Diabetes Mellitus

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 invented and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Diabetes Mellitus

Example 1 of 1 · fictitious patient (Veteran CB)

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 invented and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

BOP Code: 49 of 2020 (Diabetes Mellitus)
RH Code: 48 of 2020 (Diabetes Mellitus)

ADF History

Veteran CB, date of birth 12 April 1979, Australian Army, Carpenter (Royal Australian Engineers construction trade), enlisted 16 February 1998, medically discharged 20 November 2013. Operational service: East Timor, 20 January 2000 to 25 July 2000 (warlike); Solomon Islands, 05 August 2003 to 20 December 2003 (non-warlike); Afghanistan, 10 February 2008 to 18 May 2008 (warlike, ended by aeromedical evacuation).

Occupational History

Construction tradespeople in the Royal Australian Engineers build and repair accommodation, bridges, defensive structures and camps in barracks, on exercise and on deployment. The trade involves sawing, drilling and handling timber, including salvaged and locally sourced timber treated with preservatives such as pentachlorophenol and copper chrome arsenate, often without adequate dust extraction or respiratory protection in the field. Work is heavy and physical, carried out in heat, and deployed camps may rely on untreated bore water.

In the period of this veteran's service, smoking was common in workshops, crib rooms, vehicles, tents and shared accommodation, exposing non-smokers and smokers alike to enclosed tobacco smoke. Engineers on operations travel by road through areas threatened by improvised explosive devices and are at risk of blast injury, massive haemorrhage and battlefield transfusion with fresh whole blood from unscreened donors.

History

Veteran CB, a carpenter in the Royal Australian Engineers, developed insulin-requiring diabetes mellitus on 18 April 2014, in early pregnancy, after a 2008 improvised explosive device blast in Afghanistan that caused splenectomy, distal pancreatectomy, traumatic pancreatitis, a below-knee amputation and transfusion-acquired HIV and hepatitis C. These led to a liver transplant, long-term tacrolimus and prednisolone, haemolytic uraemic syndrome and chronic renal failure. Earlier service exposures to dioxin-contaminated timber, arsenic and tobacco smoke, a germ cell tumour treated with bilateral orchiectomy and abdominal radiotherapy, and service-related psychiatric illness also contributed. The diabetes worsened with diabetic ketoacidosis in a second pregnancy in June 2019.

Timeline

14 Apr 2004 — Assessment by a dermatologist and occupational physician after the Solomon Islands deployment. The veteran had palmar and plantar hyperkeratoses, transverse white nail lines and peripheral paraesthesia. Urinary arsenic was markedly raised. Chronic arsenic toxicity was diagnosed, attributed to drinking camp bore water and sawing copper chrome arsenate treated timber on deployment, with further exposure to pentachlorophenol-treated timber in East Timor and the Solomon Islands. Fasting glucose 4.9 mmol/L. She smoked 15 cigarettes a day. "chronic arsenic toxicity, FPG 4.9"
12 Jul 2006 — Investigation of a right adnexal mass found a seminoma arising in the testicular component of a right ovotestis, and karyotype and imaging confirmed 46,XX ovotesticular difference of sex development with bilateral ovotestes. After embryo cryopreservation, a surgeon performed bilateral orchiectomy, excising the testicular tissue of both gonads and preserving ovarian tissue. Para-aortic radiotherapy of 25 Gy followed, with the pancreas in the treatment field. She had a first child in March 2005 and had been unable to breastfeed after being recalled to field duties. "bilateral orchiectomy, para-aortic RT"
18 May 2008 — On warlike service in Afghanistan the veteran's vehicle struck an improvised explosive device. She sustained a ruptured spleen, a laceration of the tail of the pancreas and a traumatic left below-knee amputation. At the role 3 hospital she underwent splenectomy and distal pancreatectomy and received a massive transfusion including fresh whole blood from a walking blood bank. Post-operative acute pancreatitis with a lipase of 2,400 U/L was treated in intensive care. "splenectomy, distal pancreatectomy, transfused"
14 Mar 2012 — Liver transplant for decompensated cirrhosis from hepatitis C infection, which had been diagnosed together with HIV infection in September 2008 and traced to the battlefield transfusion. She was maintained on tacrolimus, prednisolone 15 mg daily and antiretrovirals including darunavir. By then she was also being treated by a psychiatrist for posttraumatic stress disorder, depression, bipolar disorder and schizophrenia with olanzapine, sodium valproate and sertraline. "liver transplant, tacrolimus, prednisolone"
10 Jun 2013 — A renal physician commenced haemodialysis for chronic renal failure following tacrolimus-associated haemolytic uraemic syndrome diagnosed on 18 September 2012, with an eGFR below 15 mL/min/1.73 m2 since April 2013. Hypertension and gout were being treated. Laboratory-confirmed Coxsackie B4 myopericarditis had occurred in October 2012. Annual transplant bloods on 05 March 2013 showed HbA1c 5.8 per cent and fasting glucose 6.1 mmol/L, without diabetes. She stopped smoking on 15 January 2013. "haemodialysis, HUS, HbA1c 5.8"
22 Apr 2014 — Presented to the antenatal clinic at nine weeks' gestation after a frozen embryo transfer on 27 February 2014, with four days of thirst, polyuria and fatigue since 18 April 2014. Fasting plasma glucose was 10.6 mmol/L and HbA1c 7.6 per cent. She had completed peginterferon alfa for recurrent hepatitis C in the graft on 20 December 2013, had received goserelin since January 2013, and had ingested a pyrinuron (Vacor) rodenticide during a psychotic relapse on 25 March 2014. BMI 29.4, waist 96 centimetres. "FPG 10.6, HbA1c 7.6, pregnant"
24 Apr 2014 — An endocrinologist confirmed diabetes mellitus on a second fasting plasma glucose of 11.2 mmol/L. C-peptide was very low and GAD antibodies were positive, indicating near-total insulin deficiency, with marked insulin resistance from glucocorticoids, tacrolimus, cirrhosis and obesity. Basal-bolus insulin was commenced. A graft biopsy on 03 February 2014 had shown cirrhosis with steatohepatitis. "diabetes confirmed, insulin commenced"
14 Jun 2019 — Admitted with diabetic ketoacidosis at eleven weeks' gestation in a second pregnancy after frozen embryo transfer on 10 April 2019. Blood glucose was 24.8 mmol/L, pH 7.12 and ketones 5.8 mmol/L. HbA1c had risen from 7.2 per cent in February 2019 to 10.9 per cent, and her insulin requirement doubled. She had again ingested pyrinuron rodenticide during a psychotic relapse on 30 May 2019, and approval for an insulin pump and continuous glucose monitor had been pending for eleven months. "DKA, HbA1c 10.9, insulin doubled"

Symptoms

At onset the veteran had thirst, frequent urination, fatigue and blurred vision, which she initially attributed to early pregnancy and dialysis. Home glucose readings ranged from 9 to 18 mmol/L before insulin was started.

Since onset she has required multiple daily insulin injections with frequent hypoglycaemia and hyperglycaemia, made worse by dialysis days, steroid doses and pregnancy. After the 2019 worsening she had diabetic ketoacidosis and her insulin requirements doubled. She now reports unstable glucose levels, recurrent hypoglycaemic episodes with confusion, fatigue, numbness in her remaining foot and slow healing of stump abrasions.

Imaging

11 Jul 2006 — MRI pelvis: "Right adnexal solid mass of 4.1 centimetres arising from a gonad containing both ovarian and testicular tissue, with a similar smaller left gonad. Normal uterus. No lymphadenopathy."
18 May 2008 — CT abdomen (trauma): "Shattered spleen with haemoperitoneum. Laceration through the tail of the pancreas with peripancreatic fluid. No other solid organ injury."
20 May 2014 — CT abdomen: "Post-distal pancreatectomy remnant of the pancreatic head and body with diffuse atrophy. Absent spleen. Transplanted liver with a nodular contour consistent with cirrhosis and steatosis. Small native kidneys."

Onset Date

The most likely date of onset of this condition is 18 Apr 2014.

At that date the veteran had been medically discharged for five months after service ending in November 2013. She was nine weeks pregnant after a frozen embryo transfer on 27 February 2014, on haemodialysis for chronic renal failure, taking tacrolimus and prednisolone after her 2012 liver transplant, and taking olanzapine, sodium valproate and sertraline for service-related psychiatric illness. On 18 April 2014 she developed thirst, polyuria and fatigue.

This date is appropriate because her annual transplant bloods on 05 March 2013 showed an HbA1c of 5.8 per cent and a fasting glucose of 6.1 mmol/L, below the diagnostic thresholds, and she first presented on 22 April 2014 with a fasting glucose of 10.6 mmol/L and an HbA1c of 7.6 per cent after four days of symptoms. The diagnosis was confirmed by a second fasting glucose of 11.2 mmol/L on 24 April 2014.

For the glucocorticoid factor, she took prednisolone 15 mg daily continuously from 14 Mar 2012 to onset. The 7 days before onset for the Specified List 1 drugs run from 11 Apr 2014 to 18 Apr 2014, during which she took tacrolimus and darunavir. The three months before onset for the antidepressant and antipsychotic factors run from 18 Jan 2014 to 18 Apr 2014 (six weeks from 07 Mar 2014 under the Reasonable Hypothesis). The 30 days before onset for the Vacor factor run from 19 Mar 2014 to 18 Apr 2014 and include the ingestion of 25 Mar 2014. The six months before onset for interferon run from 18 Oct 2013 to 18 Apr 2014; her last dose was on 20 Dec 2013. The three years before onset for Coxsackie B run from 18 Apr 2011 to 18 Apr 2014 and include the infection of October 2012. The five years before onset for overweight and physical inactivity run from 18 Apr 2009 to 18 Apr 2014; her BMI exceeded 25 and her waist 80 centimetres throughout, and she was unable to exceed 4 METs from her amputation in May 2008. The one year before onset for anti-androgen therapy runs from 18 Apr 2013 to 18 Apr 2014; goserelin depots were given from 10 Jan 2013 to 30 Jan 2014, the last maintaining suppression to late April 2014. She ceased smoking on 15 Jan 2013 and her enclosed second-hand smoke exposure ended in 2008, both within 15 years of onset. Her exposure to pentachlorophenol-treated timber totalled about 560 hours between 2000 and 2003, within one ten-year period, beginning more than five years before onset and ceasing less than 25 years before it.

For the worsening factors, the documented worsening was the diabetic ketoacidosis of 14 Jun 2019, with HbA1c rising from 7.2 to 10.9 per cent. The 30 days before the worsening run from 15 May 2019 to 14 Jun 2019 and include the second rodenticide ingestion of 30 May 2019. The three months before run from 14 Mar 2019 to 14 Jun 2019, the five years before from 14 Jun 2014 to 14 Jun 2019, and the one year before from 14 Jun 2018 to 14 Jun 2019, during which she took goserelin from April 2018 with the last depot on 22 Mar 2019. She was again pregnant, still on dialysis, prednisolone, tacrolimus, olanzapine and sertraline, and the other conditions persisted.

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

The formal diagnosis is Diabetes Mellitus (ICD-10-AM E13.9), insulin-requiring, with near-total insulin deficiency meeting the definition of type 1 diabetes mellitus and marked insulin resistance with features of type 2 diabetes mellitus, presenting in pregnancy and with drug-induced and secondary components, under the Statements of Principles concerning diabetes mellitus, Balance of Probabilities No. 49 of 2020 and Reasonable Hypothesis No. 48 of 2020.

Diabetes mellitus is persistent hyperglycaemia caused by deficient insulin secretion, resistance to the action of insulin, or both. Type 1 diabetes results from near-total loss of the insulin-producing beta cells of the pancreas, from autoimmune destruction, pancreatic surgery or injury, toxins such as pyrinuron, viral infection or radiation, and requires daily insulin. Type 2 diabetes results from insulin resistance with impaired insulin secretion and is driven by obesity, physical inactivity, smoking, liver disease, chronic infection, psychiatric illness and its treatment, and many medicines, including glucocorticoids, calcineurin inhibitors and antipsychotics. Pregnancy increases insulin resistance. Long-term complications include kidney, eye, nerve and cardiovascular disease.

The condition began on 18 April 2014, was confirmed on 24 April 2014 and worsened with diabetic ketoacidosis on 14 June 2019.

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

When did the veteran first experience symptoms attributable to this condition?

18 April 2014.

When did the veteran first present to a health / medical provider for this condition?

22 April 2014.

When was the condition confirmed / formally diagnosed?

24 April 2014.

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

15 July 2025.

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

The diagnosis was confirmed by two positive laboratory tests on separate days: a fasting plasma glucose of 10.6 mmol/L on 22 April 2014 and a fasting plasma glucose of 11.2 mmol/L on 24 April 2014, with an HbA1c of 7.6 per cent. This meets the Statement of Principles definition of diabetes mellitus (two fasting plasma glucose concentrations of at least 7.0 mmol/L on separate days), and the hyperglycaemia has persisted since. It is not impaired glucose tolerance.

An endocrinologist confirmed the diagnosis and classification. A very low C-peptide and positive GAD antibodies showed near-total insulin deficiency, and she has required daily insulin since 24 April 2014, which meets the definition of type 1 diabetes mellitus; marked insulin resistance from glucocorticoids, tacrolimus, cirrhosis, obesity and pregnancy contributes, consistent with type 2 features. The worsening was confirmed by diabetic ketoacidosis on 14 June 2019 with a blood glucose of 24.8 mmol/L, which also meets the definition, and by the rise in HbA1c to 10.9 per cent.

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.

Legislation: the clinical onset of this condition was on 18 April 2014, after 1 July 2004 and after discharge, and the principal factors arise from the veteran's warlike service in Afghanistan in 2008. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. Factors arising from service before 1 July 2004 relate to her operational service in East Timor and the Solomon Islands under the Veterans' Entitlements Act 1986, where the Statements of Principles also apply, and to peacetime service under the DRCA. The Reasonable Hypothesis instrument applies to operational (warlike and non-warlike) service, and the Balance of Probabilities instrument to peacetime service.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Balance of Probabilities — Statement of Principles concerning Diabetes Mellitus, No. 49 of 2020

Causative factors

Factor 9(1): having an endocrine disorder from the specified list of endocrine disorders before the clinical onset of diabetes mellitus; — MET

- An endocrinologist diagnosed iatrogenic Cushing syndrome in November 2012, with central obesity, facial plethora, striae and proximal myopathy, from continuous prednisolone after her liver transplant. Cushing syndrome is on the specified list and was present before onset on 18 April 2014.

Factor 9(2): having a solid organ transplant or bone marrow transplant before the clinical onset of diabetes mellitus; — MET

- The veteran received a liver transplant on 14 March 2012 for cirrhosis from hepatitis C acquired through battlefield transfusion after the 2008 blast. This was two years before onset.

Factor 9(3): having glucocorticoid therapy as specified, before the clinical onset of diabetes mellitus, and where the glucocorticoid therapy as specified has ceased or decreased, the last dose of the therapy was received within the 30 days before the clinical onset of diabetes mellitus; — MET

- From 14 March 2012 she took prednisolone 15 mg daily without interruption to onset, a cumulative dose of more than 11,000 mg at an average rate above 12.5 mg a day, which is equivalent glucocorticoid therapy as specified. The therapy had not ceased or decreased at onset.

Factor 9(4): being treated with a drug from the Specified List 1 of drugs, which cannot be ceased or substituted, for at least the seven days before the clinical onset of diabetes mellitus; — MET

- She took tacrolimus to prevent rejection of her liver graft, and darunavir, a protease inhibitor, for transfusion-acquired HIV, throughout the seven days before onset, from 11 April 2014 to 18 April 2014. Her transplant physician recorded that tacrolimus could not be ceased or substituted because of previous rejection on cyclosporine and toxicity on sirolimus.

Factor 9(5): being treated with a drug from the antidepressant or antipsychotic classes of drugs, which cannot be ceased or substituted, for at least the three months before the clinical onset of diabetes mellitus; — MET

- The veteran took olanzapine and sertraline continuously from 2011 for schizophrenia and depression that followed her service-related posttraumatic stress disorder, throughout the three months before onset from 18 January 2014 to 18 April 2014. Her psychiatrist recorded that olanzapine could not be ceased or substituted because of psychotic relapses on two alternative antipsychotics.

Factor 9(6)(a): for type 1 diabetes mellitus only: undergoing surgery to the pancreas before the clinical onset of diabetes mellitus; — MET

- A distal pancreatectomy was performed on 18 May 2008 for a laceration of the tail of the pancreas sustained in the improvised explosive device blast, removing about 40 per cent of the gland. Her near-total insulin deficiency meets the type 1 definition.

Factor 9(6)(b): for type 1 diabetes mellitus only: having a specified pathological condition involving the pancreas before the clinical onset of diabetes mellitus; — MET

- She had acute pancreatitis after the pancreatic injury and surgery in May 2008, with a lipase of 2,400 U/L, requiring intensive care. Acute pancreatitis is a specified pathological condition involving the pancreas.

Factor 9(6)(c): for type 1 diabetes mellitus only: having haemolytic uraemic syndrome before the clinical onset of diabetes mellitus; — MET

- Tacrolimus-associated haemolytic uraemic syndrome, with renal failure, microangiopathic haemolytic anaemia and thrombocytopaenia, was diagnosed by a renal physician on 18 September 2012, before onset.

Factor 9(6)(d): for type 1 diabetes mellitus only: ingesting N-3-pyridyl methyl-N'-p-nitrophenyl urea (Vacor) within the 30 days before the clinical onset of diabetes mellitus; — MET

- On 25 March 2014, during a relapse of her schizophrenia, the veteran ingested a pyrinuron (Vacor) rodenticide and was treated in hospital with nicotinamide. This was 24 days before onset. Vacor is toxic to pancreatic beta cells.

Factor 9(6)(e): for type 1 diabetes mellitus only: being treated with interferon alpha within the six months before the clinical onset of diabetes mellitus; — MET

- She was treated with peginterferon alfa-2a from 01 July 2013 to 20 December 2013 for recurrent hepatitis C in her liver graft. The last dose was within the six months before onset, which run from 18 October 2013 to 18 April 2014.

Factor 9(7)(a): for type 2 diabetes mellitus only: having smoked at least five pack-years of tobacco products before the clinical onset of diabetes mellitus, and where smoking has permanently ceased, the clinical onset of diabetes mellitus has occurred within 15 years of cessation; — MET

- The veteran smoked about 15 cigarettes a day from initial training in 1998 until 15 January 2013, about 11 pack-years. Onset on 18 April 2014 was 15 months after she stopped.

Factor 9(7)(b): being exposed to second-hand smoke for at least 5,000 hours before the clinical onset of diabetes mellitus, and where exposure to second-hand smoke has permanently ceased, the clinical onset of diabetes mellitus has occurred within 15 years of cessation; — MET

- From 1998 to 2008 she worked and lived in enclosed workshops, crib rooms, vehicles, tents and shared accommodation where colleagues smoked, for at least four hours a day, more than 5,800 hours in total. The exposure ceased in 2008, six years before onset.

Factor 9(7)(c): being overweight or obese for at least five years before the clinical onset of diabetes mellitus; — MET

- Her BMI was 26.8 in 2008 and rose to 29.4 by April 2014, with a waist circumference above 80 centimetres throughout, after her amputation, glucocorticoid therapy and olanzapine. She was overweight for the whole of the five years from 18 April 2009 to 18 April 2014.

Factor 9(7)(d): an inability to undertake moderate physical activity of at least four METs for at least the five years before the clinical onset of diabetes mellitus; — MET

- After her traumatic left below-knee amputation on 18 May 2008, recurrent stump breakdown, chronic pain, liver failure and then dialysis prevented any activity above about 3 METs, as recorded by her rehabilitation physician, for the whole of the five years before onset.

Factor 9(7)(e): having cirrhosis of the liver at the time of the clinical onset of diabetes mellitus; — MET

- A liver graft biopsy on 03 February 2014 showed cirrhosis from aggressive recurrent hepatitis C, confirmed on CT on 20 May 2014. It was present at onset.

Factor 9(7)(f): having non-alcoholic steatohepatitis at the time of the clinical onset of diabetes mellitus; — MET

- The same biopsy showed steatohepatitis with ballooning and fat in more than 30 per cent of hepatocytes, in a non-drinker, attributed to obesity, prednisolone and olanzapine. It was present at onset.

Factor 9(7)(g): having infection with human immunodeficiency virus before the clinical onset of diabetes mellitus; — MET

- HIV infection was diagnosed in September 2008 and traced to fresh whole blood given from a walking blood bank after the blast of 18 May 2008. It was present before onset.

Factor 9(7)(h): having infection with hepatitis C virus before the clinical onset of diabetes mellitus; — MET

- Hepatitis C infection was diagnosed in September 2008, acquired from the same battlefield transfusion, and recurred in the liver graft. It was present before onset.

Factor 9(7)(i): having depressive disorder at the time of the clinical onset of diabetes mellitus; — MET

- Major depressive disorder was diagnosed by a psychiatrist in 2009, following service-related posttraumatic stress disorder, and was active at onset with a PHQ-9 score of 19 recorded in March 2014.

Factor 9(7)(j): having bipolar disorder at the time of the clinical onset of diabetes mellitus; — MET

- Bipolar I disorder was diagnosed after a manic episode in October 2010 and was being treated with sodium valproate at onset.

Factor 9(7)(k): having schizophrenia at the time of the clinical onset of diabetes mellitus; — MET

- Schizophrenia was diagnosed in 2011 after persistent psychotic symptoms between mood episodes, and was active at onset, with a relapse in March 2014.

Factor 9(7)(l): having bilateral orchiectomy before the clinical onset of diabetes mellitus; — MET

- On 12 July 2006 the veteran, who has 46,XX ovotesticular difference of sex development, underwent bilateral orchiectomy to remove the testicular tissue of both gonads after a seminoma arose in the right gonad. This was before onset.

Factor 9(7)(m): having anti-androgen therapy with a gonadotrophin releasing hormone agonist, including goserelin and leuprorelin, for at least the one year before the clinical onset of diabetes mellitus; — MET

- She received goserelin depots from 10 January 2013 to 30 January 2014 for adenomyosis and to prepare for embryo transfer, maintaining suppression throughout the one year before onset, from 18 April 2013 to 18 April 2014.

Factor 9(7)(n): being exposed to arsenic as specified before the clinical onset of diabetes mellitus; — MET

- Chronic arsenic toxicity was diagnosed on 14 April 2004, with hyperkeratoses, nail changes, neuropathy and raised urinary arsenic, after drinking camp bore water and sawing arsenate-treated timber on deployment. This is clinical evidence of chronic arsenic toxicity.

Factor 9(8): for gestational diabetes mellitus and type 2 diabetes mellitus only, being pregnant at the time of the clinical onset of diabetes mellitus; — MET

- The veteran was nine weeks pregnant at onset on 18 April 2014, after a frozen embryo transfer on 27 February 2014 using embryos stored before her 2006 radiotherapy.

Worsening factors

Factor 9(9): having an endocrine disorder from the specified list of endocrine disorders before the clinical worsening of diabetes mellitus; — MET

- Iatrogenic Cushing syndrome persisted on continuing prednisolone and was present before the diabetic ketoacidosis of 14 June 2019, when HbA1c had risen from 7.2 to 10.9 per cent.

Factor 9(10): having a solid organ transplant or bone marrow transplant before the clinical worsening of diabetes mellitus; — MET

- The liver transplant of 14 March 2012 preceded the worsening on 14 June 2019.

Factor 9(11): having glucocorticoid therapy as specified, before the clinical worsening of diabetes mellitus, and where the glucocorticoid therapy as specified has ceased or decreased, the last dose of the therapy was received within the 30 days before the clinical worsening of diabetes mellitus; — MET

- Prednisolone 15 mg daily continued without interruption to the worsening, increased to 25 mg daily for an episode of graft rejection in May 2019.

Factor 9(12): being treated with a drug from the Specified List 1 of drugs, which cannot be ceased or substituted, for at least the seven days before the clinical worsening of diabetes mellitus; — MET

- Tacrolimus and darunavir continued throughout the seven days before the worsening, from 07 June 2019 to 14 June 2019, and could not be ceased or substituted.

Factor 9(13): being treated with a drug from the antidepressant or antipsychotic classes of drugs, which cannot be ceased or substituted, for at least the three months before the clinical worsening of diabetes mellitus; — MET

- Olanzapine and sertraline continued throughout the three months before the worsening, from 14 March 2019 to 14 June 2019, and could not be ceased or substituted.

Factor 9(14): undergoing surgery to the pancreas before the clinical worsening of diabetes mellitus; — MET

- The distal pancreatectomy of 18 May 2008 preceded the worsening, and CT showed atrophy of the pancreatic remnant.

Factor 9(15): having a specified pathological condition involving the pancreas before the clinical worsening of diabetes mellitus; — MET

- The acute pancreatitis of May 2008 preceded the worsening.

Factor 9(16): having haemolytic uraemic syndrome before the clinical worsening of diabetes mellitus; — MET

- The haemolytic uraemic syndrome of September 2012 preceded the worsening.

Factor 9(17): ingesting N-3-pyridyl methyl-N'-p-nitrophenyl urea (Vacor) within the 30 days before the clinical worsening of diabetes mellitus; — MET

- On 30 May 2019, during a further psychotic relapse, she again ingested pyrinuron rodenticide, 15 days before the diabetic ketoacidosis of 14 June 2019.

Factor 9(18): having depressive disorder at the time of the clinical worsening of diabetes mellitus; — MET

- Major depressive disorder was active at the worsening, with a PHQ-9 score of 21 recorded on admission.

Factor 9(19): having bipolar disorder at the time of the clinical worsening of diabetes mellitus; — MET

- Bipolar I disorder persisted at the worsening and was treated by her psychiatrist.

Factor 9(20): having schizophrenia at the time of the clinical worsening of diabetes mellitus; — MET

- Schizophrenia was in relapse at the worsening, from late May 2019.

Factor 9(21)(a): for type 2 diabetes mellitus only: having smoked at least five pack-years of tobacco products before the clinical worsening of diabetes mellitus, and where smoking has permanently ceased, the clinical worsening of diabetes mellitus has occurred within 15 years of cessation; — MET

- She smoked about 11 pack-years before stopping on 15 January 2013, and the worsening occurred six and a half years later.

Factor 9(21)(b): being exposed to second-hand smoke for at least 5,000 hours before the clinical worsening of diabetes mellitus, and where exposure to second-hand smoke has permanently ceased, the clinical worsening of diabetes mellitus has occurred within 15 years of cessation; — MET

- Her more than 5,800 hours of enclosed second-hand smoke exposure during service ended in 2008, eleven years before the worsening.

Factor 9(21)(c): being overweight or obese for at least five years before the clinical worsening of diabetes mellitus; — MET

- Her BMI remained between 28 and 31, with a waist above 80 centimetres, throughout the five years before the worsening, from 14 June 2014 to 14 June 2019.

Factor 9(21)(d): an inability to undertake moderate physical activity of at least four METs for at least the five years before the clinical worsening of diabetes mellitus; — MET

- Her amputation, stump problems and dialysis continued to prevent activity above about 3 METs throughout the five years before the worsening.

Factor 9(21)(e): having cirrhosis of the liver at the time of the clinical worsening of diabetes mellitus; — MET

- Cirrhosis of the liver graft persisted, with liver stiffness of 18 kPa on elastography in April 2019.

Factor 9(21)(f): having non-alcoholic steatohepatitis at the time of the clinical worsening of diabetes mellitus; — MET

- Steatohepatitis persisted at the worsening, with steatosis on imaging and raised transaminases in a non-drinker.

Factor 9(21)(g): having infection with human immunodeficiency virus before the clinical worsening of diabetes mellitus; — MET

- Transfusion-acquired HIV infection from 2008 preceded the worsening.

Factor 9(21)(h): having infection with hepatitis C virus before the clinical worsening of diabetes mellitus; — MET

- Transfusion-acquired hepatitis C infection from 2008 preceded the worsening.

Factor 9(21)(i): having bilateral orchiectomy before the clinical worsening of diabetes mellitus; — MET

- The bilateral orchiectomy of 12 July 2006 preceded the worsening.

Factor 9(21)(j): having anti-androgen therapy with a gonadotrophin releasing hormone agonist, including goserelin and leuprorelin, for at least the one year before the clinical worsening of diabetes mellitus; — MET

- Goserelin depots from 05 April 2018 to 22 March 2019, before a second embryo transfer, maintained suppression throughout the one year before the worsening, from 14 June 2018 to 14 June 2019.

Factor 9(21)(k): being exposed to arsenic as specified before the clinical worsening of diabetes mellitus; — MET

- Chronic arsenic toxicity diagnosed on 14 April 2004 preceded the worsening.

Factor 9(22): for gestational diabetes mellitus and type 2 diabetes mellitus only, being pregnant at the time of the clinical worsening of diabetes mellitus; — MET

- She was eleven weeks pregnant at the worsening on 14 June 2019, after a frozen embryo transfer on 10 April 2019.

Factor 9(23): inability to obtain appropriate clinical management for diabetes mellitus. — MET

- An insulin pump and continuous glucose monitor recommended by her endocrinologist in July 2018 for brittle diabetes on dialysis were not approved for eleven months, and she waited four months for a high-risk pregnancy diabetes review, during which the diabetes worsened to ketoacidosis. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Diabetes Mellitus, No. 48 of 2020

Causative factors

Factor 9(1): having an endocrine disorder from the specified list of endocrine disorders before the clinical onset of diabetes mellitus; — MET

- Iatrogenic Cushing syndrome, diagnosed in November 2012, resulted from the prednisolone required after a liver transplant that followed transfusion-acquired hepatitis C from the blast on warlike service in Afghanistan. It was present before onset.

Factor 9(2): having a solid organ transplant or bone marrow transplant before the clinical onset of diabetes mellitus; — MET

- The liver transplant of 14 March 2012 was needed because of hepatitis C acquired from battlefield transfusion on warlike service in Afghanistan on 18 May 2008.

- Prednisolone 15 mg daily, continuous from 14 March 2012 to onset for the transplant that followed her warlike service injuries, exceeded the specified cumulative dose and rate and had not ceased at onset.

- Tacrolimus for the liver graft and darunavir for HIV, both consequences of the warlike service transfusion, were taken throughout the seven days before onset and could not be ceased or substituted.

Factor 9(5): being treated with a drug from the antidepressant or antipsychotic classes of drugs, which cannot be ceased or substituted, for at least the six weeks before the clinical onset of diabetes mellitus; — MET

- Olanzapine and sertraline, for psychiatric illness that followed posttraumatic stress disorder from the blast on warlike service, were taken throughout the six weeks before onset, from 07 March 2014 to 18 April 2014, and could not be ceased or substituted.

Factor 9(6)(a): for type 1 diabetes mellitus only: undergoing surgery to the pancreas before the clinical onset of diabetes mellitus; — MET

- The distal pancreatectomy of 18 May 2008 was performed for a pancreatic laceration from the improvised explosive device blast on warlike service in Afghanistan.

Factor 9(6)(b): for type 1 diabetes mellitus only: undergoing splenectomy for trauma before the clinical onset of diabetes mellitus; — MET

- Splenectomy was performed on 18 May 2008 for a ruptured spleen sustained in the blast on warlike service in Afghanistan.

Factor 9(6)(c): for type 1 diabetes mellitus only: undergoing a course of therapeutic radiation for cancer, where the pancreas was in the field of radiation, before the clinical onset of diabetes mellitus; — MET

- In August and September 2006 she received 25 Gy of para-aortic radiotherapy for seminoma, with the pancreas within the treatment field according to the radiation oncologist's plan. This was before onset; the radiotherapy was provided during her service.

Factor 9(6)(d): for type 1 diabetes mellitus only: having a specified pathological condition involving the pancreas before the clinical onset of diabetes mellitus; — MET

- Acute pancreatitis followed the pancreatic injury sustained on warlike service in Afghanistan in May 2008.

Factor 9(6)(e): for type 1 diabetes mellitus only: having haemolytic uraemic syndrome before the clinical onset of diabetes mellitus; — MET

- Haemolytic uraemic syndrome in September 2012 was caused by tacrolimus required for the transplant that followed her warlike service transfusion.

Factor 9(6)(f): for type 1 diabetes mellitus only: ingesting N-3-pyridyl methyl-N'-p-nitrophenyl urea (Vacor) within the 30 days before the clinical onset of diabetes mellitus; — MET

- She ingested pyrinuron rodenticide on 25 March 2014, 24 days before onset, during a relapse of schizophrenia, an illness that developed after posttraumatic stress disorder from warlike service.

Factor 9(6)(g): for type 1 diabetes mellitus only: being treated with interferon alpha within the six months before the clinical onset of diabetes mellitus; — MET

- Peginterferon alfa-2a for recurrent hepatitis C, acquired through transfusion on warlike service, was given until 20 December 2013, within the six months before onset.

Factor 9(6)(h): for type 1 diabetes mellitus only: having infection with a Coxsackie B virus within the three years before the clinical onset of diabetes mellitus; — MET

- Coxsackie B4 myopericarditis was confirmed by viral PCR in October 2012, eighteen months before onset, while she was immunosuppressed for the transplant that followed her warlike service injuries.

- She smoked about 11 pack-years from 1998, including throughout her warlike service in East Timor and Afghanistan and non-warlike service in the Solomon Islands, and stopped on 15 January 2013, 15 months before onset.

- Enclosed second-hand smoke exposure of more than 5,800 hours, including in tents, vehicles and shared accommodation in East Timor, the Solomon Islands and Afghanistan, ended in 2008, six years before onset.

Factor 9(7)(c): being overweight or obese for at least five years before the clinical onset of diabetes mellitus; — MET

- She was overweight throughout the five years before onset, after the amputation sustained on warlike service and the glucocorticoids and antipsychotics that followed.

Factor 9(7)(d): an inability to undertake moderate physical activity of at least four METs for at least the five years before the clinical onset of diabetes mellitus; — MET

- The below-knee amputation from the blast on warlike service in Afghanistan, and its complications, prevented activity of four METs or more from May 2008 to onset.

Factor 9(7)(e): having cirrhosis of the liver at the time of the clinical onset of diabetes mellitus; — MET

- Cirrhosis of the liver graft from recurrent hepatitis C, acquired through transfusion on warlike service, was present at onset.

Factor 9(7)(f): having non-alcoholic steatohepatitis at the time of the clinical onset of diabetes mellitus; — MET

- Steatohepatitis, related to obesity, prednisolone and olanzapine that followed her warlike service injuries, was present at onset on biopsy.

Factor 9(7)(g): having infection with human immunodeficiency virus before the clinical onset of diabetes mellitus; — MET

- HIV infection was acquired from fresh whole blood given on warlike service in Afghanistan on 18 May 2008.

Factor 9(7)(h): having infection with hepatitis C virus before the clinical onset of diabetes mellitus; — MET

- Hepatitis C infection was acquired from the same battlefield transfusion on warlike service.

Factor 9(7)(i): having hypertension at the time of the clinical onset of diabetes mellitus; — MET

- Hypertension, from tacrolimus, prednisolone and chronic renal failure, was treated with two agents and present at onset, with a blood pressure of 158/96 recorded on 22 April 2014.

Factor 9(7)(j): having chronic renal failure at the time of the clinical onset of diabetes mellitus; — MET

- Her eGFR was below 15 mL/min/1.73 m2 from April 2013 and she was on haemodialysis from 10 June 2013, after haemolytic uraemic syndrome caused by tacrolimus for the transplant that followed her warlike service transfusion. Chronic renal failure was present at onset.

Factor 9(7)(k): having gout or hyperuricaemia at the time of the clinical onset of diabetes mellitus; — MET

- Gout, with serum urate persistently above 0.50 mmol/L from tacrolimus and renal failure, was treated and present at onset.

Factor 9(7)(l): having posttraumatic stress disorder at the time of the clinical onset of diabetes mellitus; — MET

- Posttraumatic stress disorder from the improvised explosive device blast on warlike service in Afghanistan was diagnosed in 2008 and active at onset.

Factor 9(7)(m): having depressive disorder at the time of the clinical onset of diabetes mellitus; — MET

- Major depressive disorder, which followed her warlike service posttraumatic stress disorder, was active at onset.

Factor 9(7)(n): having bipolar disorder at the time of the clinical onset of diabetes mellitus; — MET

- Bipolar I disorder, diagnosed in October 2010 after her warlike service injuries, was present at onset.

Factor 9(7)(o): having schizophrenia at the time of the clinical onset of diabetes mellitus; — MET

- Schizophrenia, diagnosed in 2011 and in relapse in March 2014, was present at onset.

Factor 9(7)(p): having bilateral orchiectomy before the clinical onset of diabetes mellitus; — MET

- Bilateral orchiectomy of the testicular tissue of both gonads was performed on 12 July 2006, during service, before onset.

Factor 9(7)(q): having anti-androgen therapy as specified for at least the one year before the clinical onset of diabetes mellitus; — MET

- Goserelin, a gonadotrophin releasing hormone agonist, was given from 10 January 2013 to 30 January 2014, maintaining suppression throughout the one year before onset.

Factor 9(7)(r): being exposed to arsenic as specified before the clinical onset of diabetes mellitus; — MET

- Chronic arsenic toxicity, diagnosed on 14 April 2004, followed drinking camp bore water and sawing arsenate-treated timber on non-warlike service in the Solomon Islands in 2003.

Factor 9(7)(s): inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD): (i) for a cumulative period of at least 500 hours, within a consecutive period of ten years before the clinical onset of diabetes mellitus; and (ii) where the first exposure occurred at least five years before the clinical onset of diabetes mellitus; and (iii) where that exposure has ceased, the clinical onset of diabetes mellitus has occurred within 25 years of cessation; — MET

- On warlike service in East Timor from February to July 2000 she sawed and handled salvaged pentachlorophenol-treated timber for about 320 hours, and on non-warlike service in the Solomon Islands from August to December 2003 for about 240 hours, working in dust without extraction, as recorded in her engineer task logs. The total of about 560 hours fell within one ten-year period, the first exposure was 14 years before onset, and onset was about ten and a half years after the exposure ceased.

Factor 9(7)(t): for parous women only, inability to breast feed for a cumulative period of at least six months before the clinical onset of diabetes mellitus; — MET

- After the birth of her first child in March 2005 the veteran was recalled to full-time field duties at six weeks without lactation facilities and could not breastfeed, so her infant was formula fed for the rest of the first year, a cumulative period of more than six months.

Factor 9(8): for gestational diabetes mellitus and type 2 diabetes mellitus only, being pregnant at the time of the clinical onset of diabetes mellitus; — MET

- She was nine weeks pregnant at onset on 18 April 2014.

Worsening factors

Factor 9(9): having an endocrine disorder from the specified list of endocrine disorders before the clinical worsening of diabetes mellitus; — MET

- Iatrogenic Cushing syndrome persisted before the worsening on 14 June 2019.

Factor 9(10): having a solid organ transplant or bone marrow transplant before the clinical worsening of diabetes mellitus; — MET

- The liver transplant that followed her warlike service transfusion preceded the worsening.

- Prednisolone continued to the worsening, increased to 25 mg daily in May 2019.

- Tacrolimus and darunavir continued throughout the seven days before the worsening.

Factor 9(13): being treated with a drug from the antidepressant or antipsychotic classes of drugs, which cannot be ceased or substituted, for at least the six weeks before the clinical worsening of diabetes mellitus; — MET

- Olanzapine and sertraline continued throughout the six weeks before the worsening, from 03 May 2019 to 14 June 2019.

Factor 9(14): undergoing surgery to the pancreas before the clinical worsening of diabetes mellitus; — MET

- The distal pancreatectomy for blast injury on warlike service preceded the worsening.

Factor 9(15): undergoing splenectomy for trauma before the clinical worsening of diabetes mellitus; — MET

- The splenectomy for blast injury on warlike service preceded the worsening.

Factor 9(16): undergoing a course of therapeutic radiation for cancer, where the pancreas was in the field of radiation, before the clinical worsening of diabetes mellitus; — MET

- The 2006 para-aortic radiotherapy, with the pancreas in the field, preceded the worsening.

Factor 9(17): having a specified pathological condition involving the pancreas before the clinical worsening of diabetes mellitus; — MET

- Acute pancreatitis after the warlike service blast injury preceded the worsening.

Factor 9(18): having haemolytic uraemic syndrome before the clinical worsening of diabetes mellitus; — MET

- Haemolytic uraemic syndrome in 2012 preceded the worsening.

Factor 9(19): ingesting N-3-pyridyl methyl-N'-p-nitrophenyl urea (Vacor) within the 30 days before the clinical worsening of diabetes mellitus; — MET

- She ingested pyrinuron rodenticide on 30 May 2019, during a relapse of psychiatric illness that followed her warlike service, 15 days before the worsening.

Factor 9(20): having depressive disorder at the time of the clinical worsening of diabetes mellitus; — MET

- Major depressive disorder was active at the worsening.

Factor 9(21): having bipolar disorder at the time of the clinical worsening of diabetes mellitus; — MET

- Bipolar I disorder was present at the worsening.

Factor 9(22): having schizophrenia at the time of the clinical worsening of diabetes mellitus; — MET

- Schizophrenia was in relapse at the worsening.

Factor 9(23)(a): for type 2 diabetes mellitus only: having smoked at least five pack-years of tobacco products before the clinical worsening of diabetes mellitus, and where smoking has permanently ceased, the clinical worsening of diabetes mellitus has occurred within 15 years of cessation; — MET

- About 11 pack-years were smoked during service, including on operations, and the worsening was six and a half years after cessation.

Factor 9(23)(b): being exposed to second-hand smoke for at least 5,000 hours before the clinical worsening of diabetes mellitus, and where exposure to second-hand smoke has permanently ceased, the clinical worsening of diabetes mellitus has occurred within 15 years of cessation; — MET

- More than 5,800 hours of enclosed exposure, including on operations, ended in 2008, eleven years before the worsening.

Factor 9(23)(c): being overweight or obese for at least five years before the clinical worsening of diabetes mellitus; — MET

- She was overweight throughout the five years before the worsening.

Factor 9(23)(d): an inability to undertake moderate physical activity of at least four METs for at least the five years before the clinical worsening of diabetes mellitus; — MET

- The amputation from warlike service and dialysis prevented activity of four METs throughout the five years before the worsening.

Factor 9(23)(e): having cirrhosis of the liver at the time of the clinical worsening of diabetes mellitus; — MET

- Graft cirrhosis from transfusion-acquired hepatitis C persisted at the worsening.

Factor 9(23)(f): having non-alcoholic steatohepatitis at the time of the clinical worsening of diabetes mellitus; — MET

- Steatohepatitis persisted at the worsening.

Factor 9(23)(g): having infection with human immunodeficiency virus before the clinical worsening of diabetes mellitus; — MET

- HIV acquired on warlike service preceded the worsening.

Factor 9(23)(h): having infection with hepatitis C virus before the clinical worsening of diabetes mellitus; — MET

- Hepatitis C acquired on warlike service preceded the worsening.

Factor 9(23)(i): having hypertension at the time of the clinical worsening of diabetes mellitus; — MET

- Hypertension persisted at the worsening, with a blood pressure of 162/98 on admission.

Factor 9(23)(j): having chronic renal failure at the time of the clinical worsening of diabetes mellitus; — MET

- She remained on haemodialysis for chronic renal failure at the worsening.

Factor 9(23)(k): having gout or hyperuricaemia at the time of the clinical worsening of diabetes mellitus; — MET

- Hyperuricaemia, with a serum urate of 0.56 mmol/L, and gout persisted at the worsening.

Factor 9(23)(l): having posttraumatic stress disorder at the time of the clinical worsening of diabetes mellitus; — MET

- Posttraumatic stress disorder from warlike service in Afghanistan was active at the worsening.

Factor 9(23)(m): having bilateral orchiectomy before the clinical worsening of diabetes mellitus; — MET

- The 2006 bilateral orchiectomy preceded the worsening.

Factor 9(23)(n): having anti-androgen therapy as specified for at least the one year before the clinical worsening of diabetes mellitus; — MET

- Goserelin from 05 April 2018 to 22 March 2019 maintained suppression throughout the one year before the worsening.

Factor 9(23)(o): being exposed to arsenic as specified before the clinical worsening of diabetes mellitus; — MET

- Chronic arsenic toxicity from non-warlike service in the Solomon Islands preceded the worsening.

Factor 9(23)(p): inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD): (i) for a cumulative period of at least 500 hours, within a consecutive period of ten years before the clinical worsening of diabetes mellitus; and (ii) where the first exposure occurred at least five years before the clinical worsening of diabetes mellitus; and (iii) where that exposure has ceased, the clinical worsening of diabetes mellitus has occurred within 25 years of cessation; — MET

- Her about 560 hours of pentachlorophenol-treated timber work in East Timor (warlike) and the Solomon Islands (non-warlike) between 2000 and 2003 fell within one ten-year period, began 19 years before the worsening, and ceased about 15 and a half years before it.

Factor 9(24): for gestational diabetes mellitus and type 2 diabetes mellitus only, being pregnant at the time of the clinical worsening of diabetes mellitus; — MET

- She was eleven weeks pregnant at the worsening on 14 June 2019.

Factor 9(25): inability to obtain appropriate clinical management for diabetes mellitus. — MET

- The insulin pump and continuous glucose monitor recommended in July 2018 were not approved for eleven months, and specialist pregnancy diabetes review was delayed, before the ketoacidosis of June 2019.

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

Sequelae

The diabetes has led to diabetic peripheral neuropathy in the remaining right foot, confirmed on nerve conduction studies in 2021, and to impaired healing of abrasions on the amputation stump, which have limited her prosthesis use. Recurrent hypoglycaemia on dialysis days has caused two falls, and the diabetic ketoacidosis of June 2019 required intensive care admission during pregnancy.

Unintended Consequence

Met. The diabetes is in part an unintended consequence of prednisolone, tacrolimus, darunavir, olanzapine, sodium valproate, peginterferon alfa and goserelin, prescribed for conditions arising from her service and provided and paid for by the Commonwealth while she was serving and afterwards (section 6A of the DRCA and the equivalent provisions of the MRCA). The para-aortic radiotherapy of 2006, given during her service, also contributed to loss of pancreatic function.

Inability to Attain Appropriate Medical Management

MET. In July 2018 the veteran's endocrinologist recommended an insulin pump and continuous glucose monitor for brittle, insulin-requiring diabetes complicated by dialysis, glucocorticoid therapy and planned pregnancy. Approval was not given for eleven months, and her referral to a high-risk pregnancy diabetes service waited four months, during which her HbA1c rose from 7.2 to 10.9 per cent and she developed diabetic ketoacidosis on 14 June 2019. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), administrative delays that prevent recommended treatment amount to an inability to obtain appropriate clinical management. The absence of glucose monitoring during the months she took high-dose prednisolone, tacrolimus and olanzapine before onset is a further barrier to care.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

14 Apr 2004, Dermatology and occupational medicine assessment, Dermatologist and Occupational physician
12 Jul 2006, Operation report and histology, Gynaecological oncologist and Pathologist
14 Sep 2006, Radiotherapy treatment summary, Radiation oncologist
18 May 2008, Trauma admission, CT and operation reports, Role 3 hospital, Afghanistan
22 Sep 2008, Infectious diseases consultation, Infectious diseases physician
14 Mar 2012, Liver transplant operation report, Transplant surgeon
18 Sep 2012, Renal medicine consultation, Renal physician
05 Mar 2013, Transplant clinic review and pathology, Hepatologist
03 Feb 2014, Liver graft biopsy report, Pathologist
22 Apr 2014, Antenatal clinic record and pathology, Obstetrician
24 Apr 2014, Endocrinology consultation, Endocrinologist
20 May 2014, CT abdomen, Radiologist
14 Jun 2019, Hospital admission and discharge summary, Endocrinologist and Intensive care physician
Statement of Principles concerning Diabetes Mellitus (Balance of Probabilities) No. 49 of 2020, Repatriation Medical Authority
Statement of Principles concerning Diabetes Mellitus (Reasonable Hypothesis) No. 48 of 2020, Repatriation Medical Authority

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Diabetes Mellitus — DVA claim example

Diagnostic Assessment — Diabetes Mellitus

Diagnostic Assessment