A Nonverbal 33-Year-Old Woman With Intellectual Impairment

James Robert Brasic, MD, MPH


October 20, 2021

Physical Examination and Workup

Upon examination, the patient is a well-developed, well-nourished young woman in no acute respiratory distress. She is awake, alert, and nonverbal.

The patient seems to understand and respond nonverbally to some commands but does not respond to others. She has episodes of repeated eye-blinking, followed by eye staring and unresponsiveness that lasts for several seconds. At times, she maintains a rigid posture without responding to environmental stimuli that lasts for several seconds. At other times, she stands and responds to commands instructed by the examiner. This may reflect apraxia or minor seizures, as she had been treated for seizures in the past.

When asked to stand still, the patient maintains that position. Her extremities are rigid. She resists being assisted by others to walk to other locations. She exhibits nonpurposeful stereotypic hand movements. Her hands are primarily held midline in a cupped position. Hand-wringing, clapping, and hand-rubbing are repeated behaviors that are noted, although she appears to have a limited range of motion to her upper extremities. She exhibits bouts of fluctuating awareness. An example of these behaviors is shown in the video below.

At age 29 years, an anterior-posterior radiograph of the patient's pelvis demonstrated a left-sided coxa valga (Figure 1). Both femoral heads are normally seated within the acetabula. The inferior extent of the spinal rods overlies her sacral region. In addition, bone graft material extends bilaterally about the spine.

Figure 1.

At age 33 years, a radiographic study of the patient's spine was obtained (Figure 2). Merged anterior-posterior and lateral views are presented in the image. Posterior spinal fusion of T3 to the sacrum is demonstrated. Screws, rods, crossbars, hooks, and bone graft material are present bilaterally. The hardware is intact. Significant scoliosis is absent from the images.

Figure 2.


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