This case involves a middle-aged patient with a past medical history of diabetes who presented to a podiatrist with an open callous on the bottom of her right foot. The doctor trimmed off the loose skin and noted signs of infection. The doctor put the patient on an antibiotic and recommended that she keep it covered with a band-aid or gauze. The patient continued to return to the podiatrist on a regular basis for treatment of the ulcer, during which time debridements were performed, dressings applied, and antibiotics prescribed. The patient presented to the podiatrist and reported the ulcer had gotten worse. There was no odor, but significant drainage, and her left foot and leg were warm and swollen. Nevertheless, the patient was not admitted to the hospital and was given a prescription for antibiotics. The patient eventually presented to ER because she didn’t feel well and her foot had swelled significantly. She was diagnosed with sepsis and her foot and part of her lower leg were amputated.