How do you pick a KFP MSQ answer when they are all correct?

Have a look at this hypothetical question:

Emily Watson, aged 30 years, presents with a three-day history of pain in her right breast that worsens during breastfeeding. The pain is sharp and located in the upper quadrant. She reports fatigue and a low-grade fever. Emily is 8 weeks postpartum, exclusively breastfeeding her first infant, and has noticed her baby is sleeping longer and feeding less frequently.

Emily has no significant past medical history and takes no regular medications. She does not smoke, consumes one glass of wine per week, and has no known allergies.

On examination, her temperature is 37.8°C, blood pressure is 112/76 mmHg, heart rate is 84/min regular, respiratory rate is 15/min, and oxygen saturation is 98% on room air. 

What further specific aspects of history would you enquire about to establish the most likely diagnosis?  Select five (5) specific aspects of history.

 Options:

1. Features of milk stasis (e.g., breast fullness, engorgement) (Score: 1)
2. Baby sleeping for increased periods (Score: 1)
3. Latching difficulties during breastfeeding (Score: 1)
4. Nipple pain/tenderness (Score: 1)
5. Nausea and/or vomiting (Score: 1)
6. Use of breast pumps or manual expression techniques 
7. Recent changes in feeding frequency or technique 
8. Any remedies already tried (e.g., warm compress, manual expression) 
9. Past medical history of mastitis 
10. History of breast surgery 
11. Family history of breast cancer 
12. Social support systems postpartum 
13. Features of low mood
14. Disturbed sleep

Not all KFP questions are difficult, and this one would certainly be on the easier side in terms of knowledge. Sadly though, there are many ways to lose marks – this one is all about examination technique 101.

The temptation here is to answer this the same as you might in the real world. You might enquire about social history given that she is 10 weeks postpartum, you might do a depression screen, and you might ask about family support. Notice though that all these answers score a firm nil point.

So, how should you approach this? The trick is to go back to the question itself – “What further specific aspects of history would you enquire about to establish the most likely diagnosis?”

What this question is really asking you is “what features on history do you see in someone with mastitis?” The answers immediately become far more obvious – you see nipple pain, lactation difficulties, nausea, lumps, and milk stasis.

Now look at the grid again – these answers match. However, anything that is inferred in the stem might not. In this instance she has no past medical history of note, and it is her first pregnancy, and so a past medical history of mastitis would not score here. Similarly, understanding what remedies she has tried to date is crucial to treat her holistically, but would not directly help you to establish the most likely diagnosis.

Moral of the story – if you see a history question to “confirm” or “establish the most likely diagnosis” – paraphrase the question in your mind as what features you would see in the diagnosis and then select these options as items of history.

This question shows why understanding examination technique is so crucial to mastering the KFP.

Reference:
Schuwirth LWT, van der Vleuten CPM. Different written assessment methods: What can be said about their strengths and weaknesses? Med Educ. 2004;38(9):974–979.