Pediatric ADHD Consult

Date: 2026-01-14

Patient Information:
Name: Ethan

Thank you for referring Ethan for follow-up regarding nasal symptoms and decreased appetite. 

History of Presenting Illness:
Ethan presents for a scheduled follow-up regarding previously noted nasal symptoms and decreased appetite. Since the last visit in November, his nasal symptoms have improved with the use of a prescribed nasal spray, with only mild nighttime nasal congestion persisting. The primary ongoing concern is selective eating; Ethan continues to prefer fruit and sweets while avoiding rice, meats, and most vegetables. Despite this, his weight has increased from 27.7 kg in early January to 29.1 kg on February 11th, indicating a gain of approximately 1.5 kg over one month. His parent reports increased efforts to provide a more varied and balanced diet, which may have contributed to the weight gain. Ethan is described as tall and slim, with his height above average and weight tracking around the 15th percentile.

Review of Systems:
HEENT: Nasal congestion improved with nasal spray; mild stuffiness persists at night.
Constitutional: Weight gain of 1.5 kg over one month.
Gastrointestinal: Persistent selective eating; prefers fruit and sweets, avoids rice, meats, and most vegetables.

Past Medical History:

Current Medications:
Ethan is currently using a nasal spray as previously prescribed for nasal symptoms.

Nutritional History:
Ethan demonstrates a preference for fruit and sweets and avoids rice, meats, and most vegetables. His parent reports increased efforts to offer a more balanced and varied diet, with some improvement in weight gain. Sugar intake is being limited due to a tendency to seek out sweets.

Impression:
Ethan is being followed for avoidant/restrictive food intake disorder (F50.82) and allergic rhinitis, unspecified (J30.9).

Plan:
• Continue current dietary approach, offering nutritious and varied options without forcing food.
• Continue limiting sugar intake.
• Maintain use of nasal spray as needed for nighttime nasal congestion.
• Schedule follow-up in July or August to reassess growth and nutritional status.
• Clinic coordinator will contact family to arrange next appointment.

This note was generated using voice recognition software. Please excuse any errors that may have escaped proofreading.