Case Study Hypomagnesemia
CC
Follow up hypertension, hypomagnesemia, GERD.
Eye irritation.
S
The patient is a 61-year-old gentleman who has a history of hypertension as well as PACs and PVCs. He is followed by
Erin J. Rafferty, MD for these. He was experiencing quite a bit of fatigue on metoprolol 50 mg b.i.d. and she did decrease him to 25 mg b.i.d. He states this has made a tremendous difference in his energy level. He feels tremendously improved with this. The patient does tell me his blood pressures at home have been well controlled in the 120's/70s. He is not having any chest pain, his palpitations are well controlled.
The patient does have a history of depression. He states, however that he feels as though he is doing quite well from this standpoint. …show more content…
He is on pantoprazole 40 mg one p.o. daily, which does control his GERD symptoms. He is taking magnesium citrate three tablets b.i.d. He did have a magnesium level done in February, which was normal at 2.0.
The patient also had a low vitamin D level in February. He did do prescription strength vitamin D at that time and now is taking vitamin D3, he thinks 1000 international units per day.
The patient has a new issue today of some irritation of his right eye. He does tell me this was a problem some time ago, as well and he did go to an urgent care. He was given a drop for that, at that point. He states he had leftover drops, and although they were expired, it does seem to be helping. The eye was quite red at one point. It does drain whitish discharge, especially at night. He is not having any blurry vision, no pain in the eye. It was slightly itchy, although the drops have been helping. He is not sure exactly what drops they are, but states "some type of antibiotic …show more content…
Heart
Rate is slow in the rhythm of bigeminy.
A/P
Hypertension, history of premature atrial contractions and premature ventricular contractions, well controlled, especially with blood pressures at home on metoprolol 25 mg one p.o. b.i.d. He does have a followup appointment with Dr. Rafferty.
Gastroesophageal reflux disease, hypomagnesemia, likely related to chronic proton pump inhibitor use. This is, however controlling his symptoms. He is taking magnesium and last magnesium check in February was good. He will continue same. Problem.
Likely conjunctivitis, right eye, partially treated with expired drops. I did give him a prescription for Bleph-10 one to two drops two to three hours for the next seven to 10 days. He will call his eye doctor if symptoms continue despite this.
History depression, overall doing fairly well from this standpoint.
History of thrombocytopenia, thought related to alcohol use, now not using for the past two years. Last CBC was normal.
The patient does have a history of psoriasis and requests refill of betamethasone ointment. He states he uses this sparingly. This was
Follow up hypertension, hypomagnesemia, GERD.
Eye irritation.
S
The patient is a 61-year-old gentleman who has a history of hypertension as well as PACs and PVCs. He is followed by
Erin J. Rafferty, MD for these. He was experiencing quite a bit of fatigue on metoprolol 50 mg b.i.d. and she did decrease him to 25 mg b.i.d. He states this has made a tremendous difference in his energy level. He feels tremendously improved with this. The patient does tell me his blood pressures at home have been well controlled in the 120's/70s. He is not having any chest pain, his palpitations are well controlled.
The patient does have a history of depression. He states, however that he feels as though he is doing quite well from this standpoint. …show more content…
He is on pantoprazole 40 mg one p.o. daily, which does control his GERD symptoms. He is taking magnesium citrate three tablets b.i.d. He did have a magnesium level done in February, which was normal at 2.0.
The patient also had a low vitamin D level in February. He did do prescription strength vitamin D at that time and now is taking vitamin D3, he thinks 1000 international units per day.
The patient has a new issue today of some irritation of his right eye. He does tell me this was a problem some time ago, as well and he did go to an urgent care. He was given a drop for that, at that point. He states he had leftover drops, and although they were expired, it does seem to be helping. The eye was quite red at one point. It does drain whitish discharge, especially at night. He is not having any blurry vision, no pain in the eye. It was slightly itchy, although the drops have been helping. He is not sure exactly what drops they are, but states "some type of antibiotic …show more content…
Heart
Rate is slow in the rhythm of bigeminy.
A/P
Hypertension, history of premature atrial contractions and premature ventricular contractions, well controlled, especially with blood pressures at home on metoprolol 25 mg one p.o. b.i.d. He does have a followup appointment with Dr. Rafferty.
Gastroesophageal reflux disease, hypomagnesemia, likely related to chronic proton pump inhibitor use. This is, however controlling his symptoms. He is taking magnesium and last magnesium check in February was good. He will continue same. Problem.
Likely conjunctivitis, right eye, partially treated with expired drops. I did give him a prescription for Bleph-10 one to two drops two to three hours for the next seven to 10 days. He will call his eye doctor if symptoms continue despite this.
History depression, overall doing fairly well from this standpoint.
History of thrombocytopenia, thought related to alcohol use, now not using for the past two years. Last CBC was normal.
The patient does have a history of psoriasis and requests refill of betamethasone ointment. He states he uses this sparingly. This was