Introduction
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Wash hands (and don PPE if needed)
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Introduce yourself (name and role)
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Confirm patient’s name and DOB
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Explain what the examination involves
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Involves exposing arms and legs and if they would want a chaperone for this
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Gain consent to continue
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Ask if patient in any pain before continuing
GALS Specific questions:
- Any pain in muscles joints or back
- Any difficulty getting dressed
- Any difficulty going up and down stairs
General inspection
Position the patient standing
DWASS
Deformity Wasting Asymmetry Swelling Scars
Objects and equipment
- Walking aids
- Prescriptions
Inspect from the front, side and the back
Front
- Shoulder muscles alignment
- Carian angle of elbows
- Muscle bulk on quads
- Knee deformities
Side
- Excessive kyphosis lordosis
- Knee angle
Back
- Gluteal muscle
- Popliteal swelling
- Iliac crest alignment
Gait
Ask if they have any trouble walking unassisted
Ask them to walk normally a short distance
Look for
- Shuffling
- Foot drop - peroneal nerve lesion
- Waddling - muscular dystrophy
- Ataxic - cerebellar
- Turning - if slow → Parkinsonism
- Look at footwear
Then ask for tandem gait, heel to toe, walking on toes, walking on heels
Arms
Compound movements
Hands behind head
- Shoulder abduction, external rotation and elbow flexion
- Restricted range - shoulder or elbow pathology
- Excessive - hyper-mobility
Hands help out in front with palms down
- Forward flexion of shoulders, elbow extension, wrist extension and extension of the small joints of the fingers
- Inspect dorsum of hands and nails - asymmetry, joint swelling and deformity
Hands held out palms up
- Wrist and elbow supination
- Inspect thenar (median nerve) and hypothenar (ulnar nerve) eminences for muscle wasting
Making a fist
- Flexion of fingers and overall hand function
Grip strength
- Squeeze fingers and assess strength
- May be reduced to pain or LMN lesion
Precision grip
- Touch each finger to thumb in turn
- Reduced manual dexterity may sugest inflammation or joint contractures
MCP joint squeeze
- Gently squeeze MCP joints and observe for signs of discomfort
- Tenderness is suggestive of Inflammatory Arthritis
Legs
Passive movements
- Knee flexion
- Knee extension
- Internal rotation of the hip
Patellar tap
- Presence of a moderate-to-large knee joint effusion.
- Ligament rupture, all types of arthritis
MTP joint squeeze
- Same as MCP
Spine
Flexion and shit from Thoracic and Lumbar Spine Exam
Ask patient to stand upright again
Cervical lateral flexion
- Try and touch your shoulder with your eye on each side
Lumbar flexion
- Place 2 fingers on the lumbar vertebrae
- Ask patient to bend and touch their toes
- Observe fingers as spine flexes (should move apart)
- Observe finger move back together on returning to neutral position
TMJ
- See if they can fit 3 of their fingers in their mouth
- Feel joint on opening and closing mouth
End pieces
- Thank patient for their time
- Hand over to examiner and summarise findings
“Today I performed a GALS exam on … with no periperal sigmata of note. To complete this exam I would perform a joint exam on … if abnormal. ” etc etc.
Further Assessments and Investigations
- Focused joint exam
- Further imaging