Involve the child where possible. Ask them to point to the problem area, describe the pain or discomfort or show you swollen joints.
Explore the presenting problem using open probing questions – what has been noticed and what are the concerns – consider pain, mood, swelling, change in function (sport / play / school), limp or clumsiness.
Ask about any injury including timing, mechanism, how they landed and on what surface. Could this be a fracture? Is the story consistent with the presentation? Remember that minor trauma is common and may be a ‘red herring’. Consider non-accidental injury.
Enquire about pain: site, radiation, intensity, aggravating and relieving factors. Ask the child and parent.
Discuss normal activities and consider developmental milestones – has there been any change? Has the child ‘regressed’? Is the child avoiding certain activities? Enquire about play, school, feeding, dressing and hobbies. Has there been any change in behaviour? Has the school or nursery staff passed comment about change?
Change in symptoms throughout the day can be important. Mechanical pain will often be aggravated by exercise and worse at the end of the day.
Ask about morning stiffness and relate this to normal expectations for the child’s age – small children may ask to be carried, school-age children may struggle with dressing, or getting up off the floor when sitting cross-legged. Has the school or nursery passed any comment about change?
Family history can be important and relevant ; this may help to reach a diagnosis (e.g. psoriasis and psoriatic arthropathy, ankylosing spondylitis, sickle cell disease or haemophilia).
Difficulties at school, within the family or in friendship groups may be relevant and are important to explore especially in the child with pain with no apparent pathology to explain their symptoms or where there is school absence or disproportionate functional change or pain.
Always explore the patient and family’s concerns and expectations. There may be specific questions that can be addressed such as ‘does my child need blood tests or an x-ray?’
Please note: a pdf document of these Top Tips is also available here.
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