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Dx: Periorbital Abscess Medial to the Eye
On the ultrasound images, you can see a 1.5 x 1 cm circular fluid collection just medial to the eye. There is some heterogenous material within the circumscribed area (arrow). Correlating the patient’s symptoms to the ultrasound images, you deduce that he likely has periorbital cellulitis and a periorbital abscess forming just medial to the eye (left image).
Given what you’ve seen on ultrasound, your intern decides that he is armed with enough information to call ophthalmology and get the patient admitted before the witching hour. As predicted, the ophthalmology fellow on call says “Sure, I’ll come by and see the patient…but can you order a CT scan of his orbits for me?” Attempts to talk the fellow out of exposing the patient to additional radiation are met with profound resistance. Your intern decides its time to start choosing his battles. He orders the CT scan per the ophthalmologist’s request (right image), with the contingency that the fellow will start working on the patient’s admission orders. He was right of course - the CT gives no additional information. He then decides it’s time to call back the internal medicine team for his previous admissions.
You are tickled with pride as you hear your intern say, “Hey, I originally had three admissions for you, but I was able to get ophthalmology to take one of them. Let me tell you about the other two we want admitted for further workup in the hospital…” The internal medicine team decides not to argue with that logic, and your intern was able to arrange for appropriate dispositions for all three patients within a matter of minutes. Patting him on the back for a job well done, you advise him he has just earned the right to add the title of “expert salesman” onto his list of titles and job descriptions.
Brady Pregerson (@TheSafetyDoc) manages a free online EM Ultrasound Image Library and is the editor of the Emergency Medicine Pocketbook series. For more info visit EMresource.org.
Teresa S. Wu (@TeresaWuMD) is the Associate Residency Director, and Director of Ultrasound and Simulation Programs and Fellowships, for the Maricopa EM Program in Phoenix.
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