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GALS Scree for Medical Student OSCE

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Common musculoskeletal symptoms: pain (arthralgia / myalgia / other soft tissue); stiffness; inflammation; swelling; weakness; locking and triggering; deformity; extra-articular manifestations (e.g. nodules in rheumatoid arthritis, SLE, scleroderma; bony nodules in osteoarthritis affecting the hand – Heberden’s nodes at distal interphalangeal joints)

General principals in GALS: compare opposite limb; assess active before passive movements; valgus = distal part deviates from midline, vagus = distal part deviates towards midline.

Hypermobility: mild = a normal variant; hypermobility can also be caused by Marfan’s syndrome and Ehlers-Danlos syndrome, both affecting connective tissues.

1. Screening questions: significant musculoskeletal problem unlikely if all answers are negative

   1. Pain/stiffness in muscles, joints or back? Also check before examining limbs

   2. Can you dress yourself without difficulty?

   3. Can you walk up and down stairs without difficulty?

2. Ask patient to undress to underwear. Watch for mobility problems

3. Gait

   1. Ask pt to walk straight for several steps, turn and walk back. Watch for smoothness and symmetry of gait

   2. Types of gait:

      1. Antalgic: altered to reduce pain. Leg problem ? ‘dot-dash’ gait. Spine pain ? reduced axial rotatory movements, giving slow gait with short paces. Hip pain ? pt may lean towards affected side, reducing compression force on hip joint

      2. Structural change – esp. limb length discrepancy

      3. Trendellenburg: contralateral hemipelvis falls when the affected side weight-bears – weakness in abductor function, due to weak hip abductors (polio, or paresis of superior gluteal nerve); congenital dislocation of hip; painful joints e.g. osteoarthritis

      4. Drop-foot, high steps – peroneal nerve palsy causing weakness

      5. Increased tone – commonly after upper motor neurone lesion e.g. stroke, or cerebral palsy (crouch gait)

      6. Shuffling

      7. Stamping – loss of sensation

4. Spine

   1. Stand behind patient. Assess:

      1. Straightness of spine: scoliosis – lateral curvature

      2. Muscle bulk (trunk + legs)

      3. Symmetry (trunk + legs)

      4. Asymmetry at iliac crests – unilateral leg shortening

      5. Gluteal, hamstring, popliteal and calf muscles – swelling / other abnormality

      6. Achilles tendons (pinch) + hindfoot regions – swelling / deformity

      7. Pinch supraspinatus and press trapezius

Ask patient to:

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   1.  

      1. Turn from side to side without moving feet (while holding the pelvis) – thoracolumbar rotation

      2. Slide hand down leg towards knee – lateral lumbar flexion

   2. Stand to side of pt:

      1. Assess straightness of spine: increased kyphosis / lordosis?

Kyphosis – curvature in sagittal plane, in thoracic spine

Lordosis – lumbar and cervical

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   1.  

      1. Ask pt to bend down to touch toes – abnormal spinal curvature / limited hip extension. Fingers on lumbar spinous processes.

   2. Stand in front of patient, ask him to:

      1. Touch ear to shoulder – lateral cervical flexion, the first movement affected in cervical spine spondylosis

      2. Look up at ceiling then down to floor – cervical flexion and extension

      3. Let jaw drop open; move from side to side – both temporomandibular joints

2. Arms

   1. Gently press the midpoint of each supraspinatous – hyperalgesia of fibromyalgia

   2. Ask the patient to:

      1. Put his hands behind his head, with elbows going back – abduction and external rotation of glenohumeral joint. And hands behind back.

      2. Elbows flexed 90°, by side of body. Turn palms up and down – pronation and supination, at wrist and elbow

      3. Bend arms up to touch shoulders – elbow flexion

      4. Make a prayer sign, extending wrist as far as possible. Backs of hands together, flexing wrist as far as possible.

      5. Arms straight forwards – elbow flexion

      6. Clench fists, then open hands flat. Check for full finger extension at metacarpophalangeal, proximal and distal interphalangeal joints.

      7. Squeeze patient’s carpal metacarpal heads (RA)

      8. Squeeze doctor’s index and middle fingers – power grip strength

      9. Opposition of thumbs – precision grip, coordination, concentration

   3. Ask pt to lie supine on couch

3. Legs

   1. Thomas’s test: for fixed flexion deformity (poor extension) on both hips.

   2. Crepitus in patellofemoral joint: with your hand on pt’s knee, flex each hip and knee joint

   3. Inflammation and effusions: palpate each knee for warmth and swelling, and check for patellar tap.

   4. Hip rotation: flex knee and hip to 90?; passively internally and externally rotate hip. Note pain or limited movement.

   5. Look at feet for any abnormality. Calluses and ulcers on soles – abnormal load bearing

   6. Squeeze metatarsal heads – tenderness in inflammatory conditions e.g. rheumatoid arthritis

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by: Admin
Total views: 0
Word Count: 1184
Date: Fri, 22 Jan 2010 Time: 4:01 PM
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