ADOS 2 – Module 2 - Phrase Speech Assessment Notes

Subjective:
Chief Complaint:
Follow-up for nasal issues and low appetite

History of Present Illness:
Ethan presents for follow-up regarding previously reported nasal symptoms and decreased appetite. Since the last visit in December, his nasal symptoms have improved with the use of prescribed nasal spray, with current symptoms limited to nocturnal nasal congestion. There is no report of new or worsening nasal symptoms beyond nighttime stuffiness. Regarding appetite, Ethan continues to exhibit selective eating behaviors, preferring fruits and sweets while avoiding rice, meats, and most vegetables. Despite ongoing picky eating, his parent reports a weight increase from approximately 27.7 kilograms in mid January to 29.1 kilograms on February 11th. There is no report of significant weight loss; instead, weight gain has been observed. His parent attributes this improvement to increased efforts in providing a more varied and balanced diet. No additional symptoms or concerns are reported at this time.

Development:
Ethan has consistently tracked as tall and slim, with height above average and weight around the 15th percentile. Recent weight gain of approximately 1.5 kilograms over one month has been observed, suggesting a possible growth spurt.

Current Medications:
Ethan has been using a prescribed nasal spray for nasal symptoms. There is no report of inability to recall medications, neglect of medication management, or casual attitude towards medication adherence.

Nutritional History:
Ethan exhibits selective eating behaviors, with a preference for fruits and sweets and avoidance of rice, meats, and most vegetables. His parent has implemented increased efforts to provide a more varied and balanced diet, which has contributed to recent weight gain. There is no mention of forcing food; the approach is to offer nutritious, varied options. Efforts are being made to limit sugar intake, particularly as Ethan tends to seek out sweets.

Objective:
ADOS 2 – Module 2 - Phrase Speech:
No information available regarding Ethan's phrase speech abilities, fluency, regularity, or expressive language level. There are no observations documented about the typical length of utterances, use of verbs, or estimated expressive language age range. No details are provided for the following tasks: Construction Task - Puzzle, Response to Name, Make-Believe Play, Joint Interactive Play, Conversation, Response to Joint Attention, Demonstration Task, Description of a Picture, Telling a Story from a Book, Free Play, Birthday Party, Snack, Anticipation of a Routine with Objects, or Bubble Play.

Assessment and Plan:
- Nasal congestion (R09.81): Ethan's nasal symptoms have improved with the use of nasal spray, with current symptoms limited to nighttime congestion. No urgent need to come in for a visit as the patient is doing well overall.
Plan:
• Continue current nasal spray regimen as previously prescribed.
• Monitor for any new or worsening nasal symptoms.

- Avoidant/restrictive food intake disorder (F50.82): Ethan continues to demonstrate selective eating behaviors but has shown a healthy weight gain of approximately 1.5 kilograms over the past month. No urgent need to come in for a visit as the patient is doing well overall.
Plan:
• Continue to offer a variety of nutritious and balanced food options without forcing intake.
• Maintain efforts to limit sugar consumption.
• Schedule follow-up visit in July or August to reassess growth and nutritional status, with flexibility for summer camp attendance.
• Coordinator will contact the family in the coming months to arrange the next appointment.