Chief Complaint Of Fever Research Articles

Case 2: Where have all the white cells gone?

A 23-month-old girl with a significant history for preseptal cellulitis at three months of age and pneumonia at 14 months of age presented to the emergency department (ED) with chief complaints of fever, tachypnea and cough. She was initially seen in the ED five days before admission with a five-day history of persistent fever, despite recent use of antibiotics (cephalexin, then azithromycin) for acute otitis media and pharyngitis, which were diagnosed by her family physician. At the initial ED visit, she was diagnosed with right middle lobe pneumonia and sent home on oral clindamycin. Additional laboratory test results showed an erythrocyte sedimentation rate of 70 mm/h, and a white blood cell count of 10.2×109/L, with an absolute neutrophil count of 0.51×109/L. Epstein-Barr virus titres, and blood and urine cultures were also sent and remained negative. The patient returned to the ED with persistent daily fevers (10 days total) with a maximum temperature of 38.8°C, and new-onset tachypnea and cough. Her parents denied grunting, retractions, cyanosis, vomiting, diarrhea or lethargy. Her immunizations were up to date. There was no recent travel and no known sick contacts. During the second presentation to the ED, the patient’s vital signs were a temperature of 38.8°C, heart rate of 186 beats/min, respiratory rate of 30 breaths/min, blood pressure of 141/82 mmHg and an oxygen saturation of 100% on room air. She was non-toxic in appearance and had decreased breath sounds at the right base, but an otherwise unremarkable examination. Her tachycardia resolved with administration of intravenous fluids, and her blood pressure subsequently normalized to 97/74 mmHg. A complete blood count during this second ED visit revealed a white blood cell count of 10.2×109/L with 0% neutrophils, 0% bands, 47% lymphocytes, 38% monocytes, 13% eosinophils, 0% basophils and 2% myelocytes. Her erythrocyte sedimentation rate was 65 mm/h. A chest x-ray showed minimal improvement of her pneumonia. Given her neutropenia and the lack of clinical improvement on outpatient antibiotic therapy, the patient was admitted to the hospital for further management. On admission, the patient was placed on intravenous cefotaxime. However, she remained persistently febrile, so antibiotic coverage was broadened to vancomycin and meropenem. Laboratory investigations including blood and fungal cultures, a viral respiratory panel, quantitative immunoglobulins, disseminated intravascular coagulation panel, lactate dehydrogenase, ferritin and uric acid were all unremarkable. A purified protein derivative test was negative. An abdominal ultrasound to evaluate for intra-abdominal abscess was normal. She had multiple repeat complete blood counts, which demonstrated persistent neutropenia. On her fifth day of hospitalization, the patient was able to undergo a procedure that revealed the diagnosis.

CNS Involvement by Novel Influenza Virus Type A (H1n1), the First Report from Iran

Objective This is the first report of CNS involvement by the new influenza virus (influenza A [H1N1]) in Iran. The patient was a 10-year-old boy with chief complaints of fever, malaise, and cranial nerve involvement, resulting in respiratory muscle paralysis and intubation. This shows that the new influenza virus, as well as the seasonal flu, can cause neurologic complications; however, the severity of the signs and symptoms is less and the disease may resolve without complications in the case of seasonal flu. Therefore, in each patient with neurologic involvement and typical influenza signs & symptoms or a flu-like syndrome, diagnostic tests for H1N1 flu virus should be considered, especially during epidemics, and treatment with oseltamivir should be started.

HIV associated thrombocytopenia, misdiagnosed as thrombotic thrombocytopenic purpura: a case report

IntroductionThrombocytopenia is one of the protean hematological manifestations of infection by human immunodeficiency virus. We present a case where diagnosis of human immunodeficiency virus infection was delayed because thrombocytopenia was the only presenting feature.Case presentationA female presented with chief complaint of fever, productive coughs weight loss and nocturnal sweating; was detected to have thrombocytopenia on a complete blood count, performed five months ago. Her other clinical chemistry and hematological investigations were normal. She was previously diagnosed as having TTP, and had received 55 sessions of plasma exchange before presenting to us. At this time she was detected to be HIV positive, had CD4+ counts of 26/mm3, treated with antiretroviral drugs and Cotrimoxazol, and discharged asymptomatically.ConclusionHIV should be suspected in all cases of unexplained thrombocytopenia.

Babesiosis as a rare cause of fever in the immunocompromised patient: a case report.

IntroductionThis is the case of a rare and regional disease not often considered in the immunocompromised patient presenting with a chief complaint of fever.Case presentationA 37-year-old immunocompromised Indian woman presented with a chief complaint of fever, in the absence of localizing signs and symptoms, from an area endemic to Babesia microti.ConclusionsOur patient’s case is instructive in that Babesiosis and other arthropod born illnesses should be considered in immunocompromised patients presenting with fever in the absence of localizing signs or symptoms. This is especially true when he or she presents from an area with known endemic disease. While the management of fever in immunocompromised patients is largely standardized, considering Babesiosis from the beginning may prompt early investigation of a blood smear, which has the potential to alert the emergency department physician to Babesiosis. In addition, considering the disease from the outset has the potential to accelerate administration of the appropriate antimicrobial therapy and thus prevent unnecessary morbidity and possible mortality.

Lemierre Syndrome Complicating Otitis Externa: Case Report and Literature Review

Background: Septic thrombophlebitis of the internal jugular vein, known as Lemierre syndrome, is a rare disorder usually caused by Fusobacterium necrophorum, a Gram-negative anaerobic organism that normally inhabits the oropharynx. Lemierre syndrome usually follows primary oropharyngeal infections and affects previously healthy adolescents and young adults in a characteristic manner, often with fatal results if left untreated. There have been a significantly increasing number of reported cases of Lemierre syndrome, possibly reflecting the trend to withhold antibiotics for initially uncomplicated oropharyngeal infections. Objectives: We hope to alert the reader to a potentially fatal disease process that has recently been increasingly identified, by reporting a unique manifestation of Lemierre syndrome, and by reviewing the current literature. Case Report: A 19-year-old woman presented to our Emergency Department with a chief complaint of fever, ear pain, and generalized weakness. She was noted to be in septic shock, with left neck erythema and swelling. A computed tomography scan showed thrombosis of the left internal jugular vein (IJV), which was later excised. She recovered after a course of intravenous and oral antibiotics. Conclusion: Septic thrombophlebitis of the IJV is associated with multiple sources and organisms. This case is unique in both the organism (Peptococcus anaerobius) and the source (otitis externa). This disease process must be identified early and aggressively treated to avoid significant morbidity and mortality.

A Case Report of Usual Interstitial Pneumonia after Treatment of Bronchopneumonia

Usual interstitial pneumonia (UIP) is one type of idiopathic interstitial pneumonia, characterized by its poor prognosis and gradual deterioration of clinical course. So it is important to distinguish UIP from other interstitial pneumonia. Defi nitive histological diagnosis of UIP requires lung biopsy. The criteria for diagnosis of UIP in the absence of a surgical lung biopsy were recently defi ned. We report a case of 75-year-old man who was diagnosed as bronchopneumonia with chief complaint of fever, dyspnea on fi rst visit, then fi nally diagnosed as UIP through the remaining of chest abnormality after treatment.

The Association of Overweight and Ankle Injuries in Children

Overweight children are at increased risk for many medical problems. Trauma is the leading etiology of childhood morbidity and mortality. No previous study has evaluated the association between overweight and acute ankle injuries in children. We hypothesized that being overweight is associated with an increased risk of ankle injury in children. We conducted a case-control study in an urban pediatric emergency department. Subjects aged 5 to 19 years were recruited from June 2005 through July 2006. Children with acute ankle trauma were enrolled as cases. A convenience sample of children with a chief complaint of fever, headache, or sore throat was enrolled as controls. Demographic information and anthropometric measurements were obtained. Age- and gender-specific body mass index percentiles (BMI-Ps) were calculated using pediatric norms. Multivariate unconditional logistic regression was used to assess the relationship between overweight and ankle injury, adjusting for demographic variables. Through medical records, we obtained demographic information and weight, but not height, of all cases that were not enrolled. This allowed us to conduct a sensitivity analysis in which we combined the enrolled and nonenrolled cases into a single case group and made increasingly more unlikely assumptions about the height percentiles of the nonenrolled cases. One hundred eighty cases and 180 controls were enrolled in the study. We observed a significant association between overweight and ankle injury (multivariate-adjusted odds ratio 3.26, 95% confidence interval, 1.86-5.72; P value for trend <.0001). Although this result may be an overestimate of the magnitude of the association due to a possible bias in the selection of cases, sensitivity analysis demonstrated the robustness of the statistical significance of the finding. Overweight children may be at increased risk of ankle injury.

Short-Term Outcomes of Pediatric Emergency Department Febrile Illnesses

To describe short-term outcomes relevant to children and their caregivers after evaluation in the emergency department (ED) for febrile illnesses. This was a prospective cohort study of children aged 28 days to 18 years presenting with fever (> or =38 degrees C), or chief complaint of fever, who were evaluated and discharged to home from tertiary care pediatric ED. Enrollment occurred on randomly selected study days over 1 year. Caregivers were then contacted via telephone after 7 to 10 days to assess outcomes, including days of fever, child and family activity impairments, as well as return to health care. Follow-up was complete for 322 (72%) of 451 enrolled subjects. Mean age of subjects was 31.5 months. The most common discharge diagnosis was undifferentiated febrile illness (20.5%). Mean total duration of fever was 4.41 days (95% confidence interval [CI], 4.14-4.81); 38.9% remained febrile for 5 days or longer. For children, impairments in each outcome (activity, oral intake, sleep, behavior) persisted longer than 2.5 days; over 14% of them remained impaired at follow-up in each outcome. Children missed a mean of 2.63 days of day care or school (95% CI, 2.21-3.06); 37.4% missed 3 days or longer. Primary caregivers missed 1.47 days of work or school (95% CI, 1.19-1.75); 10.5% missed 5 days or longer. After ED evaluation, 23.7% made a nonscheduled revisit to the primary medical doctor or ED. Children, and their caregivers, experience prolonged fever and impairments in activities, and frequently relapse to health care as a result of febrile illnesses. Often considered minor in nature, febrile illnesses have considerable effects on the child, caregivers, and families after ED evaluation.

CRITERIA FOR EVALUATING FEBRILE 29- TO 60-DAY-OLD INFANTS: A 3-YEAR RETROSPECTIVE REVIEW FROM BIRMINGHAM.

Purpose This retrospective study examines 29- to 60-day-olds who presented to an emergency department (ED) between 1/1/02 and 12/31/04 with a chief complaint of fever. A set of criteria can predict which patients will not have serious bacterial infections (SBI). Methods Fever is defined as ≥ 100.4°F rectally. Exclusion criteria: previous vaccination (other than hepatitis B), surgeries (other than circumcision), antibiotics, immune deficiency syndromes, non-well appearance, and signs of bacterial infection. Inclusion criteria were well appearance with a complete blood count (CBC) with a white blood cell count (WBC) of 5,000 to 20,000 with a band/neutrophil ratio of 40, and negative Gram stain. A univariate analysis of each variable against predictability of positive cultures and SBIs was performed using EPISTAT. The chi-square of each variable was used to calculate a two-tailed p value. Results Of 552 charts, there were 565 diagnoses; 434 had a fever by our definition. Of these 434, 111 met the inclusion criteria. Of these 111 patients, 110 did not have an SBI (one patient had a urinary tract infection). Of the 323 patients with fever who failed to meet the inclusion criteria, 187 had either a bacterial or serious viral infection. The prevalence of SBI in our study is 15% (83/552) from all causes and 10% (56/552) culture proven. The inclusion criteria have a positive predictive value of 99.1% (110/111), specificity of 98.6% (70/71), sensitivity of 31.2% (110/352), and negative predictive value of 22.4% (70/312) for predicting negative SBI. The inclusion criteria have a positive predictive value of 99.1% (110/111), specificity of 97.8% (44/45), sensitivity of 29.1% (110/378), and negative predictive value of 14.1% (44/312) at predicting negative cultures. Of the criteria, well appearance (p Conclusion A large number of patients are seen in the ED for fever. Many may be safely discharged home without antibiotics.

Predictors of treatment error for children with uncomplicated malaria seen as outpatients in Blantyre district, Malawi

Past studies have shown that health workers in developing countries often do not follow clinical guidelines, though few studies have explored with appropriate methods why errors occur. To develop interventions that improve health worker performance, factors affecting treatment practices must be better understood. We analysed data from a health facility survey in Blantyre District, Malawi, in which health workers were observed treating ill children, and then children were independently re-examined by 'gold-standard' study clinicians. The analysis was limited to children with uncomplicated malaria (defined according to Malawi's guidelines as fever or anaemia without signs of severe illness), and a treatment error was defined as failure to treat with an effective antimalarial. Twenty-eight health workers and 349 ill-child consultations were evaluated; 247 (70.8%) children were treated with an effective antimalarial, and 102 (29.2%) were subject to treatment error. Logistic regression analysis revealed that in-service malaria training was not associated with treatment quality (univariate odds ratio (OR) = 1.16, 95% confidence interval (CI): 0.46-2.93); whereas acute respiratory infections training was associated with making an error (adjusted OR (aOR) = 2.42, 95% CI: 1.23-4.76). High fever and chief complaint of fever were associated with fewer errors (aOR = 0.25, 95% CI: 0.10-0.60 and aOR = 0.25, 95% CI: 0.13-0.48, respectively). Errors were more likely to occur in consultations starting before 1 p.m. (aOR = 1.88, 95% CI: 1.07-3.31). Supervision was not associated with better treatment quality. These results suggest that the disease-specific training and supervision, performed before the survey, did not lead to long-term improvements in health care quality. Furthermore, case management training for one specific disease may have worsened quality of care for another disease. These results support integration of guidelines for multiple conditions. Interventions should be evaluated for unintended negative effects on overall quality of care.

Febrile cancer patients seeking acute care: How tired are they?

8252 Background: Fever is a very common symptom in cancer patients and the leading cause of emergency center (EC) visits at M.D. Anderson Cancer Center. Cancer-related fatigue is also common among cancer patients, affecting approximately 70–100%. Our objectives are to describe clinical factors in oncology patients with fever and fatigue and to determine fatigue levels in EC patients presenting with fever. Methods: A retrospective cohort of 247 cancer patients with a chief complaint of fever or T>38oC admitted to our EC from 5/1/01 to 8/15/01 was studied. Data abstracted from the medical records included demographics and clinical and cancer treatment factors. Descriptive statistics and univariate analysis were utilized. Fatigue was measured by asking the patient at triage, “What is your worst fatigue in the last 24 hours on a 0 - 10 scale with 10 being the worst fatigue?” Results: The mean age was 53 years (range 18–86). About half (53%) of patients had solid tumors and the rest hematologic malignancy. The overall median fatigue level was 7.0 and 82% had moderate to severe fatigue (4 -10). (Table) Conclusions: This is the first report of fatigue levels in febrile cancer patients. The majority of febrile cancer patients seeking acute care had severe levels of fatigue. Poorer performance status and female gender were associated with more severe levels of fatigue. Interventions to assess and reduce fatigue in this group may be warranted; however, further prospective studies are necessary. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Ortho-Biotech Ortho-Biotech Ortho-Biotech

The Impact of the SARS Outbreak on an Urban Emergency Department in Taiwan

Emergency departments (ED) were on the front lines for possible cases of transmission during the severe acute respiratory syndrome (SARS) epidemic. The purpose of this study was to investigate the impact of the SARS catastrophe on an urban ED. The patients' characteristics in an urban ED were collected from March to May 2003 during the SARS outbreak in Taiwan. The crisis period was divided into 2 periods: 30 days before (period 1) and after (period 2) April 21, the date of the first hospital-associated transmission. Problem severity in the ED and stress levels of ED staff during the SARS catastrophe were rated from mild (1 point) to severe (5 points). The number of ED patients declined 33.4% in period 2. There was a 2.1% (95%CI, 0.4-3.8) increase in the percentage of male patients, a 2.5% (95% CI, 1.5-3.7) increase in percentage of fever (>38 degrees C), and a 4.0% (95% CI, 2.6-5.4%) increase in chief complaint of fever in period 2. The number of nontrauma patients younger than 18 years had declined by 44.5% in period 2. The total charge for reimbursement from an insurance institution declined 21.7%. During the SARS outbreak, the most severe stress experienced by either physicians or nurses occurred during emergency resuscitation (median stress rating point, 4; interquartile range, 1). The SARS catastrophe affected the ED visit volume, finances, various patient characteristics, and stress levels in the ED physicians and nurses. EDs must be fully prepared to face the challenges of the next outbreak of SARS or other infectious disease.

皮膚病変，歯肉潰ようを認めた肺好酸球性肉芽腫様Ｌａｎｇｅｒｈａｎｓ ｃｅｌｌ ｇｒａｎｕｌｏｍａｔｏｓｉｓの１症例

We report here a case of Langerhans cell granulomatosis resembling so-called pulmonary eosinophilic granuloma. Patient was a 38 year-old male with chief complaints of fever and general fatigue, and also showed skin lesions with crust and ulcer of gingiva. Chest X-ray film in hospitalization showed diffuse abnormal shadows which were not detected two months before the admission. In both lung fields, diffuse multiple small cystic lesions with thin wall, small nodules and patchy lesions were also seen on chest computed tomography. Abnormal shadows were dominant in upper lung fields. No other involvement of organs including bones were found by garium and bone scintigraphies.Biopsy specimens were obtained from transbronchial lung biopsy, skin and gingiva. Granuloma formation with Langerhans cells and eosinophils invasion were found in all biopsy specimens by hematoxylin-eosin staining and immunostaining against the S-100 protein. On the basis of these findings, we gave the preferable diagnosis of Langerhans cell granulomatosis rather than pulmonary eosinophilic granuloma, because the patient showed systemic involvement. However, main organ involved was the lung and the clinical findings were looked like pulmonary eosinophilic granuloma as a localized disease. Interestingly, without specific treatment excluding smoking cessation, clinical symptoms and chest X-ray abnormalities improved spontaneously in this case.

A Useful Diagnostic Method for Drug-induced Pneumonitis

A 51 year-old male was admitted to our hospital with chief complaints of fever, dry cough and dyspnea. Chest X-ray films and his history of taking Chinese medicine for liver dysfunction were suggestive of drug-induced pneumonitis. Lymphocyte stimulation test (LST) to causative Chinese medical drugs of Sho-saiko-to and Dai-saiko-to was negative with peripheral blood lymphocytes (PBL), but was positive with lymphocytes from bronchoalveolar lavage fluid (BALF). In vivo challenge test for Sho-saiko-to was positive. The LST with BALF-lymphocytes proved to be very useful in making a diagnosis of drug-induced pneumonitis.

びまん性汎細気管支炎に対するErythromycin (EM) 長期治療中に発症したEM耐性肺炎球菌による急性増悪の症例に関する臨床的, 細菌学的検討

The first case was a 73-year-old woman with chief complaints of fever, cough, purulent sputum and dyspnea. EM therapy was begun in December 1983 due to a diagnosis of diffuse panbronchiolitis (DPB). Subsequently, P. aeruginosa was persistently detected, while in February 1991 at the time of an acute exacerbation of the DPB P. aeruginosa and S. pneumoniae were detected by TTA. The second case was a 65-year-old man with chief complaints of fever, cough and purulent sputum. DPB was diagnosed and EM therapy was begun in December 1985. In January 1991, pneumonia developed, at the time when S. pneumoniae was detected by TTA. In both cases, rapid disappearance of S. pneumoniae from the sputum and alleviation of symptoms were obtained with carbapenem antibiotic administration. Both strains were resistant to EM, Tetracycline (TC), Minocycline (MINO) and Clindamycin (CLDM). Particularly, S. pneumoniae of case 2 showed low sensitivity to Ampicillin (ABPC), Cefotiam (CTM) and Cefoxitin (CFX) as well. These cases showed acute exacerbations due to EM-resistant pneumococcus during long-term therapy with EM, and are of interest in that they may shed light on the relation between long-term EM therapy and the emergence of resistant pneumococcus.

EFFECTIVENESS OF STEROID PULSE THERAPY IN A CASE OF IDIOPATHIC INTERSTITIAL PNEUMONIA PRESENTING WITH FEVER OF UNKNOWN ORIGIN

Idiopathic interstitial pneumonia has an unknown etiology and a poor prognosis. Here we report a case of acute idiopathic interstitial pneumonia that presented with fever of unknown origin and was effectively treated with steroid pulse therapy. The patient was a 71-year-old woman. She visited our clinic as an outpatient with chief complaints of fever, malaise and polyarthralgia and was admitted for detailed examination and treatment. At that time we suspected bronchial pneumonia and administered antibiotics, but without effect. We then initiated examinations for fever of unknown origin. Respiration worsened after admission and the combined findings of a chest x-ray and respiratory function tests led to the diagnosis of acute idiopathic interstitial pneumonia. Treatment consisted of steroid pulse therapy (methylprednisolone, total dose = 6, 000mg). Symptoms improved markedly after this therapy. Moreover, after adding the immunosuppressant agent cyclophosphamide we were able to gradually reduce the steroid dose.The group of diseases designated as acute idiopathic interstitial pneumonia apparently consists of diseases clinically responsive to steroid pulse therapy, and other non-responsive diseases. Thus, according to pathology, a new classification and new therapies shoud be developed.

A CASE OF VON RECKLINGHAUSEN'S DISEASE ASSOCIATED WITH NONFUNCTIONING PHEOCHROMOCYTOMA AND MALIGNANT SCHWANNOMA

A case of von Recklinghausen's disease associated with nonfunctioning pheochromocytoma and malignant schwannoma is reported. A 48-year-old female came to our hospital with the chief complaints of fever and abdominal mass. She had generally spread small skin tumors with cafe au lait spots. Her glandmother, mother and sister had been also pointed out to have von Recklinghausen's disease. Abdominal ultrasonography, computed tomography and angiography showed a huge adrenal tumor 13 cm in diameter and an egg-sized retroperitoneal tumor. The adrenal tumor appeared cystic and was suspected of abscess formation due to infection. As laboratory examinations revealed no endocrinological activity of the adrenal tumor, both tumors were resected without any preoperative treatments. The removed adrenal tumor measured 13×15×13 cm and weighed 649 g. The center of the tumor was necrotic and contained brownish pus. The retroperitoneal tumor measured 5×5×3 cm and was yellow in color. The histological examination revealed malignant pheochromocytoma and malignant schwannoma, respectively. The patient is well at present, one and half year after operation.

TWO CASES OF NON-FUNCTIONING LANGERHANS ISLET CARCINOMA

Case 1. A 16-year-old woman, with the chief complaint of fever, was diagnosed as having an upper abdominal tumor by CT, ultrasonic examination and angiogaphy, and was operated on. The primary location of the tumor was at the pancreatic tail with a diameter of approximately 10 cm. The lesion was surrounded by the stomach, mesentery and spleen especially being tightly adhered to the stomach wall. The tumor was capsulated with necrotizing contents in it. Pancreatectomy, including the tumor, was performed at the distal and the lateral portions.Case 2. A 62-year-old man, an outpatient of the Department of the Internal Medicine with diabetes and hypertension, was suspected of having a neoplasm of the pancreas. The patient, without any complaints, was diagnosed to have a pancreatic carcinoma by detailed examinations and was operated on. The carcinoma existed at the pancreatic body with partially calcificated solid lesion. It showed neither infiltration to the other organs nor metastasis to the liver and lymph node. Histopathologically it was a non-functioning carcinoma of the Langerhans islet.

A CASE OF SPLENIC ABSCESS UNKOWN ORIGIN

A case of splenic abscess, an extremely rare condition, is reported with a review of the literature. The patient, a 71-year-old man was admitted to our hospital with the chief complaints of fever and chills. There was no abdominal pain or tenderness. Soon after admission antibiotics were given, but fever did not subside. Two days after admission ultrasonography was done to detect abscess of the abdominal cavity. Ultrasonography revealed multiple hypoechoic areas in the spleen, but not in the liver, resulting in a diagnosis of splenic abscess. On the 8th day after admission splenectomy was carried out and antibiotics were given. The postoperative course was smooth and the patient discharged with no abdominal symptons.

Psychology of the scientist: LVII. Can humanity theory contribute to our understanding of medical problem-solving?

Maslow's humanistic model of cognition would suggest that the most thoughtful physicians have acquired more than conceptual skills; they also have learned to get a direct, preconceptual sense of how the patient is feeling through personal interactions with the patient. To explore this possibility, we asked 5 highly regarded attending pediatricians, as well as some pediatricians still in training (14 interns and 9 residents), to report all their thoughts and feelings as they conducted their usual evaluations of children under the age of two years brought to an emergency room with a chief complaint of fever. The findings generally indicated that the attending physicians did make the greatest effort to form preconceptual impressions of the children through warm and personal interactions with them. A second, questionnaire study indicated that as students and physicians-in-training gain experience, they increasingly appreciate the preconceptual, interpersonal approach of the advanced attending pediatrician.