Pediatric-Acute emp

Subjective:
Historian:
History provided by Ethan's father.

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

History of Present Illness:
Ethan presents for follow-up of chronic nasal symptoms and decreased appetite. The parent reports that since the last visit in November, Ethan's nasal symptoms have improved with the use of prescribed intranasal medication, with residual nocturnal nasal congestion. Regarding appetite, Ethan continues to exhibit selective eating behaviors, preferring fruits and sweets while avoiding rice, meats, and most vegetables. The parent notes that efforts have been made to increase dietary variety and provide more balanced meals. Ethan was weighed at home on January 13th and measured 29.1 kilograms, compared to 27.7 kilograms in mid-December, indicating a weight gain of approximately 1.5 kilograms over one month. No acute concerns or new symptoms are reported. There is no history of forced feeding or significant dietary restriction. No reports of gastrointestinal symptoms, fever, or other systemic complaints.

Review of Systems:
- General: No acute concerns or new symptoms reported.
- HEENT: Residual nocturnal nasal congestion. No other HEENT symptoms reported.
- Cardiovascular: No cardiovascular symptoms reported.
- Respiratory: No respiratory symptoms reported.
- Gastrointestinal: No gastrointestinal symptoms reported.
- Genitourinary: No genitourinary symptoms reported.
- Musculoskeletal: No musculoskeletal symptoms reported.
- Neurological: No neurological symptoms reported.
- Psychiatric: No psychiatric symptoms reported.
- Endocrine: No endocrine symptoms reported.
- Hematologic/Lymphatic: No hematologic or lymphatic symptoms reported.
- Allergic/Immunologic: No allergic or immunologic symptoms reported.

Current Medications:
Ethan is using a prescribed intranasal spray for chronic nasal symptoms.

Objective:
Vital Signs:
- Weight: 29.1 kilograms (measured at home on January 13th)
- Height: No information available
- Temperature: No information available

Focused Physical Exam:
General:  Active and alert with no acute distress. Non-toxic appearing.

Head:  Normo-cephalic and atraumatic

Eyes:  PERRLA, extra-ocular movements intact bilaterally. Conjunctiva is not injected and no discharge is present. No photophobia.

Ears:  Bilateral tympanic membranes pearly pink with a good light reflex and normal bony landmarks. Ear canals patent.

Nose:  Bilateral nares patent with no discharge present.

Oropharynx:  Normal gums, mucosa and tongue. Pharynx without erythema or exudate. Normal tonsils and uvula midline. Moist mucosa.

Neck:  Soft, supple and without masses or adenopathy.

Cardiovascular:  Heart rate and rhythm are normal. No murmurs, gallops, or rubs. Cap refill time < 3 seconds. Normal pulses.

Respiratory:  Bilateral breath sounds equal and clear. Good air entry. No retractions or Tachypnea noted.

Chest:  No deformities, no retractions, symmetric

Abdomen:  Soft, non-distended, non-tender with no masses or organomegaly. No guarding or rigidity

Neuro:  Alert and active, non focal exam

Skin:  Normal turgor and color. No rashes. No suspicious lesions.

Physical Examination:
Ethan's weight was measured at home as 29.1 kilograms on January 13th, compared to 27.7 kilograms in mid-December. His height is described as above average, and his weight is around the 15th percentile for age and sex. No acute physical abnormalities or distress were reported or observed.

Assessment and Plan:
- Nasal congestion (R09.81): Ethan has experienced improvement in nasal symptoms with continued use of intranasal medication, with only residual nocturnal congestion.
Plan:
• Continue current intranasal therapy as previously prescribed
• No urgent follow-up required unless symptoms worsen

- Avoidant/restrictive food intake disorder (F50.82): Ethan continues to exhibit selective eating behaviors, with a preference for fruits and sweets and avoidance of rice, meats, and most vegetables. He has demonstrated a weight gain of approximately 1.5 kilograms over one month, suggesting a possible growth spurt. His weight remains within a healthy range.
Plan:
• Continue to offer a variety of nutritious and balanced meal options without forcing intake
• Limit access to sweets and encourage healthy eating habits
• Schedule follow-up visit in July or August to reassess growth and dietary progress
• Family advised to expect a call from the clinic coordinator to arrange the next appointment

Medical Decision Making:
- Ethan is a pediatric patient presenting with chronic nasal congestion and selective eating behaviors for the past several months, accompanied by residual nocturnal nasal congestion and low appetite.
- Initial differential diagnosis included chronic rhinitis and feeding difficulties, but clinical presentation is more consistent with improvement in nasal symptoms and ongoing selective eating without acute illness.
- Examination revealed stable weight gain and absence of acute distress, which are characteristic of a healthy pediatric patient rather than one with underlying systemic disease.
- Recent improvement in nasal symptoms supports the diagnosis of resolving chronic nasal congestion.
- Decision to continue current management and monitor growth based on clinical presentation and recent weight gain.
- Consideration of patient's selective eating behaviors and preference for fruits and sweets, ruling out need for urgent intervention.
- Pain management not indicated as there is no report of pain.