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.