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Acquired Muscular Torticollis

Acquired Muscular Torticollis

Sample Answer 

Acquired Muscular Torticollis

According to the information gathered from the history of the present illness and the past medical history of the child, he reports normal feeding, sleeping, and appropriate excretion. Additionally, the mother also denies tobacco, drug, or alcohol use during pregnancy. The infant also received the required immunizations and did not report any known allergies or medications. From the history of the infant, he seems to be okay. However, the possible diagnoses for the infant, based on the complaints presented by the mother, including difficulty in holding his head up and turning his head to the right side, would infer developmental milestones (Jones et al., 2018). The baby could have congenital or acquired muscular torticollis or plagiocephaly, as noticed and reported by the mother. According to the three possible diagnoses, and considering the HPI and PMH, both indicate that the baby was delivered normally, the infant could be suffering from acquired muscular torticollis, which led to the plagiocephaly on the right side of the head.

When babies are born, the sternocleidomastoid (SCM), a long muscle on each side of the neck, should be checked for complications. Torticollis refers to a condition that affects the SCM muscle, thereby causing the head to tilt downwards and making it difficult to maintain the head in a raised posture (Colebatch and Rothwell, 2004). The condition can be a result of the fetus being in abnormal positions or being cramped inside the womb. Additionally, the problem can be acquired at birth if the baby’s SCM is put under pressure at birth. In either case, the SCM muscle becomes shortened on one side, thereby making movements to the longer side difficult. In most cases, movements to the right side become difficult for infants.

The mother should try laying the baby on her tummy most of the time and allowing him to make movements that help in the therapy. Since the infant’s skull is still weak, which results in the deformation of the shape of the head, the mother should try to change the sleeping positions every time to ensure the baby does not lie on one side for long (Jones et al., 2018). Additionally, the mother should encourage motor skills as the baby starts to move on his own and improve neck movements by stretching and exercising with the baby.

References

Colebatch, J. G., & Rothwell, J. C. (2004). Motor unit excitability changes mediating vestibulocollic reflexes in the sternocleidomastoid muscle. Clinical neurophysiology115(11), 2567-2573.

Jones, M. A., King, J. M., Chen, T., Lee, C. M. Y., Macintyre, S., Urquhart, D. M., & Antares, J. B. (2018). Non‐surgical and non‐pharmacological interventions for congenital muscular torticollis in the 0‐5 year age group. The Cochrane Database of Systematic Reviews2018(3).

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Question 


Acquired Muscular Torticollis

250-300 words discussion with APA references:

  • Please evaluate the subjective and objective information provided to you in the file below (**File below).
  • Identify all pertinent positive and negative information.
  • Then create a differential diagnosis list with at least 3 possibly actual diagnosis based on your findings (**File below).
  • Second part is to create a plan utilizing clinical practice guidelines for the priority diagnosis, as well as expected health promotion and expected developmental milestones.
  • Include APA in-text citations and provide full reference citation at the end of the discussion

NU632 Unit 2 Discussion Case (**File below)

Acquired Muscular Torticollis

Acquired Muscular Torticollis

C.C. 2-month-old well-child visit

HPI: Mother presents to clinic with D.J. a 2 month 4 day old Male, for their 2-month-old checkup. Mother reports D.J. taking in 6 oz of baby formula every 3 hours while awake. Wakes up once a night for a bottle. Having appropriate number of wet diapers and at least 1 BM per day. D.J. does not attend day-care and still at home with Mother. Mother will be going back to work in 4 weeks. Mother reports D.J. smiling and responding to her presents. However, she is concerned that he keeps his turning his head to the right-side and does not turn his head to the left on his own. Has noticed this when trying to get him to turn his head to her. She also has noticed difficulty with holding his head up. Mother noticed this after birth, but it has become more obvious as he is growing and moving more on his own. The right side of his head is now flat causing a deformity of his head.
PMH: Born at 40 weeks 5 days gestation vaginally. There were no complications at birth. There were no complications throughout the pregnancy. The infant’s mother denies tobacco use, drug use, or alcohol use during pregnancy. The infant uses Enfamil formula and is not breastfed. The infant received first Hep B immunization.

Allergies: No known drug allergies

Medications: None

Social History: The infant lives with his mother. Mom will be back to work in 4 weeks. He does not attend day-care at this time but will in 4 weeks. The infant is not exposed to tobacco smoke.

Family History: Mother denies any significant medical history. Maternal grandmother has hyperlipidemia and hypertension. Maternal grandfather has hypertension. Minimal history on father due to artificial insemination but no significant history is known.

Health Maintenance/Promotion:

Review of Systems General: Mother denies any concerns, unexplained fevers, or growth concerns. She is concerned with not turning head. Skin: The infant’s mother denies any rash, lesions, or concerns with eczema. Head: Mother reports the right side of the infant’s head is flat from always favoring his right-side. ENT: Mother denies any concerns with the infant’s ears, nose, or throat. Neck: The infant’s mother reports that his neck is stiff and only turns towards the right side. Per mom his head is difficult to turn to the right.CV: The infant’s mother denies any cyanotic spells or a discoloration of the skin (cyanotic).Lungs: The infant’s mother denies any cough, congestion, wheezing, or difficulty breathing.GI: The infant is negative for feeding or food intolerances. The infant is not having difficult with constipation or diarrhea.GU: Negative for diaper rash.

Objective VS: Temperature: 98.9F, HR: 152, Ht: 24 in (85.43%), Wt.: 13lbs, 8.6 oz (88.07%), HC: 40.25 cm (57.01%), BMI: 16.5 (48.51%).General: Well developed, well-nourished and hydrated, no apparent distress. Skin: No evidence of rash or lesions.

Head: Plagiocephaly noted on the right side of the head. Flattening of right cheek. Eyes: The lids and conjunctiva are normal. Pupils are irises are normal fundoscopic exam reveals red reflex present bilaterally. ENT: Normal nose. Asymmetric ears: right ear folded compared to left. Normal external auditory canals and tympanic membranes. Hearing is grossly normal. Lips/teeth/gums: no oral leukoplakia. Oropharynx: normal mucosa, palate, and posterior pharynx. Neck: Infant favoring right side. Limited ROM noted. Shortened sternocleidomastoid muscle on right side. No palpable lymphadenopathy. Does not appear in distress w/ palpation. CV: Normal rate and rhythm. Normal S1 and S2 heart sounds heard on auscultation with no S3 or S4. No murmurs. Femoral pulse 2+ bilaterally. Lungs: Normal respiratory rate and pattern with no apparent distress. Bilateral breath sounds clear on auscultation without rales, rhonchi, or wheezes. Abd: Normal bowel sounds. No masses or tenderness or organomegaly observed.GU: Penis: normal circumcised male. Testes descended with no inguinal hernia noted. MSK: Grossly normal tone and muscle strength. Normal range of motion in extremities. Negative for “hip click”.

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