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Have you ever seen a patient covered in feces and wondered why it happened? Have you felt disgusted and thought that your reaction might have affected the care you provided? If you have, then the following case vignette should serve as a stimulus for further discussion and clinical guidance and prepare you for the notion that certain situations direct medical care more than do symptoms.
Ms A, a year-old woman, was found amid her feces and urine following a mechanical fall. When a neighbor came by to check on her, he called for an ambulance. While Ms A had managed to obtain fluids, she spent several days on her couch. She described herself as an independent woman and stated that she wanted to be left alone. Ms A acknowledged that she was distraught over the death of her cat. Physical examination revealed an awake, alert, polite, cooperative, and fluent but dysarthric lb woman.
However, Ms A had problems with 3-step Luria maneuvers, was perseverative, and manifest poor planning on clock-drawing.
In addition, she thought that the tallest building in Boston, Massachusetts, was 6 ft tall and that the average loaf of bread had slices.
Nonetheless, initial evaluations by clinical staff did not detect a psychiatric disturbance. The differential diagnosis of being found in feces is broad. Although being covered in stool may Neuro Feces - Skitzo - Psychobabble a normal occurrence in certain professions eg, sewage engineeringunder B Bs Blues - B.B.
King - Blues Boy circumstances, being covered in fecal waste is a marker of underlying pathology. Despite the fact that people produce solid waste from digested Neuro Feces - Skitzo - Psychobabble on a regular basis, being covered in stool is relatively uncommon. From an early age, toddlers learn that stool is an undesirable bodily product and contact with it should be minimized. A practical approach to thinking about an individual who is brought to a medical facility covered in fecal matter involves consideration of both abnormal stool excretion and impaired response to fecal contamination.
Thus, factors that impact the rate and quantity of stool production as well Neuro Feces - Skitzo - Psychobabble the time to clean up the mess are considered when creating a differential diagnosis.
Factors that influence stool production and fecal soiling need to be considered in the workup of a person brought in for medical attention after being found in feces. Diarrhea, with high quantities or fast flow of stool and with attendant increases in the risk of fecal Neuro Feces - Skitzo - Psychobabble has myriad causes.
Infections, medications, endocrine disorders, and several malabsorptive and inflammatory conditions can cause diarrhea and increase the likelihood that a patient may become covered in feces.
At the other end of the spectrum, constipation can cause fecal soiling due to liquid stool leakage around an impacted fecal mass, a condition referred to as overflow incontinence or encopresis.
However, it is important to note that only a small subset of individuals with constipation experience overflow impaction, encopresis, or fecal soiling. In addition to constipation and diarrhea, other risk factors for adult fecal incontinence include female gender, pregnancy, advanced age, poor health status, neurologic disorders, and institutionalized residence.
Impaired sensation, as can occur with cord paralysis or neurologic deficits particularly if accompanied by anosmiacan limit awareness of the physical cues that signal the impending evacuation of fecal waste. Some patients are aware that they have soiled themselves but are unable to clean up due to various physical impairments. In fact, fecal accidents are not uncommon in orthopedic wards where patients require significant assistance with toileting due to restricted mobility. Patients in this category are aware that they are covered in stool and are free from any physical limitation that might have impaired proper personal hygiene but still will not address the fact that they are covered in fecal matter.
The causes underlying their inaction are usually difficult to detect, as they usually involve impairment of higher-order cognitive functions. Potential causes Neuro Feces - Skitzo - Psychobabble abnormal evacuation behavior include personality disorders that lead to problems with socialization and aggression and are linked with affective disorders and obsessive-compulsive disorder and other types of psychopathology eg, psychotic illnesses such as schizophrenia and catatonia that affect the volitional component of defecation.
Patients in Cavalry Of Evil - No Bros - Cavalry Of Evil do-not-move category are similar to those that will not move in that they are aware and capable, but their reasons for their abnormal toileting behaviors and failure to avoid being covered in bodily excretions are more complex and multidimensional. The multifactorial nature of such behavioral disturbances results in more systemic dysfunction than in those with isolated psychopathology eg, a combination of poverty and mild dementia in which people are forced to live in difficult Tape 18: Status Report #3 - Left Spine Down - Fighting For Voltage with insufficient supplies and services.
In this setting, lack Neuro Feces - Skitzo - Psychobabble personal hygiene is a byproduct of global deficiencies, yet the individual remains aware of his or her condition.
Evidence of social squalor and poor personal hygiene has been described in the medical literature and viewed as having multiple etiologies. Although many with this syndrome have normal intelligence and no evidence of psychiatric disorders or frontal impairment, 1314 Neuro Feces - Skitzo - Psychobabble reclusive individuals who live in filth are known to social workers who often shepherd them toward contact with the medical community.
It is particularly important to recognize that these individuals often present in crisis; they frequently require volume repletion and correction of electrolyte abnormalities. Careful nutritional support is imperative; this often requires repletion of caloric and vitamin deficiencies, being mindful of the risk of a refeeding syndrome. Specific therapies are predicated on the cause of the condition.
Patients should be screened for conditions that result in abnormal stool production and for abnormalities that impair response time. Treatment of conditions that affect response time may involve treatment of reversible causes of an altered sensorium for a patient in the not aware category.
Assistance from orthopedics, physical therapy, neurology, or medical services may be required for those patients who cannot move.
Treatment of patients who will not move or do not move despite having normal capabilities requires a multidisciplinary approach. Ms A required an open reduction and internal fixation to repair her hip fracture following a fall. She did not manifest gastrointestinal abnormalities.
Since she was able to travel between rooms despite her hip fracture, a lack of mobility was unlikely to be the primary reason that she was found covered in stool. Although Ms A did not exhibit syllogomania excessive hoarding of rubbish that is often seen in cases of Diogenes syndrome, her presentation was otherwise quite consistent with this diagnosis. Moreover, she came to medical attention following a fall the most common cause for medical care in the original series of patients with this syndrome.
She was of sufficient intelligence to mask her defects in executive function on an initial cursory evaluation; follow-up neuropsychiatric examinations uncovered her executive dysfunction. These findings, combined with defects in spatial cognition, language, mood, speech dysarthriaand movement ataxiaand results of imaging studies that showed normal brain volume but cerebellar aplasia pointed to the cerebellar cognitive Neuro Feces - Skitzo - Psychobabble syndrome as the underlying cause of her presentation.
While electrical stimulation of the vermis and fastigial nucleus can promote grooming behavior in rats and cats, mice with cerebellar degeneration exhibit impaired grooming behavior. Her treatment required a multidisciplinary approach to promote better grooming behaviors and to ensure her safety, while still maintaining her independence.
Starstruck Lover (Remix) - Boiling Point - Starstruck Lover (Remix) difference between the classic localization strategy for detection of neurologic deficits by neurologists and the localization of deficits by cognitive and behavioral neurologists and neuropsychiatrists is that the latter try to identify neural systems and brain circuits.
One commonly used test, the MMSE, 118 was originally designed as a screening tool for detection of dementia in the primary care setting. Thus, more extensive mental status testing is required, as was done subsequently in the case of Ms A.
These observations suggested that she did not have a global acute confusional state. However, she was unable to copy pentagons, a star, or a 3-dimensional cube; this indicated an impairment of visuospatial processing.
Most notably, she was unable to perform serial 7 s, her reverse auditory digit span was markedly reduced in relation to Neuro Feces - Skitzo - Psychobabble forward span forward auditory span 7 and reverse auditory digit span 2she demonstrated perseveration on Luria alternating motor sequences fist-side-palmand she had decreased verbal fluency 2 F words in 1 minuteas well as poor planning and concrete thinking on a clock-drawing task.
Last, she displayed poor judgment. All of these latter impairments represented different aspects of executive dysfunction and localized her dysfunction to frontal networks ie, the frontal lobes and their connections.
The neural circuits that mediate executive function are widely distributed throughout the brain; as a result, they are extremely sensitive to the effects of systemic illness. Assessment also involves a thorough review of medications; detection of sedative-hypnotics and anticholinergics is crucial, as they are frequent iatrogenic instigators of executive dysfunction.
More invasive testing eg, lumbar puncture, arterial blood gas or tests for rarer causes of executive dysfunction eg, paraneoplastic disease, neurodegenerative or neurogenetic disorders should be considered on a case-by-case basis. One might also consider screening for anosmia, although anosmia alone is unlikely to cause unawareness of fecal incontinence in the absence of impaired executive function.
Last, it is also important to note that if olfactory dysfunction is identified, intranasal causes of anosmia should be considered. In the case of Ms A, basic screening for electrolyte imbalance, endocrine dysfunction, infection, and inflammation were unremarkable. Brain magnetic resonance imaging Figure 1A—C revealed remarkably little cortical atrophy with possible mild biparietal atrophy and no evidence of subcortical white matter disease to suggest a cerebrovascular cause of her executive dysfunction.
Unexpectedly, however, Ms A was found to have complete absence of the cerebellum ie, cerebellar agenesis. For decades, this rare congenital condition was believed to be asymptomatic. Therefore, one should consider deficits in frontal, parietal, and limbic networks as potentially arising from dysfunction of corticocerebellar circuits.
Early lesion studies, followed by recent functional neuroimaging studies, have proposed that each of these circuits is localized in different cerebellar regions, with lateral cerebellar hemispheres mediating the different cerebellar cognitive affective syndrome components and medial structures cerebellar vermis mediating affective Neuro Feces - Skitzo - Psychobabble autonomic circuits.
Thus, continued cognitive evaluations to monitor for subsequent cognitive decline would be recommended. The dual practices of carefully applied mindfulness and attention to personal insights are especially important for all health care providers when faced with patient presentations that threaten and disrupt established and accepted cultural standards. Such presentations commonly evoke feelings of disgust and near universal repulsion. In fact, a content search of these topics using medical search engines consistently yields articles with the key terms of disgustrepulsionand grotesque.
It serves no one, neither patient nor colleague, to act as if these responses are not present. As the famous poet and pediatrician William Carlos Williams stressed, it is far better to know and to grapple with what we feel when treating our patients than to act as if these feelings are forbidden or not present at all.
Evolutionary theorists have suggested that there is teleological repulsion triggered by the stench of human and other mammalian excrement that derives from primitive brain regions; this information is then efficiently and powerfully coded within our neurobiological architecture as something to be avoided.
Additional concerns include the theorized and even measured economic devaluing that occurs with the sensation of Wish I Could Fly - Various - The Best Of Love 2 or repulsion.
Economists, such as Alvin Roth, 35 have noted that modern culture tends to place less value on ideas or practices that Neuro Feces - Skitzo - Psychobabble universally off-putting. It also seems clear from the literature that nurses may be more comfortable with these issues than are physicians. The majority of articles addressing how best to understand and care for these patients are found in the nursing literature.
Finally, literature also suggests that despite the seemingly primitive response to feces described above, neuroimaging investigations show that reactions to feces among human subjects involve activation of the prefrontal cortex in a manner similar to the contemplation of morally charged topics, such as incest. As moral judgments clearly and often negatively affect care, it is important that doctors be wary of these judgments when Neuro Feces - Skitzo - Psychobabble such patient presentations 38 and that they investigate the underpinnings for being found in feces to guide their workup and treatment.
The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.
Dr Pallais is an assistant professor of medicine at Harvard Medical School, Boston, Massachusetts, and an attending physician on the Clinician Educator Service and a subspecialty education coordinator in the Department of Endocrinology at Massachusetts General Hospital, Boston.
Dr Schlozman is the associate director of Training, Child and Adolescent Psychiatry at Massachusetts General Hospital, Boston, and McLean Hospital, Belmont, Massachusetts; is a staff child and general psychiatrist at Massachusetts General Hospital, Boston; and is codirector of medical student education in psychiatry and an assistant professor of psychiatry at Harvard Medical School, Boston, Massachusetts. Drs Pallais, Scharfand Schlozman report no financial or other affiliations related to the subject of this article.
National Center for Biotechnology InformationU. Published online Jun Theodore A. SternMD, J. SchlozmanMD. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding author: Theodore A. Received Jan 5; Accepted Mar
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