Rule out dyslipidemia because of calf pain

The patient is here for a followup visit with complaints of pain in both legs. She is a pleasant female who was initially being followed at the practice for radicular pain down the left leg and she had physical therapy and transforaminal injection with significant amount of pain relief, but the pain never went away completely. Her pain started coming back since more than in a year and it is now appreciated more in the outer side of the leg and the calf on both legs, worse on the left as compared to the right. She described the pain as an aching and burning. Pain is intermittent. Pain is worse on standing. Walking really does not increase the pain that much. She has to start doing stretching exercises daily, also had acupuncture last year with some relief. She denies any bowel or bladder involvement. She denies any burning or numbness. She denies any other change in her past medical history and social history since last visit.

Lumbosacral radiculopathy.
Rule out dyslipidemia because of calf pain.
Discogenic pain.
Myofascial pain syndrome.
Muscle spasm.

I will request authorization from insurance for an MRI of L-Spine. I also told the patient to bring me the result of the blood test, which she had recently from her primary care doctor. I also will send the patient to physical therapy two to three times a week for four weeks. We will see the patient back after the blood test and we will decide further course of treatment.


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