A unique presentation of Colovesical fistula.

A colovesical fistula (CVF) is a pathological connection between the colon and the urinary bladder. Although they are uncommon, consequences can severely affect quality of life and mortality. Diverticula are the most common cause of CVF. This case details a patient's CVF diagnosis in the emergency department with unremitting gastrointestinal and urinary symptoms. A 78-year-old male patient with recent hospitalization for stroke and left carotid endarterectomy complicated by urinary retention treated with a Foley catheter presented to the Emergency Department with a chief complaint of hematuria and unremitting diarrhea. Foley exchange resulted in improved urinary retention and diarrhea during hospitalization. One day following hospital discharge, the patient presented again with a blocked Foley catheter and diarrhea. Foley irrigations resulting in near immediate diarrhea and lack of bladder filling on bladder scan portended to a diagnosis of colovesical fistula despite no history diverticula or colon malignancy. An abdominal/pelvic computed tomography scan and cystogram confirmed a colovesical fistula. This case highlights the need for consideration of colovesical fistula in a seemingly simple ED complaint of urinary retention. It is prudent to closely follow bladder scan volumes when flushing a Foley catheter. Given the significant comorbidities such as urosepsis and health care impact of repeat ED visits and hospitalizations, CVF can and should be entertained and rapidly diagnosed in the emergency department. Our case highlights the need for consideration of a vesico-colic fistula despite the absence of initial relevant risk factors.

Acute sphenoid sinusitis induced blindness: a case report.

BACKGROUND: Acute, isolated sphenoid sinusitis is a rare but potentially devastating clinical entity. Missing this diagnosis can lead to permanent vision loss due to injury of the optic nerve. Patients may present with preseptal inflammation, lid edema, chemosis, or ophthalmoplegia. OBJECTIVE: We report a case of acute sphenoid sinusitis in a 10-year-old child who presented to the Emergency Department with essentially painless vision loss. CASE REPORT: Previously healthy, the patient reported progressive decrease in vision in her right eye for the 5 days prior. Other than blurred vision in the right eye, she complained of a mild frontal headache and right eye irritation the past week, which had abated. On examination, she was reading a book with her head tilted to one side. She had no photophobia, or facial or eyelid swelling. Her pupils were 5 mm bilaterally, but the right was non-reactive to light. She was unable to see two fingers 6 inches in front of her face (right eye), whereas her visual acuity on the left was 20/25. She had bilateral elevated intraocular pressures and a Marcus Gunn pupil on the right. Ophthalmology was consulted and the diagnosis of acute sphenoid sinusitis causing compression and vascular compromise to the optic nerve was diagnosed ultimately by magnetic resonance imaging. The patient was transferred to the nearest pediatric specialty hospital, where an emergent endoscopic sphenoidotomy was performed. The patient's vision subsequently returned. CONCLUSION: Sphenoid sinusitis should be considered in patients presenting with acute vision loss. Awareness, early diagnosis, and intervention help prevent permanent complications.

A Case of Bedside Ultrasound in COVID-19 to Prognosticate Functional Lung Recovery.

Introduction. The fight against COVID-19 poses questions as to the clinical presentation, course, diagnosis, and treatment of the condition. This case study presents a patient infected with COVID-19 and suggests with additional research, that bedside ultrasound may be used to diagnose severity of disease and potentially, prognosticate functional lung recovery without using unnecessary resources and exposing additional healthcare professionals to infection. Case Report. A 46-year-old male presented to the emergency department (ED) with cough, fever, and shortness of breath. Chest X-ray showed patchy airspace opacities bilaterally. Rapid testing resulted positive for SARS-CoV-2. Bedside ultrasound showed abnormal lung parenchyma, with diffuse comet tail artifacts, consistent with interstitial pulmonary edema. Following a prolonged intubation, patient's abnormal lung ultrasound findings are resolved.

Patient safety: make it a priority for your organization!

Ten years have passed since the lnstitute of Medicine released its landmark report To Err is Human-Building a Safer Health System. Creating public awareness that tens of thousands of Americans were dying every year because of medical errors led to the establishment of multiple agencies and efforts to address this problem. Research on patient safety had originally focused on systems within the hospital setting, and now more attention is directed toward studying processes in the ambulatory setting (e.g., physician practices). This article reviews the research and other tools that are available to help leaders, executives, and providers create safer systems of care for patients seen throughout the physician practice environment.

Funding your EMR: how to get the money you need.

Many practices today are considering the purchase of an electronic medical record (EMR) system. "When should we get one? Are we ready for this type of technology in our practice? How will the physicians feel about it? How about the staff? How will it change our work flow? And most of all, who is going to pay for it?" are common questions that arise. In fact, funding the EMR is the number one reason most practices delay the decision to move forward with this type of technology in the office.

Gender Differences in CDC Guideline Compliance for STIs in Emergency Departments.

INTRODUCTION: Sexually transmitted infections (STIs) are a common reason for emergency department (ED) visits. The objective of this study was to determine if there were gender differences in adherence to Centers for Disease Control and Prevention (CDC) STI diagnosis and treatment guidelines, as documented by emergency providers. METHODS: We performed a retrospective chart review to identify patients treated for urethritis, cervicitis, and pelvic inflammatory disease (PID) in the EDs of three hospitals in a Pennsylvania network during a calendar year. Cases were reviewed to assess for compliance with CDC guidelines. We used descriptive statistics to assess the distributions of study variables by patient sex. In the analysis we used Student's t-tests, chi-square tests, and logistic regression. Statistical significance was set at p ≤ 0.05. RESULTS: We identified 286 patient records. Of these, we excluded 39 for the following reasons: incorrect disease coding; the patient was admitted and treated as an inpatient for his/her disease; or the patient left the ED after refusing care. Of the 247 participants, 159 (64.4%) were female. Females were significantly younger (26.6 years, SD=8.0) than males (31.2, SD=11.5%), (95% confidence interval [CI] [2.0- 7.0], p=0.0003). All of the males (n=88) in the cohort presented with urethritis; 25.8% of females presented with cervicitis, and 74.2% with PID. Physician compliance for the five CDC criteria ranged from 68.8% for patient history to 93.5% for patient diagnostic testing, including urine pregnancy and gonorrhea/chlamydia cultures. We observed significant differences by patient sex. Fifty-four percent of the charts had symptoms recorded for female patients that were consistent with CDC characteristics for diagnostic criteria compared to over 95% for males, OR=16.9; 95% CI [5.9-48.4], p<0.001. Similar results were observed for patient discharge instructions, with physicians completely documenting delivery of discharge instructions to 51.6% of females compared to 97.7% of complete documentation in males, OR=42.3; 95% CI [10.0-178.6] p<0.001). We observed no significant sex differences in physician documentation for physical exam or for therapeutic antibiotic treatment. CONCLUSION: This retrospective study found patient gender differences in how emergency providers complied with documenting with regard to the 2010 CDC guidelines for the diagnosis and treatment of urethritis, cervicitis, and PID. Specifically medical records of men were more likely to have complete documentation of symptoms recorded (95% CI 5.9-48.4) and to have discharge instruction documentation (95% CI 10.0-178.6) than records of women.

Research priorities for the influence of gender on diagnostic imaging choices in the emergency department setting.

Diagnostic imaging is a cornerstone of patient evaluation in the acute care setting, but little effort has been devoted to understanding the appropriate influence of sex and gender on imaging choices. This article provides background on this issue and a description of the working group and consensus findings reached during the diagnostic imaging breakout session at the 2014 Academic Emergency Medicine consensus conference "Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes." Our goal was to determine research priorities for how sex and gender may (or should) affect imaging choices in the acute care setting. Prior to the conference, the working group identified five areas for discussion regarding the research agenda in sex- and gender-based imaging using literature review and expert consensus. The nominal group technique was used to identify areas for discussion for common presenting complaints to the emergency department where ionizing radiation is often used for diagnosis: suspected pulmonary embolism, suspected kidney stone, lower abdominal pain with a concern for appendicitis, and chest pain concerning for coronary artery disease. The role of sex- and gender-based shared decision-making in diagnostic imaging decisions is also raised.