This case involves a middle-aged female patient in Kansaswho suffered from morbid obesity as well as diabetes, who was being followed by a vascular surgeon for a wound on her hallux. The wound was initially managed as an outpatient with antibiotics, however, it continued to worsen and x-ray imaging showed signs of possible osteomyelitis. The plan was made for surgical debridement and treatment with broad-spectrum antibiotics. However, this plan was changed after the completion of the case and the patient was discharged home that day and instructed to continue with the same regimen of antibiotics. She returned to her surgeon’s office several days later complaining of worsening of the wound despite the previous surgical debridement. It was then noted that testing of the patient’s wound had revealed the presence of antibiotic resistant bacteria, however, her medication regimen was never adjusted. She was eventually admitted to the hospital, where she underwent an amputation of her foot.