2. Common Complaints Flashcards
1
Q
Describe clinical features: Breath holding spells (2)
A
Types
- cyanotic (more common), usually associated with anger/frustration
- pallid, usually associated with pain/surprise
2
Q
Describe etiology: Breath holding spells (1)
A
- child is provoked (usually by anger, injury, or fear) → holds breath and becomes silent→ spontaneously resolves or loses consciousness
3
Q
Describe management: Breath holding spells (3)
A
- usually resolves spontaneously and rarely progresses to seizure
- help child control response to frustration and avoid drawing attention to spell
- may be associated with iron deficiency anemia, improves with supplemental iron
4
Q
Name common etiologies: Crying/Fussing Child (4)
A
- functional (e.g.hungry,irritable)
- colic
- trauma
- illness
5
Q
Describe history: Crying/Fussing Child (7)
A
- description of baseline feeding, sleeping, crying patterns
- infectious symptoms: fever, tachypnea, rhinorrhea, ill contacts
- feeding intolerance: gastroesophageal reflux with esophagitis, N/V, diarrhea, constipation
- trauma
- recent immunizations (vaccine reaction) or medications (drug reactions), including maternal drugs taken during pregnancy (neonatal withdrawal syndrome) and drugs that may be transferred via breast milk
- inconsistent history, pattern of numerous emergency department visits, high-risk social situations all raise concern of maltreatment
- consider broad array of possible underlying causes such as meningitis, sepsis, respiratory distress, constipation, etc.
6
Q
Describe clinical features: Infantile Colic (2)
A
- unexplained paroxysms of irritability and crying for > 3h/d,
- >3d/wk for >3wk in an otherwise healthy, well-fed baby (rule of 3s)
7
Q
Describe epidemiology: Infantile Colic (2)
A
- 10% of infants;
- usual onset 10d to 3 mo of age with peak at 6-8wk
8
Q
Describe etiology: Infantile Colic (2)
A
- unknown.
- Theories: alterations in fecal microflora, cow’s milk intolerance, GI immaturity or inflammation, poor feeding, maternal smoking
9
Q
Is infantile colic a diagnosis of exclusion? (1)
A
diagnosis of exclusion after thorough history and physical exam to rule out identifiable causes such as otits media, cow’s milk intolerance, GI problem, fracture
10
Q
Describe management: Infantile Colic (6)
A
- parental relief, rest, and reassurance
- hold baby, soother, car ride, music, vacuum, check diaper
- some evidence for probiotics
- maintain breastfeeding but eliminate allergens (cow’s milk protein, eggs, wheat, and nuts) from mother’s diet
- time-limited (2 wk) trial of protein hydrolysate formula (e.g. Nutramigen®)
- time – all resolve, most in the first 3-6 mo of life, no long-term adverse effects
11
Q
Describe: primary dentition (4)
A
- (20 teeth)
- first tooth at 5-9 mo (lower incisor), then 1/mo
- 6-8 central teeth by 1 yr
- assessment by dentist 6 mo after eruption of first tooth and certainly by 1 yr of age (Grade B recommendation)
12
Q
Describe: Secondary dentition (1)
A
- first adult tooth is 1st molar at 6 yr, then lower incisors
13
Q
Describe: Early childhood caries (1)
A
- presence of one or more decayed, missing (due to caries), or filled tooth surfaces in any primary tooth in a preschool-aged child
14
Q
Describe etiology: Caries (2)
A
- multifactorial with biomedical factors (e.g.diet, bacteria, host) and social determinants of health
- inappropriate feeding practices are important factors (e.g.
- frequent, prolonged bottle feeding,
- putting to bed with bottle,
- prolonged breast feeding,
- and excessive juice consumption)
15
Q
Name prevention techniques: Caries (5)
A
- no bottle at bedtime, clean teeth after last feed
- minimize juice and sweetened pacifier
- clean teeth with soft damp cloth or toothbrush and water
- water fluoridation
- ensure every child has a dentist by 1 year of age
16
Q
Define: Enuresis (1)
A
involuntary urinary incontinence by day and/or night in child >5yr
17
Q
Describe general approach: Enuresis (5)
A
should be evaluated if:
- dysuria
- change in colour, odour, or stream
- secondary or diurnal
- change in gait
- or stool incontinence are present
18
Q
Treatment for primary nocturnal enuresis should not be considered until when? (1)
A
until 7 yr of age due to high rate of spontaneous cure
19
Q
Describe clinical feature: Primary Nocturnal Enuresis (2)
A
- involuntary loss of urine at night
- bladder control has never been attained
20
Q
Describe epidemiology: Primary Nocturnal Enuresis (4)
A
- boys>girls
- 10% of 6yr olds
- 3% of 12 yr olds
- 1% of 18yr olds
21
Q
Describe etiology: Primary Nocturnal Enuresis (1)
A
developmental disorder or maturational lag in bladder control while asleep
22
Q
Describe management: Primary Nocturnal Enuresis (5)
A
- time, reassurance (~20% resolve spontaneously each yr), and avoidance of punishment or humiliation to maintain self-esteem
- behaviour modification (limiting fluids and avoid caffeine-containing food before bedtime, void prior to sleep, ensure access to toilet, take out of diapers)
- conditioning: “wet” alarm wakes child upon voiding (70% success rate)
- medications (for children >7 yr, considered second line therapy, may be used for sleepovers/camp):
- DDAVP oral tablets (similar success rate as “wet” alarm therapy but higher relapse rate), imipramine (Tofranil®) (rarely used, lethal if overdose, SE: cardiac toxicity, anticholinergic effects)
23
Q
Describe clinical features: Secondary Enuresis (2)
A
- involuntary loss of urine at night
- develops after child has sustained period of bladder control (>6 mo)
24
Q
Describe etiology: Secondary Enuresis (2)
A
- inorganic regression due to stress or anxiety (e.g. birth of sibling, significant loss, family discord, sexual abuse)
- secondary to organic disease (UTI, DM, DI, sleep apnea, neurogenic bladder, CP, seizures, pinworms)
25
Describe management: Secondary Enuresis (1)
treatunderlyingcause
26
Describe clinical feature: Diurnal Enuresis (1)
daytime wetting (60-80% also wet at night)
27
Describe etiology: Diurnal Enuresis (6)
micturition deferral (holding urine until last minute) due to
* psychosocial stress (e.g.shy),
* structural anomalies (e.g. ectopic ureteral site, neurogenic bladder)
* UTI
* constipation
* CNS disorders
* DM
28
Describe management: Diurnal Enuresis (3)
* treat underlying cause, behavioural (scheduled toileting,double voiding,good bowel program, sitting backwards on toilet, charting/incentive system, relaxation/biofeedback)
* good constipation management
* pharmacotherapy
29
Describe clinical feature: Encopresis (1)
fecal incontinence in a child \> 4yr old, at least once per mo for 3 mo
30
Describe prevelance: Encopresis (2)
* 1-1.5% of school-aged children (rare in adolescence)
* M:F=6:1 in school-aged children
31
Name causes: Encopresis (7)
* chronic constipation (retentive encopresis)
* Hirschsprung disease
* hypothyroidism,
* hypercalcemia
* spinal cord lesions
* anorectal malformations
* bowel obstruction
32
Define: Retentive Encopresis (1)
child holds bowel movement, develops constipation, leading to fecal impaction and seepage of soft or liquid stool (overflow incontinence)
33
Describe etiology: Retentive Encopresis (2)
* physical: painful stooling often secondary to constipation
* emotional: disturbed parent-child relationship, coercive toilet training, social stressors
34
Describe history: Retentive Encopresis (5)
* crosses legs or stands on toes to resist urge to defecate
* distressed by symptoms, soiling of clothes
* toilet training coercive or lacking in motivation
* may show oppositional behaviour
* abdominal pain
35
Describe physical exam: Retentive Encopresis (3)
* digital rectal exam or abdo x-ray: large fecal mass in rectal vault
* anal fissures (result from passage of hard stools)
* palpable stool in LLQ
36
Describe management: Retentive Encopresis (3)
* complete clean-out of bowel: PEG 3350 given orally is most effective, enemas and suppositories may be second line therapies, but these are invasive and often less effective maintenance of regular bowel movements (see Constipation, P39)
* assessment and guidance regarding psychosocial stressors
* behavioural modification
37
Name complications: Retentive Encopresis (3)
* recurrence
* toxic megacolon (requires \> 3-12 mo to treat)
* bowel perforation
38
Describe: Toilet Training (3)
* 90% of children attain bowel control before bladder control
* generally, females train earlier than males
* 25% by 2 yr (in North America), 98% by 3yr have daytime bladder control
39
Name signs of toilet readiness (7)
* ambulating independently
* stable on potty
* desire to be independent or to please caregivers (i.e. motivation)
* sufficient expressive and receptive language skills (2-step command level)
* can stay dry for several h (large enough bladder)
* can recognize need to go
* able to remove clothing
40
Define: Failure to Thrive (4)
* weight \<3rd percentile, falls across two major percentile curves, or \<80% of expected weight for height and age
* inadequate caloric intake most common factor in poor weight gain
* may have other nutritional deficiencies (e.g. protein, iron, vitamin D)
* factors affecting physical growth: genetics, intrauterine factors, nutrition, endocrine hormones, chronic infections/diseases, psychosocial factors
41
Describe history: Failure to thrive (5)
* nutritional intake
* current symptoms
* past illnesses
* family history: growth, puberty, parental height and weight including mid-parental height
* psychosocial history
42
Describe physical exam: Failure to thrive (7)
* growth parameters, plotted: height, weight, head circumference (if ≤2 yr)
* \<2 yr: height, weight, head circumference
* ≥2 yr: height, weight, BMI
* vital signs
* complete head to toe exam
* dysmorphic features or evidence of chronic disease
* upper to lower segment ratio
* sexual maturity staging
* signs of maltreatment or neglect
43
Describe investigations: Failure to thrive (4)
(as indicated by clinical feature)
* CBC, blood smear, electrolytes, T4, TSH
* bone age x-ray
* chromosomes/karyotype
* chronic illness: chest (CXR, sweat Cl–), cardiac (CXR, ECG, Echo), GI (celiac screen, inflammatory markers, malabsorption), renal (urinalysis), liver (enzymes, albumin)
44
Describe: Mid-Parental Height (3)
* Boys target height = (father ht + mother ht+13)/2
* Girls target height = (father ht +mother ht–13)/2
* Note: height should be taken in cm
45
Name: Clinical Signs of FTT (8)
SMALL KID
* Subcutaneous fat loss
* Muscle atrophy
* Alopecia
* Lethargy
* Lagging behind normal
* Kwashiorkor
* Infection (recurrent)
* Dermatitis
46
The Upper to Lower Segment Ratio is increased when? (5)
* achondroplasia,
* short
* limb syndromes
* hypothyroid
* storage diseases
47
The Upper to Lower Segment Ratio is decreased when? (4)
* Marfan’s
* Klinefelter’s,
* Kallman’s syndromes
* testosterone deficiency
48
How to calculate: The Upper to Lower Segment Ratio (3)
* upper segment/lower segment
* Upper segment: top of head to pubic symphysis
* Lower segment:pubic symphysis to floor
49
Describe etiology: Failure to thrive (1)
an interplay between pathophysiology and psychosocial influences
50
Investigations should assess what in failure to thrive? (4)
* complex factors in the parent-child relationship
* dietary intake, knowledge about feeding, improper mixing of formula
* feeding environment
* parent-child interaction, attachment
* child behaviours, hunger/satiety cues
* postpartum depression
* social factors: stress, poverty, neglect, child/domestic abuse, parental substance abuse, restricted diets
* inadequate caloric intake: inadequate milk supply/latching, mechanical feeding difficulty (cleft palate), oromotor dysfunction, toxin-induced anorexia
* inadequate absorption: biliary atresia, celiac, IBD, CF, inborn errors of metabolism, milk protein allergy, pancreatic cholestatic conditions
* increased metabolism: chronic infection, CF, lung disease from prematurity, hyperthyroidism, asthma, IBD, malignancy, renal failure
51
Describe management: Failure to thrive? (5)
* most as outpatient using multidisciplin aryapproach: primary care physician, occupational therapist, dietitian, psychologist, social work, CAS
* medical: oromotor problems, iron-deficiency anemia,gastro-esophageal reflux
* nutritional: educate about age-appropriate foods, calorie boosting, mealtime schedules, and
* environment; goal to reach 90-110% IBW, correct nutritional deficiencies, and promote catch-up growth/development
* behavioural: positive reinforcement, meal time environment, no distractions (e.g.toys,books,orTV) during mealtime
52
53
Define: Overweight and Obesity (2)
* overweight is BMI \>85th percentile
* obesity is BMI \>95th percentile for age and height
54
Name risk factors: Obesity (2)
* genetic predisposition (e.g. both parents obese – 80% chance of obese child)
* psychosocial/environmental contributors
55
Describe etiology: Obesity (5)
organic causes are rare (\<5%), but may include
* Prader-Willi
* Carpenter
* Turner
* Cushing syndromes
* hypothyroidism
56
Name complications: Obesity (10)
* association with HTN, dyslipidemia
* slipped capital femoral epiphysis
* type 2 DM,
* asthma
* obstructive sleep apnea
* gynecomastia
* polycystic ovarian disease
* early menarche
* irregular menses
* psychological trauma (e.g. bullying, decreased self-esteem, unhealthy coping mechanisms, depression)
57
True or False
## Footnote
Childhood obesity often persists into adulthood
True
58
Describe investigation: Obesity (3)
* BP
* pulse
* screen for: dyslipidemia, fatty liver disease (ALT), type 2 DM (based on risk factors)
59
Describe management: Obesity (8)
* encouragement and reassurance; engagement of entire family
* diet: qualitative changes (do not encourage weight loss, but allow for linear growth to catch up with weight), special diets used by adults and very low calorie diets are not encouraged
* behaviour modification: increase activity, change eating habits/meal patterns, limit juice/sugary drinks, ensure adequate sleep
* education: multidisciplinary approach, dietitian, counselling
* surgery and pharmacotherapy are rarely used in children
* increase physical activity (1 h/d), reduce screen time (\<2 h/d)
* small changes in energy expenditure and intake (lose 1 lb/mo)
* long term goal: maintain BMI \<85th percentile
60
Describe: Poison Prevention (5)
* keep all types of medicines, vitamins, and chemicals locked up in a secure container
* potentially dangerous: medications,illicit drugs,drain cleaners,furniture polish, insecticides, cosmetics, nail polish remover, automotive products
* do not store any chemicals in juice,soft drink,or water bottles
* keep alcoholic beverages out of reach: 3oz hard liquor can kill a 2yr old
* always read labels before administering medicine to ensure correct medication drug and dose and/or speak with a pharmacist or healthcare provider
61
Describe: Screen Time Guidelines (Canadian Society for Exercise Physiology) (3)
* Not recommended for children under 2 yr
* \<1h/d screentime is appropriate for children aged 2-5 yr
* \<2h/d screentime is appropriate for children5-17 yr
62
Name ddx of common pediatric rashes (11)
* Diaper Dermatitis
* Irritant contact dermatitis
* Seborrheic dermatitis
* Candidal dermatits
* Other Dermatitis
* Atopic dermatitis
* Nummular dermatitis
* Allergic contact dermatitis
* Irritant contact dermatitis
* Dyshidrotic dermatitis
* Infectious
* Scabies
* Impetigo
* Tinea corporis
63
Describe appearance and management: Irritant contact dermatitis
* Appearance: Shiny, red macules/patches, no skin fold involvement
* Management:
* Eliminate direct skin contact with urine and feces
* allow periods of rest without a diaper
* frequent diaper changes
* topical barriers (petrolatum, zinc oxide or paste)
* short-term low-potency topical corticosteroids (severe cases)
64
Describe appearance and management: Seborrheic dermatitis
* Appearance: Yellow, greasy macules/plaques on erythema, scales
* Management: Short-term, moisturisers, topical antifungal (ketoconazole), low-potency topical
65
Describe appearance and management: Candidal dermatits
* Appearance: Erythematous macerated papules/plaques, satellite lesions, involvement of skin folds
* Management: Antifungal agents (e.g. clotrimazole, nystatin)
66
Describe appearance and management: Atopic dermatitis
* Appearance: Erythematous, papules/plaques, oozing, excoriation, lichenification, classic areas of involvement
* Management: Eliminate exacerbating factors, maintain skin hydration (daily baths and moisturisers), corticosteroids,, topical calcineurin inhibitor (2nd line)
67
Describe appearance and management: Nummular dermatitis
* Appearance: Annular erythematous plaques, oozing, crusting
* Management: Avoid irritant if identified, potent topical steroid in emollient base, short-term systemic steroids ± antibiotics (severe)
68
Describe appearance and management: Allergic contact dermatitis
* Appearance: Red papules/plaques/vesicles/bullae, only in area of allergen
* Management:
* Mild: soothing lotion (e.g. calamine lotion)
* Moderate: low-to-intermediate potency topical corticosteroids
* Severe: systemic corticosteroids and antihistamine
69
Describe appearance and management: Irritant contact dermatitis
* Appearance: Morphology depends on irritant
* Management: Avoid skin contact
70
Describe appearance and management: Dyshidrotic dermatitis
* Appearance: Papulovesicular, cracking/fissuring, hands and feet (“tapioca pudding”)
* Management:
* Mild/moderate: medium/potent topical corticosteroids
* Severe: systemic corticosteroids, local PUVA or UVA treatments
71
Describe appearance and management: Scabies
* Appearance:
* Polymorphic (red excoriated papules/nodules, burrows), in
web spaces/folds, very pruritic
* Often affects multiple family members
* Management: Permethrin (Nix®) 5% cream for patient and family (2 applications, 1 wk apart)
72
Describe appearance and management: Impetigo
* Appearance: Honey-coloured crusts or superficial bullae
* Management: Topical antibiotics if mild: fucidic acid or mupirocin cream; Oral antibiotics if severe (e.g. cephalexin/erythromycin)
73
Describe appearance and management: Tinea corporis
* Appearance: Round erythematous plaques, central clearing and scaly border
* Management: Topical anti-fungal for skin, systemic anti-fungals for nails/head
74
Name: Types of Sleep Disturbances (4)
* insufficient sleep quantity
* poor sleep quality
* obstructive sleep apnea
* parasomnias
75
Describe: Insufficient sleep quantity (4)
difficulty falling asleep (e.g. limit setting sleep disorder)
* preschool and older children
* bedtime resistance
* due to caregiver’s inability to set consistent bedtime rules and routines
* often exacerbated by child’s oppositional behaviours
76
Describe: Poor sleep quality (3)
frequent arousals (e.g. sleep-onset association disorder)
* infants and toddlers
* child learns to fall asleep only under certain conditions or associations (e.g. with parent, held, rocked or fed, with light on, in front of television), and loses ability to self-soothe
* during the normal brief arousal periods of sleep (q90-120 min), child cannot fall back asleep because same
77
Describe: Obstructive sleep apnea
* definition
* epidemiology
* clinical features
* complications
* etiology
* **definition**: partial or intermittent complete airway obstruction during sleep causing disrupted ventilation and sleep pattern
* **epidemiology**: 1-5% of preschool aged children, more common in African American children
* **clinical features**: snoring/gasping/noisy breathing during sleep and irritable/tired/hyperactive during the day
* **complications**: cardiovascular (HTN/LV remodelling due to sympathetic activation), growth, cognitive, and behavioural deficitis
* **etiology**: adenotonsillar hypertrophy, craniofacial abnormalities, obesity
78
Describe investigations: Obstructive sleep apnea (1)
polysomnography is gold standard for diagnosis but not required (expensive, inaccessible)
79
Describe management: Obstructive sleep apnea (4)
* adenotonsillectomy and weight management are first-line tx, follow-up for residual OSA. Watchful waiting acceptable in mild-moderate cases
* adenotonseillectomy does not improve executive function/attention but improves behaviour, QOL, polysymnographic findings
* use CPAP if adenotonsillectomy is contraindicated (cleft palate/bleeding disorder/acute tonsillitis), OSA w/ minimal adenotonsillar tissue, residual OSA
* avoid pollutants/tobacco smoke, allergens
* avoid use of corticosteroids and antibiotics
80
Describe: parasomnias (2)
* episodic nocturnal behaviours (e.g. sleepwalking, sleep terrors, nightmares)
* often involves cognitive disorientation and autonomic/skeletal muscle disturbance
81
Describe: Daily Sleep Requirement according to age
* \<6 mo
* 6 mo
* 12 mo
* 2 yr
* 4 yr
* 6 yr
* 12 yr
* 18 yr
* \<6 mo: 16 h
* 6 mo: 14.5 h
* 12 mo: 13.5 h
* 2 yr: 13 h
* 4 yr: 11.5 h
* 6 yr: 9.5 h
* 12 yr: 8.5 h
* 18 yr: 8 h
82
Describe nap patterns at:
* 1yr
* 2yr
* 5yr
* 2/d at 1 yr
* 1/d at 2 yr: 2-3 h
* 0.5/d at 5 yr: 1.7 h
83
Describe Management of Sleep Disturbances (7)
* set strict bedtimes and “wind-down” routines
* do not send child to bed hungry
* positive reinforcement for: limit setting sleep disorder
* always sleep in own bed, in a dark, quiet, and comfortable room
* avoid screens before bedtime and avoid caffeine-containing food
* do not use bedroom for timeouts
* systematic ignoring and gradual extinction for: sleep-onset association disorder
84
Describe: Nightmares
* Epidemiology
* Clinical features
* Management
* **epidemiology**: common in boys, 4-7 yr old
* associated with REM sleep (anytime during night)
* **clinical feature**: upon awakening, child is alert and clearly recalls frightening dream ± associated with daytime stress/anxiety
* **management**: reassurance
85
Describe: Night Terrors
* Epidemiology
* Clinical features
* Management
* **epidemiology**: 15% of children have occasional episodes
* usually in first one third of night; arousal from deep (slow wave) sleep
* **clinical feature**: abrupt sitting up, eyes open, screaming/vocalization, occurs in early hours of sleep, stage 4 of sleep; signs of autonomic arousal with no memory of event, disoriented if awakened, inconsolable, stress/anxiety can aggravate them
* **management**: reassurance from parents, ensure child is safe (e.g. if sleepwalks), often remits spontaneously at puberty
86
Define: Sudden Infant Death Syndrome (1)
* sudden and unexpected death of an infant \<12 mo of age in which the cause of death cannot be found by history, examination, or a thorough postmortem and death scene investigation
87
Describe epidemiology: Sudden Infant Death Syndrome (5)
* 0.5/1000 (leading cause of death between 1-12 mo of age); M:F = 3:2
* more common in children placed in prone position
* in full term infants, peak incidence is 2-4 mo, 95% of cases occur by 6 mo
* increase in deaths during peak respiratory syncytial virus season
* most deaths occur between midnight and 8 AM
88
Describe risk factors: Sudden Infant Death Syndrome (3)
* prematurity (\<37 wk), early bed sharing (\<12 wk), alcohol use during pregnancy, soft bedding, low birthweight, Indigenous background, male, no prenatal care, smoking in household, prone sleep position, poverty
* risk of SIDS is increased 3-5x in siblings of infants who have died of SIDS
* bed sharing: sleeping on a sofa, adult sleeping with an infant after consumption of alcohol/street drugs or extreme fatigue, sleeping on a surface with a fixed wall (couch/sofa), infant sleeping with someone other than primary caregiver
89
Describe prevention: Sudden Infant Death Syndrome (7)
* “Back to Sleep, Front to Play” (place infant on back when sleeping, daily supervised play/“tummy time” in prone position)
* avoid sharing bed with infant
* avoid overheating and overdressing
* appropriate infant bedding (firm mattress, avoid loose bedding, pillows, stuffed animals, and crib bumper pads)
* exclusive breastfeeding in first mo and no smoking
* pacifiers appear to have a protective effect; do not reinsert if falls out during sleep
* infant monitors do not reduce incidence
90
Describe link between Brief Resolved Unexplained Events (BRUE) and Sudden Infant Death syndrome (4)
* Brief Resolved Unexplained Events (BRUE) These are sudden, brief and now resolved episodes in an infant with one or more of the following: cyanosis or pallor; absent, decreased or irregular breathing; change in tone; and/or altered level of consciousness.
* The observer fears the child may be dying. The child should be asyptomatic on presentation and there is no explanation after a history and physical for the cause. There is no clear connection between most BRUEs and SIDS. Evaluating for a cause of the BRUE (e.g. infection, cardiac, neurologic) is guided by history, physical exam, and period of observation
* These are sudden, brief and now resolved episodes in an infant with one or more of the following: cyanosis or pallor; absent, decreased or irregular breathing; change in tone; and/or altered level of consciousness.
* The observer fears the child may be dying. The child should be asyptomatic on presentation and there is no explanation after a history and physical for the cause. There is no clear connection between most BRUEs and SIDS. Evaluating for a cause of the BRUE (e.g. infection, cardiac, neurologic) is guided by history, physical exam, and period of observation
