Pediatric Allergy – Eosinophilic Esophagitis (EoE) Assessment

Ethan presents for follow-up for nasal symptoms and decreased appetite. This letter is for the Allergy part of the multidisciplinary assessment. Dad's name is David.

Problems:  1.  Abnormal weight gain (R63.5):
 -Ethan has gained approximately 1.5 kg over one month, from 27.7 kg in early January to 29.1 kg by February 8th. He remains tall and slim, with height above average and weight tracking around the 15th percentile. Family is making increased efforts to provide a more varied and balanced diet, and sugar intake is being limited.

2.  Allergic rhinitis, unspecified (J30.9):
 -Nasal congestion has improved with prescribed nasal spray, with residual nighttime nasal stuffiness. Continue current nasal spray as previously prescribed.

Impression and recommendations: 
1.  Continue current dietary approach, offering nutritious and varied foods without forcing intake.
2.  Limit sugar intake, especially sweets.
3.  Follow up in July or August to reassess growth and nutritional status.
4.  Clinic coordinator to contact family to schedule next appointment.