the human body where you can actually see arteries and veins at work are in the back of the eye. So, you can also often detect problems when the patient does not even know that problem is there. For example, untreated or poorly controlled hypertension can show up as hypertensive retinopathy. 

Keep in mind, hypertension is generally an asymptomatic disease. Undiagnosed or poorly controlled diabetes can manifest itself in the back of the eye with the presence of microaneurysms and altered optic cup to disc ratio can be seen in open angle glaucoma, a condition that's typically asymptomatic until there has been considerable ocular problems, including loss of peripheral vision. This is just a short list of problems that can be detected on funduscopic exam.  

Of course, if any of these findings are noted, further evaluation is needed. But this is a great place to start with. That is background. Let's go back and take a look at the question. Which of the two following findings would be anticipated and the normal funduscopic exam of a healthy 40-year-old woman who is normotensive, generally in good health, and without ocular complaint? 

A: Arteriovenous nicking. This is incorrect. AVR nicking, as it's often called, is a pathologic condition in the back of the eyes caused by longstanding, poorly controlled hypertension and or other ASCVD-related diseases. What happens is the diseased artery sits over the vein, causing a nick or a nip in the appearance of the vein. One way to think of this is the underlying vein now has an hourglass appearance where the artery crosses and this is, in the US, usually called a nicking. 

In some other countries, particularly in the UK, it's called AV nipping. Okay. This condition is avoidable with adequate hypertension control and overall management of ASCVD risk factors. By the way, the nicking usually does not cause any alteration in vision. B: An optic cup to disc ratio of less than 0.5. This is one of the correct answers. Causes of alteration in the optic cup to disc ratio can include open and closed angle glaucoma, optic disc atrophy, and when accompanied by blurring of the optic disc, potentially edema. 

In other words, a number of really pathologic conditions see retinal arteries brighter and narrower than that. This is another one of the correct answers. And if you're thinking, wow, this is a lot to commit to memory, I kindly ask you not to think of this as another factoid. You just have to stick in the memory bank, but more conceptualize this. 

Remember what you have for a knowledge base already you have taken anatomy, physiology, pathophysiology. You have a very robust memory bank there with this information from these classes. If you take a moment to call it back up, what do you know about arteries? They have a lot more tone in their walls than veins and they carry oxygenated blood. 

Therefore, if you were to take a look at an artery or a vein, and you were able to see them in vivo as they are working, like let's just say in a person's arm, what would you notice? The artery will be tighter and brighter, much narrower than the vein. And think of it this way. What vessel do we typically use to draw blood? 

The vein. Could we draw blood from the artery? Yeah, but it's much harder to get into. It's going to bleed like crazy, you know. So what do we do? We go with the vein because it's wider. It's easier to access. So sometimes if you go back to anatomy and physiology 101, this can help you think through the correct answer on boards. 

D: Slight bulging of the optic disk. This is also incorrect. Think of this again. If the optic disc was bulging instead of being more saucer shaped as it usually is, the optic cup to disc ratio would be altered and the optic disc margins should be blurred. The optic disc margin should be crisp, sometimes towards the nasal margin of the optic disc. 

It's not quite as crisp as it is with the rest of this, but the optic disc should always appear as if you're looking into a slightly concave structure. When the optic disc is bulging, one of the first things you need to think of is, is there too much pressure behind the eye, i.e. in the brain? Key takeaway: A question I'm often asked is how do you get good at looking in the back of the eye? 

And my answer always is practice, practice, practice. You'll pick up the nuances as you hone your clinical skills. As with any other clinical condition, correlate your findings, both normal and abnormal, with the patient's clinical presentation, and you'll hone your clinical decision-making skills that are critical to any board success. 

Voiceover: Thank you for listening to NP certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast, and for more NP resources, visit fhea.com.