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Mr. Pich and Ms. Chan Part I, for active infection, Sources:, 1..https…
Mr. Pich and Ms. Chan Part I
Learning Issue 1: what arere the treatment options available for PTSD with respect to providing trauma informed care?
Treatment
Trauma focused psychotherapy is preferred treatment
in individuals with comorbid disorders such as depression or psychosis, pharmalogical therapy is recommended until the symptoms are stable, then add psychotherapy.
SSRI or SNRI for patients with comorbid depression
Ms Chan should be screened for comorbid depression
Prazosin is recommended for individuals who experience sleep disturbance symptoms like nightmares.
Mr Pich has been having vivid nightmares that started when they were in Cambodia and have gotten much worse since he returned home. He may benefit from prazosin therapy.
for patients with psychotic symptoms usually augment an SSRI with second generation antipsychotic medication
use shared decision making and patient preference
work with patient to establish treatment goals
goals: maintain safety of patient and others, reduce symptoms of distress, reduce hyperarousal, reduce avoidant behaviors, address comorbities, and improve adaptive functioning
Since both Mr. Pich and Ms. Chan are experiencing symptoms of PTSD (Mr. Pich with panic attacks and nightmares and Ms Chan with withdrawn mood) they should both be offered focused psychotherapy
Trauma informed Care
ASA defines trauma as "exposure to actual or threatened death, serious injury or sexual violence in one or more ways"
PTSD is a diagnosis applied when traumatic events result in negative changes in cognition and mood, intrusion, avoidance and state of hyperarousal
Sovann mentions that his mother has been very quiet about the trip and somewhat withdrawn
a framework that considers patients previous experiences with trauma and informs providers interactions with patients.
first step is identification of trauma and asking the 4 basics: when the trauma occurred, timing and duration, the perpetrator, and whether or not the patient is currently safe
not every patient wants to disclose their history of trauma to their health care provider
providers should be alert to warning signs of prior trauma and PTSD
physiologic reaction of distress, such as startle response, negative alterations in cognition and mood, somatic symptoms like headache, insomnia, weight loss, abdominal pain, sexual dysfunction
increased anxiety, hyperarousability, dissociation, distrust, unexplained recent injuries like bruising
specific for a victim of sex trafficking: recurrent STI's, frequent pregnancies/abortions, delayed care, companion who speaks for patient, discrepancies in history
important to screen for trauma when discussing mental health and prior to physical exams. PTSD screening tools can be helpful too
what are the reporting laws regarding a positive TB test in the United States and the treatment for latent Tb?
any health care provider (broad terms) needs to notify the local board of health within 24 hours
including, doctor, dentist, nurse, social worker, chiropractor, psychologist, intern, resident, fellow medical officer, ect.
Any person in charge of clinical laboratory should report the date and result of test, name and DOB, and name and address of the physician
failure to report Tb can result in citations and fines
The report should contain all the following information:
-name, address, county
-telephone number
-sex, DOB
-race/ethnicict
-country of origin and year patient arrived in US
-occupation
-site of the disease
-chest x ray and results
-specimin source, smear, nucleic acid amplification, culture and drug susceptibility tests results
-skin test history
-HIV status
-resident of correctional or long term care facility
-alcohol or drug use
initial drug regimen
-drug toxicity and monitoring records for drug-drug itneractions
-signature of person submiting the report
-date report is submitted
For latent tuberculosis infection diagnosed by PPD antigen that results in positive test, should be reported to local health authority or DPH within three calendar days
Mr Pich has a positive Quantiferon-Tb-gold test, and his chest X ray is negative, and he is not experiencing symptoms so he would classify as latent Tb.
He had the BCG vaccine when in Cambodia, so his PPD test will always show up positive, the quantiferon gold needs to be used to determine if he was infected with Tb.
Treatment for Latent Tb
rifamycin base regimen is recommended over isoniazid monotherapy
Rifampin daily for 4 months
Isoniazid and rifampin daily for 3 months
Isoniazid and rifapentine weekly for 3 months
All three of these methods have better completion rates and less toxicity compared to isoniazid monotherapy
These are all options to discuss with Mr. Pich for his latent Tb
this is known as the "3HP treatment", there are important side effects like hypersensitivity, flu like symptoms, light headedness, dizziness, headache, n/v, syncope, and angioedema
3 HP usually is administered via directly observed therapy to facilitate side effect review.
Isoniazid monotherapy
fewer drug interactions relative to the rifamycin based regimens
used mostly for patients with contraindications to use of rifamycin, like drug-drug interactions or hypersensitivities.
for active infection
Sources:
1..
https://www.cdc.gov/tb/programs/laws/menu/caseid.htm
https://www-uptodate-com.online.uchc.edu/contents/treatment-of-tuberculosis-infection-latent-tuberculosis-in-nonpregnant-adults-without-hiv-infection?sectionName=Selecting%20a%20regimen&topicRef=141409&anchor=H3370092875&source=kpp#H3370092875
https://www-uptodate-com.online.uchc.edu/contents/posttraumatic-stress-disorder-in-adults-treatment-overview?search=PTSD&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H4224074612
https://www-uptodate-com.online.uchc.edu/contents/health-care-for-female-trauma-survivors-with-posttraumatic-stress-disorder-or-similarly-severe-symptoms?search=trauma%20informed%20care&source=search_result&selectedTitle=1~22&usage_type=default&display_rank=1#H3639824336
https://www.cdc.gov/tb/education/FAQforPharmacists.htm