LORIGA CASE

"I'm Not Feeling Right Since Having My Baby"

Assignment Instructions

Read the following unfolding case carefully. Additional information is revealed as the patient's condition changes.

Answer all seven questions using current evidence-based clinical guidelines (ACOG, CDC, SMFM, and current literature).

Requirements

APA 7th edition formatting

Minimum of three current scholarly references

Provide evidence-based rationales for all answers

Total length: 3 pages (excluding title and references)

Learning Objectives

Upon successful completion, the student will be able to:

Differentiate normal postpartum recovery from postpartum infection.

Recognize postpartum endometritis and early maternal sepsis.

Develop appropriate differential diagnoses.

Interpret laboratory and diagnostic findings.

Determine appropriate disposition.

Develop an evidence-based treatment plan.

Describe the FNP's role in recognizing and managing postpartum complications.

Patient Case

A 29-year-old G2P2 female presents to your family practice clinic for an urgent same-day appointment.

She is 14 days postpartum following a vaginal delivery.

She tells you,

"I've been feeling worse every day. I thought I'd be getting better, but now I have chills and this awful pelvic pain."

She reports:

Fever for two days

Increasing lower abdominal pain

Chills

Fatigue

Foul-smelling vaginal discharge

Poor appetite

Mild headache

She has been taking ibuprofen every six hours with minimal relief.

Obstetric History

Vaginal delivery at 39 weeks

Labor lasted 22 hours

Manual removal of placenta because membranes were retained

Second-degree perineal laceration

Breastfeeding successfully

No postpartum visit yet

Past Medical History

Obesity (BMI 34 kg/m²)

Diet-controlled gestational diabetes

No medication allergies.

Physical Examination

General

Appears ill, tired, and uncomfortable.

Vital Signs

Vital Sign	Patient	Normal
Temperature	102.1°F (38.9°C)	97–99°F (36.1–37.2°C)
Heart Rate	116 bpm	60–100 bpm
Respiratory Rate	22/min	12–20/min
Blood Pressure	102/66 mmHg	<120/80 mmHg
Oxygen Saturation	98% RA	≥95%

Physical Examination

Abdomen

Moderate suprapubic tenderness

No rebound

Mild guarding

Pelvic Examination

Purulent foul-smelling lochia

Significant uterine fundal tenderness

Cervix slightly dilated

No excessive vaginal bleeding

Perineal laceration healing appropriately

Laboratory Results

Laboratory	Patient	Normal Range
WBC	19,400/mm³	4,500–11,000/mm³*
Neutrophils	88%	40–70%
Hemoglobin	10.1 g/dL	12–16 g/dL
Hematocrit	31%	36–46%
Platelets	305,000/mm³	150,000–400,000/mm³
Lactate	2.8 mmol/L	0.5–2.0 mmol/L
C-Reactive Protein	18 mg/dL	<0.5 mg/dL
Procalcitonin	1.9 ng/mL	<0.1 ng/mL
Urinalysis	Trace leukocytes; nitrites negative; bacteria absent	Negative
Blood Cultures	Pending	Negative

*Note: Mild leukocytosis may persist postpartum, but this degree of elevation accompanied by fever and uterine tenderness is concerning for infection.

Imaging

Transvaginal Ultrasound

Thickened endometrial lining

Small amount of intrauterine fluid

No retained products of conception

No tubo-ovarian abscess

The Case Progresses

Thirty minutes later, while awaiting EMS transport:

Repeat Vital Signs

Vital Sign	Patient	Normal
Temperature	102.4°F	97–99°F
Heart Rate	128 bpm	60–100 bpm
Respiratory Rate	28/min	12–20/min
Blood Pressure	90/58 mmHg	<120/80 mmHg
Oxygen Saturation	97%	≥95%

The patient states,

"I feel dizzy... I think I'm going to pass out."

Her skin is pale and diaphoretic.

Capillary refill is delayed.

Questions

Question 1 (15 points)

What is the most likely diagnosis?

Support your diagnosis using at least four findings from the case.

Question 2 (15 points)

Develop a prioritized differential diagnosis.

Include at least four possible diagnoses and explain why each is either supported or ruled out.

Question 3 (15 points)

The patient's condition deteriorates while in your office.

As the Family Nurse Practitioner, describe your immediate priorities of care before transfer to the Emergency Department.

Question 4 (15 points)

Interpret the laboratory and ultrasound findings.

Explain how each abnormal finding supports the diagnosis and influences management.

Question 5 (20 points)

Develop a comprehensive evidence-based treatment plan.

Include:

Appropriate disposition

Intravenous fluids

Blood cultures

Antibiotic therapy (drug, dose, route, and rationale)

Additional laboratory testing

Monitoring

Consultation

Sepsis management

Question 6 (10 points)

Develop a discharge education plan after successful hospitalization.

Include:

Medication adherence

Breastfeeding

Warning signs

Follow-up

Prevention of future complications

Question 7 (10 points)

Discuss the role of the Family Nurse Practitioner in recognizing postpartum infections.

Include:

Early recognition

Collaboration

Patient advocacy

Maternal sepsis screening

Evidence-based practice