a 42-year-old man with a past medical history of hypertension presents with intermittent fever of 6 weeks duration. he has an associated cough, dyspnea, anorexia, arthralgias, abdominal pain, diarrhea, a widespread rash throughout his body, and back pain. he has come to see you because he has experienced acute left upper and lower extremity weakness and painless hematuria since this morning. he denies chills, a history of travel, sick or confined contacts, exposure to animals, bites, stings, cigarette smoking, otalgia, sore throat, swollen glands, drug use, dysuria, preceding gi or gu infections, previous surgeries, or sexual contact in the past year. his physical exam is remarkable for fever, a generalized petechial rash and petechiae of the mucous membranes, dark red linear lesions of the nailbeds, tender subcutaneous nodules of the digital pads, and nontender maculae on the palms and soles. his heart is notable for a new harsh, medium pitched pansystolic murmur at the apex with radiation to axilla, reduced strengths to the left upper and lower extremities, and splenomegaly. question: what is the most likely diagnosis?
