A middle aged woman with chronic sore throat, worse with swallowing especially solids, and bad breath comes to the clinic. On exam, there is an enlarged firm right tonsil with a 2 cm ulceration. Also, 2 enlarged firm, fixed, nontender lymph nodes in the right side of her neck.  What is the most likely diagnosis, the most likely underlying etiology, and the next step in management? She most likely has head & neck squamous cell carcinoma due to HPV and the next steps involve getting a biopsy, HPV status, CT scan and endoscpy. An elderly patient with long history of heavy smoking has chronic sore throat that doesn’t get better…