1
A patient presents for their annual routine eye exam. Which of the following findings on
fundoscopy examination warrants rapid lowering of the blood pressure?
A. Arteriovenous nicking B. Cotton-wool spots
C. Papilledema D. Microaneurysms
All patients with newly diagnosed hypertension should receive a fundoscopy because the retina
is the only part of the vasculature that can be visualized noninvasively. Ocular diseases directly
related to hypertension are progressive and can be classified by their degree of severity.
Arteriovenous nicking alone indicates mild hypertensive retinopathy, whereas cotton-wool
spots, hemorrhages, and microaneurysms are indicative of moderate hypertensive retinopathy.
Severe hypertensive retinopathy is indicated by swelling of the optic disc (papilledema),
alongside retinal hemorrhages, hard exudates, cotton-wool patches, microaneurysms, and
arteriovenous nicking. The presence of papilledema warrants rapid lowering of the blood
pressure. It occurs when increased intracranial pressure spreads to the optic nerve sheath.
Urgent diagnosis, evaluation, and treatment are needed to prevent serious complications.
Inhalation of cocaine can cause which of the following conditions?
A. Nasal polyps B. Allergic rhinitis
C. Rhinitis medicamentosa D. Nasal septal perforation
Snorting or inhalation of cocaine is a common cause of nasal septal perforation. Chronic cocaine
use can also lead to a plethora of other complications: neurologic, psychiatric, cardiovascular,
pulmonary, gastrointestinal, and reproductive system effects.
A patient presents with fever, generalized fatigue, and anorexia. Upon physical assessment,
white-gray lesions are noted with an erythematous base on the buccal mucosa of about 2 mm in
size. This clinical finding suggests:
A. Epstein-Barr virus B. Herpes zoster
C. Mumps D. Measles
Measles, a highly contagious viral illness, is characterized by the clinical stages of incubation (6-
21 days), prodrome, exanthem (red maculopapular rash), and recovery. The prodrome phase is
characterized by fever, malaise, anorexia, conjunctivitis, coryza, and cough. Patients may
develop Koplik’s spots, which are 1- to 3-mm whitish, grayish, or bluish lesions with an
erythematous base. These are often found on the buccal mucosa opposite the molar teeth. They
generally last 12-72 hours and are pathognomonic for measles.
The NP uses the Snellen chart to evaluate the patient’s visual acuity, which is 20/50. How does
the NP explain this finding to the patient?
A. The denominator is the distance in feet at which the patient stands from the Snellen chart.
B. The patient can read letters while standing 20 feet from the chart that the average
person could read at 50 feet.
C. The numerator is dependent on the patient’s vision.
D. The patient can read letters while standing 50 feet from the chart that the average person
could read at 20 feet.
, 2
Which of the following bedside tests can be used to identify CSF in patients who present with
otorrhea or rhinorrhea?
A. Beta-2 transferrin examination B. Halo test
C. Head impulse test D. Test of skew
In patients with suspected craniofacial trauma, the clinician should inspect the nose and ears for
drainage. If present, rhinorrhea and otorrhea should be tested for the presence of CSF. The halo
test (the ring or target sign) is a quick bedside tool that may be used to determine the presence
of CSF. A drop of fluid is placed on a tissue; a rapidly expanding ring of clear fluid around red
blood suggests a positive test. While this is considered a nonspecific finding, it may be helpful to
identify patients who may need a higher level of care and neuroimaging to confirm a CSF leak.
A CSF leak may be diagnosed when CSF proteins, such as beta-2 transferrin, are found by
laboratory analysis of a collected sample. While this is highly specific and sensitive for a CSF
leak, it involves analysis by immunohistochemical assays and cannot be performed at the
bedside. The HINTS examination (which includes the head impulse test, evaluation for direction-
changing nystagmus, and a test of skew) can be used to suggest central rather than peripheral
vertigo in patients.
A middle-aged adult presents with anxiety and dizziness. They complain that upon getting out of
bed that morning, they had severe dizziness and almost fell because “the room was spinning so
much.” The patient’s gait is unstable with some swaying noted. They report becoming very dizzy
and having problems with balance when moving their head quickly. The patient denies trauma,
hypertension, tinnitus, hearing loss, and fever. The Romberg test is positive. Which of the
following conditions is most likely?
A. Benign paroxysmal positional vertigo (BPPV) B. Ménière’s disease
C. Acoustic neuroma D. CVA
BPPV is the most common cause of vertigo in the US; caused by calcium carbonate crystals in
the semicircular canals. An initial treatment is the Epley maneuver - the head is turned
sequentially, which helps to move the crystals in the semicircular canals by gravity. Several
repositioning maneuvers may be needed at the same visit; recurrences can occur. There is no
tinnitus or hearing loss, so Ménière’s disease and acoustic neuroma can be ruled out. No limb
weakness/ slurred speech, CVA can also be R/O.
Regarding the previous case, which of the following tests will help diagnose this patient?
A. Lachman B. Dix-Hallpike C. Obturator D. Finkelstein
The Dix–Hallpike test or maneuver is the gold-standard test for benign paroxysmal positional
vertigo (BPPV). It is positive if classic rotary nystagmus is seen with latency (limited duration).
The Lachman maneuver is a test for the anterior cruciate ligament (ACL) of the knee. The
obturator test is used for acute appendicitis. The Finkelstein test is used to assess for De
Quervain’s tenosynovitis.
A patient presents for their annual routine eye exam. Which of the following findings on
fundoscopy examination warrants rapid lowering of the blood pressure?
A. Arteriovenous nicking B. Cotton-wool spots
C. Papilledema D. Microaneurysms
All patients with newly diagnosed hypertension should receive a fundoscopy because the retina
is the only part of the vasculature that can be visualized noninvasively. Ocular diseases directly
related to hypertension are progressive and can be classified by their degree of severity.
Arteriovenous nicking alone indicates mild hypertensive retinopathy, whereas cotton-wool
spots, hemorrhages, and microaneurysms are indicative of moderate hypertensive retinopathy.
Severe hypertensive retinopathy is indicated by swelling of the optic disc (papilledema),
alongside retinal hemorrhages, hard exudates, cotton-wool patches, microaneurysms, and
arteriovenous nicking. The presence of papilledema warrants rapid lowering of the blood
pressure. It occurs when increased intracranial pressure spreads to the optic nerve sheath.
Urgent diagnosis, evaluation, and treatment are needed to prevent serious complications.
Inhalation of cocaine can cause which of the following conditions?
A. Nasal polyps B. Allergic rhinitis
C. Rhinitis medicamentosa D. Nasal septal perforation
Snorting or inhalation of cocaine is a common cause of nasal septal perforation. Chronic cocaine
use can also lead to a plethora of other complications: neurologic, psychiatric, cardiovascular,
pulmonary, gastrointestinal, and reproductive system effects.
A patient presents with fever, generalized fatigue, and anorexia. Upon physical assessment,
white-gray lesions are noted with an erythematous base on the buccal mucosa of about 2 mm in
size. This clinical finding suggests:
A. Epstein-Barr virus B. Herpes zoster
C. Mumps D. Measles
Measles, a highly contagious viral illness, is characterized by the clinical stages of incubation (6-
21 days), prodrome, exanthem (red maculopapular rash), and recovery. The prodrome phase is
characterized by fever, malaise, anorexia, conjunctivitis, coryza, and cough. Patients may
develop Koplik’s spots, which are 1- to 3-mm whitish, grayish, or bluish lesions with an
erythematous base. These are often found on the buccal mucosa opposite the molar teeth. They
generally last 12-72 hours and are pathognomonic for measles.
The NP uses the Snellen chart to evaluate the patient’s visual acuity, which is 20/50. How does
the NP explain this finding to the patient?
A. The denominator is the distance in feet at which the patient stands from the Snellen chart.
B. The patient can read letters while standing 20 feet from the chart that the average
person could read at 50 feet.
C. The numerator is dependent on the patient’s vision.
D. The patient can read letters while standing 50 feet from the chart that the average person
could read at 20 feet.
, 2
Which of the following bedside tests can be used to identify CSF in patients who present with
otorrhea or rhinorrhea?
A. Beta-2 transferrin examination B. Halo test
C. Head impulse test D. Test of skew
In patients with suspected craniofacial trauma, the clinician should inspect the nose and ears for
drainage. If present, rhinorrhea and otorrhea should be tested for the presence of CSF. The halo
test (the ring or target sign) is a quick bedside tool that may be used to determine the presence
of CSF. A drop of fluid is placed on a tissue; a rapidly expanding ring of clear fluid around red
blood suggests a positive test. While this is considered a nonspecific finding, it may be helpful to
identify patients who may need a higher level of care and neuroimaging to confirm a CSF leak.
A CSF leak may be diagnosed when CSF proteins, such as beta-2 transferrin, are found by
laboratory analysis of a collected sample. While this is highly specific and sensitive for a CSF
leak, it involves analysis by immunohistochemical assays and cannot be performed at the
bedside. The HINTS examination (which includes the head impulse test, evaluation for direction-
changing nystagmus, and a test of skew) can be used to suggest central rather than peripheral
vertigo in patients.
A middle-aged adult presents with anxiety and dizziness. They complain that upon getting out of
bed that morning, they had severe dizziness and almost fell because “the room was spinning so
much.” The patient’s gait is unstable with some swaying noted. They report becoming very dizzy
and having problems with balance when moving their head quickly. The patient denies trauma,
hypertension, tinnitus, hearing loss, and fever. The Romberg test is positive. Which of the
following conditions is most likely?
A. Benign paroxysmal positional vertigo (BPPV) B. Ménière’s disease
C. Acoustic neuroma D. CVA
BPPV is the most common cause of vertigo in the US; caused by calcium carbonate crystals in
the semicircular canals. An initial treatment is the Epley maneuver - the head is turned
sequentially, which helps to move the crystals in the semicircular canals by gravity. Several
repositioning maneuvers may be needed at the same visit; recurrences can occur. There is no
tinnitus or hearing loss, so Ménière’s disease and acoustic neuroma can be ruled out. No limb
weakness/ slurred speech, CVA can also be R/O.
Regarding the previous case, which of the following tests will help diagnose this patient?
A. Lachman B. Dix-Hallpike C. Obturator D. Finkelstein
The Dix–Hallpike test or maneuver is the gold-standard test for benign paroxysmal positional
vertigo (BPPV). It is positive if classic rotary nystagmus is seen with latency (limited duration).
The Lachman maneuver is a test for the anterior cruciate ligament (ACL) of the knee. The
obturator test is used for acute appendicitis. The Finkelstein test is used to assess for De
Quervain’s tenosynovitis.
