BMJ 2011: 342: 557 – 606 (12th March)

If a patient’s ear discharge doesn’t seem to be clearing up satisfactorily with the usual otitis externa treatment, or if it’s very recurrent and you can’t get a good look at the eardrum, consider whether the problem might actually be cholesteatoma.  Likewise with other ear symptoms – hearing loss, earache, vertigo, or tinnitus.  Likewise with facial palsy – always check the eardrum on that side.  Cholesteatoma is most common in the 5 – 15 age group, but can occur at any age and you don’t want to miss it.  If you can’t get a good look at the eardrum to exclude it, refer to ENT as ‘soon’ (within few weeks), although if facial palsy or other neurological symptoms/signs are present the referral should be urgent.

In hyponatraemic patients, examine to look for signs of hypervolaemia or hypovolaemia (peripheral oedema/raised JVP, or postural hypotension).  It will affect your differential diagnosis.  Also, check the chest and heart, and look for signs of severe hypothyroidism, which is a rare possible cause.

And, if anyone tries to get you to refer a patient with a leg ulcer for ultrasound therapy, decline.  The evidence base is very poor and has just been thrown into major doubt by a rather better-quality study that showed it to be ineffective.

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About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in Clinical biochemistry, ENT. Bookmark the permalink.

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