Medical Imaging Analysis Report

I. Imaging Findings

1. Marked swelling is observed near the distal interphalangeal (DIP) joint of the patient’s right (or left) hand, with the skin appearing reddish-purple, shiny, and showing local breakage.
2. A yellowish-white, curd-like discharge is seen oozing from the ulceration, resembling a cheese-like texture, suggesting a sizable soft tissue mass or deposit.
3. X-ray shows soft tissue swelling around the DIP joint. Localized “punched-out” bone destruction is visible, and the articular surfaces are irregular, with some localized erosion or bony defects at the joint surface.
4. Focal cortical erosion is noted, and mild periosteal reaction or sclerosis may be present near the bone margins. No apparent fracture signs are detected in the distal phalanx epiphysis or phalanx.

II. Potential Diagnoses

1. Gout
   - Pathophysiology: Caused by the deposition of monosodium urate crystals in joints and soft tissue, often presenting as recurrent episodes of arthritis.
   - Imaging Features: Small distal joints may show soft tissue swelling and typical “punched-out” erosions. Tophus (gouty tophi) may form around joints or in subcutaneous tissue, appearing as yellowish-white nodules or discharge.
   - Clinical Characteristics: Usually presents with sudden onset of redness, swelling, heat, and severe pain. The presence of “cheese-like” exudates is highly suggestive of gout. The yellowish-white discharge from the ulceration in this case is strongly indicative of gouty tophi.
2. Septic Arthritis or Soft Tissue Infection (e.g., Pyogenic Arthritis)
   - Pathophysiology: Acute arthritis due to bacterial or other pathogen infection.
   - Imaging Features: Significant soft tissue swelling, bone destruction, and osteopenia may be seen, often accompanied by abscesses in the joint cavity or nearby soft tissue. In this case, the discharge is more consistent with a cheese-like deposit rather than purulent fluid.
   - Clinical Characteristics: Often presents with systemic or local signs of infection such as fever, redness, and marked tenderness. Pus is typically thick and yellowish-green if drained.
3. Rheumatoid Arthritis (RA)
   - Pathophysiology: An autoimmune condition characterized by multiple joint and symmetrical involvement, mainly affecting the proximal interphalangeal (PIP) joints and wrists.
   - Imaging Features: Commonly presents with symmetrical joint space narrowing, marginal erosions, and soft tissue swelling. “Cheese-like” discharge is not typical.
   - It is less likely here since the lesion site and presentation are more suggestive of gout.

III. Most Likely Final Diagnosis

Considering the patient’s age (66 years old, female), acute onset of redness, swelling, ulceration around the DIP joint, and the discharge of yellowish-white cheese-like material resembling gouty tophi, as well as the X-ray findings of local “punched-out” bony erosions, a most likely diagnosis is Gouty Arthritis (Tophus Formation).
To confirm, microscopy of the discharged material (under polarized light) may be performed to detect negatively birefringent urate crystals. Additional tests, such as serum uric acid levels, blood work, and pathological examination, can provide further support.

IV. Treatment Plan and Rehabilitation

1. Treatment Strategy

1. Medication
   
   • Nonsteroidal Anti-inflammatory Drugs (NSAIDs): Examples include ibuprofen, naproxen, and indomethacin to relieve acute flare-ups.
   • Colchicine: Used early in acute gout attacks to suppress inflammatory reactions.
   • Corticosteroids: For severe cases or when NSAIDs are contraindicated, short-term oral or intra-articular corticosteroid injections can be considered.
   • Uric Acid-Lowering Agents: Such as allopurinol or febuxostat, recommended for long-term management of hyperuricemia.
2. Surgical Intervention
   - In cases where gouty tophi are large or severely affecting joint function, surgical removal or joint exploration can be performed to prevent further joint damage.
3. Lifestyle Modifications
   - Restrict high-purine foods (e.g., beer, seafood, organ meats).
   - Increase fluid intake to promote uric acid excretion.
   - Maintain a healthy weight and avoid excessive alcohol consumption.

2. Rehabilitation and Exercise Prescription

During acute gout attacks, reduce joint activity to avoid additional load or trauma. Once symptoms improve, gradually increase activity to restore joint function.

• Acute Phase
  - Rest, apply cold compresses, or elevate the affected limb to reduce swelling and pain.
  - Isometric exercises of the muscles around the joint can help prevent disuse muscle atrophy; however, avoid excessive stretching.
• Remission Phase
  - Frequency: 3–4 times per week.
  - Intensity: Low to moderate, ensuring that it does not trigger joint pain.
  - Time: 20–30 minutes per session, possibly divided into segments.
  - Type: Activities in water (to reduce joint stress), light extension-flexion exercises for upper or lower limbs, hand-grip exercises, or joint range-of-motion training.
  - Progression: Gradually increase intensity and duration as symptoms improve, avoiding excessive weight-bearing or high-impact motions.
• Individualized Principle
  - If the patient is elderly or has other comorbidities (e.g., cardiovascular diseases), exercise should be conducted under medical or rehabilitation guidance, ensuring safety.

3. Precautions

If significant joint pain, fever, or swelling occurs during exercise, stop immediately and consult a healthcare professional. Patients on diuretics or with renal dysfunction should regularly monitor their serum uric acid levels and adjust medications if necessary.

Disclaimer: This report is based on current clinical and imaging data, and is intended for reference only. It is not a substitute for in-person diagnosis or professional medical advice. A specialist physician should determine the final treatment plan based on the patient’s complete medical history, laboratory tests, and clinical presentation.