Diagnosing Acute Pyelonephritis, Prostatitis, and Complicated Cystitis

Neurological & Male Genitourinary Disorders
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Subject and Section
Professor’s name
Date
1 What other subjective data would you obtain?
In this case, it is crucial to obtain the general data, including the age and birthdate, sex, race, ethnicity, and religion. Moreover, the interview date or admission should also be included as this will give information for the next healthcare provider, especially if the case will be transferred (Bickley & Szilagyi, 2012).
The history of present illness should contain OPQRST data, which stands for the onset, precipitation, quality, relieving factors, severity, and timing (Bickley & Szilagyi, 2012). In the case, only the onset (5 days ago), incomplete details on severity (increased frequency of urination without quantification), and associated symptoms (dysuria and nocturia). It is essential to mention significant negatives for the past medical history, such as not having hypertension or diabetes. The latter is especially important since it is a risk factor for complicated urinary tract infection (UTI) (Sabih & Leslie, 2020).
The drug history revealed that the patient used or is still using Rosuvastatin 20 mg andOlmesartan 20 mg. It must be indicated whether these drugs are still being taken or are previously taken. Moreover, it is essential to complete the prescription information, including the frequency of use, duration, and indications (Hilal-Dandan & Brunton, 2016). The subjective part did not also have a history of allergies, family history, social history, and a complete review of systems. Allergies must be investigated since drugs, especially antibiotics, result in anaphylactic reactions (Blumenthal et al., 2019). In this case, antibiotics might be prescribed if the patient’s case is pointed out as a urinary tract infection (Tan et al., 2016). The family history will reveal familial diseases that may be the direct or indirect cause of the disease. The social history should tackle the patient’s home and environment, employment, eating behaviors, education, activities, sexuality, drugs, and presence of depression or suicidal ideations. Lastly, the review of systems is essential in identifying other systems affected that may or may not directly relate to the primary chief complaint. In this case, the review of systems only tackled a few pertinent details and missed other essential parts (Podder et al., 2020).
2 What other objective findings would you look for?
In the objective findings, it is critical to evaluate the signs related to the past medical history, including benign prostatic hyperplasia, kidney stones on the left, and urinary tract infection. A digital rectal examination was performed. However, the examiner did not mention the presence or absence of masses. If masses are present, it must be described based on the quantity, quality (i.e., soft, firm, complex), borders (i.e., regular or irregular), shape (i.e., round), and size (i.e., length x width x height or diameter if it is circular). Moreover, the presence or absence of fecal material should have been described if this is present after the examining finger was pulled. This examination is significant in identifying an obstruction in the urinary tract secondar...