The GALS Screen

Question 1

Define the following terms:

a. Arthritis
b. Arthralgia
c. Subluxation
d. Synovitis
e. Dislocation

Answer 1

Arthritis: definite inflammation of a joint
Arthralgia: Pain within a joint without demonstrable inflammation
Subluxation: Partial dislocation of a joint
Synovitis: Inflammation of the synovium
Dislocation: Articulating surfaces are displaced + no longer in contact

Question 2

What does GALS stand for?

Answer 2

Gait
Arms
Legs
Spine

Question 3

What is gout caused by?

Answer 3

Deposition of monosodium urate (MSU) crystals as a result of hyperuricaemia

Question 4

What are the key clinical features of gout?

Answer 4

Gouty arthritis

Tophi: aggregated deposits of MSU in tissue

Question 5

Which joint is commonly affected by gouty arthritis?

Answer 5

1st Metatarsophalangeal joint

Question 6

List 3 signs of irreversible joint damage.

Answer 6

Joint deformity
Crepitus
Loss of joint range or abnormal movement

Question 7

List 2 signs of a mechanical defect in the joint.

Answer 7

Painful restriction of motion in the absence of features of inflammation e.g. knee locking
Instability

Question 8

Distinguish between monoarthritis, oligoarthritis and polyarthritis

Answer 8

Monoarthritis: Single joint affected
Oligoarthritis: 2-4 joints involved
Polyarthritis: >4 joints involved

Question 9

Describe the pattern of arthritis in the following diseases including the joints that are commonly affected:

a. Rheumatoid arthritis
b. Reactive arthritis
c. Gout

Answer 9

Rheumatoid: Bilateral + symmetrical polyarthritis involving large + small joints
Reactive: Lower limb asymmetrical oligoarthritis + axial involvement
Gout: exclusive 1st metatarsophalangeal joint

Question 10

What is the main extra-articular feature of gout?

Answer 10

Tophi: subcutaneous deposits of uric acid

Question 11

What are the two types of synovial lining cell?

Answer 11

Type A: macrophage-like

Type B: fibroblast-like (secrete hyaluronic acid)

Question 12

What is a synovial effusion?

Answer 12

Abnormal increase in synovial fluid volume

Question 13

State two causes of syonovial effusion and describe the synovial fluid composition in each of them.

Answer 13

Abnormal mechanical stimulation: can stimulate fibroblasts to produce more hyaluronic acid
Increases oncotic pressure + synovial volume= normal composition
In synovitis due to inflammation, effusion is inflammatory exudate= Abnormal composition with inflammatory cells + reduced hyaluronic acid

Question 14

What features of the synovial fluid are examined to determine the cause of the synovial effusion?

Answer 14

How turbid it is

Presence + quantity of inflammatory cells (WCC + neutrophils)

Question 15

When is synovial fluid examination performed?

Answer 15

When joint infection is suspected

Useful for confirming diagnosis of crystal arthritis

Question 16

What are some contraindications for arthrocentesis?

Answer 16

Conditions that increase risk of bleeding e.g. anti-coagulant drugs
Overlying skin infection

Question 17

List 3 possible complications of arthrocentesis

Answer 17

Risk of introducing infection
Bleeding into the joint
Damage to structures of the joint

Question 18

What technique is used to detect crystals in the synovial fluid?

Answer 18

Polarising light microscopy

Question 19

What is a common feature of most connective tissue diseases?

Answer 19

Raynaud’s phenomenon (intermittent vasospasm of digits on exposure cold)

Question 20

What is Sjogren’s syndrome and what are its symptoms?

Answer 20

AI exocrinopathy (destruction of lacrimal + salivary glands)
Symptoms: 
Dry eyes
Dry mouth 
Parotid gland enlargement  
Non-erosive arthritis + Raynaud’s

Question 21

Which antibodies are associated with Sjogren’s syndrome?

Answer 21

ANA

Rheumatoid factor

Question 22

What is inflammatory muscle disease and what are the two types?

Answer 22

Proximal muscle weakness due to AI-mediated inflammation either with (dermatomyositis) or without a rash (polymyositis)

Question 23

Describe the skin changes that take place in dermatomyositis.

Answer 23

Lilac rash on eyelid, malar region + naso-labial folds
Red/ purple lesions on knuckles (Gottron’s papules)
Subcutaneous calcinosis
Mechanic’s hands (fissuring + cracking of the skin over finger pads)

Question 24

What is systemic sclerosis?

Answer 24

Thickened skin with Raynaud’s phenomenon
Dermal fibrosis
Cutaneous calcinosis
Telangiectasia

Question 25

What are the two types of systemic sclerosis and what are the differences between them?

Answer 25

``` Diffused systemic sclerosis Proximal to elbows or knees Pulmonary fibrosis + renal involvement SHORT history of Raynaud’s Limited systemic sclerosis Hands, forearms, feet, neck + face Pulmonary hypertension LONG history of Raynaud’s ```

Question 26

What is overlap syndrome?

Answer 26

When features of >1 connective tissue disease are present

Question 27

List 5 clinical manifestations of SLE

Answer 27

``` Malar rash (nasolabial fold sparing) Photosensitive rash Mouth ulcers Hair loss Raynaud's phenomenon ```

Question 28

What are the signs of inflammation?

Answer 28

``` Swelling tenderness Redness Warmth Loss of function ```

Question 29

What lifestyle choice predisposes one to gout?

Answer 29

Purine rich diet (e.g. red meat)

Question 30

Give 4 characteristics of gout

Answer 30

Abrupt onset Extremely painful Joint swollen, tender, red + warm Resolves spontaneously with 10 days

Question 31

Give 2 examples of enthesopathies other than ankylosing spondylitis

Answer 31

Achilles tendinitis | Plantar fasciitis

Question 32

What is an enthesopathy?

Answer 32

Pathology at the enthesis (where ligament or tendon inserts into bone)

Question 33

Give an example of a chronic condition in which joint deformity may occur

Answer 33

Ankylosing spondylitis

Question 34

Which joints are spared in Rheumatoid arthritis?

Answer 34

DIP Thoracic spine Lumbar spine

Question 35

Which joints are spared in Osteoarthritis?

Answer 35

``` MCP Wrist Elbow Shoulder Ankle Tarsal joints ```

Question 36

Which joints are spared in polyarticular gout?

Answer 36

Axial

Question 37

What are the main extra-articular feature of rheumatoid arthritis?

Answer 37

Subcutaneous nodules

Question 38

What is the main extra-articular feature of SLE?

Answer 38

Malar rash (spares nasolabial folds)

Question 39

What is synovial fluid, and what increases it's viscosity?

Answer 39

Viscous fluid in joint space of synovial joints | Hyaluronic acid increases viscosity

Question 40

What type of crystal is present in pseudogout?

Answer 40

CPPD