Objective Structured Clinical Examination Case Study
You are Cathy Noonan, a 38-year-old woman, who has just given birth after a long period of labor. You just delivered your second child, a daughter, who was born after a 40-week pregnancy. During labor, you pushed for 3 hours, and your daughter was born at 10:30 pm last night. You did not have any medications or an epidural to assist in your labor.
Your daughter weighed 8 lb, 12 oz. You tried breastfeeding her right after her birth last night. She nursed on each breast for about 5 minutes. At 6 am this morning you tried again, but your baby was too tired to nurse. You are now trying to feed her for the third time. You want to nurse your daughter, but are concerned because you weren’t able to successfully breastfeed your older child when he was born.
You work as an administrative assistant in the Geology Department at University of New Mexico (UNM). You graduated from college, where you majored in Medieval History.
You live in a house with your husband and 3-year-old son. Your mother watches your son while you are at work. Your husband works full time as an optics laboratory technician in the UNM physics department.
You wear a hospital gown so it opens in front. Under the gown you wear a white T-shirt. You will pin an artifcial breast to the shirt on one side over your own breast. You will hold the gown closely so only your artifcial beast is revealed as you work with the clinician. You are wearing either sweat pants or pajama bottoms. You will have a newborn mannequin in a receiving blanket.
Patient Presentation and Emotional Tone
You are tired after your long labor and appear anxious. When talking with the clinician, you will use non-medical terminology.
Your communication style is Sensing/Thinking (S/T). As a patient with the S/T personality type, you do the following:
- Expect brief, concise facts
- Want your clinician to be straight forward and honest
- Ask questions (what and how) about the facts about your condition
- Request information on the specifc treatment options so you can weigh them (apply the information to your own circumstances)
- Follow information best when it is presented in a step-wise logical way,
- without deviations
- Appreciate factual written information about your condition/treatment
- Want to hear any available percentages or relevant data for comparison and information
- Are very comfortable questioning (testing) your clinician. You value order and self-control
"How do I know if my baby is getting enough milk?"
"I had such trouble before. I'm so worried that I won't be able to breastfeed my daughter."
You experienced a tear in your perineum during birth and a nurse just gave you some Tylenol with codeine for the pain. If asked you would describe the pain as 10 on a scale of 1 to 10.
Medication Allergies/ Adverse Reactions
Past Medical History
You have gestational diabetes and you have controlled your blood sugar by watching your diet very carefully. You had no other medical problems during the pregnancy. Your first child, a boy, was born 3 years ago through vaginal birth. He was full-term and weighed 8 lbs. You attempted to breastfeed him, but you quit at 2 weeks because your nipples were cracked and bleeding.
- Sexual History: Monogamous, 2 sexual partners total in lifetime
- Alcohol: None during pregnancies, may have 3 drinks a year otherwise
- Drugs: Tried marijuana once or twice in high school, none since
- Tobacco: None
Health Maintenance Practices
- Diet: watched diet very carefully during pregnancy
- Exercise: 2-mile stroll every other day
- Physical checkups: good prenatal care
- PAP tests: yearly, all normal
Family Medical History
Father, takes pills for diabetes; Mother, in good health; 3 younger sisters, all in good health
What Standardized Patients can expect
- You will breastfeed your baby while being observed by the student.
- Initially you are in an uncomfortable position (hunched over) and the baby has only the nipple (not the whole areola or dark part of the breast) in her mouth.
Questions to ask the clinician
You will have a printed list with you. It's one you wrote in advance of this appointment so you would be sure to address all of your concerns. (You may ask the questions in any order.)
- "How do I know if my baby is getting milk?"
- "What does breastfeeding do for my baby?" or "What is the benefit of breastfeeding to my baby?"
- "If my nipples get sore like last time, what can I do?"
- You attempt to get the baby to attach but the infant is sleepy and will not wake up so you ask the clinician, "What do you suggest?"
- Once you are able to get the baby awake, she attaches on the tip of the nipple. This is extremely painful. "My nipple is white when she lets go, how can I treat it?"
- You describe how the infant's cheeks are drawn in and there is a clicking sound while she is feeding. "Is that OK?"
- "Who can I talk to if I have any problems or questions?"
- "When should I wean the baby (stop breastfeeding)?" or "What is the recommended length of time to breastfeed?" or "How old should she be when I stop breastfeeding?"
- "Should I go ahead and give my baby some formula? She hasn't eaten for so long and doesn't seem to be getting enough."
- "How often should I feed her and for how long?"
- "What can I do to take good care of myself?"
Particular items to note
If the student touched you or the baby, did they wash their hands?
Did the student ask to watch you breastfeed? Consider this in relation to communication skills.
This case was authored by Cheryl Wallerstedt MS, RNC, IBCLC, revised by K. Alvarez, T. McCarty and E. Espey, and provided by Tony Ogburn, MD, FACOG, from the University of New Mexico School of Medicine, 2006.