Top Tips for History Taking
Always involve the child, regardless of their age, whenever possible. Ask them to point to the problem area, describe the pain or discomfort, or show you swollen joints. Use age-appropriate language (e.g., "Show me your 'owwie'", instead of "Where does it hurt" in young children).
Use open probing questions about concerns and what has been noticed – consider pain, mood change, swelling, change in function (sport / play / school), limp or 'clumsiness'. Explore presence of symptoms to suggest serious illness ('Red flags') including malignancy, infection or non-accidental injury. Consider risk factors for infections relevant to endemic areas (e.g., Tuberculosis, Human Immunodeficiency Virus, Brucellosis, Acute Rheumatic Fever, Dengue). Consider the course of symptoms and asking whether they have progressed; a static state of symptoms over a long time may be less concerning than a rapidly progressing history with increasing concerns.
Ask about 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, Onset, Character, Radiation, Associated features, Timing, Exacerbating and relieving factors, Sleep - SOCRATES). Ask the child/young person and parent bearing in mind that young children may not verbalise pain but may have changes in behaviour or mood. Use developmentally appropriate language and tools (e.g Visual Analogue Scales or Smiley Faces).
Enquire about preceding illness (e.g., recent sore throat with/without fever, could this be Rheumatic Fever? If recent gastroenteritis, could this be a reactive arthritis?) Consider risk factors for sexually acquired infection (including HIV).
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? Have the school or daycare / nursery staff mentioned any concerns?
Change in symptoms throughout the day can be important. Mechanical pain will often be aggravated by exercise and is worse at the end of the day. The opposite is true for inflammatory pain (i.e., worse in the morning, and improved with movement).
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. Have the school or daycare / nursery staff noted any change(s)?
Family history can be important and relevant; this may help to reach a diagnosis (e.g., rheumatoid arthritis, systemic lupus erythematosus, psoriasis/psoriatic arthropathy, ankylosing spondylitis, inflammatory bowel disease, sickle cell disease or haemophilia, muscular dystrophy).
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 refusal or disproportionate functional change or pain.
Ask about diet. Consider risk factors for rickets (e.g., periods of exclusive breastfeeding, type of milk formula and whether vitamin D supplements were given). Consider Brucellosis in endemic areas; ask about whether milk is pasteurised, or ingestion of non-dairy milk (such as camel or goat).