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Old 06-01-2012
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Question A 64-year-old woman has hypertension and hypercholesterolemia

A 64-year-old woman is evaluated during a health maintenance examination. She has hypertension and hypercholesterolemia. She has no symptoms to report. She is a current smoker, with a 20 pack-year history. Current medications are atenolol and hydrochlorothiazide. Vital signs are normal. BMI is 28. Funduscopic examination reveals bright, yellow, refractile deposits scattered in the retina of the right eye, with approximately five deposits seen on direct ophthalmoscopy. The left fundus appears normal. On visual acuity testing, near vision is 20/20 with reading glasses, and distance vision is 20/25 for both eyes. The remainder of the physical examination is normal. A lipid panel obtained prior to todayís visit reveals a total cholesterol of 190 mg/dL (4.92 mmol/L); LDL cholesterol of 120 mg/dL (3.11 mmol/L); HDL cholesterol of 40 mg/dL (1.04 mmol/L); and triglycerides of 150 mg/dL (1.70 mmol/L). Which of the following is the most effective management option for this patientís ocular findings?

A Antioxidant supplements
B Atorvastatin
C Lower blood pressure to below 130/85 mm Hg
D Smoking cessation
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Old 06-01-2012
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Originally Posted by Novobiocin View Post
A 64-year-old woman is evaluated during a health maintenance examination. She has hypertension and hypercholesterolemia. She has no symptoms to report. She is a current smoker, with a 20 pack-year history. Current medications are atenolol and hydrochlorothiazide. Vital signs are normal. BMI is 28. Funduscopic examination reveals bright, yellow, refractile deposits scattered in the retina of the right eye, with approximately five deposits seen on direct ophthalmoscopy. The left fundus appears normal. On visual acuity testing, near vision is 20/20 with reading glasses, and distance vision is 20/25 for both eyes. The remainder of the physical examination is normal. A lipid panel obtained prior to todayís visit reveals a total cholesterol of 190 mg/dL (4.92 mmol/L); LDL cholesterol of 120 mg/dL (3.11 mmol/L); HDL cholesterol of 40 mg/dL (1.04 mmol/L); and triglycerides of 150 mg/dL (1.70 mmol/L). Which of the following is the most effective management option for this patientís ocular findings?

A Antioxidant supplements
B Atorvastatin
C Lower blood pressure to below 130/85 mm Hg
D Smoking cessation
A .....????
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Old 06-01-2012
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Originally Posted by Novobiocin View Post
A 64-year-old woman is evaluated during a health maintenance examination. She has hypertension and hypercholesterolemia. She has no symptoms to report. She is a current smoker, with a 20 pack-year history. Current medications are atenolol and hydrochlorothiazide. Vital signs are normal. BMI is 28. Funduscopic examination reveals bright, yellow, refractile deposits scattered in the retina of the right eye, with approximately five deposits seen on direct ophthalmoscopy. The left fundus appears normal. On visual acuity testing, near vision is 20/20 with reading glasses, and distance vision is 20/25 for both eyes. The remainder of the physical examination is normal. A lipid panel obtained prior to todayís visit reveals a total cholesterol of 190 mg/dL (4.92 mmol/L); LDL cholesterol of 120 mg/dL (3.11 mmol/L); HDL cholesterol of 40 mg/dL (1.04 mmol/L); and triglycerides of 150 mg/dL (1.70 mmol/L). Which of the following is the most effective management option for this patientís ocular findings?

A Antioxidant supplements
B Atorvastatin
C Lower blood pressure to below 130/85 mm Hg
D Smoking cessation
aks to pt to quit smoking every visit
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Old 06-02-2012
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This patient has early age-related macular degeneration (AMD), which can affect one or both eyes. Early AMD is characterized by the finding of drusen (yellow deposits in the retina, as noted on examination in this patient) or retinal pigment changes. (A few small, scattered drusen are a normal part of aging.) The clearest risk factors for the development of AMD are increasing age and smoking (>10 pack-year history). Thus, all smokers with AMD, regardless of stage, should be advised to quit smoking. Patients who have quit smoking for more than 20 years are at no higher risk of AMD than nonsmokers.

There is no indication for initiating antioxidant supplementation in patients with early AMD, as it has not been shown to prevent progression. Patients with intermediate AMD in one or both eyes, or advanced AMD in one eye, should be treated with antioxidant therapy; for these patients, the Age-Related Eye Disease Study demonstrated significant reduction in the risk of progression of visual loss, and in some patients, improvement in vision, in those taking a combination of antioxidants (vitamin C, vitamin E, β-carotene) plus zinc and copper daily. However, patients who are smokers should not take β-carotene supplements, as this may increase the risk of lung cancer, and vitamin E supplementation can increase the risk of heart failure in patients with diabetes mellitus or coronary artery disease. In these subgroups, supplementation with zinc and copper alone may be just as effective.
Hypertension and hypercholesterolemia should be treated according to national guidelines regardless of the presence of AMD. Further reduction of this patientís LDL cholesterol level or blood pressure will have no additional beneficial effect on this patientís AMD
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