Master Eye & ENT
for PMDC NLE Step 1

What the PMDC NLE Step 1 Tests in Eye & ENT

The PMDC NLE Step 1 Eye & ENT section tests your ability to diagnose and manage common presentations: red eye, sudden vision loss, hearing loss, vertigo, and epistaxis. You must differentiate between medical emergencies (e.g., acute angle-closure glaucoma, orbital cellulitis, temporal arteritis, epiglottitis) and benign conditions (e.g., conjunctivitis, presbycusis, BPPV). Questions require knowledge of diagnostic criteria (e.g., Snellen chart values, Rinne/Weber test interpretation, tuning fork frequencies), first-line pharmacotherapy (e.g., topical antibiotics, systemic antivirals, intranasal corticosteroids), and indications for surgical referral (e.g., tonsillectomy criteria, myringotomy). You must also recognize red flags: sudden painless vision loss, diplopia, stridor, unilateral hearing loss, and vertigo with neurological signs. Emphasis is on clinical decision-making, not rare syndromes.

High-Yield Concepts

• Acute Angle-Closure Glaucoma: Presents with sudden severe eye pain, red eye, blurred vision, halos around lights, and a fixed, mid-dilated pupil. Intraocular pressure (IOP) > 21 mmHg (often >40). Emergency treatment: immediate acetazolamide 500 mg IV/PO, topical pilocarpine 2%, and topical beta-blocker (e.g., timolol). Definitive management: laser peripheral iridotomy.
• Central Retinal Artery Occlusion (CRAO): Sudden, painless, profound vision loss in one eye. Fundoscopy: cherry-red spot at fovea with pale retina. Ocular emergency: immediate ocular massage, acetazolamide, and reduction of IOP to dislodge embolus. Must rule out giant cell arteritis (check ESR/CRP) and arrange urgent stroke workup.
• Otitis Media with Effusion (OME): Common in children; presents with hearing loss, no pain/fever. Diagnosis: tympanometry shows flat curve (type B). Management: watchful waiting for 3 months; if bilateral hearing loss >25 dB persists, consider grommet insertion. Adenoidectomy if nasal obstruction present.
• Benign Paroxysmal Positional Vertigo (BPPV): Brief (<1 minute) episodes of vertigo triggered by head movement, with nystagmus on Dix-Hallpike test. Diagnosis is clinical. Treatment: Epley manoeuvre (canalith repositioning). Avoid vestibular suppressants; they delay central compensation.
• Acute Epiglottitis: Presents with severe sore throat, drooling, muffled voice, stridor, and tripod positioning. Do NOT examine the throat or attempt intubation in a child; this can precipitate complete airway obstruction. Emergency: call anaesthesia, give IV dexamethasone 0.15 mg/kg, IV ceftriaxone 50 mg/kg, and prepare for urgent airway management.
• Tonsillectomy Criteria (Paradise Criteria): Indicated for recurrent acute tonsillitis: ≥7 episodes in the past year, OR ≥5 episodes/year for 2 years, OR ≥3 episodes/year for 3 years. Each episode must be documented with fever >38.3°C, cervical lymphadenopathy, tonsillar exudate, or positive GAS culture.
• Giant Cell Arteritis (Temporal Arteritis): Suspect in patients >50 years with new headache, jaw claudication, scalp tenderness, and elevated ESR (>50 mm/hr) or CRP. Urgent high-dose prednisolone (40-60 mg/day) to prevent blindness. Confirm with temporal artery biopsy within 1 week of starting steroids.
• Presbycusis and Hearing Loss Workup: Age-related sensorineural hearing loss, typically high-frequency (>2 kHz). Rinne test: AC > BC (normal). Weber test: lateralizes to better ear. First-line: hearing aids. Differentiate from conductive loss (Rinne: BC > AC; Weber lateralizes to worse ear). Audiometry required for asymmetry >15 dB to rule out acoustic neuroma.

Common Traps in Eye & ENT Questions

• Do not use topical steroids for a red eye until you have ruled out corneal ulceration (use fluorescein staining first).
• In acute vertigo, do not treat BPPV with vestibular suppressants (e.g., prochlorperazine) — they delay central compensation; use the Epley manoeuvre instead.
• Do not prescribe topical antibiotics for viral conjunctivitis — it is self-limiting; reserve for bacterial cases with purulent discharge.
• In a child with stridor and drooling, do not attempt to visualize the throat or use a tongue depressor — this may trigger complete airway obstruction in epiglottitis.
• Do not assume sudden sensorineural hearing loss is idiopathic without checking for acoustic neuroma (MRI internal auditory meatus) if unilateral or asymmetric.
• Do not give oral steroids for acute angle-closure glaucoma without first lowering IOP with acetazolamide — this can worsen the condition.

How to Revise Eye & ENT for the PMDC NLE Step 1

Prioritize high-acuity presentations: red eye (differentiate conjunctivitis, iritis, acute glaucoma), sudden vision loss (CRAO, retinal detachment, optic neuritis), and vertigo (BPPV vs. vestibular neuritis vs. central causes). Practice interpreting tuning fork tests, Snellen chart values, and tympanometry curves. Questions often present a clinical vignette with a single key feature (e.g., 'fixed mid-dilated pupil' = angle-closure glaucoma; 'cherry-red spot' = CRAO). Memorize first-line drugs and dosages for emergencies (acetazolamide, ceftriaxone, dexamethasone). For ENT, focus on tonsillectomy criteria, epiglottitis management, and epistaxis control (anterior vs. posterior packing). Use practice questions that require you to choose the next best step in management, not just the diagnosis.

Practise it: MedLumen has 50 Eye & ENT questions for the PMDC NLE Step 1, each with a full explanation and references.