Berks County Medical Society Medical Record Fall 2018 - 12

Culture Race LANGUAGE
Child
Abuse RELIGION
F
employment poverty
Violence Neighborhood
EDUCATION nutrition
DISCRIMINATION family

Medical RecoRd

e at u R e

Health Determinants
Beyond the Exam Room
by Jerry Zhu
Berks County Medical Society 2018 President's Intern
Advisors: Lucy J. Cairns, MD, C. Eve J. Kimball, MD, FAAP, and
D. Michael Baxter, MD

CHIEF COMPLAINT:
"chest discomfort, difficulty breathing, shortness of breath"

HISTORY OF PRESENT ILLNESS:
A 43-year-old women presents to the emergency department with chest
discomfort and shortness of breath. The patient describes the discomfort
as tightness and pain radiating to her left arm which awoke her early in the
morning. She reports that she has previously had intermittent chest discomfort
approximately three times in the past year; however, she did not seek medical
attention.
The patient notes that she has recently been feeling especially fatigued and is
often thirsty at night. She is losing weight despite an excellent appetite. She states
that her vision is blurry, notably in the evening.
All other symptoms were negative.

PAST MEDICAL HISTORY:
The patient was previously diagnosed with diabetes mellitus type 2 in
2012. She was found at that time to be hypertensive. Her medications include
metformin 1000mg daily for diabetes and lisinopril 5mg daily for high blood
pressure.

SOCIAL HISTORY:
Patient lives in Reading with her five children. She has limited English
proficiency and has difficulty communicating with a Spanish translator due to her

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Berks County Medical Society Medical Record Fall 2018

Table of Contents for the Digital Edition of Berks County Medical Society Medical Record Fall 2018

Berks County Medical Society Medical Record Fall 2018 - 1
Berks County Medical Society Medical Record Fall 2018 - 2
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