Patient presents with complaints consistent with left orbital fracture.  Symptoms include periorbital edema, ecchymosis, and pain exacerbated by eye movement.  Onset of symptoms followed [Mechanism of Injury - e.g., blunt force trauma to the left orbit during a motor vehicle accident].  Physical examination reveals [Specific findings - e.g., tenderness to palpation of the left orbital rim, restricted extraocular movements, diplopia on upward gaze, infraorbital paresthesia].  Differential diagnosis includes orbital cellulitis, orbital hematoma, and zygomatic fracture.  Imaging studies, including a CT scan of the orbits and facial bones, were ordered to confirm the diagnosis and evaluate the extent of the fracture.  Preliminary assessment indicates a [Type of fracture - e.g., blowout fracture of the left orbital floor].  Current treatment plan includes pain management with [Medication - e.g., ibuprofen] and cold compresses.  Patient advised to avoid nose blowing and strenuous activity.  Referral to ophthalmology and otolaryngology is pending based on imaging results and clinical progression.  Follow-up scheduled in [Timeframe - e.g., one week] to reassess symptoms and discuss further management options, which may include surgical intervention for orbital reconstruction if indicated.  Patient education provided regarding potential complications such as enophthalmos, persistent diplopia, and orbital dystopia.  ICD-10 code S02.30XA assigned.