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The physician who has experience with environmental toxicants may quickly suspect that a disease or syndrome (e.g. acute lead toxicity) is associated with a hazardous environmental exposure. The problem list should still be used, however, to keep the differential diagnosis broad in the beginning. Any and all specific exposures identified by the child’s parents or caregiver(s) or suspected by a pediatrician should be listed.

Famous Libra suns include Kim Kardashian, John Lennon, Gwen Stefani, Gwyneth Paltrow, Serena Williams, Oscar Wilde, Barbara Walters, and Gandhi. No matter how we remember these stars individually, the foundation of their success was built on teamwork and balance. Their triumphs and scandals would be impossible without the collaboration of others and their distinctive appreciation for the beauty in the world.

Gemini is ruled by Mercury, the planet of communication. Chatty and curious, Gemini loves gathering and disseminating messages, gossip, and information. Gemini might be different with everyone they meet, but isn’t everybody? After all, Gemini is two for the price of one — what could be better than that!

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Gemini is a mutable sign, which means it occurs at the end of a season — spring, to be exact. Just as the blooms begin to burst, preparing for their great summer expansion, Gemini season evokes the vibrant social butterfly within. Represented by the twins, Gemini is no stranger to parties, barbecues, picnics, beach days, you name it. In fact, this sign has more social obligations than there are hours in the day, which is precisely why it needed to clone itself. How else can you be in two places at once?

A few famous Gemini suns include Paul McCartney, Marilyn Monroe, Kanye West, Prince, Awkwafina, Josephine Baker, Tupac Shakur, and Angelina Jolie. From the outside, the most obvious commonalities are the malleability of their identities over time, even in the public consciousness, even in death. Sometimes that duality is terrifying, but more often than not, it’s a beautiful strength and survival skill.

In modern astrology, Aquarius is ruled by Uranus, the planet associated with innovation, revolution, and rebellion. In traditional astrology (that is, the systems in place before the advent of the telescope), Saturn, the planet of order and discipline, governs Aquarius, making this sign a heavy hitter and a serious thinker. Aquarius is a fixed sign — occurring in the middle of winter — meaning that it’s hardened against outside influence and uncompromisingly set in its beliefs. Aquarius is unique and special, not because we aren’t all unique or special, but because they are steadfast in protecting that individuality in the face of distraction and change.

Oh, and all that nonsense about Geminis being two-faced liars is true — but it’s something that we all do on some level. This zodiac sign is the embodiment of code switching. It’s the details you leave out when your grandfather asks how life in the big city is over Christmas dinner. It’s “turning on” for an important meeting or having a “phone voice” when calling your insurance company. Our identity is ever-changing, constantly in flux — Gemini just leans into that inherent duality a little harder and less abashedly than everyone else. Whatever.

Primary health care providers can use the history, review of systems, and physical examination to establish a problem list. Then initial laboratory tests/imaging can be requested to systematically work through the differential diagnoses to come up with a diagnosis. This will be discussed in more detail in the next section.

Because children may have adverse health effects that may be subclinical or without overt clinical symptoms, as may occur with low blood lead levels, it is vital that primary care providers adopt a preventive approach to determine which of their patients may be at risk.

It is everywhere, animating everything. So it’s fitting that intellectual, curious air signs are the ultimate conduits. Air plays by different rules; without physical boundaries, these signs can drift everywhere, jumping from places to people to philosophies. They love theory over practice and can get caught in endlessly thinking or talking something out. So let’s take a page from their book — behold, everything you need to know about air.

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Libra occurs at the beginning of autumn and is a cardinal sign that loves to start new projects and (ahem) relationships. Ruled by Venus, the planet associated with love and beauty, Libra is extremely attuned to aesthetics. Sure, Venusian energy can manifest as a shallow obsession with appearances, but it can also embody a deep understanding of the most grand and abstract measures of beauty — rhythm, poetics, and the golden rule. Libra longs for justice, even in the face of the most unfair, compromised systems.

As we know, the 12 zodiac signs are divided into four different elements: air, water, fire, and earth. Each has its own traits and associations; the three signs express each element’s properties in a different way. The air signs — Gemini, Libra, and Aquarius — connect the dots. Literally.

In interpreting this table, it is important to remember that some of the hematological abnormalities of lead poisoning are similar to those of other diseases or conditions.

The air element is our breath, the most necessary and invisible function of the human body. Air is thoughts. Air is language. Air is ideas, possibilities, conversations, connections, and transmission. Air moves water, spreads fire, and picks up the earth to create transformative wind tunnels. Indeed, Dorothy only arrives in Oz thanks to an air-derived twister. Think of our intellectual and communicative air signs as experts in the ephemeral, the things of this world that lack physical form.

Those three air signs are Gemini, Libra, and Aquarius. Each of them expresses curious, clever air energy in a different way — let’s explore.

A review of systems is an inventory of specific body systems performed by the health care provider during the process of taking a medical history from the patient. It is designed to bring out clinical symptoms the patient may have overlooked, forgotten, or may not have realized were important enough to mention to the physician, but may, in fact, be key toward making an accurate diagnosis.

The importance for the clinician is to recognize ongoing lead exposure, interrupt that exposure, and treat the patient as appropriate. Only through an increased suspicion of lead exposure as the etiology of many nonspecific signs, symptoms, and common health conditions, can a diagnosis be made early so that preventive actions can take place.

Wouldn’t perfect balance be nice? It’s an impossible reality, but that doesn’t stop Libra from seeking that ideal. Represented by the scales, Libra is the sign of adjustment, of modification, of making room for the other outside of the self. Libra “holds space” and takes heed of everyone’s needs in addition to their own. Libra is constantly calibrating to accommodate others, which makes this sign a truly ambitious optimist.

Aquarius, the last air sign of the zodiac, is symbolized by the water bearer. This often confuses people — including Aquarians — into believing it’s a water sign. But Aquarius is most definitely an air sign; in fact, it plays an incredibly important role within the collection of air-sign archetypes. If Gemini relates to social connections and Libra relates to partnership, Aquarius takes a giant leap into humanitarianism. Aquarius is concerned with the bigger picture, the large-scale concepts that dreams are made of but can seldom be contained in waking reality. For this reason, Aquarians are more likely to care about large, cultural missions than they are petty, daily interaction. Unlike Gemini and Libra, they do not appreciate small talk. For Aquarians, it’s manifestos or bust, please and thank you.

Galileo, Rosa Parks, Bob Marley, Yoko Ono, Oprah Winfrey, and Paris Hilton are a few famous Aquarius suns. Their names have become synonymous with symbols, movements, and eras rather than pure reflections of their personal identities; their impact and their celebrity relates to something far bigger than themselves.

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Libra often leans into superficiality, not necessarily out of a lack of depth but because it’s often easiest to meet others on the surface. The small talk we engage in on elevator rides and supermarket checkout lines is a strength for Libra, who understands that those brief interactions can alter the course of a day. On the other hand, Libra’s innate desire for diplomacy is just as easily Libra’s weakness. Often, their willingness to meet everyone else’s needs to manifest a sense of equilibrium can be self-abnegating. In an effort to escape tension and conflict, Libra can let go of their own wants and desires entirely.

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For the child with a history of a known lead exposure, with or without symptoms, concerned parents may visit their child’s pediatrician or physician with worries that their child may become sick in the future. The parents may inquire about signs and symptoms associated with exposures.

Typically, a sign is something the health care provider “sees” or “finds” during a physical exam. A symptom is experienced and reported by the patient.

Table 6. Continuum of Signs and Symptoms of Ongoing Lead Exposure [ATSDR 2010] Lowest Exposure Dose Signs and Symptoms: Impaired Cognitive Abilities/Subclinical Neuro/Psychoneuro/Neurobehavioral Findings (patient may appear asymptomatic)

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It is important to keep in mind, that even a complete physical examination may not identify subtle neurological effects that may be associated with low-level lead exposure in children.

Children may appear to be asymptomatic at a low level lead exposure dose, but these levels may still impact the health of children and adults. With increasing exposure dose, the likelihood and severity of symptoms can be expected to increase.

The patient assessment should include a review of systems for symptoms and signs as well as a complete physical examination of patients with potential exposure to lead, in addition to the environmental exposure history.

The first signs of lead poisoning in children are often subtle neurobehavioral problems that adversely affect classroom behavior and social interaction.

Many patients who suffer from lead poisoning may be asymptomatic, hence the importance of exposure assessment and screening.

A continuum of signs and symptoms can be seen depending on level (amount), frequency, and duration of lead exposure. However, this is not a clear-cut picture of how the cases present, but a guide to understanding how the different levels of exposure reflect in the presentation. Keep in mind that categorizing the signs and symptoms by exposure dose from “lowest to high” is somewhat artificial – the signs and symptoms generally become more noticeable as BLLs increase, and no specific BLL numbers can be assigned to exposure levels in the continuum, as symptoms may vary by individual.

The problem list details the patient’s most important medical information, which includes diagnoses, family history, and past tests and procedures. It will assist in the identification of an environmentally related condition. In other situations, the initial problem list may include only