Scribe BC - Pediatric otolaryngology clinic

**Diagnosis:** 1. Bilateral chronic tonsillar hypertrophy with recurrent tonsillitis. **Plan:** 1. Discussed tonsillectomy with the patient and family. 2. Scheduled for pre-operative assessment. 3. Provided information on post-operative care. 4. Referred to speech therapy for swallowing assessment. **History:** I was delighted to meet this 5 year old female with their mother in the pediatric otolaryngology (ENT) clinic today, 1 November 2024. They were referred to us because of recurrent sore throats and difficulty swallowing. She has had multiple episodes of tonsillitis over the past year, requiring antibiotics. She also reports snoring and occasional episodes of sleep apnea. The mother reports that the child has been experiencing difficulty swallowing solid foods. **Relevant previous medical history:** No significant past medical history. **Allergies:** No known allergies. **Relevant medications:** No current medications. **Relevant Family History:** Father has a history of snoring. **Examination Findings:** General: Appears well, but with some mild nasal congestion. Ear/otoscopy: Tympanic membranes are clear bilaterally. Nose: Mild nasal congestion. Oropharynx: Tonsils are enlarged to grade 3 bilaterally, with some erythema. Neck: No palpable lymphadenopathy. **Investigations:** - None completed at this visit. **Impression:** This patient presents with bilateral chronic tonsillar hypertrophy and recurrent tonsillitis, leading to significant symptoms including recurrent sore throats, difficulty swallowing, and snoring. The clinical impression is that the patient would benefit from a tonsillectomy. **Recommendations:** We discussed the benefits and risks of tonsillectomy with the patient and her mother, including potential complications such as bleeding and pain. The mother was given the opportunity to ask questions, and her questions and concerns were addressed. The patient is scheduled for a pre-operative assessment. We have also referred the patient to speech therapy for a swallowing assessment prior to surgery. The patient and mother were provided with detailed post-operative care instructions. Thank you for this referral. Kind regards, Pediatric Otolaryngology-Head and Neck Surgeon [Insert name of hospital] "This consultation note was generated with the assistance of an AI-based medical scribe. Verbal consent for the use of this technology was obtained from the patient and their parent(s)/guardian(s) at the time of the encounter."