Patient: [Patient Name]
Date: [Date of Encounter]
I. Diagnosis:
Congenital muscular torticollis (CMT)
Age at diagnosis
Right or left torticollis (affected side)
II. Past Medical History:
Prenatal history (any mention of breech presentation)
Birth history (instrumental delivery)
Previous treatments (physiotherapy, splinting, surgery)
III. History of Present Illness:
Reason for this visit (routine follow-up, new concerns)
Current symptoms:
Degree of head tilt (measured in degrees)
Facial asymmetry (present or absent)
Difficulty turning head (limited range of motion)
Plagiocephaly (flattening of the head) – severity (mild, moderate, severe)
Developmental milestones (meeting age-appropriate milestones)
IV. Physical Exam:
Neck examination:
Palpable sternocleidomastoid muscle mass (firmness, tenderness)
Range of motion of head flexion, extension, and rotation (limited on affected side)
Head shape assessment (plagiocephaly)
V. Imaging Studies (if available):
X-rays (rarely used, may show bony changes)
Ultrasound (may show muscle mass)
VI. Assessment:
Severity of CMT (based on degree of head tilt, facial asymmetry, and plagiocephaly)
Response to previous treatments (physiotherapy, splinting)
Risk of complications (plagiocephaly, facial asymmetry, developmental delays)
VII. Plan:
Treatment plan depends on severity, age, and response to previous interventions:
Physiotherapy (stretching exercises, strengthening exercises for unaffected muscles)
Positioning techniques (to prevent plagiocephaly)
Splinting (may be used in conjunction with physiotherapy)
Surgery (sternocleidomastoid muscle release) – considered for severe cases or lack of response to conservative therapy
Follow-up schedule (frequency depends on severity and treatment plan)
Referral (if indicated):
Pediatric physical therapist for a comprehensive physiotherapy program.
Neurosurgeon (if surgery is considered).
Education:
Importance of adhering to physiotherapy program and positioning techniques.
Benefits and potential risks of each treatment option (physiotherapy, splinting, surgery).
Monitoring for developmental delays.
VIII. Notes:
Include any additional observations or concerns, such as parental understanding of the condition, compliance with recommendations, and emotional impact on the family.
IX. Resources:
Consider providing patient education materials on congenital muscular torticollis from reputable sources (e.g., American Academy of Pediatrics (AAP), National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)).