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Over the past 16 months the patient has experienced a range of neuromuscular symptoms and injuries across the body. Nerve pain has occured in all four limbs, more significant in the left leg and arm. Muscular spasms have occurred in the left calf, left hamstring, left quad, right foot, lumbar back, and the neck. Certain injuries or symptoms have resolved, while many remain ongoing. The majority of the symptoms have begun without a clear cause other than too much activity. MRI testing of teh head, neck and spine have been unrevealing. Blood tests have been unrevealing. EMG of the left leg has demonstrated nerve damage. The patient's functional limitations average around 5000 steps per day, with a maximum walking or standing endurance of 15-20 minutes, and overall arm use/movement at approximately 30% of normal. Pain levels fluctuate largely from 2-7/10 depending on activity. Physiotherapy has helped the patient regain some function and reduce some pain, but not addressed the overarching problem. Mental health symptoms include significant anxiety, mild depression and difficulty sleeping. At this time doctors, including a general practitioner, a rheumatologist and a neurologist, are unsure of a diagnosis, prognosis or treatment plan moving forward. Neurontin has had no effect.
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