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Mr. Pich & Ms. Chan - Coggle Diagram

- - - - When should you initiate latent TB treatment? What is the incidence of it turning to active TB?
      - 2 months later: Son of patients has concerns - “They just don’t seem ‘right’ since they got back from Cambodia, my mother has been very quiet about the trip and somewhat withdrawn. My father is not taking his blood pressure medication. He saw a local healer in Cambodia and underwent ‘coining’ therapy.” Concern his father has episodes of "heart pounding" and "can't move" (nothing wrong with heart on work up)
        
        How does PTSD normally present? Does this differ in males v females?
        
        Cultural barriers to not taking medications?
        
        What is coining therapy? What are other traditional practices in this region?
        
        Mr. Pich, Ms. Chan and their son (Sovann) all in same office visit f/u
        Son talks to Dr. alone: “Listen, I know I might sound pushy, but I just don’t understand my parents, they don’t want to bother anyone but I can tell they are suffering. I am a musician and I travel a lot. I know they need more help, and I am doing the best I can. My father does not like it if I speak for him. I know they are both disappointed in me because I didn’t go to college or get a steady job in Hartford...[he hopes] the doctor can help them."
        
        Mr. Pich & Ms. Chan followed malaria prophylaxis, Mr. Pich did not take lisinopril - still has HTN. Did she explain chronic HTN well? He is having panic attacks & is concerned about his heart. Son thanks and offers to talk more if needed.
        
        Dr. Gregory shows Mr. Pich image of retina damage
        
        Is this a good way to explain potential complications of chronic HTN? This "seems to improve" the likelihood he will take the meds (?) - Is there another way to go about this?
        
        Epilogue: 1 week later, Sovann sees Dr. Gregory with parent's permission
        
        Mr. Pich was tortured by the Khmer Rouge in his 20's, nearly died. Continues to have psychological and emotional effects.
        
        Son says Mr. Pich has been controlling / concerned about things like home security
        
        Dr. thinks the "anxiety" attacks triggered only by the resurgence of the memories of the war crimes he witnessed during the Khmer Rouge reign.
        
        Dr. Gregory considers referring couple to specialist with PTSD experience. Looking for professional with specific trauma experience, wonders if insurance will cover it. He will even accept that recommendation.
        
        how should they manage just Mr. Pich's PTSD?
        
        Concern for Mr. Pich - attended brother's memorial. Reminded him of family/friends passing since he left Cambodia. Has had vivid nightmares, worsening.
        
        Concern for Ms. Chan being quiet w/minimal eye contact. She has a few relatives in the US.
- - - - Seen as cheap way to access healing, people will see physician if coining therapy fails.
      - Mr. Pich may have stopped taking his medications after receiving coining therapy in Cambodia because he thought he was healed.
  - - - There are different subtypes of PTSD like dissociative subtype / different PTSD symptom clusters. Can have hyperarousal or hypo-arousal with numbing/detachment.
    - - Exposure therapy & CBT may be less preferred, as it is common in Cambodian culture to avoid talking about things that are upsetting like PTSD
  - - - may lead to a lot of emotional stress that may exacerbate existing intergenerational tensions as indicated by Sovann’s feeling that “I know they are both disappointed in me because I didn’t go to college or get a steady job in Hartford.”
  - - - may result in a false positive PPD test because the cross reactivity from antibodies generated with the skin PPD test. However, recent studies have shown “there is little relationship between BCG vaccination and PPD positivity, and that BCG vaccination status should not be considered in the interpretation of a positive PPD test.”
      - However, the BCG vaccine would not result in a positive interferon gamma release assay (also called QuantiFERON), which is a blood test looking for interferon gamma released from Th1 cells that have been exposed to the TB mycobacterium.
        
        This is what Mr. Pich was reported to test positive for, indicating he has latent TB with the negative chest XRAY.
        
        Treat ASAP because can become active. Risk factors for activation is immunosuppression, diabetes, silicosis, etc.
      - Visiting family are at greatest risk for acquiring disease. Individuals visiting home forget immunizations; may assume less susceptible to conditions (ie. such as Malaria)
        
        Cambodia recommends immunizations: MMR, Tdap, Hepatitis A, staying longer than 1 month: consider japanese encephalitis and typhoid, parasites too from fecal-oral transmission
    - - As of 2021, Cambodia is a high-incidence country (~300 cases per 100,000), and treating Mr. Pich early with sufficiently strong medication can help reduce the risk for developing multiple drug resistant TB