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Claims Library › Gastroesophageal Reflux Disease - Medication - Induced

Example Diagnostic Assessment

Gastroesophageal Reflux Disease - Medication - Induced — DVA claim example

1 de-identified example Diagnostic Assessment for Gastroesophageal Reflux Disease - Medication - Induced, written by the Veterans Health Centre for a DVA compensation claim. A Diagnostic Assessment is the claim: it is the document a DVA delegate decides on. Read it in full below — the named diagnosis and ICD-10 code, the ADF and occupational history, the referenced clinical timeline, and every Statement of Principles factor argued to MET or NOT MET.

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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 — Gastroesophageal Reflux Disease - Medication - Induced

Example 1 of 1 · fictitious patient (Veteran H)

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

Gastroesophageal Reflux Disease - Medication-Induced

Balance of Probabilities: No. 62 of 2021, s9(6) - taking a drug from the Specified List 1 of drugs at the time of clinical onset; s9(22) - taking orally a drug from the Specified List 2 of drugs at the time of clinical worsening Reasonable Hypothesis: No. 61 of 2021, s9(6) - taking a drug from the Specified List 1 of drugs at the time of clinical onset; s9(22) - taking orally a drug from the Specified List 2 of drugs at the time of clinical worsening

ADF History

The veteran, Date of Birth: [withheld] M113 Crewman/RAAC Assistant Instructor, enlistment date 06 November 1988, discharge date 10 May 2007 (CFTS ended 30 Apr 1992, General Reserves until approximately 2001, Army Standby Reserve until 2013).

Occupational History

As an M113 Crewman and RAAC Assistant Instructor in the Australian Army, the veteran service involved considerable physical demands and potential environmental exposures. His role required exposure to various military medications prescribed as part of operational medical care, including prophylactic antibiotics during deployment. Military personnel are required to take prescribed medications as directed by military medical officers, particularly during operational deployments where compliance is mandatory.

History

Mr. John the veteran, formerly an M113 Crewman in the Australian Army, developed medication-induced esophageal symptoms in July 1994 during active military service while taking prescribed Doxycycline therapy. The condition was directly caused by mandatory military medical treatment during his operational service period.

Timeline

  • 22 Jun 1991: Presented to military medical officer the treating doctor with esophageal discomfort for a few weeks, radiates to back. Had been taking Doxycycline 100mg daily for approximately 2 months as prescribed military medication. Advised to cease medication and referred to gastroenterology specialist.
  • 28 Jun 1991: Assessed by the treating doctor (Gastroenterology specialist). History documented pain when swallows feels pain, pain can be quite prompt relief when drinks cordial or water, happens several times daily even when swallowing saliva. Prescribed Mylanta antacid treatment for symptom relief.
  • 20 July 1991: Follow-up documented complete resolution of symptoms. Lost after a few days from above date his symptoms had cleared & have not recurred. This confirmed the direct causal relationship between Doxycycline therapy and esophageal symptoms.
  • 16 August 2015: DVA Diagnosis Form completed by Dr. Thomas Perkins diagnosing gastroesophageal reflux disease. First formal presentation for DVA compensation purposes addressing the historical medication-induced esophageal condition.

Symptoms

At the time of initial presentation in July 1994, the veteran experienced esophageal discomfort radiating to his back, difficulty swallowing, and pain on swallowing that was relieved by drinking liquids. Symptoms occurred multiple times daily, even when swallowing saliva. The discomfort was better if he ate very slowly. Following cessation of the causative medication, all symptoms resolved completely within days and did not recur. Current symptoms are not documented as the condition resolved following withdrawal of the causative military-prescribed medication.

Imaging

No imaging studies were performed for this condition as the diagnosis was made clinically based on the clear temporal relationship between medication use and symptom development, followed by prompt resolution upon cessation.

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

The formal diagnosis is Medication-Induced Gastroesophageal Reflux Disease, DVA SOP codes No. 61 of 2021 (Reasonable Hypothesis) and No. 62 of 2021 (Balance of Probabilities), ICD-10 code K21.9. This condition represents esophageal irritation and reflux symptoms directly caused by Doxycycline therapy prescribed during military service. Gastroesophageal reflux disease is a chronic condition involving retrograde flow of gastroduodenal contents into the oesophagus, larynx or pharynx, resulting in symptoms sufficient to warrant regular medical treatment or histological evidence of oesophageal inflammation. The temporal relationship between medication initiation, symptom development, and complete resolution upon cessation provides clear evidence of drug-induced etiology.

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

When did the veteran first experience symptoms attributable to this condition? Early July 1994, with symptoms present for "a few weeks" when presenting to the treating doctor on 22 Jun 1991.

When did the veteran first present to a health/medical provider for this condition? 22 Jun 1991 to the treating doctor (Military Medical Officer).

When was the condition confirmed/formally diagnosed? 28 Jun 1991 by the treating doctor (Gastroenterology Specialist), confirmed by symptom resolution following medication cessation on 20 July 1991.

When did the veteran first present to you (or your practice) for this condition? 15 July 2014.

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 through clinical assessment by military medical personnel and specialist gastroenterology evaluation. the treating doctor initially recognized the temporal relationship between Doxycycline use and esophageal symptoms, advising medication cessation and specialist referral. the treating doctor (Gastroenterology) conducted comprehensive assessment documenting characteristic symptoms of esophageal pain on swallowing with relief from liquids, consistent with medication-induced esophageal irritation. The diagnosis was definitively confirmed by prompt and complete resolution of symptoms following Doxycycline cessation, establishing clear cause-and-effect relationship. No invasive investigations were required due to the obvious temporal relationship and symptom resolution.

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.

Taking a drug from the Specified List 2 of drugs at the time of the clinical onset of gastro-oesophageal reflux disease - MET

  • The veteran was prescribed and taking Doxycycline 100mg daily for approximately 2 months prior to symptom onset. Doxycycline is specifically listed under "antibiotics including... tetracyclines (including doxycycline)" in Specified List 2 of drugs in both SOP No. 61 and 62 of 2021. The medication was prescribed as part of military medical care during active service.

Being overweight or obese at the time of the clinical onset of gastro-oesophageal reflux disease - NOT MET

  • The veteran BMI was consistently recorded below 25 during service, indicating he was not overweight or obese at the time of symptom onset.

Having smoked tobacco products - NOT MET

  • While the veteran reported smoking tobacco between ages 16-18, this does not meet the SOP requirements for amount (at least 1.5 pack-years for RH or 3 pack-years for BOP) or timing relative to condition onset.

Consuming alcohol - NOT MET

  • His documented alcohol consumption (2-4 times per month, 1-2 standard drinks per occasion) does not meet the SOP requirement of at least 300 grams (RH) or 500 grams (BOP) per week.

Having a hiatus hernia at the time of clinical onset - NOT MET

  • No evidence of hiatus hernia documented in medical records.

Inability to obtain appropriate clinical management - NOT MET

  • Appropriate medical management was provided promptly, with specialist referral and successful treatment through medication cessation.

Sequelae

This condition is not a sequelae of another known condition but rather represents a primary medication-induced adverse reaction.

Unintended Consequence

This condition represents an MET Unintended Consequence of ADF Medical Treatment as per section 6A of the SRCA. The veteran received Doxycycline treatment paid for by the Commonwealth during his military service, and suffered gastroesophageal reflux disease as an unintended consequence of that treatment. The temporal relationship between medication administration and symptom development, followed by resolution upon cessation, establishes clear causation. This meets the criteria under section 6A(2) where a member receives medical treatment paid for by the Commonwealth and suffers an injury as an unintended consequence of that treatment.

Inability to Attain Appropriate Medical Management

This factor is NOT MET. The veteran received prompt and appropriate medical management from military medical personnel. The condition was correctly identified as medication-induced, appropriate specialist referral was provided, and effective treatment (medication cessation) was implemented, resulting in complete symptom resolution. As referenced in Brew v Repatriation Commission, there was no objective or subjective inability to obtain appropriate clinical management in this case.

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

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

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.

Need a Diagnostic Assessment like this written from your own medical record? A VHC Chart Review finds every claimable condition in your file, and each one is written up against its Statement of Principles. Fixed fee $600 + GST per stage — see all fees or book an appointment.

About Dr Thomas Perkins

One doctor. Every report.

Founding doctor of the Veterans Health Centre in Ipswich, Queensland, and one of Australia's most experienced practitioners in veterans' medicolegal medicine.

Dr Perkins has spent more than thirteen years working exclusively with current and former ADF members — treating their conditions, writing their reports and navigating the DVA system alongside them. With over 100,000 claims submitted and 2,000 Permanent Impairment Assessments completed, he has seen precisely what separates an accepted claim from a rejected one at every level, from initial liability to the Veterans' Review Board.

Every chart review, diagnostic assessment, impairment rating and appeal that leaves this clinic is personally overseen by Dr Perkins. No template, no locum, no hand-off.

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