382.A 4-year-old boy is brought to the ED by his mother with a com-
plaint of ear pain since last night. The patient also complains of mild con-
gestion and cough. He has normal oral intake, activity, and urine output.
On examination, the patient is alert, interactive and playful. His tempera-
ture is 100.6°F, HR 128 beats per minute, RR 26 breaths per minute, and
pulse oxymetry is 98% on room air. His right tympanic membrane has
slight erythema with several bubbles of clear fluid noted inferiorly. His left
tympanic membrane is erythematous and bulging with opaque, purulent
fluid noted. There is no neck stiffness, mastoid tenderness, or difficulty
breathing. The patient has a primary-care physician who they see regularly.
Which of the following is the best treatment for this patient?
a. Analgesics only
b. A third-generation cephalosporin
c. Amoxicillin 40 to 50 mg/kg/day
d. Treatment with analgesics initially and consideration of oral high dose amoxi-
cillin in 48 to 72 hours if no resolution of symptoms
e. No treatment is needed for this viral illness
383.A 3-week-old girl is brought to the ED by her parents after they noticed
blood in her stool. The patient is the full-term product of an uncomplicated
pregnancy and delivery without any medical issues up to this point. She has
been feeding well (breastfeeding primarily) and active without fever, respira-
tory problems, or fussiness. She has had several episodes of nonforceful, non-
bilious emesis after feeds with multiple wet diapers each day. She normally has
several soft, seedy stools. In the last day, the parents noticed streaks of blood
in her stool and today she had grossly bloody stool. The patient does not seem
to be in any distress or discomfort. On examination, the temperature is 98.9°F,
HR 155 beats per minute, and RR 44 breaths per minute. The patient is
awake, active and in no apparent distress. Her abdomen is soft and nontender
with normal bowel sounds and no masses. Examination of her anus does not
reveal a fissure. Which of the following is the most likely diagnosis?
a. Acute gastroenteritis
b. Milk protein colitis
c. Clostridium difficilecolitis
d. Intestinal malrotation
e. Necrotizing enterocolitis
408 Emergency Medicine