Below I have written some ‘single best answer’ questions (SBA). I don’t think that I have done these with you before so I will explain how to answer them. SBAs are useful because they make you think more like a doctor. Doctors collect symptoms and signs and must try to decide what is the most likely diagnosis for the patient.

 

An SBA consists of a clinical scenario and five possible diagnoses. All that you need to do is to read the case scenario and decide which of the five diagnoses is most likely. A lot of the diagnoses may seem to fit the scenario but only one of them will be the best fit. I will give an example.

 

Example SBA:

 

A 40-year-old man presents with a sore throat. He has had it for two months. There is no hoarseness in his voice, he can swallow normally and he has not lost weight. He does have pain radiating to his right ear when he swallows. He is a smoker. Your examination shows a normal oropharynx but there is a hard 4 by 5 cm lump beneath his mandible on the right side. The lump is not tender.

 

Which of the following diagnoses is most likely to be correct?

 

1. Tonsillitis

2. Chronic pharyngitis

3. Thyroid cancer

4. Tonsillar cancer

5. Pharyngeal cancer

 

The single best answer for this question is 5 – pharyngeal cancer. It is not likely to be tonsillitis because the neck node is not tender and his oropharynx is normal. Chronic pharyngitis is possible but the examination is normal and hard neck lumps usually mean a cancer. Chronic pharyngitis does not cause referred otalgia. Thyroid cancer is possible, too, but the neck lump is not in the thyroid, it is much higher in the neck and is probably in a lymph node. Tonsil cancer would also fit but the tonsil looks normal. So it must be pharyngeal cancer.

 

He has two red flag symptoms (smoking and referred otalgia) and the neck lump is not inflamed. This makes pharyngeal cancer the most likely diagnosis.

 

If this is not clear you must check with me before you start the next examples. There will be diseases and signs that you are not familiar with through my teaching. I have placed an * next to these because you will need to look up the symptoms of these diseases before you can answer the question. Good luck!

 

 

Question 1.

 

A 40-year-old man has a sore throat. It has been there for five months and is not getting better. He has a hoarse voice and smokes 30 cigarettes every day. He is not losing weight but has coughed up a little fresh blood in the last few weeks. He can swallow normally. Examination finds a normal oral cavity and oropharynx. His neck is also normal to palpation.

 

Which of the following diagnoses is most likely?

 

1. Chronic pharyngitis

2. Tonsillitis

3. Pharyngeal cancer

4. Acute laryngitis*

5. Laryngeal cancer

 

 

Question 2.

 

An eight-year-old girl comes to see you. She has had a sore throat for three days and is feeling unwell. She has tender neck nodes on both sides under her jaw. Oropharyngeal examination finds swellings in both tonsils and this is symmetrical. They are red and are covered with pus. She has an elevated temperature.

 

What is the most likely diagnosis?

 

1. Quinsy

2. Chronic pharyngitis

3. Acute pharyngitis

4. Tonsil cancer

5. Tonsillitis

 

 

Question 3.

 

A 14-year-old boy comes to see you. He has had a severe sore throat for four days and is feeling unwell. He can swallow food and fluids but it is painful to do so. Examination finds a mild fever, multiple small tender neck lymph nodes and a large tonsil on the right side. The left tonsil is inflamed but a normal size. He has trismus* and his uvula is pushed to the left.

 

Which is the most likely diagnosis?

 

1. Acute tonsillitis

2. Quinsy

3. Glandular fever*

4. Acute pharyngitis

5. Tonsil cancer

 

Question 4.

​

A 30-year-old man comes to you complaining of sore throat. He has had it for many months and it is not getting better. He has tried an antibiotic but this did not help. He is a smoker. He does not have a fever and he can eat and drink normally. He has no hoarseness. Examination finds a red oropharynx but his tonsils are normal. He has no neck nodes.

 

Which is the most likely diagnosis?

 

1. Tonsillitis

2. Acute pharyngitis

3. Pharyngeal cancer

4. Chronic pharyngitis

5. Laryngeal cancer