ENT Follow-Up Visit Note

ENT Follow-Up Visit Note: Date and Purpose of Review: 1 November 2024, follow-up for chronic sinusitis and post-adenoidectomy assessment. Subjective Update: Patient reports significant improvement in nasal obstruction and facial pressure since initiating fluticasone spray. No new episodes of epistaxis. Occasional mild post-nasal drip, which is less bothersome than previously. Mother reports child is sleeping better and snoring has markedly reduced following adenoidectomy. Objective Findings: Otoscopy: Tympanic membranes intact, mobile, no effusion bilaterally. Anterior Rhinoscopy: Mild mucosal erythema, no polyps visible. Septum midline. Oropharynx: Clear, no tonsillar hypertrophy. Neck: Supple, no palpable lymphadenopathy or masses. Investigations or Procedures Reviewed: Reviewed CT Sinus scan from 15 September 2024, which showed mild mucosal thickening in maxillary sinuses. Reviewed post-operative adenoidectomy report confirming complete removal. No new audiometry or lab results available for review. Management Update: Continue fluticasone nasal spray daily. Discussed proper technique for nasal spray administration. Advised on saline nasal rinses as needed for post-nasal drip. No changes to current medication regimen. Formulary availability for fluticasone confirmed through local pharmacy networks. Plan: Continue current management. Patient to return in 3 months for further follow-up to assess long-term response to medical management for sinusitis and ensure no recurrence post-adenoidectomy. No immediate referrals required.