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Answer to our medical student fundoscopy question: About a third of you got this right!

Here is our answer to our fundoscopy question from January the 8th.

Here's the original picture from the question. Thanks for tom for pointing out that we initially uploaded a picture of the left fundus, just to confuse you! The image above is from the original question, and is the right eye!

Well now we have the answer, lets go through it step by step. Remember this is from the perspective of a general medicine/ internal medicine doctor, NOT from that of an ophthalmologist, who may have all sorts of other interesting comments to make.*

*These comments are only likely to be interesting to other ophthalmologists

First the history: There is no history! There are no particular conditions which we would link to asthma and opthalmological problems. The blood pressure and observations are all normal.

A couple of caveats:

• in medical questions when you see asthma we always have ‘could this be alpha one anti trypsin deficiency and not asthma’ in the back of our minds
• The blood pressure bits always make us recap: could this be one of the primary causes of hypertension (e.g. phaeochromocytoma, where the blood pressure can be normal?

But… hang on a bit, the history suggests nothing of the sort. So we are left with the fundoscopy. Is it normal?

Lets start:

1. Which eye:  looking from the front, the optic disc is on the nasal half of the field, so this must be the RIGHT eye!
   

   Three quarters of you got the right eye, because yes, this is the 'right eye'. For the other 11%, don't worry, x-rays of the hands confuse us too...

2. Is the optic disc normal? Colour,  yes normal (it should be pale yellow: optic atrophy is one cause of a pale optic disc, and there are multiple causes for this (such as MS, ischameia etc). Shape yes, its spherical. Margins. Distinct-the pale yellow optic disc has nice clear margins here. Blurring of these margins may represent papilloedema, which is one sign of raised intra ocular pressure. This is a key finding in cases of headache as a ‘red flag’. You can also measure the optic cup to disc ratio, and we’re not going to into this now!
3. Vessels: Follow from the disc outwards. Which ones are arteries and which ones are veins? Easy- the arteries are the thinner ones that are often paler than the veins. Now check for common signs: ‘AV nipping’- in hypertension this is when an artery crosses a vein, the vein edges are squeezed in at this point. Its one of the signs of hypertensive retinopathy, or end organ damage caused by hypertension. There is nothing like that here.
4. Anything else on the retina? What about aneurysm formation or exudates (diabetic retinopathy) or dot and blot haemorrhages? nothing of the sort here, the discs otherwise look nice and clear. remember to check the macula area. Nothing to find here suggesting any of these problems.

So, all in all from this quick check we can see nothing up! This is a normal fundoscopy. So…

35 % of you were correct: The answer is to reassure the patient that the examination is normal! No other scans or referrals are needed on the basis of this history and examination.

35% of you got this right at last check on the 21st of January!

To recap the question see below…. or click the link here. Please add any comments or questions!

A medical student is practising for her OSCE exams on the ward…

She examines a 19 year old female patient admitted with asthma on the medical assessment ward for revision purposes.

The patient has a past medical history she has the occasional migraine, and eczema.
The observations are as follows.

BP 128/70

Pulse  98 regular

Fingerprick blood glucose 8.3

Oxygen Sats 97% on Air

She performs a cardiovascular and opthalmological examination.

Cardiovascular examination: Split S2 (second heart sound) on deep inspiration.

Ophthalmology examination: Normal Eye movements. Pupils 6mm and reactive to light. Eye movements normal. Visual fields normal. No scotoma. Fundoscopy examination of one eye is shown below…

Do you get this good a view when performing fundoscopy? Of course not, this is a digital retinal photograph-remember when you are using a hand held opthalmoscope you only get to view a bit of this at a time, which is why its important you should know which eye this is!

Why not have a go at the questions below? We’ll put up the answers in a couple of days…

What is the correct course of action?

• Reassure the patient (35%)
• Request a CT Brain (24%)
• Refer opthalmology: check intra-ocular pressure (24%)
• Repeat blood pressure (12%)
• Request neurology/ clinical geneticist review (5%)

By the way, which eye is shown?

• Right eye (71%)
• Left eye (18%)

I’m not sure I get like this with x-rays of hands too… (11%)