Complex Developmental & Behavioral Conditions (CDBC) Assessment

Date of Assessment: 2026-01-23

PATIENT ID & REASON FOR ASSESSMENT
Ethan was seen for follow-up regarding nasal symptoms and decreased appetite. 

Ethan has a history of persistent picky eating and previously noted nasal symptoms. He was last seen in December for these concerns. Since then, his nasal symptoms have improved with the use of a prescribed nasal spray, with only occasional nighttime nasal stuffiness remaining. The primary ongoing concern is persistent picky eating, characterized by a preference for fruit and sweets and avoidance of rice, meats, and most vegetables. His parent reports a weight gain from 27.7 kg in mid January to 29.1 kg on February 20th, indicating a 1.5 kg increase over one month. Ethan has a history of being tall and slim, with height above average and weight tracking around the 15th percentile. The family has been offering more variety and balanced meals, which appears to have contributed to his recent weight gain.

History was obtained from caregiver interview.

REVIEW OF SYSTEMS
HEENT: Nasal symptoms improved with current treatment; occasional nighttime nasal stuffiness persists.
Constitutional: Reports of weight gain over the past month.
Gastrointestinal: Persistent picky eating; prefers fruit and sweets, avoids rice, meats, and most vegetables.

MEDICATIONS
Ethan is currently using a nasal spray as previously prescribed for nasal symptoms.

ALLERGIES
None known

NUTRITIONAL HISTORY
Ethan demonstrates selective eating behaviors, favoring fruit and sweets while avoiding rice, meats, and most vegetables. The family is actively offering a greater variety of balanced meals and is working to limit sugar intake.

ASSESSMENT
1. Inappropriate diet and eating habits (Z72.4)
2. Allergic rhinitis, unspecified (J30.9)

PLAN
• Continue current nasal spray as needed for nighttime nasal stuffiness
• Maintain efforts to provide a variety of nutritious, balanced meals and limit sugar intake
• No urgent follow-up required; schedule next follow-up in July or August to reassess growth
• Clinic coordinator will contact family to arrange the next appointment