A 56-year-old man with hypertension, borderline type II diabetes mellitus, and obesity presents to your urgent care clinic with a chief complaint of right leg cellulitis. He believes it began with an insect bite about 10 days earlier but doesn’t actually recall an insect bite in the area of concern. The area has become increasingly red and painful, and now he says that from the knee down, the affected leg is more swollen than his other leg. The only scheduled medication he takes is daily lisinopril. Review of systems is negative for headache, dizziness or near syncope, chest pain, shortness of breath, or fever. He has no other new symptoms. His vital signs include: heart rate, 77 beats/min; blood pressure, 152/88 mm Hg; respiratory rate, 16 breaths/min; O2 saturation, 97%; temperature, 99.2°F.
The physical examination is unremarkable except for slightly asymmetric pretibial edema of the right lower extremity compared to the left, as well as minimal warmth and discoloration of the right lower extremity diffusely distal to the knee joint. Pedal pulses are easily palpable and symmetric, and there is no discernable puncture wound, fluctuance, or significant point tenderness. He is requesting antibiotics to cover cellulitis. What is the most appropriate course of action?
a. Check finger stick blood glucose. If under 200 mg/dL, prescribe oral cephalexin and TMP/SMX to cover streptococcal and staphylococcal pathogens. Arrange for follow-up with a primary care provider within the next week for a recheck.
b. Check CBC and lactate level. If normal, discharge with instructions for primary care provider follow-up since infection is unlikely.
c. Send CBC, BMP, blood cultures, and lactate level to the hospital lab STAT. If these show no significant aberrations, the patient may be discharged on oral cephalexin with follow-up blood culture results in his primary care provider’s office.
d. Question the patient further about DVT risk factors and strongly consider outpatient lower extremity doppler ultrasound or ED transfer if this is not feasible from your clinic.
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Answer: D. Urgent care clinicians should not be led astray by patient self-diagnosis or the opinions of patients’ neighbors, friends, or relatives. It’s important not to anchor on a specific diagnosis too early in a patient evaluation — if the history and examination raise suspicion for an etiology other than what the patient suggests, that etiology should be pursued, especially if it is a potentially dangerous one.