Endocrine Case Report: Antibiotics Not Working

A patient in their mid-50s with a history of diabetes who had already been on antibiotics for 4 days for cellulitis diagnosed in your emergency department, but had not improved, and then, yesterday, noticed an ankle wound. What additional testing should be considered for this patient?

History of Present Illness:

A patient in their mid-50’s with a history of diabetes presents to the hospital with a right ankle wound. She has already been on antibiotics for 4 days for cellulitis diagnosed in your emergency department, but had not improved and then yesterday the wound was noticed. Per her daughter, she didn’t feel pain from the wound and it was only noticed it because it was dripping onto the floor. She has had ulcers on her feet from diabetes in the past but not recently and never in this location. She denies trauma or any history of peripheral neuropathy and states she can feel fine on the other leg.

Notes from Previous Visit: “presents with sudden swelling and pain to right ankle after she sustained apparent bug bite while at work today. no h/o allergies, no h/o dvt/pe, denies falls or direct injury otherwise. no numbness or weakness”. At that visit duplex was negative and she was sent home on Keflex.

Vital Signs & Physical Exam:

Vital signs are normal. Physical exam is also normal except for diagnostic testing results highlighted below.

Initial Diagnostic Testing:

  • CBC: normal except for macrocytic anemia with Hb 8.8, but CRP elevated at 22
  • Chem-7: normal except for glucose 357. No DKA.

What additional testing should be considered?