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History Taking: What to Ask & Why?

Key Questions to Ask When Taking a Musculoskeletal History from the Parent or Caregiver or Child.  Open, probing questions are needed.

Questions to parent / carer (and the child as appropriate)

Points to check for 

Comments and interpretations 

What have you or anyone else noticed?

Behaviour, mood, joint swelling, limping, bruising, falling, difficulty getting up from the floor, difficulty in climbing stairs, inability to sit cross-legged or inability to squat?
 
 
 
 
 
 
 
 
Limping, whether intermittent or persistent always warrants further assessment. Abnormal gait, including waddling in child over 3 years of age is abnormal.  Deterioration in school performance (e.g., sport, handwriting) is always significant. Joint swelling is always significant but can be subtle and easily overlooked by the parent (and even health care professionals!), especially if the changes are symmetrical.
Falling, child seeming unsteady on feet and falling more than their friends, difficulty getting up from the floor once sitting down, inability to jump, and struggling to climb stairs all imply muscle weakness.
Rather than describing stiffness, the parents may notice the child is reluctant to weight bear or that they limp in the mornings or ‘gel’ after periods of immobility (e.g., after long car rides or sitting in a classroom).
Difficulty in climbing stairs or an inability to squat may suggest proximal weakness as well as joint disease (hip or knee).
Inability to sit cross legged may suggest hip (or knee) disease.

What is the child like (behaviour) as compared to normal ? 

Irritability, grumpy, “clingy”, reluctant to play, systemic features (e.g., fever, anorexia, weight loss). Is there a recent history of sore throat? If so, was a throat swab taken?
Young children in pain may not verbalise pain but may present with behavioural changes or avoidance of activities previously enjoyed.
Systemic features including “red flags” that can suggest malignancy or infection including Tuberculosis.
Acute Rheumatic Fever may follow streptococcal throat infection.

Where is the pain (ask the child to point) and what is it like?

Take a pain history and focus on the site of the pain, exacerbating/relieving factors, timescale pattern.
Uniliateral, persistent focal pain is invariably a cause for concern. Referred pain from the hip may present with non-specific pain in the thigh or knee.

Acute Joint pain +/- swelling, particularly of large joints and that may move from one joint to another is characteristic of acute rheumatic fever.

How is he/she in the mornings and during the day?

Diurnal variation and daytime symptoms (e.g., limping, difficulty walking, dressing, toileting, stairs?).
Pain on waking or daytime symptoms suggestive of stiffness or gelling (after periods of inactivity), are indicative of inflammatory joint (or muscle) disease.

What is he/she like with walking and running? Has there been any change in his activities (at home / school or in sports?)

Gait and Motor milestones and suggestion of delay or regression of achieved milestone, including speech and language.  Avoidance of activities that were previously enjoyed (e.g., sport, play) are noteworthy.  Have teachers or nursery/daycare staff had any concerns?
Regression of achieved motor milestones, functional impairment or avoidance of activity (including play, sport or writing), are more suggestive of acquired joint or muscle disease (and especially inflammatory causes). Urgent assessment of global neuro-development is indicated with delay or regression in speech, language or motor skills.  In a child with gross motor delay, think muscle disease.
Clumsiness” is a non-specific term but may indicate significant musculoskeletal, muscular or neurological disease.

How is he/she at school / nursery/daycare?

School attendance (consider school avoidance, bullying). 
Have teachers or nursery/daycare staff had any concerns?
 
Behavioural problems in the young child may manifest as non-specific pains (headaches, tummy aches or leg pains). Sensitive questioning may reveal stressful events at home or school.

Does pain wake the child from sleep? 

Pattern of night waking.
Night pain is a common feature of growing pains  (and usually intermittent, and often predictable, but not usually waking from a deep sleep.). Conversely persistent night waking, especially if there are other concerns (such as unilateral pain, limping, unusual location or red flags) are of concern and invariably necessitate further investigation.

Can you predict when the pain may occur?

Relationship to physical activity (including during or after sporting activities).
Growing pains tend to be worse later in the day, evenings and often after busy days. Mechanical pain tends to worsen with activity, whilst inflammatory pain tends to improve or remain stable.

What do you do when he/she is in pain?

Response to analgesics, anti-inflammatory medication, massages, and reaction of parent.
Lack of response to simple analgesia is a concern. Vicious circle of reinforced behaviour can occur.

Does the child take a long time to eat?

 Has the child always been a “difficult eater”? Do they struggle to swallow or chew food? Is there choking? 
This can be a sign of muscle weakness or fatigability.

Ask about child's diet

Is there ingestion of non-dairy milk - such as camel or goat's milk? Is the milk pasteurised? 
In young children and infants, ask about feeding history including the period of exclusive breastfeeding, type of formula and whether vitamin D supplements were given
Consider brucellosis in areas where this is endemic.
Consider risk factors for rickets.

What is your main concern?

Sleep disturbance, cosmesis, anxiety about serious disease (Arthritis, Cancer, family history), pain control.
Consider family history of infection and risk to the child (e.g., Human Immunodeficiency Virus [HIV], Tuberculosis [TB]).
Consider travel history, activities and risk of endemic infections (e.g., Arboviruses, Lyme Disease).
 
 
A family history of Muscle Disease, Arthritis or Autoimmune Disease may indicate a predisposition to muscle or joint disease. Observed “abnormalities” (such as flat feet, curly toes) may be part of normal development. The parent or caregiver will undoubtedly have anxieties and concerns about the child, often fear severe illness and both child and parent have an expectation of investigations (i.e., blood tests!)

 


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