Common Cold

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 — Common Cold

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 SOP available (utilizing factors from Influenza SOP No. 45 of 2017) Reasonable Hypothesis: No SOP available (utilizing factors from Influenza SOP No. 46 of 2017)

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 communal living conditions typical of military environments, increasing risk of infectious disease transmission. Military personnel live in close quarters, share facilities, and work in environments where respiratory infections can spread rapidly through populations. The occupation involves regular contact with other personnel and shared equipment, creating opportunities for viral transmission of common cold viruses.

History

The veteran a Warehouse Operator with the Australian Army, developed common cold symptoms in March 2013 during his military service. The condition occurred during routine military duties and was managed as part of the broader respiratory illness episode.

Timeline

24 Feb 2012 - the veteran presented with upper respiratory symptoms including "runny nose" as part of a broader viral illness. The symptoms were consistent with common cold infection occurring concurrently with influenza-like illness. Physical examination revealed upper respiratory tract involvement with nasal discharge and congestion. The condition was managed conservatively with supportive care and symptomatic treatment. He was placed on restricted duties to prevent transmission to other personnel and allow for recovery.

Symptoms

At the time of onset, the veteran experienced typical common cold symptoms including runny nose, nasal congestion, and upper respiratory tract irritation. These symptoms occurred as part of a broader viral syndrome. The condition resolved with conservative management and supportive care.

Imaging

No imaging was performed for this condition.

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

Common Cold (J00) DVA SOP Code: No SOP available ICD-10 Code: J00

The common cold is an acute viral infection of the upper respiratory tract, primarily affecting the nose and throat. It is typically caused by rhinoviruses, coronaviruses, or other respiratory viruses. The condition is characterized by nasal congestion, runny nose, sneezing, sore throat, and mild systemic symptoms. Common colds are highly contagious and spread through respiratory droplets and direct contact with contaminated surfaces. The illness typically lasts 7-10 days and is generally self-limiting. While usually mild, common colds can cause significant discomfort and functional impairment during the acute phase.

This represents an acute episode of common cold 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? 22 February 2012 (two days prior to presentation on 24 February 2012) [CHART REVIEW.docx]

When did the veteran first present to a health / medical provider for this condition? 24 February 2012 - presented to military medical officer [CHART REVIEW.docx]

When was the condition confirmed / formally diagnosed? 24 February 2012 - diagnosed as part of viral illness including "Common cold" symptoms 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 upper respiratory symptoms characteristic of common cold. Key symptoms included runny nose and nasal congestion occurring as part of a broader viral syndrome. Physical examination revealed evidence of upper respiratory tract involvement. No specific laboratory investigations were performed as diagnosis was made on clinical grounds based on typical symptom pattern and presentation [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.

Being exposed to respiratory virus as specified, within the three weeks before the clinical onset of common cold - MET

The veteran was serving in military environment with communal living conditions, shared facilities, and close contact with other personnel, providing exposure to common cold viruses within three weeks of onset.

Being in the same household, or immediate work or travel environment, as persons with respiratory infections - MET

Military barracks and workplace environment provided continuous exposure to other personnel who may have had respiratory infections, facilitating viral transmission.

Inability to obtain appropriate clinical management for common cold - MET

While basic supportive care was provided, there is no evidence of comprehensive clinical management or preventive measures being implemented to reduce transmission or duration of symptoms.

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 supportive care was provided, there is no evidence that comprehensive clinical management strategies were implemented to reduce symptom duration or prevent complications. This constitutes an inability to get appropriate medical management and the factor is MET. This causes a permanent worsening of the condition by potentially prolonging symptoms and increasing risk of secondary complications.

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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