Step 1: Take a History

Objective :

Persistent pain and swelling is a red flag

A 12 year old boy is brought to you by his mother, complaining of pain in his left knee:

You ask him to tell you more about it.

Tip 1

Open ended questions establish which symptoms are most important to the patient and promote good rapport.

More direct questions can follow later.

Close

He says:

  • He thinks he hurt his knee during hockey practice a few months ago
  • The pain has been there about 3 months
  • The pain is worse at night
  • The knee is becoming swollen
  • He can’t play hockey anymore
Tip 2

Night pain is very concerning. Most traumatic causes would not be painful at night.

Close

You want to know more, so you ask him about...

...Any other pain?

Tip 3

He says no. This is an important question to distinguish a local from a systemic process.

Close

...Weight loss or appetite changes?

Tip 3

His mother says she hasn’t noticed any changes.

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...Fevers/chills or night sweats?

Tip 3

He says no. Type B symptoms are uncommon with sarcomas.

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...What other treatments has he had?

Tip 3

He had some physio for a few weeks but it didn’t help. His mother has been giving him paediatric Tylenol.

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...Other Health

Tip 3

He is a usually well child. Normal development, no medications.

Close
More Info Next Step

Red Flags in this case are the persistence of the pain after three months, and that the pain is occurring at night. It hasn’t improved with simple methods such as physio. Generally any child with joint or bone pain for longer than three months should have an X-ray to rule out serious causes of the pain. Leukaemia can also present with unexplained bone or joint pain, so a CBC with smear is probably indicated with this history, depending on the examination findings.