Information sources to claim it, who appears to be a reliable historian.

Records available
for review include a single note from, or pardon me, include a adult function report as
well as a single note from hospital visit 2023 dealing with
as gouty arthritis of the right great NTP. The claimant's chief complaint is injury from
explosion while serving in the military, severe back injury and TBI, history of present
illness. Mr. Odegaard is a 41-year-old who served in the Army from 2001 to 2005 he was
actually in Iraq stepping out of a window onto a concrete support or wall when this wall
was hit by a round the wall collapsed and he fell at least 12 to 15 feet directly on his
back.
Klayman states that in the process of the blast Klayman also obtained a traumatic brain
injury. issues surrounding this and TBI has been evaluated and determined to be causing
significant memory problems as well as increasing depression, causing irritability and
problems with impulse control and processing. initial injury he had injury at L5, S1 and
to some extent other adjacent areas. He states that he's had a laminectomy performed to
try to remove pressure from his right side nerve roots which was leading to significant
pain and weakness in the leg with the leg
giving way. He states the laminectomy helped some with the weakness but only to a
certain extent. He states the pain is still ever present and the back pain continues to be
present. He has tried multiple modalities, including conservative measures such as
medications and therapy. He has had injections, TENS units, and other alternative
methods, none of which have provided
any sustained relief. surgery given his age and the type of injury. The claimant states he
does have some problems with the neck, particularly on the right side with some mild
degenerative changes. He states that the thoracic spine is unremarkable. Period
paragraph.
The claimant's other issue is also service related and is related to his left knee. The
claimant states that he was on a maneuver, stepped over a log and did not realize there
was another log on the other side. This was at night and he could not see well.
Unfortunately, this caused a significant twist in the knee. He did not have surgery for this
but has continued to have some pain and stiffness as a result. Period paragraph. The
claimant states that he has difficulty standing, sitting, or lying down for long
periods of time and jobs that he's been able to do since he left the military, which include
private security, grant writing for a children's hospital, and city code enforcement in
Clearwater, Florida, have all made accommodations for this, allowing him to freely stand,
sit, and even lie down as the need arose. The claimant states he can tolerate one or two
hours in any seated position, but has to be able to move around. A straight back chair is
much more difficult.
He states generally he doesn't tolerate more than two hours in any seated position,
including in a car, and cannot tolerate even six to eight hours over the course of a day
staying in a seated position. The claimant indicates that he has difficulty standing for long
periods. He similarly has limitations 20 or 30 minutes up on his feet before having to sit.
Walking is a little better than standing in one place. The claimant also has significant
problems bending, lifting, and twisting. Sleep
is significantly problematic, not due just to his back pain and leg pain, but of course due
to his traumatic brain injury, PTSD, anxiety, and depression, period. He states he doesn't
get more than about two hours of sleep at a time before he's up, having to reposition, out
or otherwise perform other activities to get back to sleep. Period. Paragraph. Klayment is
able to make short trips through the supermarket, rarely goes out.
He can climb a few stairs with some knee pain and back pain. Doesn't do this repeatedly.
He rarely climbs ladders. He also has some difficulty squatting and kneeling, a fair bit of
pain bending and twisting, lifting and carrying limited to 40 or 50 pounds. Rarely, typical
lifting is considerably less than this and he tries to avoid heavy lifting as
much as possible as almost any lifting will increase back pain. The claimant is able to
perform small amounts of housework, his family take care of most of this. He can use a
riding lawnmower, although this does hurt his back. He doesn't use a push mower, cannot
use a weed eater, doesn't do heavy scrubbing. He is able to wash a few dishes, prepare
something light to eat, spot sweep, use a light mop, fold some laundry, and wipe off
countertops.
He also manages his own dressing and hygiene and is able to drive. Period paragraph.
Past medical history is significant for the above, as well as hypertension. The claimant
does get weekly headaches as well, lasting anywhere from 15 minutes to several hours.
There are variable intensity, often associated with photophobia. Past surgical history
includes tonsillectomy, medications, resuvistatin, gabapentin, mirtazapine, alopurinol,
trazodone.
He has no known drug allergy. Social history, claimant does not smoke, drink alcohol, or
use street drugs. Education, bachelor's degree, primary care physician, VA medical
center, most recent job, Clearwater City Code Enforcement 2021. Family history is non-
contributory. In review of systems, plastic or leg pain, otherwise SBROS.
Physical, claimant has a height of 5 feet, excuse me, 6 feet 2 inches, weight 251 pounds,
blood pressure 115 over 70 with a large adult cuff, pulse 77, respirators 12, SpO2 is 96%
at rest on room air. He has uncorrected visual acuity of 2013 right, 2013 left. He is right-
handed, is able to read and write. He

ambulates at a gait which is somewhat stiff and somewhat antalgic, savoring the right leg
as well.
Put that he is comfortable in a sitting position for brief periods, somewhat uncomfortable
in a supine position, but that he is stable at station. You can leave that. Put that the gait is
not wide-based, unsteady, lurching, or unpredictable. Recent remote memory from
medical events was a little spotty.
The rest is written in H, E, E, and T dentition under markable Sb neck, Sb chest, Sb cv,
abdomen is mildly obese, separate extremities, Sb ue, hands, Sb ha, lower extremities,
take the word knees out of the first sentence, there is mild crepitus to the right knee,

more substantial crepitus of the left knee, as well as medial joint line tenderness of that
knee. Anterior drawer sign is negative. , so make sure to include that. That's not usually
in the template. And then you can change range of motion on the knees to

120 degrees with the right knee, 130 degrees with the left. That is correct. It's more
movement with the knee that was injured. Then SBCS, minimal tenderness, change a
rotation to 70, SBTS, SBDLS, straightening of the normal curvature, mild tenderness to
percussion of the dorsal and respinous processes,
and some tenderness to pressure over the paraspinous muscles and the SI joints. Change
bending forward at the waist to 75 to 80 degrees, hip flexion to 85 to 90 on the right, 95
on the left.
Put straight leg raise test in the supine position was positive on the right at 30 degrees,
equivocal on the left. And last sentence, ABA deduction, internal and external rotation of
the

right hip did reveal a significant pain with extremes of movement. Neurologic, as written,
put Klayman

had difficulty walking on heels and toes, standing on one leg at a time, especially the
right leg. He had some difficulty with tandem gait and squatting.
Psyched, mood depressed, affect is very blunted. Skin, SV, skin, objective, mid-arm
circumference of 37 right, 35 left, mid-forearm 33 right, 31 left, mid-thigh 50 right, 49
left, mid-cap 36, bilaterally, grip strength 32, 36, 36 on the right, 30, 29, 30 on the left.
Impression number one, traumatic brain injury and severe back and leg injury due to
injury in the service in Iraq, number two, left knee injury, service related, number three,
other.
Plan number one, claimant has significant injury with the back which has been well
documented. Treatment has basically exceeded any benefit and at this point he is not a
candidate for additional treatments. The claimant states that back pain and leg pain have
continued to be a major issue despite this. Period records I'm sure will further clarify the
specifics. Number next, or period. The claimant also has traumatic brain injury which is
related to the explosion.
Prentiss discussed more below in Prentiss's paragraph. Claimant has a history of knee
injury. Imaging may be available for this. X-ray might not be much help. MRI perhaps
would be. There may be some meniscal injury as well as some ligament injury,
but again, I don't have the specifics. There does not appear to be instability of the joint.
Number next. Claimant has a number of organic brain issues and psychological issues
which are all giving rise to cognitive and mood-related problems. The claimant also is,
these should be well described
in medical records, Prentiss, although he felt that his visit to the psychologist for
disability was somewhat brief in Prentiss. I'm sure he has extensive records through the
VA system. In addition, he is listed as having myofascial pain, which would be discussed
in other medical records, and irritable bowel syndrome with fecal continence, which also
should be discussed in medical records.
Period paragraph. S.B. worksome, moderately impaired due to some physical findings,
consistent. Put another paragraph after that, but before S.B. worksome. I want a separate
paragraph that puts claimants' jobs that had been worked had generally required
significant accommodation by persons who were already associated with the claimant.
Jobs that he has tried to obtain that have not provided him with such benefit have not
been successful. Put jobs or interviews related to a more typical motive of payment and
employment had not been successful. So, I'm sorry, I know that's stilted. So SB works,
some moderately impaired, consistent, sends his dictation on Ryan Odegaard. So SB
works, some moderately impaired, consistent, sends his dictation on Ryan Odegaard.
Thanks.