{"id":3961,"date":"2023-11-22T15:16:00","date_gmt":"2023-11-22T15:16:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=3961"},"modified":"2025-10-01T11:39:35","modified_gmt":"2025-10-01T19:39:35","slug":"usmle-step-1-question-of-the-day-fundoscopy-findings","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-fundoscopy-findings","title":{"rendered":"USMLE\u00ae Step 1 Question of the Day: Fundoscopy findings"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-fundoscopy-findings\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-fundoscopy-findings\/#A_Edematous_optic_disc_with_blurred_margins\" >A.&nbsp;Edematous optic disc with blurred margins<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-fundoscopy-findings\/#Incorrect_answer_explanations\" >Incorrect answer explanations<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-fundoscopy-findings\/#B_Enlarged_optic_cup_with_an_increased_cupdisc_ratio\" >B. Enlarged optic cup with an increased cup\/disc ratio<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-fundoscopy-findings\/#C_Extensive_retinal_hemorrhage_and_venous_engorgement\" >C. Extensive retinal hemorrhage and venous engorgement<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-fundoscopy-findings\/#D_Retinal_neovascularization\" >D. Retinal neovascularization<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-fundoscopy-findings\/#E_Crinkling_of_retinal_tissue\" >E. Crinkling of retinal tissue&nbsp;<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-8\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-fundoscopy-findings\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-9\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-fundoscopy-findings\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-10\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-fundoscopy-findings\/#i\" >________________________<\/a><\/li><\/ul><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em><strong><em>This week, we are sharing another USMLE\u00ae&nbsp;<strong><em><strong><em>Step 1-style<\/em><\/strong><\/em><\/strong>&nbsp;practice question to test your knowledge of medical topics.&nbsp;<\/em><\/strong><strong><em>Today&#8217;s case focuses on a 66-year-old man with altered mental status, headache, and more. Can you identify the fundoscopy finding that affects a diagnostic lumbar puncture? Test your diagnostic skills with this USMLE Step 1 question.<\/em><\/strong><\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 66-year-old man is brought to the emergency department by his partner to evaluate his altered mental status. The patient\u2019s partner states that he said he had a headache and blurry vision earlier that morning with associated nausea and vomiting. He tried taking acetaminophen with minimal relief. His past medical history includes hypertension and a 35 pack-year smoking history. His temperature is 38.5\u00b0C (101.3\u00b0F), pulse is 102\/min, and blood pressure is 158\/98 mmHg. There is spontaneous flexion of the hips with passive flexion of the neck. Which of the following findings on fundoscopy contraindicates the performance of a diagnostic lumbar puncture?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Edematous optic disc with blurred margins<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Enlarged optic cup with an increased cup\/disc ratio<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Extensive retinal hemorrhage and venous engorgement<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Retinal neovascularization<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Crinkling of retinal tissue&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Scroll down for the correct answer!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"A_Edematous_optic_disc_with_blurred_margins\"><\/span>A.&nbsp;<strong>Edematous optic disc with blurred margins<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the Main Explanation, let&#8217;s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_answer_explanations\"><\/span>Incorrect answer explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"B_Enlarged_optic_cup_with_an_increased_cupdisc_ratio\"><\/span>B. Enlarged optic cup with an increased cup\/disc ratio<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;This finding suggests open-angle glaucoma, which typically presents as progressive peripheral vision loss with findings of an enlarged optic cup with an increased cup\/disc ratio (\u201ccupping\u201d of the optic disc) on fundoscopy.&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"C_Extensive_retinal_hemorrhage_and_venous_engorgement\"><\/span>C. Extensive retinal hemorrhage and venous engorgement<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;This fundoscopic finding is often observed in patients with retinal vein occlusion. Patients typically present with sudden onset, painless, monocular vision loss.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"D_Retinal_neovascularization\"><\/span>D. Retinal neovascularization<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Formation of new blood vessels (neovascularization) is often seen in the advanced stages of diabetic retinopathy. This finding occurs secondary to retinal ischemia and subsequent upregulation of pro-angiogenic cytokines, namely, vascular endothelial growth factor (VEGF). Neovascularization is not a contraindication to the performance of a lumbar puncture.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"E_Crinkling_of_retinal_tissue\"><\/span>E. Crinkling of retinal tissue&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Retinal detachment typically presents as flashes or floaters followed by sudden, painless visual field loss in the affected eye. Vision loss typically begins in the periphery and progresses toward loss of the central visual axis over hours to weeks. A fundoscopic examination may demonstrate wrinkling\/crinkling of retinal tissue or changes in blood vessel direction. These fundoscopic findings do not suggest papilledema and hence do not contraindicate the performance of a lumbar puncture.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span><strong>Main Explanation<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient presents with fever, altered mental status, and a positive Brudzinski sign&#8211;concerning meningitis. Unless contraindicated, every patient with suspected meningitis should undergo lumbar puncture (LP). Suppose a lumbar puncture is performed in the setting of increased intracranial pressure (ICP). In that case, &nbsp;a cerebral herniation may ensue due to the rapid change in intracavitary pressure as cerebrospinal fluid is removed for analysis. Any diagnostic physical exam findings that suggest elevated ICP (e.g., papilledema) prohibit the performance of this procedure.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Papilledema refers to swelling of the optic disc and has multiple etiologies. Meningitis may cause elevated ICP via obstructive hydrocephalus or impaired cerebrospinal fluid absorption due to &nbsp;inflammation at the level of arachnoid granulations. Fundoscopic findings of papilledema demonstrate an enlarged blind spot and an elevated, edematous disc, with blurred disc margins and engorged blood vessels.<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"1004\" height=\"694\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_b82899.png\" alt=\"table of the causes of papilledema\" class=\"wp-image-3963\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_b82899.png 1004w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_b82899.png?resize=300,207 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_b82899.png?resize=768,531 768w\" sizes=\"auto, (max-width: 1004px) 100vw, 1004px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Papilledema refers to swelling of the optic disc. Fundoscopic examination typically shows an elevated, edematous disc, with blurred disc margins and engorged blood vessels.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>References<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Chen, J. J., &amp; Bhatti, M. T. (2019). Papilledema. International Ophthalmology Clinics, 59(3), 3\u201322. doi:10.1097\/iio.0000000000000274<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"i\"><\/span><strong><em>________________________<\/em><\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more USMLE\u00ae Step 1 practice questions? Try Osmosis by Elsevier today! Access your\u00a0<em><strong><a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a><\/strong><\/em>\u00a0and find out why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/www.osmosis.org\/ultimate-guide\/usmle-step-1\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_ad32b4.png\" alt=\"Osmosis sign up ad\" class=\"wp-image-3971\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_ad32b4.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_ad32b4.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.osmosis.org\/ultimate-guide\/usmle-step-1\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><br><em><sub>The United States Medical Licensing Examination (USMLE\u00ae) is a joint program of the Federation of State Medical Boards (FSMB\u00ae) and National Board of Medical Examiners (NBME\u00ae). Osmosis is not affiliated with NBME nor FSMB.\u00a0<\/sub><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>This week, we are sharing another USMLE\u00ae&nbsp;Step 1-style&nbsp;practice question to test your knowledge of medical topics.&nbsp;Today&#8217;s case focuses on a 66-year-old man with altered mental status, headache, and more. Can you identify the fundoscopy finding that affects a diagnostic lumbar puncture? Test your diagnostic skills with this USMLE Step 1 question. A 66-year-old man is [&hellip;]<\/p>\n","protected":false},"author":202,"featured_media":3962,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,1366,1369,44],"tags":[],"class_list":["post-3961","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-questions","category-step-1-questions","category-step-1"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 1 Question of the Day: Fundoscopy findings - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-fundoscopy-findings\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 1 Question of the Day: Fundoscopy findings - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"This week, we are sharing another USMLE\u00ae&nbsp;Step 1-style&nbsp;practice question to test your knowledge of medical topics.&nbsp;Today&#8217;s case focuses on a 66-year-old man with altered mental status, headache, and more. Can you identify the fundoscopy finding that affects a diagnostic lumbar puncture? Test your diagnostic skills with this USMLE Step 1 question. 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Can you\u2026","rel":"","context":"In &quot;Allopathic Medicine (MD)&quot;","block_context":{"text":"Allopathic Medicine (MD)","link":"https:\/\/www.osmosis.org\/blog\/category\/medicine"},"img":{"alt_text":"","src":"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-altered-mental-state_5c198b.webp","width":350,"height":200,"srcset":"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-altered-mental-state_5c198b.webp 1x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-altered-mental-state_5c198b.webp 1.5x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-altered-mental-state_5c198b.webp 2x"},"classes":[]},{"id":799,"url":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-lumbar-puncture","url_meta":{"origin":3961,"position":4},"title":"USMLE\u00ae Step 2 Question of the Day: Lumbar puncture","author":"Marina Horiates Kerekes, MD &amp; Team","date":"May 24, 2023","format":false,"excerpt":"This week, we are sharing another USMLE\u00ae Step 2-style practice question to test your knowledge of medical topics.\u00a0Today's case focuses on a 56-year-old man that has an occipital headache that progressed and is now associated with nausea, vomiting, and fever. 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