Pain

Laboratory tests are not very helpful when trying to determine whether a child with musculoskeletal complaints has any of the rheumatic diseases of childhood, and using adult models to evaluate these children is equally ineffective.

Steven, a 13-year-old boy, experienced his first headache at age 7 years. The frequency, intensity, and duration of his headaches have been increasing over the past 6 months. Steven now experiences 7 to 10 headaches each month that last up to 8 hours. The headaches are associated with mild nausea, light and sound sensitivity, dizziness, fatigue, occasional abdominal discomfort, and difficulty in concentrating. Last year, he had a vomiting episode because of a headache. The pain is usually more prominent in the forehead and does not favor either side of the head. The headaches usually begin in the morning before he leaves for school. As a result, Steven has missed nearly 25% of his school days this semester; his parents are considering home tutoring for "sick children who are unable to attend school."

Musculoskeletal infections in children include osteomyelitis, septic arthritis, and pyomyositis. Most of these infections are bacterial. Staphylococcus aureus is the most common organism in children in all age cat-egories. Others include group A Streptococcus, Neisseria meningitidis in purpura fulminans, Streptococcus pneumoniae, Neisseria gonorrhoeae, Mycobacterium tuberculosis, and Borrelia burgdorferi.

Infants and toddlers will put just about anything into their mouths. Each year in this country, between 100,000 and 200,000 incidents of foreign-body ingestions are reported to poison control centers.1,2 The large majority of ingestions are accidental. (In adolescents, ingestions are usually intentional.)

A 17-year-old boy with no history of foot problems decided to try some new moves with his skateboard on a steep ramp. Midway down the ramp, he tumbled head over heels and landed with most of his weight on his plantar-flexed right foot.

A 9-year-old girl was hospitalized because of a painful, vesicular rash on her genitals, groin, and buttocks. There was also concern about possible genital herpes infection in a minor.

A 12-year-old girl complains of left knee pain and swelling that resulted from a collision with another player while she was playing kickball the day before. Her left foot was planted as she tried to catch a ball, and she was hit on the outside of the left knee. She fell to the ground and was unable to walk on the injured leg; overnight, the knee became more swollen and painful.

"Headaches" is the chief complaint. Acne was the problem last year for 17-year-old Michelle. Otherwise her history is unremarkable. What's causing these daily headaches?