AI Scribe for Otolaryngologists

PATIENT: 8-year-old male
DATE OF SERVICE: 04/12/2026
PROVIDER: PatientNotes Clinical Team

CHIEF COMPLAINT:
Recurrent ear infections - referred for tympanostomy tube evaluation.

HISTORY OF PRESENT ILLNESS:
Mother reports 6 episodes of acute otitis media in the past 12 months, the most recent 2 weeks ago, treated with amoxicillin-clavulanate 875 mg/125 mg PO BID for 10 days. Episodes characterized by ear-pulling, fever, and decreased oral intake. Persistent middle ear effusion noted at the last 2 PCP visits. Mother reports school speech-language pathologist has flagged delayed articulation and concern about hearing during classroom listening tasks. No drainage from ears currently. No recent URI symptoms. Allergies to environmental triggers per mother (pollen).

PAST MEDICAL HISTORY: Eczema, mild
ALLERGIES: NKDA
MEDICATIONS: Cetirizine 5 mg PO daily PRN, fluticasone nasal spray 1 spray each nostril BID
IMMUNIZATIONS: Up to date including PCV13
FAMILY HISTORY: Older sibling with PE tubes at age 4

REVIEW OF SYSTEMS:
ENT: Frequent ear infections, occasional ear-pulling, parental concern about hearing
Constitutional: No fever today, normal appetite
Neuro: Speech delay per SLP; no other concerns
All other systems reviewed and negative.

PHYSICAL EXAM:
Vitals: T 98.4 F, HR 96, RR 18, SpO2 99%, Wt 28 kg
General: Well-appearing, well-nourished, in no acute distress
HEENT:
  External ear: No auricular deformity, no pre-auricular pit, no postauricular tenderness or swelling bilaterally
  Otoscopy:
    Right TM: Retracted, dull, amber-tinged middle ear effusion, no perforation, no acute inflammation
    Left TM: Retracted, dull, amber middle ear effusion, no perforation, no acute inflammation
    Pneumatic otoscopy: Markedly reduced mobility bilaterally
  Anterior rhinoscopy: Inferior turbinates 2+ enlarged, no septal deviation, no purulence
  Oral cavity / oropharynx: 2+ tonsils without exudate, palate intact, no asymmetry
  Neck: Supple, no lymphadenopathy
  Voice: Hyponasal quality
Cranial nerves II-XII intact.

DIAGNOSTIC RESULTS (today):
Tympanometry:
  Right: Type B (flat), volume normal
  Left: Type B (flat), volume normal
Audiometry (play audiometry, age-appropriate):
  Right ear: PTA 35 dB HL (mild conductive loss); SRT 35 dB; WRS 92% at 60 dB
  Left ear: PTA 35 dB HL (mild conductive loss); SRT 35 dB; WRS 92% at 60 dB
  Air-bone gap of 25 dB bilaterally consistent with conductive hearing loss
Conclusion: Bilateral conductive hearing loss consistent with persistent middle ear effusion.

ASSESSMENT:
1. Recurrent acute otitis media - 6 episodes in 12 months (H66.93)
2. Bilateral chronic otitis media with effusion - >12 weeks duration, conductive hearing loss (H65.193)
3. Mild bilateral conductive hearing loss likely contributing to speech-articulation delay (H90.6)
4. Adenoid hypertrophy (J35.2) - clinically significant given hyponasality and tube candidacy

PLAN:
1. Bilateral myringotomy with tympanostomy tube placement (CPT 69436) recommended given >3 months of effusion with audiometry-confirmed conductive hearing loss and >3 episodes of AOM in 6 months. Meets AAO-HNS guideline criteria.
2. Adenoidectomy (CPT 42830) recommended concurrent with tubes given hyponasality, adenoid facies, and history of recurrent AOM.
3. Pre-operative clearance with PCP. Surgery scheduling: outpatient ASC, general anesthesia, expected duration 20-30 minutes.
4. Pre-op education provided to mother: postoperative ear drops (ciprofloxacin-dexamethasone), water precautions, expected 12-18 months of tube retention.
5. Continue cetirizine and fluticasone nasal spray for environmental allergies.
6. Post-op audiogram in 4-6 weeks; speech therapy continuation through school SLP.
7. Mother verbalized understanding of risks (anesthesia, persistent perforation 1-2%, otorrhea, early tube extrusion). Consent forms reviewed.

ICD-10: H66.93, H65.193, H90.6, J35.2
CPT: 69436 (bilateral myringotomy with PE tubes), 42830 (adenoidectomy), 99214 (E/M)