This 56 year-old homeless, alcoholic male presented to your emergency department complaining of generalized malaise, diffuse bony aches and a rash to his lower extremities. The symptoms had been present for 2 weeks without any fever, chills or known sick contacts, and the rash was noticed 1 week ago and was progressing. It was nonpruritic, and the patient denied any traumatic event or prior history of a similar rash. The patient was malnourished but alert and oriented. His vital signs were stable. His exam was otherwise insignificant except for diffuse muscle/bony aches and a lower extremity rash (figures 1 and 2).  

Figure 1 (click on image to enlarge)

Figure 2 (click on image to enlarge



 

What are your concerns as you examine this patient?
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