MDM - Periorbital Cellulitis

[##]-year-old [male/female] with [periorbital/eye redness] with history and exam consistent with likely [right/left]-sided periorbital cellulitis.

Initial considerations in this patient included periorbital and orbital cellulitis, dacryocystitis, allergic reaction, various etiologies of conjunctivitis, blepharitis, orbital tumors, cavernous sinus thrombosis, chalazion, stye, herpes simplex, and contact dermatitis amongst others.

Patient presented with redness, [tenderness,] and swelling of the eyelids and periorbital area for the past [time frame].  No evidence of proptosis, loss of extraocular muscle function, pain with extraocular movements, diplopia, or vision loss to suggest orbital cellulitis or mass effect on exam in the ED.  Based on findings on exam, further imaging [was deemed unnecessary at this time/was obtained and noted to be without evidence of orbital cellulitis or other deep space infections].  No significant conjunctival injection, irritation, or discharge noted on exam to suggest conjunctivitis.

Prior to discharge, we discussed plan for treatment with antibiotics and stressed the importance of completing the full course of antibiotics with the [patient/parents].  We discussed return precautions, specifically for evidence of worsening infection or orbital cellulitis, and follow up with primary care doctor within 2-3 days for further evaluation, and the [patient/patient’s parents] demonstrated understanding and agreement with this plan.