Flu-like Symptoms and A Painful Breast — Free SCA Practice Case
Postnatal woman with flu-like symptoms and a painful breast
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Sarah Harding
Age
28 years
Consultation Type
VideoAge
28
Situation
Video Consultation.
Reason for Encounter
"Patient is 10 days postnatal following her first baby. Complaining of feeling like she has the flu and severe pain in her right breast."
Medical Records
- ●PMH: Nil significant.
- ●Medications: Pregnacare vitamins, Paracetamol PRN.
- ●Allergies: Penicillin (Causes a mild rash - documented in childhood).
Recent Notes
- ●10 days ago: Uncomplicated Normal Vaginal Delivery (NVD) at 39 weeks. Discharged day 1. Midwife notes from day 5 indicate baby was slightly slow to regain birth weight, mother working on breastfeeding attachment.
Patient Script
For the friend playing the patient role
Character Overview: You are Sarah. You had your first baby, Leo, 10 days ago. You are exhausted, hormonal, and currently feeling incredibly unwell. You woke up last night shivering uncontrollably, aching all over, and your right breast is hot, red, and agonizingly painful. You are hiding a deep sense of failure. You have been struggling with breastfeeding since day one; your nipples are cracked and bleeding, and every feed makes you want to cry. Your mother-in-law keeps telling you "breast is best," making you feel like a terrible mother for wanting to give up. Furthermore, you haven't fed Leo from the right breast since yesterday afternoon because you are terrified that you will pass "infected milk" or pus to your newborn. You will not volunteer this fear or your desire to stop breastfeeding unless the doctor actively asks how feeding is going, explores your mood, or asks what you are worried about.
Social History and Lifestyle Impact
You work as a hairdresser but are currently on maternity leave. Your partner, James, works shifts as a warehouse supervisor and has been back at work since day 3. He tries to help when he's home but is often on nights, which means you are doing most of the feeds and nappy changes alone overnight. Your mother-in-law lives nearby and comes round most days — she means well but her constant advice about breastfeeding is making you feel judged rather than supported. You don't have many close friends with babies and feel quite isolated.
The illness is making daily life with a newborn feel impossible. You could barely lift Leo out of his cot this morning because the pain in your breast was so bad, and you were shaking so much last night that you were frightened to hold him in case you dropped him. You haven't slept more than two hours in a row since he was born, and now on top of everything you feel like you have the worst flu of your life. You are running on empty and starting to wonder how other mothers cope.
Consultation Flow & Responses:
- ●The Opening
- ●If the doctor asks an open question: "Hi Doctor. I feel absolutely awful. I thought I was getting the flu because I was shivering so much last night and my whole body aches. But my right breast is also bright red, rock hard, and it hurts so much I can barely wear a bra. I don't know what's wrong with me."
- ●Data Gathering (The Layers)
- ●Layer 1: The Breast Symptoms & Abscess Screen:
- ●"It's the outer half of my right breast. It's a big, red, hot wedge."
- ●"There is a hard lump there. It doesn't squish when I press it, it's just solid and throbs."
- ●"My nipple on that side is cracked and has a little scab on it."
- ●Layer 2: Systemic / Sepsis / Postnatal Screen:
- ●"I took my temperature this morning and it was 38.5."
- ●"I feel dizzy when I stand up, but I'm drinking plenty of water."
- ●"My bleeding (lochia) is normal, like a light period. My tummy doesn't hurt. No pain in my legs." (Crucial for ruling out endometritis or DVT).
- ●Layer 3: The Feeding History (The Clinical Trap):
- ●If asked how feeding is going: "It's been really hard. He struggles to latch on properly. It hurts every time."
- ●If asked when she last fed from the right breast: "I haven't fed him from that side since yesterday. I've just been using the left side."
- ●Layer 4: ICE & Maternal Mood (The Core Revelation) - ONLY REVEAL IF ASKED:
- ●If the doctor asks: "Why did you stop feeding from the right side?" or "Are you worried about anything?"
- ●Reaction (The Reveal): You burst into tears. "Because my breast is infected! I can't give him poisoned milk, it will make him sick! I'm trying so hard, Doctor, but I am in absolute agony. My mother-in-law says I just need to try harder, but I secretly just want to put him on a bottle so I can sleep. Does wanting to stop make me a terrible mother?"
ICE — Ideas, Concerns, Expectations
Actor guidance: Do not volunteer any of this unprompted. These responses surface only if the candidate directly explores the patient's perspective through open questioning about ideas, concerns, or expectations.
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Ideas: You think the breast is infected — you've looked it up online and are fairly sure it's mastitis. You believe the cracked nipple is what let the infection in. You also think the milk from that breast is now contaminated and dangerous for Leo to drink.
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Concerns: Your deepest fear is that you are harming Leo — either by feeding him "infected milk" or by being too unwell and exhausted to look after him safely. You are also terrified that wanting to stop breastfeeding makes you a bad mother, especially with the pressure from your mother-in-law. Underneath all of this, you are worried that you are not coping and that this feeling of being overwhelmed will not get better.
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Expectations: You want something to make you feel better quickly — you assume you need antibiotics. You also desperately want someone to tell you it is okay to stop breastfeeding if you choose to, without being judged. You would value practical advice on how to manage the breast pain and keep feeding Leo safely in the short term.
If Asked — Medical History and Medications
Actor guidance: Respond naturally if the candidate asks about your medical history, current medications, or allergies. Do not volunteer this information unless directly asked.
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If asked about past medical history: "No, I've never really had anything. I've always been pretty healthy."
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If asked about the penicillin allergy: "I was told I got a rash from penicillin when I was little — I think I was about four or five. I don't really remember it myself, my mum told me about it. It's always been on my records."
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If asked about Pregnacare vitamins: "Yes, I've been taking the postnatal ones — the midwife said to keep going while I'm breastfeeding. I take one a day with breakfast."
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If asked about paracetamol: "I've been taking two paracetamol every four to six hours since last night. It takes the edge off the aching but it doesn't really touch the breast pain."
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If asked about the delivery: "It was a normal birth, no stitches or anything. I was in for about twelve hours and came home the next day. Everything was fine with the delivery itself."
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If asked about midwife follow-up: "The midwife came on day 5. She said Leo was a bit slow getting back to his birth weight and watched me try to feed him. She said his latch wasn't quite right and showed me a different position, but it still hurts every time. She was supposed to come back but I haven't heard from her."
If Asked — Associated Symptoms
Actor guidance: Respond only if the candidate specifically asks about these symptoms. Keep answers brief and natural.
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If asked about discharge or pus from the nipple: "No, there's no pus coming out. Just a tiny bit of blood from the crack sometimes when he latches on."
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If asked about the other breast: "The left side is fine — a bit tender from doing all the feeds, but nothing like the right. No redness or lumps."
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If asked about a rash anywhere else on the body: "No, no rash anywhere. Just the red area on my breast."
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If asked about chest pain or shortness of breath: "No, nothing like that. I get a bit out of breath going up the stairs but I think that's just because I'm knackered."
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If asked about headache or visual disturbance: "No headaches, no. My vision is fine."
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If asked about urinary symptoms: "No, that's all normal. No burning or anything."
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If asked about appetite: "I'm not eating much to be honest. I don't feel like it — I just feel sick and run down. I'm making sure I'm drinking water though."
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If asked about mood or how she is coping emotionally: "I'm just so tired. I feel like I'm doing everything wrong. I thought having a baby would be hard but I didn't expect to feel this alone and useless." (Allow the candidate to screen for postnatal depression — Sarah is tearful and struggling but this is an acute crisis rather than a sustained low mood. She does not describe anhedonia, thoughts of self-harm, or difficulty bonding with Leo.)
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If asked about thoughts of harming herself or Leo: "No! God, no. Nothing like that. I love him, I just feel like I'm failing him."
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If asked about any previous breast problems: "No, never had any problems with my breasts before."
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If asked about recent illness or contact with unwell people: "No, nobody at home has been ill. I just assumed this was the flu at first because of the shivering and aching."
Negotiation & Collaborative Management Plan
- ●If the Doctor tells you to completely stop breastfeeding on that side:
- ●Reaction: "So I was right? The milk is toxic? Will my milk dry up now?" (Note: Candidate fails for giving dangerous advice that can increase the likelihood of a breast abscess).
- ●If the Doctor prescribes antibiotics but ignores the Penicillin allergy:
- ●Reaction: "Flucloxacillin? Is that a penicillin? Because it says on my record I got a rash from penicillin when I was a kid." (Testing prescribing safety).
- ●If the Doctor tells you that you MUST feed from the infected breast to clear it:
- ●Reaction: Panics. "But the cracked nipple hurts so much! And what if there is bacteria in the milk? Won't Leo get a stomach bug?" (Doctor must explain milk immunology and suggest expressing if feeding directly is too painful).
- ●If the Doctor validates your desire to switch to formula:
- ●Reaction: Relieved. "Really? You don't think I'm failing him? That takes so much pressure off me."
- ●Safety Netting / Follow-up
- ●If the Doctor mentions checking for an abscess if the lump doesn't go away:
- ●Reaction: "Okay, so if this hard lump turns soft and squishy like a grape, or the antibiotics don't work in a couple of days, I need to come back?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Pathophysiology and Diagnosis
- ●Lactational mastitis arises from a combination of milk stasis and bacterial infection. Milk stasis — caused by poor infant attachment, engorgement, missed feeds, or suddenly reducing feeds — creates the conditions for bacterial proliferation.
- ●The most common causative organism is Staphylococcus aureus, which typically enters via cracked or fissured nipples (as in this case). Recognising nipple damage as the portal of entry is clinically important: it both confirms the infective aetiology and identifies a modifiable risk factor.
- ●The characteristic clinical picture is a wedge-shaped area of localised breast erythema, heat, and tenderness, combined with systemic features (fever, rigors, myalgia). The wedge distribution reflects the segmental anatomy of the breast lobules.
- ●Differentiating mastitis from breast abscess at presentation is essential: mastitis produces a firm, tender, diffuse induration; abscess produces a discrete, fluctuant lump. If the mass does not soften with antibiotics, abscess must be excluded by ultrasound.
Investigating Mastitis
- ●Mastitis is a clinical diagnosis — no routine investigations are required in straightforward cases.
- ●Blood cultures and FBC are not indicated in primary care unless sepsis is suspected (see Red Flags below). Breast ultrasound is not indicated at first presentation unless there is clinical uncertainty about abscess formation.
- ●Milk culture (of expressed milk from the affected side) is recommended by NICE CKS in recurrent mastitis, treatment failure after 48 hours, or hospital-acquired mastitis — but is not required at first presentation in primary care.
Antibiotic Prescribing — Including the Penicillin Allergy
- ●Antibiotics are indicated when systemic symptoms are present (fever, rigors), nipple fissures provide a clear portal of entry, or conservative management has failed after 12–24 hours. This case meets all three criteria.
- ●First-line (no allergy): Flucloxacillin 500 mg QDS for 10–14 days (NICE CKS). A full 10–14-day course is important — shorter courses carry a higher rate of recurrence and abscess.
- ●Penicillin-allergic (as in this case): Erythromycin 250–500 mg QDS or clarithromycin 500 mg BD for 10–14 days. Both are safe during breastfeeding; only small amounts pass into breast milk and no harm to the infant has been demonstrated.
- ●A documented childhood rash from penicillin warrants clarification before prescribing. However, the documented allergy must still be respected when prescribing until formally reviewed — flucloxacillin is a penicillinase-resistant penicillin and is contraindicated in this patient.
- ●Clarithromycin is generally preferred over erythromycin in practice due to a more tolerable GI side-effect profile and simpler twice-daily dosing, improving adherence.
The Golden Rule: Keep Emptying the Breast
- ●The single most dangerous management error is advising the mother to stop feeding from the affected breast. Cessation of breast emptying causes worsening milk stasis, which accelerates bacterial proliferation and dramatically increases the risk of abscess formation.
- ●Continue frequent feeding from the affected side. If direct feeding is too painful due to nipple damage, expressing (by pump or hand) is an equally effective and safe alternative for clearing milk stasis.
- ●Breast milk from an infected breast is safe for the baby. The infection resides in the breast tissue, not the milk itself. The milk contains maternal antibodies that are beneficial to the infant. This is a commonly held misconception among patients and must be directly and clearly addressed.
Analgesia and Comfort Measures
- ●Ibuprofen (400 mg TDS with food, if no contraindications) is the preferred analgesic for mastitis due to its anti-inflammatory action in addition to analgesia. It should be added to paracetamol for optimal effect. Ibuprofen is safe during breastfeeding in standard doses.
- ●Paracetamol alone (as this patient is already using) is often insufficient to control the pain of established mastitis — adding ibuprofen regularly, rather than PRN, is important.
- ●Practical comfort measures: warm compress before feeds to aid milk let-down and ease breast emptying; cold compress after feeds to reduce swelling and inflammation.
Addressing the Root Cause: Latch and Nipple Care
- ●Poor latch is the most common modifiable cause of cracked nipples and subsequent mastitis. Without addressing the latch, recurrence is highly likely despite successful antibiotic treatment.
- ●A lactation consultant or specialist infant feeding team can provide the hands-on positional and attachment support that cannot be delivered in a 12-minute consultation. This referral is a core part of management — not optional for a patient who has been struggling with latch since birth.
Breastfeeding Decisions and Shared Decision-Making
- ●Breastfeeding is a patient choice, not a clinical obligation. If a patient expresses a clear wish to transition to formula or combination feeding, this must be validated without judgment. The role of the GP is to support informed, autonomous decision-making — not to pressure continuation.
- ●Combination feeding (breast and formula) is a legitimate middle ground that can reduce the feeding burden while maintaining some of the benefits of breastfeeding, if the patient wishes.
- ●The framing that matters: a well mother and a fed baby takes priority over the method of feeding. This is especially important in the context of postnatal mental health.
Referral Criteria and Red Flags for Abscess
- ●Lactational mastitis progresses to breast abscess in approximately 3–11% of cases, most commonly when feeding is stopped from the affected side or antibiotics are inadequate.
- ●Refer urgently if: the indurated area becomes fluctuant (fluid-filled and compressible); skin becomes shiny, thinned, or necrotic; fever persists or worsens after 48 hours of appropriate antibiotics; or severe systemic deterioration occurs.
- ●Abscess management requires ultrasound-guided aspiration (preferred for smaller abscesses) or incision and drainage — arranged via the on-call surgical or breast team.
Postnatal Red Flags and Sepsis Safety-Netting
- ●Postpartum sepsis can deteriorate rapidly. Advise the patient to attend A&E or call 999 immediately if she develops: confusion, difficulty breathing, inability to keep fluids down, a non-blanching rash, or feels acutely and significantly worse.
- ●A fever of 38.5°C with rigors at 10 days postnatal requires the clinician to briefly screen for other serious causes of postpartum fever before attributing all symptoms to mastitis: ask about heavy or offensive vaginal discharge and abdominal pain (endometritis), and calf pain or leg swelling (DVT/PE).
- ●UK Sepsis Trust / NICE guidance recommends a low threshold for urgent assessment in postnatal women with systemic sepsis features — if in doubt, same-day in-person review or emergency referral is appropriate.
Follow-Up and Continuity
- ●Arrange review in 48–72 hours — by phone or in person — to assess antibiotic response, reassess the lump for fluctuance, and check how feeding is going. Do not leave a systemically unwell postnatal patient without a planned review point.
- ●Consider chasing the overdue midwife visit — the community midwife should have followed up latch concerns raised at the day-5 visit. This is a continuity gap that should be flagged.
- ●At a follow-up appointment, formally screen for postnatal depression using the Edinburgh Postnatal Depression Scale (EPDS). This patient describes isolation, exhaustion, feeling like a failure, and difficulty coping — features that warrant structured follow-up beyond the acute illness, even though she does not currently describe anhedonia or thoughts of self-harm.
Postpartum Wellbeing and the Broader Consultation
- ●A consultation at 10 days postnatal is never solely about the presenting complaint. Acknowledge the acute difficulty of early new motherhood — the isolation, exhaustion, and loss of confidence this patient describes are clinically significant and require a response.
- ●The Edinburgh Postnatal Depression Scale (EPDS) is the validated screening tool used in primary care and midwifery. A score ≥13 suggests probable depression; a score ≥10 warrants monitoring and follow-up. Arrange this formally if not already done.
- ●Signpost to additional support: health visitor input, peer breastfeeding support groups, and — if the patient is struggling significantly — mental health support via the GP or perinatal mental health team.
Mapped to the RCGP curriculum topic: Maternity and Reproductive Health.
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