You are FY2 in GP surgery
Personal Details:
Name: Mrs. Jones
Age: 28
Medical Record:
Past medical history: Gave birth 1 month ago.
Notes:
A 28-year-old woman who is breastfeeding her one-month-old baby presents with a few-day history of unilateral breast pain.
Task:
1. Take a focused history and discuss the likely diagnosis.
2. Discuss the management plan.
Opening Sentence: “Doctor, my right breast is so painful, and I’m finding it really hard to feed my baby.”
Open History (to give freely): “It started a few days ago. My right breast is red and warm and feels firm. It’s agony when the baby latches on. I feel a bit flu-like and shivery as well”
ICE (Ideas, Concerns, Expectations):
Ideas: “I think it’s an infection.”
Concerns: “Shall I continue breastfeeding? Is it something serious? Could it be breast cancer?”
Expectation: “What are you going to do for me? I need some antibiotics, don’t I?”
How to Act: You are in pain, exhausted. You are a new mother who is worried about her baby and her own health.
More History (only if asked): You have not noticed any lumps or swelling in your breast, no pus or blood from the nipple.
You have no family history of breast cancer. The baby is otherwise well.
Social History: First-time mother.
Questions to ask:
“Is it safe for the baby to keep feeding from that breast?
“What if the antibiotics don’t work?”
Examination: area of redness and tenderness on the right breast. No lumps or swelling.
T 37.8 BP110/70 HR91 SPO2 98
History of Presenting Complaint:
It sounds like you are in a lot of pain. Can you tell me what’s been happening?
When did this start?
You said you feel flu-like. Have you had a fever?
Breastfeeding History:
How is breastfeeding going generally? Is the baby latching on well?
Have you had any cracked nipples or other problems?
Red Flag Screening:
Have you noticed any discharge from the nipple, like pus or blood?
Have you felt any lumps or swelling in your breast?
Is there anyone in your family with a history of breast problems?
ICE (Ideas, Concerns, Expectations):
What were your own thoughts about what this could be?
Is there anything you are worried about I should know off?
What were you hoping I could do for you today?
Explain the situation, the likely diagnosis:
It sounds like you are having a really tough time. Being a new mum is hard enough without this. Based on your symptoms and after examination, I think you have a very common condition in breastfeeding mothers called lactational mastitis. This is an inflammation of the breast tissue, which has likely become infected.
Addressing and answering the patient’s ICE:
You’re worried if you should continue breastfeeding and if it could be something serious like cancer. Let me reassure you that it is not serious, and it’s a very common infection. The most important part of the treatment, and I know this sounds counterintuitive when it’s so painful, is to keep breastfeeding from that breast. It is the most effective way to clear the blockage and drain the infection. It is perfectly safe for your baby.
Next Steps:
Because you have a fever and the signs of infection, you do need a course of antibiotics. I will prescribe you a flucloxacillin 500mg one tablet three times a day for a 10-14 day course of an antibiotic that is safe to take while breastfeeding. It’s very important you complete the whole course, even if you start to feel better.
Self-help measures:
Before a feed, you can use a warm compress or take a warm shower to help the milk flow. Make sure the baby is positioned and latched on correctly, and try to fully empty the affected breast at each feed. If it’s too painful to feed directly, you can try expressing the milk by hand or with a pump. After a feed, a cold pack can help with the pain and inflammation. Simple painkillers like paracetamol or ibuprofen are also safe to take.
You asked what happens if the antibiotics don’t work. You should start to feel better within 48 hours of starting the antibiotics. If you are not improving, or if you feel you are getting worse, you must come back to see us. This is because, occasionally, the mastitis can turn into a breast abscess, which is a collection of pus that may need to be drained. But for most women, the antibiotics and continuing to feed work very well.
The management is: 1. Prescribe a breastfeeding-safe antibiotic (e.g., Flucloxacillin). 2. Provide detailed practical advice on effective milk removal (warm compresses, correct positioning, expressing). 3. Advise on simple analgesia. 4. Give clear safety-netting advice on when to return (if not improving, suspecting an abscess).
What is scenario testing? This case tests the candidate’s knowledge of a common postnatal problem. The most critical part of the station is the advice to continue breastfeeding, as many women mistakenly believe they should stop. It also tests the ability to provide practical self-care advice and appropriate safety-netting.