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OSCE - examinations > GALS > Flashcards

GALS Flashcards

1
Q

What is a GALS screening?

A

GALS examination (gait, arms, legs and spine), is often used as a quick screening tool to detect locomotor abnormalities and functional disability in a patient

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2
Q

What should patients wear for a GALS screening?

A

Shorts and undergarments

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3
Q

How would you position the patient for GALS screening?

A

Standing

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4
Q

How would you structure a GALS screening?

A
  1. Questions
  2. Gait
  3. General inspection
  4. Spine
  5. Arms
  6. Legs
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5
Q

What questions would you ask at the start of a GALS screening?

A
  1. “Do you have any pain or stiffness in your muscles, joints or back?”
  2. “Do you have any difficulty getting yourself dressed without any help?”
  3. “Do you have any problem going up and down the stairs?”
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6
Q

“Do you have any pain or stiffness in your muscles, joints or back?”

What does this question screen for?

A

This question screens for common symptoms present in most forms of joint pathology (e.g. osteoarthritis, rheumatoid arthritis, ankylosing spondylitis).

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7
Q

“Do you have any difficulty getting yourself dressed without any help?”

What does this question screen for?

A

This question screens for evidence of fine motor impairment and significant restriction joint range of movement.

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8
Q

“Do you have any problem going up and down the stairs?”

What does this question screen for?

A

This question screens for evidence of impaired gross motor function (e.g. muscle wasting, lower motor neuron lesions) and general mobility issues (e.g. restricted range of movement in the joints of the lower limb).

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9
Q

How would you inspect a patient’s gait?

A

Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying attention to:

  1. Symmetry
  2. Smoothness
  3. Normal heel strike then toe-off
  4. Normal step height
  5. Range of movement
  6. Turning: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.
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10
Q

What are the 6 phases of normal gait?

A
  1. Heel-strike: initial contact of the heel with the floor.
  2. Foot flat: weight is transferred onto this leg.
  3. Mid-stance: the weight is aligned and balanced on this leg.
  4. Heel-off: the heel lifts off the floor as the foot rises but the toes remain in contact with the floor.
  5. Toe-off: as the foot continues to rise the toes lift off the floor.
  6. Swing: the foot swings forward and comes back into contact with the floor with a heel strike (and the gait cycle repeats).
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11
Q

How would you structure the general inspection?

A
  1. General inspection
  2. Posterior view
  3. Lateral view
  4. Anterior view
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12
Q

What would you consider in the general inspection?

A
  1. Body habitus: obesity is a significant risk factor for joint pathology due to increased mechanical load (e.g. osteoarthritis).
  2. Scars: may provide clues regarding previous surgery.
  3. Wasting of muscles: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron injury.
  4. Psoriasis: typically presents with scaly salmon coloured plaques on extensor surfaces (associated with psoriatic arthritis).

Look for aids and prescriptions

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13
Q

What would you consider in the posterior inspection?

A

Look from head to toe:

  1. Shoulder muscle bulk and symmetry
  2. Spinal alignment (scoliosis)
  3. Iliac crest alignment (pelvic tilt can indicate hip abductor weakness)
  4. Gluteal muscle bulk and symmetry
  5. Popliteal swelling
  6. Calf muscle bulk and symmetry
  7. Hindfoot abnormality or deformity
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14
Q

What can cause popliteal swelling?

A 
Baker's cyst
Popliteal aneurysm (pulsatile)
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15
Q

What would you consider in the lateral inspection?

A

Look from head to toe:

  1. Normal cervical lordosis
  2. Normal thoracic kyphosis
  3. Normal lumbar lordosis
  4. Knee flexion or hyperextension
  5. Foot arch
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16
Q

What is lordosis? And what is hyperlordosis a sign of? And hypolordosis?

A

Inwards curvature of the spine

Hyperlordosis is associated with chronic degenerative joint disease (e.g. osteoarthritis)

Loss of normal lumbar lordosis suggests sacroiliac joint disease (e.g. ankylosing spondylitis).

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17
Q

What is kyphosis? And what is hyperkophosis a sign of?

A

Outwards curvature of the spine (the normal amount of thoracic kyphosis is typically between 20-45º.)

Hyperkyphosis is associated with Scheuermann’s disease (congenital wedging of the vertebrae).

18
Q

What would you sa about the foot arch?

A

Inspect for evidence of flat feet (pes planus) or an abnormally raised foot arch (pes cavus).

19
Q

What would you consider in the anterior inspection?

A

Look from head to toe:

  1. Shoulder muscle bulk and symmetry
  2. Elbow extension
  3. Quadriceps muscle bulk and symmetry
  4. Knee swelling and deformity
  5. Foot arches
  6. Midfoot and forefoot abnormality or deformity
20
Q

What would you sa about elbow position?

A

Inspect the patient’s carrying angle which should be between 5-15°. An increased carrying angle is known as cubitus valgus.

Cubitus valgus is typically associated with previous elbow joint trauma or congenital deformity (e.g. Turner’s syndrome). A decreased carrying angle is known as cubitus varus or ‘gunstock deformity’.

Cubitus varus typically develops after supracondylar fracture of the humerus.

21
Q

How would you structure inspection of the spine?

A
  1. Cervical spine

2. Lumbar spine

22
Q

How would you inspect the cervical spine?

A
  1. Lateral flexion: try to touch your ear to each shoulder
  2. Flexion: put your chin down on your chest
  3. Extension: put your head back as far as you can
  4. Rotation: look over each shoulder
23
Q

How would you inspect the lumbar spine?

A
  1. Flexion: try to touch your toes

Observe degree of hup and lumbar spine flexion

  1. Place two of your fingers on the lumbar vertebrae approximately 5-10cm apart.
  2. Ask the patient to bend forwards and touch their toes.
  3. Observe your fingers as the patient’s lumbar spine flexes (they should move apart).
  4. Observe your fingers as the patient extends their spine to return to a standing position (your fingers should move back together).
24
Q

How would you assess the arms?

A
  1. Shoulders and elbows: move by putting both hands behind back (shoulder abduction and external rotation + elbow flexion)
  2. Hands
25
Q

How would you assess the hands?

A
  1. Look; swelling, deformity, muscle wasting
  2. Feel: squeeze MCP joints to check for tenderness
  3. Move
    a. Pronation and supination
    b. Power grip: squeeze my fingers tightly
    c. Fine pincer grip: touch your thumb to each finger in turn
26
Q

How would you asses the legs?

A

Patient lying flat with one pillow

  1. Hips and knees: feel and move
  2. Feet: feel and move
27
Q

How would you assess the hips and knees?

A

Feel for patellar tap for knee effusion:

  1. With the patient’s knee fully extended, empty the suprapatellar pouch by sliding your left hand down the thigh to the upper border of the patella.
  2. Keep your left hand in position and use your right hand to press downwards on the patella with your fingertips.
  3. If there is fluid present you will feel a distinct tap as the patella bumps against the femur.

Move:

a. Active hip and knee flexion (bring knee up to your chin)
b. Passive hip internal rotation (hip at 90 degrees, knee at 90 degrees, hold knee and ankle, gently move foot away from other leg)

28
Q

How would you assess the feet?

A

Look: swelling deformity and callus formation (abnormal callus may be gait abnormality)

Feel: squeeze MTP joints to check for tenderness (sign of synovitis and possible inflammatory arthropathy)

29
Q

How would you conclude the GALS screening?

A

“I would like to assess [joint] in more detail”

30
Q

Name 7 gait abnormalities

A
  1. Antalgic: less time spent on one painful limb
  2. Waddling gait
  3. Parkinsonian (shuffling, hesitation, loss of arm swings, small steps, forwards trunk)
  4. Sensory ataxic
  5. Cerebellar (broad-based, high-stepping, looking carefully ahead)
  6. Hemiplegic (foot plantarflexed and knee extended, leg swung around axis, arm may be held in UMN position)
  7. Foot drop: high stepping
31
Q

What causes a waddling gait?

A
  1. Hip ABductor weakness (nerve lesion, root lesion, muscular dystrophy, myopathy, polio)
  2. Neck of femur fracture
  3. Developmental dislocation of hip
  4. Slipped upper femoral epiphysis
32
Q

What causes a sensory ataxic gait?

A
  1. Sensory peripheral neuropathy

2. Dorsal column loss (MS, subacute degeneration of the cord, tabes dorsalis)

33
Q

What causes a cerebellar gait?

A

Cerebellar lesion (usually vermis)

34
Q

What causes a hemiplegic lesion?

A

UMN lesion: tumour, stroke, MS

35
Q

What causes foot drop?

A
  1. common perineal nerve palsy
  2. Sciatic nerve palsy
  3. L4/L5 root lesion
  4. MND
  5. Peripheral motor neuropathy (alcoholism)
36
Q

What are investigations for acute mono or oligoarthritis?

A

XRAY, bloods for inflammatory markers, blood cultures if pyrexial, consider joint aspiration

37
Q

What is GRASP?

A

Gout
Reactive Arthritis
Septic joint
Pseudogout

38
Q

What is the age of onset for:

  1. Gout
  2. Reactive Arthritis
  3. Septic joint
  4. Pseudogout
A
  1. Gout: middle to elderly
  2. Reactive Arthritis: young
  3. Septic joint: any age
  4. Pseudogout: middle to elder
39
Q

What is the joint involvement for:

  1. Gout
  2. Reactive Arthritis
  3. Septic joint
  4. Pseudogout
A
  1. Gout: 1st MTPJ > ankle > knee> upper limb
  2. Reactive Arthritis: lower limb joint
  3. Septic joint: any
  4. Pseudogout: knee or wrist
40
Q

What specific investigation would you consider for:

  1. Gout
  2. Reactive Arthritis
  3. Septic joint
  4. Pseudogout
A
  1. Gout: serum urate
  2. Reactive Arthritis: stool sample, STD swab
  3. Septic joint: aspiration
  4. Pseudogout: chonedrocalcinosis on cray
41
Q

What organism often causes septic joints?

A

Staphylococcus in older patients

Gonococcus in young patient

42
Q

What infections are associated with reactive arthritis?

A

GUM and GI

Take GI, sexual and GU history

Look for rash, balanitis, conjunctivitis

OSCE - examinations (13 decks)

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