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American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for management of rheumatoid arthritis: 2002 update. Arthritis Rheum 2002:46:328-346. Lee DM, Weinblatt ME. Rheumatoid arthritis. Lancet 2001;358:903-911. Lipski PE. Rheumatoid arthritis. In: Kasper DL. Braunwald E, Fauci AS, et al, eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill, 2005:1968-1977.

A 36-year-old man comes to the office complaining of 7-10 days of low-grade fevers with fatigue, myalgias, and headaches, which he attributes to the "flu." When he awoke this morning, he noticed that he had weakness of the right side of his face. He denies cough, congestion, sore throat, abdominal pain, diarrhea, or any urinary symptoms. He has had a mildly pruritic rash near his waist for the last several days, which he thought was "jock itch." He works as a Wall Street commodities broker, is married, and is monogamous. He recently accompanied his son on a weekend Boy Scout camping trip in New Jersey, but he does not recall any bites or injury.

On physical examination, his temperature is I00.8°F. heart rate 94 bpm. and blood pressure 128/79 mmHg. He is alert and talkative, and he appears comfortable. He has drooping of the right corner of his mouth and inability to elevate his eyebrow on the right. His conjunctivae are clear, and he has no oral lesions. His neck is somewhat stiff when passively flexed. His chest is clear, and his heart rhythm is regular without murmurs. His abdominal examination is benign, without liver or splenic enlargement. He has a 10-cm x 6-cm raised erythematous annular plaque with partial central clearing at his waistline (Figure 23-1). He has no joint swelling or erythema, and except for the facial weakness, he has no focal neurologic deficits.

♦ What is the most likely diagnosis?

^ What is the most appropriate next step?

Figure 23-1. Skin rash. (Reproduced, with permission, from Fitzpatrick TB, Johnson RA, Wolff K, et al. Color atlas and synopsis of clinical dermatology, 3rd ed. New York: McGraw-Hill, 1997:679.)

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