Family medicine
Sore Throat
Sore throat is a painful inflammation of the pharynx, most commonly caused by viral or bacterial infections, resulting in odynophagia and pharyngeal erythema.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Viral pharyngitis / URTI | Cough + coryza + low-grade fever + no exudate [1][2] | 「有冇咳？流鼻水？」 Coryzal Sx present → viral |
| GAS pharyngitis | Centor ≥3: fever, exudate, tender anterior LN, NO cough [1] | 「有冇發燒、喉嚨有白嘢、頸淋巴腫痛、冇咳？」 | |
| Serious Not To Miss | Peritonsillar abscess (quinsy) | Unilateral tonsillar swelling + trismus + uvula deviation [3] | 「張口開唔開到？有冇一邊特別腫？」 |
| Acute epiglottitis | 4D: Dysphagia, Dysphonia, Drooling, Distress; rapid onset [4] | 「有冇流口水？透唔到氣？」 — Medical emergency | |
| NPC (Nasopharyngeal carcinoma) | Blood-stained post-nasal drip + unilateral OME + neck mass, Chinese male [5] | 「有冇流鼻血？耳仔塞住？」 | |
| Deep neck space infection / Ludwig angina | Floor of mouth swelling, bilateral submandibular, airway compromise | 「舌底有冇腫起嚟？」 | |
| Acute rheumatic fever | Sore throat 2–3w prior → joint pain + carditis + rash (Jones criteria) [8] | 「之前喉嚨痛之後有冇關節痛或者心跳快？」 | |
| Pitfalls | Infectious mononucleosis (EBV) | Prolonged fatigue + posterior cervical LN + splenomegaly + atypical lymphocytes [9] | 「攰咗幾耐？後面頸有冇淋巴腫？」 |
| Gonococcal pharyngitis | Hx oral sex + pharyngeal exudate [7] | 「有冇口交嘅性行為？」 | |
| Agranulocytosis (drug-induced) | Taking carbimazole/clozapine + sore throat + ulcers + ↓WBC | 「有冇食緊甲亢藥或者精神科藥？」 | |
| Masquerades | GERD | Chronic sore throat + heartburn + worse lying down [10] | 「有冇胃酸倒流、夜晚瞓低會覺得個喉嚨痛啲？」 |
| Thyroiditis (subacute / De Quervain) | Tender thyroid + preceding viral illness + ↑ESR | 「頸前面（甲狀腺位置）有冇腫痛？」 | |
| Depression / Anxiety (somatisation) | Globus sensation, no organic findings, mood symptoms | 「心情點呀？有冇覺得個喉嚨好似有嘢頂住？」 | |
| Trying to Tell Me Something? | Fear of cancer (NPC) | Chinese patient with FHx or friend dx NPC | 「你係咪擔心會唔會係癌症？」 |
| Wants sick leave / Abx | Asks directly for MC or medication | 「你係咪需要病假紙？」 | |
| Stress / school-work pressure | Recurrent sore throat + stress + sleep deprivation | 「最近壓力大唔大？瞓得夠唔夠？」 |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生，今日由我幫你睇症。你可以叫我X醫生。請問點稱呼你？」「今日咩事嚟睇醫生呀？」 | Interpersonal marks: greeting, using patient's name, open question |
| 0:30–2:00 | HPI – symptom analysis (onset, duration, severity, associated Sx, red flags) | 「喉嚨痛咗幾耐？」「有冇發燒？」「有冇咳？」「有冇流鼻水？」「吞嘢嗰陣痛唔痛？」「有冇面/頸腫咗？」 | Core history marks; Centor criteria elements |
| 2:00–3:00 | ICE – Ideas, Concerns, Expectations + hidden agenda | 「你自己覺得可能係咩事？」(Idea)「你最擔心啲咩？」(Concern)「你今日最想我幫你做啲咩？」(Expectation)「有冇咩特別原因今日先嚟睇？」(Hidden agenda) | ICE is directly tested in Case Report Form; hidden agenda often = reason for consultation |
| 3:00–4:00 | Targeted review / Red flags / PMH / Drug / Allergy / Social | 「有冇食過任何藥？」「之前有冇長期病患？」「有冇藥物敏感？」「你做咩工作？」「有冇食煙飲酒？」「屋企人有冇人病？」 | Completeness marks for PMH, DH, SH |
| 4:00–4:30 | Functional impact & psychosocial screen | 「喉嚨痛有冇影響到你返工/返學？」「瞓得好唔好？」「壓力大唔大？」 | Biopsychosocial problems |
| 4:30–5:15 | Signpost → brief physical exam if allowed / summarise | 「聽完你講，等我整理一下…」「我想睇下你個喉嚨同頸，可唔可以？」 | Signposting + permission = interpersonal marks |
| 5:15–6:00 | Summarise back, safety-net, close | 「我覺得最有可能係…我會幫你做/開…」「如果燒唔退，或者吞嘢愈嚟愈痛、透唔到氣，你要即刻返嚟急症室。」「仲有冇嘢想問？」 | Closing with empathy + safety net = strong finish |
Uncovering the hidden agenda: "Why today?" is key. A patient with sore throat may come because they fear cancer (NPC if Chinese/HK context), need a sick note, worry about spread to family, or want antibiotics. Ask: 「其實今日嚟，係咪有啲特別嘢擔心緊？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | When did the sore throat start? | 「喉嚨痛咗幾耐？幾時開始？」 | Acute ( < 2w) vs chronic; guides DDx | Acute → viral/GAS; Chronic → NPC, GERD, malignancy |
| Severity | How bad is the pain? Can you swallow? | 「痛到咩程度？吞口水痛唔痛？食到嘢嗎？」 | Odynophagia / dysphagia → peritonsillar abscess, epiglottitis | Severe dysphagia → abscess / epiglottitis |
| Fever | Any fever? | 「有冇發燒？」 | Centor criterion [1]; differentiates bacterial vs viral | Fever → GAS, EBV, peritonsillar abscess |
| Cough | Any cough? | 「有冇咳？」 | Absence of cough = Centor criterion [1]; cough suggests viral | Cough present → viral URTI likely |
| Runny nose / coryzal Sx | Runny nose, sneezing, blocked nose? | 「有冇流鼻水、打乞嗤、鼻塞？」 | Coryzal Sx favour viral pharyngitis [2] | Yes → viral URTI |
| Tonsillar exudate | Has a doctor seen white patches on your tonsils? | 「有冇人睇過你個喉嚨有冇白色嘢？」 | Centor criterion – exudate [1] | Exudate → GAS, EBV |
| Neck lumps | Any swollen glands on your neck? | 「頸有冇腫咗、有冇摸到粒嘢？」 | Tender anterior cervical adenopathy = Centor criterion [1]; also NPC | Tender = GAS/viral; hard, painless = NPC/lymphoma |
| Voice change | Any change in voice / muffled voice? | 「把聲有冇變咗？有冇好似含住嘢咁講嘢？」 | Hot-potato voice → peritonsillar abscess [3]; hoarseness → laryngeal CA | Muffled → abscess; hoarse → laryngeal pathology |
| Trismus | Can you open your mouth fully? | 「你張口開唔開到盡？」 | Trismus = key sign of peritonsillar abscess [3] | Trismus → peritonsillar abscess |
| Drooling / stridor | Any drooling or difficulty breathing? | 「有冇流口水或者透唔到氣？」 | Airway compromise → epiglottitis (urgent) [4] | 4D (Dysphagia, Dysphonia, Drooling, Distress) → epiglottitis |
| Rash | Any rash? | 「身上有冇出疹？」 | Scarlatiniform rash → scarlet fever; maculopapular → EBV (esp. if given amoxicillin) | Rash → scarlet fever / EBV |
| Ear pain | Any ear pain? | 「有冇耳仔痛？」 | Referred otalgia from tonsillitis, peritonsillar abscess, NPC [3] | Otalgia → think NPC if unilateral + Chinese adult |
| Nasal/aural Sx | Any bloody nose, blocked ear, hearing loss? | 「有冇流鼻血？耳仔有冇塞住、聽嘢唔清楚？」 | Epistaxis + unilateral OME + neck mass → NPC [5] | NPC – must not miss in HK context |
| Contact / travel | Anyone around you sick? Any travel? | 「屋企或者公司有冇人病？最近有冇去旅行？」 | TOCC – epidemiological link; cluster → influenza [6] | Cluster → influenza; travel → diphtheria/COVID |
| Weight loss / fatigue | Any weight loss or persistent fatigue? | 「有冇消瘦？成日好攰？」 | B symptoms → lymphoma; prolonged fatigue → EBV | Wt loss → malignancy; fatigue weeks → EBV/mono |
| Sexual Hx | (If appropriate) Any new sexual contacts? Oral sex? | 「（如果適合問）最近有冇新嘅性伴侶？有冇口交？」 | Gonococcal pharyngitis [7]; syphilis; HIV seroconversion | STI-related pharyngitis |
| PMH | Any chronic diseases? Diabetes? Immune problems? | 「有冇長期病患？糖尿病？免疫力問題？」 | Immunocompromised → atypical infections | Deeper neck space infection, fungal |
| Drug Hx | Taking any medication? Antibiotics already? | 「有冇食緊藥？有冇自己買過抗生素食？」 | Prior Abx masks culture; drugs causing sore throat (e.g. carbimazole → agranulocytosis) | Carbimazole / clozapine → agranulocytosis → sore throat |
| Allergy | Allergies to any medications? Penicillin? | 「有冇藥物敏感？青霉素敏唔敏感？」 | Determines Abx choice (penicillin vs macrolide) | — |
| Smoking / alcohol | Do you smoke or drink? | 「有冇食煙飲酒？」 | Smoking → ↑risk H&N CA, chronic pharyngitis [2] | Smoker → think laryngeal / pharyngeal CA |
| Occupation | What do you do for work? | 「你做咩工作嘅？」 | Teacher/singer → functional impact; dusty environment → irritant pharyngitis | Sick leave need → hidden agenda |
| FHx | Family history of NPC or cancers? | 「屋企有冇人生過鼻咽癌或者其他癌症？」 | FHx NPC is strong risk factor in HK Chinese [5] | FHx + epistaxis + OME → NPC |
Case Report Form Answer Builder
- CC: Sore throat × ___ days
- HPI high-yield points to capture:
- Onset, duration, progression
- Associated symptoms: fever, cough, coryza, odynophagia, dysphagia, voice change, rash, ear pain
- Centor criteria elements documented explicitly [1]
- Red flags screened: stridor, drooling, trismus, epistaxis, hearing loss, neck mass, weight loss
- PMH, DH (esp. carbimazole), allergy, SH (smoking, occupation, contacts)
- Likely RFC examples:
- "Pain and difficulty swallowing affecting eating/work"
- "Worried the sore throat could be something serious (e.g. cancer)"
- "Wants antibiotics / medical certificate for sick leave"
- "Persistent sore throat not improving despite self-treatment"
- Phrasing tip: Choose the one that best answers "Why did this patient come TODAY?" – often the concern or expectation, not the symptom itself.
| Likely Content | Suggested Wording for CRF | |
|---|---|---|
| Idea | "I think I have tonsillitis" / "Maybe it's the flu" | Patient thinks it is tonsillitis / infection |
| Concern | "I'm worried it could be cancer / NPC" / "I'm worried about spreading it" | Patient is worried it could be something serious (e.g. NPC) |
| Expectation | "I want antibiotics" / "I need a sick note" / "I want a throat swab" | Patient expects antibiotics and/or sick leave certificate |
- Most likely: Acute viral pharyngitis (common cold / URTI) if cough + coryza + low-grade fever present
- Alternatively: GAS pharyngitis if Centor ≥3 and no cough
- Minimum supporting evidence: Acute onset sore throat + coryzal symptoms (cough, runny nose) + low-grade or no fever + absence of exudate/tender LN → viral pharyngitis
- Decision rule: If the simulated patient has cough & coryza → viral; if no cough, exudate, tender LN, fever → GAS [1]
| DDx | Key Discriminator |
|---|---|
| GAS pharyngitis (or viral, whichever is not #1) | Centor score; RADT/culture differentiates |
| Infectious mononucleosis (EBV) | Prolonged fatigue (>1w), posterior cervical LN, hepatosplenomegaly, atypical lymphocytes |
| Peritonsillar abscess | Unilateral swelling, trismus, uvula deviation, "hot-potato" voice [3] |
(Alternative DDx if clinical context: NPC, influenza, GERD)
| Domain | Problem |
|---|---|
| Biological | Sore throat causing odynophagia and reduced oral intake |
| Psychological | Anxiety / fear about serious illness (e.g. NPC, cancer) |
| Social | Unable to attend work/school; needs sick leave; concern about infecting family members |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Dx |
|---|---|---|---|
| Viral pharyngitis (most likely) | Pharyngeal erythema WITHOUT exudate; coryzal features (nasal discharge) | Ask patient to open mouth, use tongue depressor + torch to inspect oropharynx | Erythema without exudate + coryza = viral; exudate absent makes GAS unlikely [1][2] |
| GAS pharyngitis | Tonsillar exudate + tender anterior cervical lymphadenopathy | Inspect tonsils for whitish exudate; palpate anterior cervical LN for tenderness | Centor criteria components; supports bacterial over viral [1] |
| Peritonsillar abscess | Unilateral peritonsillar swelling with uvula deviation + trismus [3] | Inspect oropharynx: swelling pushing tonsil medially and uvula contralaterally; test mouth opening | Unilateral bulge + deviation = abscess vs simple tonsillitis |
| Infectious mononucleosis | Posterior cervical lymphadenopathy ± splenomegaly | Palpate posterior triangle LN; palpate for spleen (LLD) | Posterior (not anterior) LN + splenomegaly differentiates EBV from GAS [9] |
| NPC | Hard, non-tender cervical lymph node (level II) + unilateral middle ear effusion [5] | Palpate upper cervical LN; otoscopy for fluid level behind TM | Hard LN + OME in Chinese adult = high suspicion NPC |
Exam Discriminators and Traps
Top Traps That Lose Marks
- Forgetting to ask about cough – absence of cough is a Centor criterion; if you don't ask, you cannot score or rule out GAS.
- Not asking ICE – this is directly on the Case Report Form and heavily weighted.
- Jumping to antibiotics – IDSA 2012 guidelines: do NOT treat empirically based on symptoms alone; test first (RADT or culture) [1]. Writing "prescribe amoxicillin" without evidence of GAS loses marks.
- Missing NPC in a Chinese patient – especially if > 40, epistaxis, unilateral hearing loss, neck mass; HK-specific must-not-miss [5].
- Missing peritonsillar abscess – trismus + unilateral swelling + uvula deviation; needs urgent ENT referral and drainage [3].
- Missing drug-induced agranulocytosis – always ask about carbimazole, clozapine, methotrexate.
- Not documenting the Centor score – even if you don't use the exact term, document the 4 elements.
- Confusing anterior vs posterior cervical LN – anterior = GAS; posterior = EBV.
| Red Flag | Implies | Action |
|---|---|---|
| Stridor / drooling / tripod position | Acute epiglottitis | Do NOT examine throat → call for anaesthetics/airway support → A&E |
| Trismus + unilateral swelling | Peritonsillar abscess | Urgent ENT for drainage |
| Neck mass + epistaxis + OME | NPC | Urgent ENT for nasoendoscopy + biopsy |
| Sore throat + carbimazole use | Agranulocytosis | Urgent FBC → if neutropenic → A&E |
| Failure to improve after 7–10 days / worsening | Complications (abscess, deeper infection) | Re-assess / refer |
"如果你燒超過三日唔退、吞嘢愈嚟愈痛、透唔到氣、或者流口水，你要即刻去急症室。" (English: "If your fever doesn't settle after 3 days, swallowing gets worse, you can't breathe, or you start drooling, go to A&E immediately.")
High Yield Summary
What to ASK: Centor criteria (fever, exudate, tender anterior cervical LN, NO cough) + red flags (stridor, drooling, trismus, epistaxis, hearing loss, neck mass, weight loss) + ICE + drug history (carbimazole!) + smoking + FHx NPC + TOCC.
What to WRITE: CC with duration → HPI with Centor elements documented → RFC (why today) → ICE → Most likely Dx (viral pharyngitis or GAS based on Centor) → 3 DDx with discriminators → 3 biopsychosocial problems → 1 physical sign (pharyngeal erythema ± exudate; anterior cervical LN).
What NOT to MISS: NPC in HK Chinese, peritonsillar abscess (trismus), epiglottitis (4D), agranulocytosis (drug-induced), EBV (posterior LN + splenomegaly).
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 021. Upper respiratory tract infections.pdf (p26–27, p52) [2] Senior notes: Ryan Ho Respiratory.pdf (p48, p51) [3] Lecture slides: GC 219. Infections and tumours in pharynx and oral cavity.pdf (p12, p17) [4] Senior notes: MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (p145) [5] Past papers: 2022 Fourth Summative MCQ.pdf (Q66 – NPC) [6] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p126 – TOCC for influenza) [7] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p1050 – gonococcal pharyngitis) [8] Senior notes: Ryan Ho Cardiology.pdf (p146 – ARF and Jones criteria) [9] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p1811 – EBV/infectious mononucleosis) [10] Senior notes: Maksim Medicine Notes.pdf (p122 – GERD extraoesophageal manifestations)
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