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Stem
A 39-year-old man presents with a 4-month history of a painful, swollen right second toe that he describes as looking "like a sausage", pain at both Achilles tendon insertions, and morning stiffness in his hands lasting over an hour that improves with activity. He has had scaly, red, well-demarcated plaques over his elbows, scalp and around his umbilicus for years. Examination reveals a tender, diffusely swollen right second toe (dactylitis), tenderness at the Achilles and plantar fascia insertions, several swollen and tender distal interphalangeal joints, and nail pitting with onycholysis of multiple fingernails. He is afebrile. He takes no regular medications and has no significant past history.
Questions
a) What is the most likely diagnosis, and which single clinical feature most strongly associates the arthritis with the skin disease? (2 marks)
b) Name the five classical clinical patterns of this condition and state which is the commonest. (3 marks)
c) Outline the investigations that would support the diagnosis, including two characteristic radiographic findings. (3 marks)
d) Describe the staged management, from first-line therapy through to biological agents, and name one screening test required before starting a biologic. (2 marks)