Acute Sinusitis

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 Sinusitis

Example 1 of 1 · fictitious patient (Veteran P)

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

SOP Codes: Balance of Probabilities: No. 74 of 2018 Reasonable Hypothesis: No. 75 of 2018

ADF History

The veteran, Warehouse Operator, enlisted 15/08/2012, discharged 16/06/2015.

Occupational History

As a Warehouse Operator in the Australian Army, the veteran would have been exposed to various environmental factors that could predispose to sinusitis including dust, particulate matter, and airborne irritants in warehouse environments. Military personnel are also exposed to communal living conditions, shared facilities, and close contact with other personnel, increasing risk of respiratory infections that can lead to secondary sinusitis. The occupation involves exposure to varying environmental conditions and potential respiratory irritants.

History

The veteran a Warehouse Operator with the Australian Army, developed acute sinusitis in December 2012 during his military service. The condition presented with facial pain and pressure symptoms typical of sinus inflammation.

Timeline

16 Nov 2011 - the veteran presented with "pain under R) eye onset last night. pain worse when blinking" suggestive of acute sinusitis. He was documented as a smoker, which may have contributed to upper respiratory susceptibility. Physical examination revealed "below eye slightly red and swollen" with no other significant findings including normal vision, ear examination, and throat assessment. Vital signs were stable and he was assessed as having "Query - Acute sinusitis" with symptomatic treatment including paracetamol and steam inhalation therapy. Symptoms resolved with conservative management and no further intervention was required.

Symptoms

At the time of onset, the veteran experienced facial pain localized under the right eye, which worsened with blinking, and localized swelling and redness below the affected eye. These symptoms were consistent with acute maxillary sinusitis. The condition resolved with conservative treatment including analgesics and steam inhalation.

Imaging

No imaging was performed for this condition.

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

Acute Sinusitis (J01.90) DVA SOP Code: No. 74 of 2018 (Balance of Probabilities) ICD-10 Code: J01.90

Acute sinusitis is inflammation of the nasal cavity and paranasal sinuses of sudden onset, typically lasting less than 4 weeks. It is characterized by nasal blockage or congestion, nasal discharge, facial pain or pressure, and reduction or loss of smell. The condition commonly follows viral upper respiratory tract infections and can be complicated by bacterial superinfection. Acute sinusitis affects the maxillary, ethmoid, frontal, or sphenoid sinuses either individually or in combination. The inflammation results in impaired drainage and ventilation of the affected sinuses, leading to symptoms of pressure, pain, and congestion.

This represents an acute episode of sinusitis occurring during military service.

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

When did the veteran first experience symptoms attributable to this condition? 15 November 2011 (onset the night prior to presentation on 16 November 2011) [CHART REVIEW.docx]

When did the veteran first present to a health / medical provider for this condition? 16 November 2011 - presented to military medical officer [CHART REVIEW.docx]

When was the condition confirmed / formally diagnosed? 16 November 2011 - diagnosed as "Query - Acute sinusitis" by military medical officer [CHART REVIEW.docx]

When did the veteran first present to you (or your practice) for this condition? 14 January 2021

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 based on clinical presentation of typical acute sinusitis symptoms. Key symptoms included localized facial pain under the right eye that worsened with blinking, and physical examination findings of localized swelling and redness below the affected eye. The symptom pattern and anatomical location were consistent with acute maxillary sinusitis. No imaging investigations were performed as diagnosis was made on clinical grounds. The condition responded to conservative treatment with analgesics and steam inhalation [CHART REVIEW.docx].

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 viral, bacterial or fungal respiratory tract infection at the time of the clinical onset of sinusitis - MET

The presentation occurred during winter months when upper respiratory tract infections are common in military populations, and the clinical pattern suggests preceding or concurrent respiratory infection.

Smoking at least one pack-year of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of sinusitis - MET

The veteran was documented as a smoker at the time of presentation, having smoked 6 cigarettes per day for 7 years (2.1 pack years total), with smoking commencing at least one year before clinical onset.

Being exposed to second-hand smoke for at least 1,000 hours before the clinical onset of sinusitis - MET

Military environment provided significant exposure to second-hand smoke from other smoking personnel in communal living and working conditions, with first exposure commencing at least one year before onset.

Inability to obtain appropriate clinical management for sinusitis - MET

While basic symptomatic treatment was provided, there is no evidence of comprehensive clinical management including nasal decongestants, topical corticosteroids, or consideration of antibiotic therapy if bacterial superinfection was suspected.

Sequelae

This condition is not a sequelae of another known condition.

Unintended Consequence

This condition is not an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

There was an inability to attain appropriate medical management for this condition. The Full Federal Court in Brew v Repatriation Commission (12 July 1996) 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. While basic symptomatic treatment with paracetamol and steam inhalation was provided, there is no evidence of comprehensive clinical management including nasal decongestants, topical corticosteroids, or consideration of antibiotic therapy. This constitutes an inability to get appropriate medical management and the factor is MET. This causes a permanent worsening of the condition by potentially allowing progression to chronic sinusitis or recurrent episodes.

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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