Master CPS - Dermatology/ENT/Eyes
for MSRA

Core Concepts

This section covers common presentations and high-yield conditions across Dermatology, ENT, and Eyes. Key principles include distinguishing inflammatory from infective causes, identifying 'red flags' for urgent referral, and understanding first-line management for benign conditions. Consider age, associated symptoms, and systemic involvement.

Clinical Presentation

• Dermatology:
  • Eczema (Atopic): Pruritic, erythematous, dry, scaly patches, often flexural; lichenification in chronic cases.
  • Psoriasis: Well-demarcated erythematous plaques with silvery scales, typically on extensor surfaces (elbows, knees, scalp). May have nail pitting, onycholysis.
  • Acne Vulgaris: Comedones (blackheads/whiteheads), papules, pustules, nodules, cysts on face, chest, back.
  • Rosacea: Facial flushing, persistent erythema, papules, pustules, telangiectasia; no comedones. Triggers: heat, alcohol, spicy foods.
  • Urticaria: Evanescent, intensely pruritic wheals (hives) with surrounding erythema, lasting <24 hours in any one spot.
  • Cellulitis: Spreading erythematous, warm, tender, oedematous area of skin, often with systemic symptoms (fever, malaise). Usually unilateral.
  • Fungal (Tinea): Annular, erythematous, scaly patch with central clearing and raised border. Pruritic.
  • Scabies: Intense nocturnal pruritus, burrows (web spaces, wrists, ankles), papules. Affects close contacts.
  • Melanoma: New or changing mole following ABCDE criteria: Asymmetry, irregular Border, varied Colour, Diameter >6mm, Evolving.
• ENT:
  • Otitis Media (Acute): Otalgia, fever, hearing loss, bulging/erythematous tympanic membrane (TM).
  • Otitis Externa: Ear pain (exacerbated by tragal/pinna movement), discharge, hearing loss, inflamed ear canal.
  • Tonsillitis/Pharyngitis: Sore throat, dysphagia, fever, often exudates on tonsils, tender cervical lymphadenopathy.
  • Sinusitis (Acute Bacterial): Facial pain/pressure (worse on bending), nasal congestion, purulent discharge, reduced smell, lasting >10 days or worsening after initial improvement.
  • Epistaxis: Anterior (Little's area) most common; unilateral nosebleed.
  • Peritonsillar Abscess (Quinsy): Severe unilateral sore throat, dysphagia, trismus (difficulty opening mouth), "hot potato" voice, uvula deviation away from affected side.
  • Laryngitis: Hoarseness or aphonia (loss of voice), usually viral, acute.
• Eyes:
  • Conjunctivitis (Bacterial/Viral/Allergic): Red eye, discharge (purulent/watery), irritation/itchiness (allergic). Vision usually normal, pupil reactive.
  • Keratitis (Corneal Ulcer): Pain, photophobia, reduced vision, red eye (ciliary injection), corneal opacity/defect (can be subtle). Contact lens wearers at higher risk.
  • Acute Angle Closure Glaucoma (AACG): Sudden onset severe pain, red eye (ciliary flush), blurred vision, haloes, fixed mid-dilated pupil, hard globe on palpation, nausea/vomiting.
  • Retinal Detachment: Sudden, painless vision loss (curtain falling across vision), flashes (photopsia), floaters.
  • Amaurosis Fugax: Transient monocular vision loss ("curtain coming down"), brief, resolves completely. TIA of the eye.
  • Central Retinal Artery Occlusion (CRAO): Sudden, profound, painless monocular vision loss. Fundoscopy: 'cherry red spot' macula.
  • Central Retinal Vein Occlusion (CRVO): Sudden, painless, monocular vision loss (less profound than CRAO). Fundoscopy: 'blood and thunder' appearance (diffuse retinal haemorrhages).
  • Anterior Uveitis: Pain, photophobia, blurred vision, ciliary flush, small/irregular pupil (synechiae).
  • Corneal Abrasion: Severe pain, foreign body sensation, photophobia, tearing. History of trauma or contact lens wear.
  • Orbital Cellulitis: Painful, swollen eyelids, proptosis (eyeball bulging), restricted and painful eye movements, reduced vision, systemic signs (fever).

Diagnosis (Gold Standard)

For most dermatological and ENT conditions, diagnosis is clinical. Specific tests include: skin scrape/microscopy for fungal infections or scabies; throat swab for bacterial tonsillitis (rarely done in primary care); otoscopy for ear conditions; flexible nasendoscopy for persistent hoarseness or unilateral ear/nasal symptoms in adults. Ophthalmic conditions often require specialist assessment: visual acuity testing, slit lamp examination (keratitis, uveitis, glaucoma), tonometry (glaucoma), fundoscopy (retinal detachment, CRAO/CRVO, diabetic retinopathy).

Management (First Line)

• Dermatology:
  • Eczema: Emollients (first-line), topical corticosteroids (potency based on site/severity).
  • Psoriasis: Topical corticosteroids, topical Vitamin D analogues (calcipotriol).
  • Acne Vulgaris: Topical retinoids (adapalene), benzoyl peroxide, topical antibiotics (clindamycin). Oral antibiotics (tetracyclines) for moderate/severe.
  • Rosacea: Topical metronidazole, oral tetracyclines. Avoid triggers.
  • Urticaria: Oral antihistamines (e.g., cetirizine, loratadine).
  • Cellulitis: Oral antibiotics (flucloxacillin; clindamycin or doxycycline if penicillin allergic). IV if severe/systemic.
  • Fungal (Tinea): Topical antifungals (clotrimazole, terbinafine cream). Oral antifungals (terbinafine) for extensive or scalp involvement.
  • Scabies: Permethrin 5% cream (neck down, repeat 1 week later). Treat close contacts.
  • Melanoma: Urgent excisional biopsy with appropriate margins.
• ENT:
  • Otitis Media (Acute): Analgesia (paracetamol/ibuprofen). Watchful waiting for 48-72 hours. Antibiotics (amoxicillin) for severe pain, young children (<2), bilateral, or persistent symptoms.
  • Otitis Externa: Topical ear drops (antibiotic +/- steroid, e.g., Fucidic acid, Ofloxacin).
  • Tonsillitis/Pharyngitis: Analgesia. Antibiotics (penicillin V) if bacterial (e.g., Centor score guidance, or severe).
  • Sinusitis (Acute): Analgesia, nasal saline irrigation, intranasal corticosteroids. Antibiotics (amoxicillin) for severe, persistent (>10 days) or worsening symptoms.
  • Epistaxis: Lean forward, pinch soft part of nose for 10-15 minutes. Topical nasal decongestants (xylometazoline) or cautery/packing by ENT for persistent.
  • Peritonsillar Abscess (Quinsy): Emergency ENT referral for IV antibiotics and aspiration/drainage.
  • Laryngitis: Voice rest, hydration.
• Eyes:
  • Bacterial Conjunctivitis: Topical antibiotics (chloramphenicol eye drops/ointment).
  • Viral Conjunctivitis: Supportive care, cool compresses.
  • Allergic Conjunctivitis: Topical antihistamine eye drops (e.g., olopatadine), oral antihistamines.
  • Keratitis: Urgent ophthalmology referral (topical antibiotics/antivirals/antifungals depending on cause).
  • AACG: Emergency ophthalmology referral. Topical drops (pilocarpine, timolol), systemic acetazolamide.
  • Retinal Detachment: Emergency ophthalmology referral for surgical repair.
  • Amaurosis Fugax: Urgent TIA/stroke workup (carotid Doppler, ECG).
  • CRAO/CRVO: Emergency ophthalmology referral.
  • Anterior Uveitis: Urgent ophthalmology referral. Topical corticosteroids, cycloplegics (dilate pupil, relieve ciliary spasm).
  • Corneal Abrasion: Topical antibiotic eye drops (chloramphenicol), analgesia. Usually heals rapidly.
  • Orbital Cellulitis: Emergency ophthalmology referral, IV antibiotics.