Berks County Medical Society Medical Record Fall 2018 - 13

regional dialect. No medical records exist between 2013 and 2018.
It is unknown if the patient sees her family medicine physician or is
compliant with medications. A more detailed history could not be
obtained due to the language barrier.
______________________________________________
In this fictional scenario, the patient, Mrs. Rodriguez, has
uncontrolled type 2 diabetes and hypertension that have resulted in
a worst case scenario: a myocardial infarction. However, if her heart
attack were to be attributed simply to diabetes and hypertension, her
physicians would be ignoring the most important determinants of
Mrs. Rodriguez's health and so missing opportunities to improve it.
Mrs. Rodriguez's story begins long before she arrived at the
emergency department with chest pain. If a more thorough social
history had been obtained, it might have enabled a diagnosis of
unrecognized depression which will interfere with her recovery .
Pain was not something new to Mrs. Rodriguez. Having grown
up in northeastern Mexico, she fled to the United States in 2004 to
escape violence and economic destitution. With little money in the
family to spare, she was used to working long hours in landscaping,
which took a physical and mental toll on her. Despite being in her
early 40s, the white hairs and wrinkled skin made her look closer to
60.
The chest tightness began around 11:30 P.M. after Mrs.
Rodriguez put her eldest child to bed. Thinking that it was a muscle
spasm, the mother of five proceeded to do a few stretches, which
helped alleviate but did not eliminate the discomfort.
Around 2 A.M., Mrs. Rodriguez was awoken by a sharp stabbing
pain in her chest and profuse sweating. Immediately, she knew
something was wrong but didn't know what. Concerned by her
difficulty breathing, she knocked on a neighbor's door in hopes
that he would be able to give her a ride to the hospital. After being
dropped off at the nearest emergency room, Mrs. Rodriguez had
difficulty communicating with the triage nurse due to her broken
English. Because of the language barrier and a reliance on nonverbal
communication she was at first believed to have had a severe case
of heart burn, which delayed treatment for her life threatening
condition. After an hour-long wait for a translator, the attending
emergency physician struggled to obtain her history and-becoming
increasingly frustrated-started to raise his voice and slow his words.
When asked about her medications, Mrs. Rodriguez was unable
to recall the names of her prescriptions and indicated that she
had not taken any in the past year. Taken aback by his tone and
overwhelmed by the amount of questions, Mrs. Rodriguez meekly
agreed to the physician's care plan despite not fully understanding
what was to be done.
During her time at the emergency department, providers
described her as "challenging," "difficult," and "non-compliant."
These labels obscure the proximal cause of her actions. While her
medical decisions may seem reckless, her actions are the direct result
of the social, economic, and cultural conditions of her environment.
Mrs. Rodriguez's inability to comply with medications is due
to food insecurity and limited health literacy. Forced to choose
between feeding her children or purchasing medication with her
available funds, she chooses the former option. After running out of

her refills, she is unable to see a primary care physician due to work
commitments and lack of available transportation. With only a high
school education and a basic understanding of English, navigating
the health care system has been especially challenging and often
times seems out of her hands. After her diabetes diagnosis, she
felt devastated and became depressed. Due to the cultural stigma
surrounding mental illness, she hid her symptoms and refused to
seek help. Due to the hopelessness and helplessness that accompany
her untreated depression, she is unlikely to comply with the diet
counseling and new medications prescribed to her after her visit to
the ED.
The compounding effect of these external factors exacerbated
Mrs. Rodriguez's chronic conditions, resulting in her heart attack
and influencing the quality of her care. These are considered social
determinants of health-the conditions that people experience
outside the exam room that affect an individual's health risks and
outcomes. An analysis published in the New England Journal of
Medicine concluded that only 10 percent of health is determined by
health care (Schroeder, 2007). The major determinants of overall
health are individual behavior and social/environmental factors
(Figure 1). In the community, these factors appear as socioeconomic
status, education, neighborhood environment, employment, and
support networks (Artiga and Hinton, 2018). Moreover, social
determinants of health are shaped by the distribution of resources,
power, and money across the local, national, and global level
contributing to health disparities (WHO, 2017). Health disparities,
the differences that exist among specific population groups in the
achievement of an individual's full health potential, are particularly
palpable along racial, ethnic, gender, age, and socioeconomic lines
(CDC, 2010).
"Your zip code is a better predictor of your health than your
genetic code," said Melody Goodman, assistant professor of surgery at
Washington University in St. Louis.
In recent years, the national trend in health disparities is
especially alarming among racial and ethnic minorities. Although
great progress has been made to reduce differences in health
outcomes, health disparities are still pervasive and efforts to eliminate
these health gaps have not come to fruition (NCHS, 2016). Infant
mortality rate, an important indicator for overall health care quality
and population health, has nationally decreased by 14 percent
from 2004 to 2014; however, racial disparities continue to exist
(HHS, 2014). Non-Hispanic blacks had the highest rates of infant
mortality, with almost twice the infant mortality rate of all racial
groups combined (Sawyer and Gonzales, 2017). Moreover, in 2015
the percentage of low-birthweight infants in the U.S. increased for
the first time in seven years. This change is attributed to marked
rate increases in low-birthweight infants in the African American
and Hispanic populations, while the rate in the White population
remained essentially unchanged (Hamilton et al., 2016).
Additionally, disparities in the rate of chronic illness and
comorbidities continue to exist, particularly among Hispanics and
African Americans. Obesity, a precursor condition for diabetes
and its comorbidities, is highest among Hispanic children and
adolescents between the ages of 2-19 at 21.9 percent (NCHS, 2016).
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FALL 2018

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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
