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Answer 4
  1. Aspirate the olecranon bursa. It is extremely important to obtain aspirate from a patient who presents with a swollen bursa, especially in cases in which 1 joint or bursa is more remarkable than the others. Fluid should be sent for cell count and culture and should be examined for crystals. Crystals characteristic of gout are thin and needle-shaped and are often intracellular as a result of leukocyte phagocytosis. Even if uric acid crystals are found in the aspirate, obtaining a culture is important to ensure that an infection is not the cause of the patient’s symptoms. It is important to note that patients with chronic gout often have uric acid crystals in the bursa or synovial fluid, even when an attack is not occurring.4 Radiography may be performed to verify that there are no fractures, but it is not an immediate necessity in this case. If infection is suspected, antibiotics should be started as soon as possible. However, just as in septic arthritis, aspiration and cultures should be obtained to target the proper bacteria. Pain medication and colchicine are important but should not be the first priority in this situation.

    4. Bomalaski JS, Lluberas G, Schumacher HR Jr. Monosodium urate crystals in the knee joints of patients with asymptomatic nontophaceous gout. Arthritis Rheum 1986;29:1480-4.

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