Position, movements, speech, and voice

Position
 
Stand and walk
 
Abnormal movements
 
Speech
 
Voice

Position
 
A healthy individual is relaxed, able to take any position. A significant defect of either somatic or psychic character changes the situation, forcing the patient to take a certain position, which is demanded by the type of disorder, or to lie passively.
 
Forced position
 

	Orthopneic occurs in case of heavy cardiac or pulmonary dyspnoea. The patient is sitting, leaning on his arms, and using auxiliary respiration muscles to breath.
	Unsettled occurs in case of threatening or developing shock – the patient is restless, looks for a relief position, changing it frequently. It can be observed in renal or biliary colic.
	On the back with inflected legs the patient avoids movement; can be observed in peritonitis.
	On the side the patient restrains breathing on the affected side; can be observed in pleuritis.
	On the side with reclined head and inflected legs (in thighs and knees); can be observed in meningitis.
	"On all fours" the patient leans on the inflected forearms; can be observed in pancreatic tumour or chronic pancreatitis.
	Reclined head with dorsal flexion of the spine occurs in tetanus.

Orthopneic
position
in anasarca

Passive position
is characteristic for an immobile patient in a severe clinical state with cerebral apoplexy.
 
Posture and walk
 
Posture of a healthy individual is upright, walking is springy, extremities can move freely. Abnormalities occur in neurological and muscular disorders.
 

	In Parkinson's syndrome a slight forward bending of the head and trunk is observed. Walking consists of small, often shuffling steps. This syndrome occurs in brain arteriosclerosis.
	Hemiparesis, hemiplegia means paralysis of the extremities on the same side of the body; a mild degree is called hemiparesis, a more severe one is called hemiplegia. The way of moving depends on the type and extent of the disorder. The patient can, for instance, move his upper extremity inflected in elbow, or his leg extended, moving it in external arc (circumduction). In the most severe cases the mobility is so limited, that neither standing nor walking is possible. This is mostly seen in patients with cerebral apoplexy.
	Ataxia with unsure walking is represented by a wide-basis walking with stagger. It occurs in alcohol intoxication, disorders of dorsal roots of the spinal cord in pernicious anaemia, and tabes dorsalis.
	Rolling ("duck") walking is present in congenital luxation of the iliac joint and in myopathia.
	The so-called stork walking is present in paresis of the fibular nerve; the patient compensates the defect by lifting the limb.

 
Abnormal movements
 
are not present under physiological circumstances. In pathological situations they may have various forms, e.g. shiver, chorea or athetosis, tics, spasms, orofacial dyskinesia.
 
Tremor
 

	Static tremor is quiescent, slow, and soft, diminishes or vanishes in voluntary movements. It is manifested in the fingers, forearm or the whole arm, chin, or the whole head. It can be found in Parkinson's disease.
	Postural tremor represents a soft, fast shivering of the hands, which can be observed in hyperthyroidism.
	Intentional tremor is dependent on the movement and is not present at rest. It can be observed in diffuse sclerosis.
	"Flapping tremor" is characterised by a slow flexion and extension of the fingers. Its presence indicates a severe defect of the CNS in liver failure.

 
Chorea represent unintentional, buffeting movements, present in the face, head, and hands. These occur in chorea minor in rheumatic fever.
 
Athetosis is characterised by slow sinuous, sometimes bizarre, movements with large amplitude. They are present in the face and lower extremities. They are associated with brain arteriosclerosis or occur as a result of prenatal encephalopathy.
 
Tics are fast, repeated, stereotype short-time muscular contractions mostly present in the face (around the eyes, on the cheeks) of neurotics.
 
Cramps (spasms) of skeletal muscles are caused by a spasm of some muscular groups as localised or generalised spasms. They can be divided into:
 

	Tonic (fastening) – enhanced muscle tension (tetanus);
	Clonic (twitching) - with visible muscular twitches;
	Tonic-clonic - generalised, accompanied by unconsciousness, foam at the mouth, apnoea and cyanosis, incontinence of the urine and faeces, and biting of the tongue (grand mal - great epileptic attack), or localised in one part of the body without the loss of  consciousness (jacksonian seizure);
	Trismus represents a local spasm in the jaw muscles, which gives the patient a look of bitterness (risus sardonicus in tetanus).

 
Orofacial dyskinesia is characterised as regular, repeated, bizarre movements present mostly in the face, mouth, tongue, and jaws. They can be found in some psychoses, treated with phenothiazines.
 
Speech
 
is a typically human expression. It is fluent, clear, and characteristic for each individual.
 

	Scanned speech is present in diffuse sclerosis.
	Dysarthria and anarthria is a defect of pronunciation: missing and mixing letters.
	Aphasia is a speech disability due to severe damage of the speech centre.    Expressive aphasia means that the patient is unable to speak, but able to understand both speech and writing.    Sensory aphasia is manifested by the lack of understanding the speech and writing, but the ability to speak is retained.    Mixed aphasia means a combination of the two above.

 
The defects occur in neurological disorders, especially in cerebral apoplexy.
 
Voice
 
Men and women have characteristic voice differences related to sex (women have a higher voice, men have a lower voice).
 

	High voice occurs in infantile men.
	Rough, deep voice with slower speech is present in hypothyroidism of both sexes and in acromegaly.
	Hoarse voice (dysphonia) occurs in paresis of the laryngeal recurrent nerve in aortic aneurysm, mediastinal or bronchial tumours, or in inflammation or tumour of the vocal cords.
	Weakened or almost inaudible voice occurs in dehydration, and severe clinical conditions e.g. advanced Parkinsonism.
	Mumbling voice (nasolalia) is typical for congenital cleft palate and paralysis of the soft palate.

Passive position
of the patient