Dr. Johnson 's Case

1304 WordsJun 29, 20166 Pages
On 2-10-15, Neurologist, Dr. Johnson documented Mr. Durland complained of hemorrhoids, difficulty with bowel movements, a change in bowel habits, urgency, and rectal pain. Dr. Johnson documented that Mr. Durland’s PCP examined him, as well as a proctologist, urologist, neurosurgeon, GI physician, and a pain management physician. Dr. Johnson documented that Mr. Durland had various test and procedures, rectal exams, and no one had ever found anything. Dr. Johnson documented that Mr. Durland’s pain was perirectal/perineum and burning, occasionally he had pains down the medial aspect of both legs, right greater than left, and along the medial right thigh region. Mr. Durland complained that when it had "flared up" it was hard for him to sit and he had to lay or sit on his side because his perineum region was so tender. Mr. Durland denied numbness, was able to get erections, could ejaculate, and described the pain as being internal. Dr. Johnson documented that Mr. Durland did not have any radicular components to his pain. Mr. Durland stated that for the most part the pain was stable but did fluctuate and it was worse when he sat. Mr. Durland stated that his lumbar spinal injection had helped his pain to some degree. Dr. Johnson documented that Mr. Durland stated he had no previous lumbar spine problems. Dr. Johnson documented that Mr. Durland admitted to having a history of neck pain and migraine headaches which his primary care physician was treating with medication. Dr.
Open Document