Plan of Care Please evaluate the subjective and objective information provided to you in the file below.
Plan of Care
Please evaluate the subjective and objective information provided to you in the file below.
The first part of the discussion board is to identify all pertinent positive and negative information.
Then create a differential diagnosis list with at least 3 possibly actual diagnosis based on your findings.
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.
Be sure to include APA in-text citations and provide full reference citation at the end of the discussion
NU632 Unit 2 Discussion Case
C.C. 2-month-old well-child visit
HPI: Mother presents to clinic with D.J. a 2mo 4d old M, 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: 98.9 F, 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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