SCA practice case · Video consultation
“My ear’s really painful and itchy with some discharge — worse when I touch it. I’ve been using cotton buds”
The candidate brief
This is what you would read in the 3-minute window before the patient connects. Read it once, note two or three hypotheses and one thing you must not miss, then stop.
Patient
Owen Pryce · 45 years · male
Setting
Video consultation, with otoscopy arranged face to face — a painful, discharging, itchy ear.
Past history
- Nil recorded
Medication
- Nil recorded
Allergies
NKDA
Recent notes
No previous ear consultations.
Reason for contact
“Painful, itchy right ear with discharge. Can you sort it?”
Practise this case
The full case is in the Hot Seat with the Gold plan. You get a 12-minute timer, a role-player script with facts released only when asked, examiner checkpoints by the three RCGP domains, a model consultation and the guidance behind it.
What this case tests
Show the learning points (spoiler: read after you have practised)
OTITIS EXTERNA (inflammation of the external ear CANAL) presents with ear PAIN, ITCH and DISCHARGE, PAIN ON MOVING the tragus/pinna, and a blocked/muffled-hearing sensation, with a red, swollen, debris-filled canal; it is provoked by WATER/SWIMMING ("swimmer’s ear"), local TRAUMA (cotton buds), and skin conditions (eczema/seborrhoeic dermatitis/psoriasis). Distinguish it from otitis MEDIA (deeper pain, systemic/febrile especially in children, a bulging/red drum, no tragal tenderness; discharge if the drum perforates), and consider a foreign body, a furuncle, and FUNGAL OE/otomycosis (itch-predominant, fungal debris, may need antifungal drops). Manage uncomplicated OE: adequate ANALGESIA, AURAL TOILET (cleaning/microsuction improves drop delivery), analgesia and local heat first, then topical ACETIC ACID (over 12s) or a TOPICAL antibiotic +/- corticosteroid (similar cure rates at 7 days — UKHSA Summary of antimicrobial prescribing guidance 2025; choice per BNF) rather than systemic antibiotics, avoiding aminoglycoside drops if the drum is perforated or cannot be seen unless the ENT UK criteria are met, keeping the ear DRY (avoid water/swimming during treatment) and using an ear WICK (ENT) if the canal is very swollen; reserve oral flucloxacillin, with referral to exclude necrotising OE, for cellulitis spreading beyond the canal or systemic signs. Advise prevention and technique — STOP cotton buds (they cause trauma and push debris in), keep ears dry, treat underlying skin conditions, and use drops correctly. The critical RED FLAG is MALIGNANT (NECROTISING) OTITIS EXTERNA in a high-risk patient (elderly DIABETIC or immunocompromised): SEVERE, persistent pain (out of proportion, worse at night), copious discharge, GRANULATION tissue in the canal, and/or cranial-nerve involvement (e.g. facial palsy) — a skull-base osteomyelitis that is serious/potentially life-threatening and needs same-day ENT/hospital referral (UK consensus 2023), imaging and IV antibiotics, not routine OE treatment. The skill is correct topical management, advice/technique, and screening the malignant-OE red flags; otoscopy needs a face-to-face appointment.
The guidance behind it
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