Mother presents to clinic with D.J. a 2mo 4d old M, for their 2-month-oldcheckup. 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.
The information by the mother shows that the child is having progressive growth without any difficulties. In the cases of subjective data, the mother has presented that there is no challenge in the process of growth of the child, eating, or any socialization. The child is at risk of various health issues as a result of the genetic background. The mother has indicated that the grandmother from the mother’s side has hyperlipidemia while the grandfather has hypertension. The child is therefore at risk of having hypertension and these conditions.
The mother is worried as a result of the case where the child is unable to turn his head to the left on his own. The child can be able to turn his head to the right without a problem. On examination of the child, it is found that the head of the child is flat becoming deformed on the right side and the child has had difficulties in holding his head up. This has been seen from birth but the mother did not take it seriously at first. This is seen from the objective data….
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