Acute Pericarditis

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Acute Pericarditis

Example 1 of 1 · fictitious patient (Veteran N)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Balance of Probabilities: Statement of Principles concerning Pericarditis (Balance of Probabilities) (No. 91 of 2023) Reasonable Hypothesis: Statement of Principles concerning Pericarditis (Reasonable Hypothesis) (No. 90 of 2023)

ADF History

The veteran, Chef (Army Catering Force), 09 January 2009, 27 Mar 2016.

Occupational History

Military chefs are exposed to various occupational hazards including prolonged standing, repetitive manual tasks, heavy lifting of kitchen equipment, exposure to high temperatures, potential burns from cooking equipment, handling raw food products with risk of infectious diseases, psychological stressors from high-pressure work environments, shift work patterns, and exposure to cleaning chemicals and kitchen environments that may contribute to respiratory irritation.

History

The veteran the veteran, serving as a Chef in the Australian Defence Force, first presented with acute pericarditis on 10 August 2013 while on active military service. The condition developed suddenly with right-sided chest pain that was worse with deep inspiration and movement, progressing to require emergency hospital admission when elevated troponin levels were detected.

Timeline

10 August 2013 - the veteran presented with onset of right sided chest pain first noticed on waking that morning, worse with deep inspiration and movement. He denied shortness of breath, syncope or being otherwise unwell. Examination revealed pain with palpation over costochondral joints and pain with springing of chest wall. Multiple investigations were ordered including CBC, EUC, LFTs, D-dimer, CRP, and chest X-ray for right chest pain worse with deep inspiration. Chest X-ray was normal and D-Dimer was negative, but phone call from pathology informed that there had been an elevated Troponin 24. Emergency hospital admission was arranged due to elevated troponin with unilateral chest pain, with ambulance transport organized for comprehensive cardiac evaluation.
12 August 2013 - the veteran returned from St Andrews Westside Methodist Hospital with comprehensive cardiac workup including echocardiogram, MRI, chest X-ray, numerous ECGs and blood tests with conclusion of pericarditis. Costochondritis was noted as a plausible differential diagnosis. Pain was evident with movement and relieved somewhat by sitting up.
14 August 2013 - the veteran was discharged with diagnosis of pericarditis with pain worse lying flat or sitting forward but minimized at 45 degrees. He also had tenderness to anterior chest wall and was discharged on ibuprofen and pantoprazole only. Colchicine 500 microgram tablets were started in keeping with guidelines for pericarditis management.
10 September 2013 - Clinical impression was costochondritis that was improving. Right upper chest wall was tender with pain reproducible on pectoralis activation. Cardiovascular examination showed heart sounds with no murmurs and no pericardial rub.
31 September 2013 - During first day of physical training since 10 August 2013, the veteran started to get pain to right parasternal area within 200 meters of warm-up jogging. The case was noted as unusual given the troponin leak but normal cardiac investigations.
17 January 2014 - the veteran was doing physical training that morning and started getting right sided chest pain identical to his previous costochondritis episodes. The pain increased with deep breathing and there was tenderness on palpation of sternum.

Symptoms

At the time of injury, the veteran experienced sudden onset right-sided chest pain that was positional, being worse with deep inspiration and movement, and associated with elevated cardiac enzymes requiring emergency hospitalization. After the injury, he developed chronic costochondritis with recurring chest pain episodes triggered by physical training activities, requiring ongoing medical management and restricted duties. The condition evolved into a chronic chest wall pain syndrome that significantly impacted his military service capacity and required prolonged periods of activity restriction.

Imaging

12 August 2013 - Comprehensive cardiac workup including echocardiogram, cardiac MRI, chest X-ray, numerous ECGs and blood tests with conclusion of pericarditis.

1. What is the formal diagnosis of the condition claimed above?

Acute Pericarditis, ICD-10 code I30.9, Statement of Principles concerning Pericarditis (Balance of Probabilities) (No. 91 of 2023) and (Reasonable Hypothesis) (No. 90 of 2023).

Pericarditis is an inflammation of the pericardium, the thin, two-layered, fluid-filled sac that surrounds the heart. Acute pericarditis typically presents with characteristic chest pain that is sharp, pleuritic, and positional - often worse when lying flat and improved when sitting forward. The condition may be associated with elevated cardiac biomarkers and can progress to complications such as pericardial effusion or constrictive pericarditis. The diagnosis is typically made based on clinical presentation, ECG changes, elevated inflammatory markers, and imaging findings.

The temporal relationship shows initial acute pericarditis in September 2015 followed by chronic costochondritis representing the ongoing sequelae of the original inflammatory condition.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition? 10 August 2013 - first noticed chest pain on waking that morning.

When did the veteran first present to a health / medical provider for this condition? 10 August 2013 - presented to military medical officer with chest pain worse with deep inspiration.

When was the condition confirmed / formally diagnosed? 12 August 2013 - diagnosed with pericarditis following comprehensive cardiac workup by cardiologist the treating doctor at St Andrews Westside Methodist Hospital.

When did the veteran first present to you (or your practice) for this condition? 12 Jun 2018

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.

The diagnosis was confirmed by Cardiologist the treating doctor at St Andrews Westside Methodist Hospital through comprehensive cardiac workup including echocardiogram, cardiac MRI, chest X-ray, multiple ECGs, and blood tests. Initial presentation showed elevated troponin levels (24) requiring emergency admission. Clinical findings included right-sided chest pain worse with inspiration, pain with costochondral joint palpation, and characteristic positional pain relief at 45 degrees. Subsequent episodes of costochondritis were confirmed by Military Medical Officers through clinical examination showing tender costochondral joints and pain reproduction with pectoralis activation.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Having a systemic viral infection within the 4 weeks before the clinical onset or clinical worsening of pericarditis - NOT MET

While this factor exists in the SOP, there is no clear documentation of a systemic viral infection in the 4 weeks prior to 10 August 2013 onset.

Inability to obtain appropriate clinical management for pericarditis before the clinical worsening of pericarditis - MET

This factor is met as per the Full Federal Court in Brew v Repatriation Commission (07 July 1993). The condition required emergency hospitalization and comprehensive cardiac investigation, indicating the severity was not initially recognized or appropriately managed, leading to clinical worsening with elevated troponin requiring emergency intervention.

Sequelae

This condition is not a sequelae of another known condition but rather represents a primary inflammatory condition of the pericardium that subsequently led to chronic costochondritis.

Unintended Consequence

This condition is not an unintended consequence of medical management. The pericarditis appears to have developed spontaneously during military service without any preceding medical procedures or treatments that could have caused it.

Inability to Attain Appropriate Medical Management

This factor is MET. The Full Federal Court in Brew v Repatriation Commission (07 July 1993) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. The initial presentation on 10 August 2013 was not immediately recognized as pericarditis, requiring emergency hospitalization when elevated troponin levels were discovered later that day. This delay in recognition and appropriate management led to clinical worsening requiring emergency cardiac evaluation and hospitalization. The condition caused permanent worsening by progressing to chronic costochondritis that required ongoing management and activity restrictions throughout his remaining military service.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

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