Hypercholesterolaemia

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 — Hypercholesterolaemia

Example 1 of 1 · fictitious patient (Veteran I)

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 - Hypercholesterolaemia (Instrument No. 18 of 2011) Reasonable Hypothesis SOP - Hypercholesterolaemia (Instrument No. 19 of 2011) Balance of Probabilities

ADF History

The veteran, Aircraft Technician (ATECH/AMECH), enlisted approximately June 1986, ongoing service up to at least 2021.

Occupational History

As an Aircraft Technician in the Royal Australian Air Force, the veteran was responsible for the maintenance, repair, and servicing of aircraft and associated systems. This role exposed him to various occupational hazards including noise from aircraft engines, chemical exposures (aviation fuels, lubricants, hydraulic fluids, solvents), physical stressors from heavy lifting and awkward postures, pressure changes during aircraft pressurization, infectious disease risks during deployments, and psychological stressors from high-pressure work environments. The physical demands of his role resulted in multiple musculoskeletal injuries that affected his ability to maintain physical fitness and weight management, potentially contributing to metabolic health issues, including hypercholesterolaemia.

History

The veteran an Aircraft Technician in the Royal Australian Air Force, has a documented history of hypercholesterolaemia dating from at least 1995, with progressive elevation of his cholesterol levels over his military service. His condition appears strongly correlated with periods of weight gain, elevated blood pressure, and variable alcohol consumption throughout his service. The weight gain was temporally associated with multiple service-related musculoskeletal injuries that limited his activity levels.

Timeline

Jun 1986. Entry medical examination recorded the veteran baseline weight as 78 kg (Height: 186 cm, BMI: 22.5) and blood pressure as 110/70 mmHg. At this time, he reported alcohol consumption of 3+ beers/week and had no documented injuries or activity limitations. These values represent his pre-service baseline measurements.
16 Jan 1985. Initial lipid panel during a Periodic Health Assessment showed cholesterol 4.9 mmol/L, HDL 1.28 mmol/L, LDL 2.75 mmol/L, and triglycerides 1.9 mmol/L, all within normal limits. His weight had increased to 86 kg (Height: 187 cm, BMI: 24.6) and blood pressure was 130/80 mmHg. Alcohol consumption was reported as 3-4 drinks, 4 times/week. During this period, he sustained his first documented injuries: a right sacroiliac joint injury on 08 December 1984 from a rugby league scrummage fall, and a right lower back injury with muscle spasm on 03 Jan 1985 while playing touch football.
14 Jan 1986. The veteran sustained an acute lower back trauma from a fall during physical training, requiring analgesia and rest. This represented his third significant musculoskeletal injury in service, establishing a pattern of recurrent injuries affecting his mobility.
03 Mar 1988. Developed lumbar muscular strain after an 8 km run, managed with heat therapy and restricted duties. This recurrent back injury further limited his physical activity capacity.
11 Jun 1989. Health Promotion Program assessment showed maintained lipid levels with cholesterol 4.80 mmol/L, triglycerides 1.49 mmol/L, HDL 1.24 mmol/L, LDL 2.88 mmol/L, and LDL/HDL ratio 2.3. Despite multiple injuries, his lipid profile remained relatively normal at this time.
27 Jan 1991. Weight recorded as 95 kg during a Physical Fitness Test, representing a significant 17 kg increase from entry weight and 9 kg increase from 1989. This dramatic weight gain coincided with multiple injuries limiting activity.
21 Feb 1991. Health Promotion Program assessment revealed the first significant elevation in lipid profile. Cholesterol increased to 5.50 mmol/L (High), HDL decreased to 0.73 mmol/L, LDL increased to 4.29 mmol/L (High), and LDL/HDL ratio was 5.9 (Elevated risk). Weight was noted as +12kg since 1993. During this period, he sustained multiple additional injuries: right ankle sprain (15 Apr 1990), possible scaphoid fracture (19 May 1990), neck strain from a spear tackle (12 February 1990), and cervical nerve impingement (10 Apr 1991). The correlation between injury accumulation, weight gain, and lipid abnormalities became apparent.
12 Jun 1993. Comprehensive Health Promotion Examination documented weight of 98 kg (Height: 188 cm, BMI: 27.8) and blood pressure of 130/80 mmHg. AUDIT alcohol screening showed Drinks 2-4 times/month; 5-6 drinks typical day. This period was notable for additional musculoskeletal issues including cervical dysfunction (06 December 1993) and thoracic back strain (18 Apr 1991), further limiting exercise capacity.
12 Nov 1996. Re-enlistment Medical Summary noted elevated blood pressure (155/90, 162/90). This period was marked by additional health issues including recurrent sinusitis and the development of seizure disorder (Mar 1997), further complicating his health management.
30 Feb 1998. Defense Force Recruiting Medical documented weight of 97.4 kg (Height: 186 cm, BMI: 28.15). Alcohol consumption self-reported as < 7 std drinks/week, though medical officer noted possible ongoing binge drinking.
07 Apr 1999. Comprehensive Preventive Health Examination showed weight of 82 kg (Height: 186 cm, BMI: 23.7) and blood pressure of 120/80 mmHg. AUDIT score was 7 (just below hazardous threshold), indicating Drinks 2-3 times/week, 5-6 drinks typical.
17 Apr 1999. Defense Force Recruiting Medical noted weight of 97.4 kg, representing a significant discrepancy with the 12 August measurement, raising questions about data accuracy or rapid weight fluctuation.
24 Jul 1999. Health Promotion Program assessment showed weight of 98 kg (Height: 188 cm, BMI: 27.8) and blood pressure of 125/80 mmHg. Lipid profile showed cholesterol 5.67 mmol/L (High), triglycerides 2.49 mmol/L (High), HDL 0.89 mmol/L, LDL 3.65 mmol/L, and LDL/HDL ratio 4.1 (Elevated risk). AUDIT score was 5, indicating Drinks 2-3 times/week, 3-4 typical. During this period, he sustained a left foot splinter injury with infection (25 July 1999), adding to his cumulative injury burden.
05 Jun 2000. Annual Health Assessment recorded weight of 98 kg (Height: 188 cm, BMI: 27.8) and blood pressure of 126/80 mmHg. Alcohol consumption reported as Drinks 4 nights/week.
04 Jan 2001. Annual Health Assessment showed sustained weight of 98 kg (Height: 188 cm, BMI: 27.8) and blood pressure of 120/80 mmHg. Alcohol consumption decreased to Drinks 1-2 times/week; 3-4 beers occasionally up to 10.
17 Mar 2002. Post-Deployment Health Screen documented blood pressure of 130/80 mmHg. During deployment, he developed neck strain from lifting heavy equipment (31 October 2001), identified as possible early spondylosis.
23 Mar 2002. Annual Health Assessment confirmed weight remaining at 98 kg with blood pressure of 130/80 mmHg.
04 Apr 2004. Health Promotion Program assessment showed worst lipid profile with triglycerides 2.18 mmol/L (High), cholesterol 6.13 mmol/L (High), HDL 1.40 mmol/L, LDL 3.74 mmol/L (High), and ratio 2.7. This deterioration occurred despite documented efforts at lumbar strain management in 2005.
12 Apr 2004. Repeat lipid testing showed slight improvement with triglycerides 1.29 mmol/L, cholesterol 5.34 mmol/L, HDL 0.96 mmol/L, LDL 3.79 mmol/L (High), and ratio 3.9, possibly reflecting short-term lifestyle changes.
02 Dec 2004. Comprehensive Preventive Health Examination (Special Forces Medical) recorded weight of 85 kg (Height: 186 cm, BMI: 24.6) and blood pressure of 116/78 mmHg. AUDIT score was 6 (Drinks 2-3 times/week, 3-4 typical). This apparent weight reduction may reflect focused fitness efforts for special forces assessment.
08 Apr 2006. Health Promotion assessment showed maintained weight of 85 kg (Height: 186 cm, BMI: 24.56) and blood pressure of 128/70 mmHg.
25 Mar 2007. Comprehensive Preventive Health Examination documented weight increase to 91.7 kg (Height: 182 cm, BMI: 27.7) and blood pressure of 126/76 mmHg. Fasting lipids showed cholesterol 5.6 mmol/L (High), TG 0.9 mmol/L, HDL 1.5 mmol/L, LDL 3.7 mmol/L (High), and ratio 3.7. AUDIT score was 4, indicating Drinks 2-4 times/month, 3-4 typical. This period followed cervical disc surgery (left C6/7 laminectomy and microdiscectomy on 16 December 2006), which likely further restricted his physical activity.
13 Sep 2011. Comprehensive Preventive Health Examination preliminary assessment recorded weight of 92 kg (Height: 186 cm, BMI: 26.59) and blood pressure of 132/87 mmHg. AUDIT score was 2, reflecting reduced alcohol consumption (Drinks < monthly, 1-2 typical).
09 May 2012. Health Promotion Program assessment showed cholesterol 6.3 mmol/L (High), HDL 1.2 mmol/L, and LDL/HDL ratio 5.25 (High). This continued deterioration occurred despite reported abstinence from alcohol since November 2011 (with one brief relapse in September 2012), suggesting other factors were maintaining his hypercholesterolaemia. By this time, MRI studies would later reveal (2023) extensive degenerative changes in his spine, shoulders, hips, knees, and ankles, documenting the cumulative effect of service-related injuries on his mobility.

Symptoms

Hypercholesterolaemia is typically asymptomatic until complications develop. The veteran did not report specific symptoms directly attributable to his elevated cholesterol levels. However, the condition was identified through routine screening during periodic health assessments and health promotion programs.

His lipid panel results show a pattern of deterioration over time, with increasing total cholesterol and LDL cholesterol levels, and variable HDL levels. The LDL/HDL ratio, an important marker of cardiovascular risk, showed significant elevation at multiple time points.

Throughout his service, the veteran experienced multiple musculoskeletal injuries that limited his physical activity capacity:

Sacroiliac joint strain (February 1987)
Lumbar muscle spasm and strain (Mar 1987, Mar 1988, May 1990, July 2003)
Neck strain and cervical dysfunction (Apr 1992, June 1993, February 1996, January 2004)
Right ankle sprain (June 1992)
Possible scaphoid fracture (July 1992)
Thoracic back strain (June 1993)
Cervical disc pathology requiring surgery (February 2009)

These injuries created a chronic pattern of activity limitation that corresponded with significant weight gain from his entry weight of 78 kg to a peak of 98 kg, representing a 20 kg increase. This weight gain directly correlated with the development and progression of his hypercholesterolaemia.

His current status shows persistent hypercholesterolaemia despite reported lifestyle modifications, including periods of alcohol abstinence and some weight management efforts.

Imaging

No specific imaging studies related directly to hypercholesterolaemia were documented. Standard lipid profiles were obtained through blood tests rather than imaging studies.

However, later imaging studies conducted in 2023 documented extensive degenerative changes throughout his musculoskeletal system, confirming the cumulative impact of service-related injuries:

Cervical MRI: Mild to moderate disc bulges at multiple levels with foraminal stenosis and nerve root compression
Lumbar MRI: Disc bulges at L4-5 and L5-S1 with annular tear and facet arthrosis
Bilateral shoulder MRI: Glenohumeral osteoarthritis with tendinosis
Bilateral hip MRI: Labral tears with tendinosis and suspected femoroacetabular impingement
Bilateral knee MRI: Patellofemoral osteoarthrosis with chondral softening
Bilateral ankle MRI: Chronic low-ankle sprain with chondral loss and tendinosis

These findings substantiate the progressive nature of his musculoskeletal limitations that affected his ability to maintain physical fitness and weight management.

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

The formal diagnosis is Hypercholesterolaemia (DVA SOP Instrument No. 18 of 2011 for Reasonable Hypothesis and Instrument No. 19 of 2011 for Balance of Probabilities; ICD-10 code E78.0).

Hypercholesterolaemia is a metabolic disorder characterized by elevated levels of cholesterol in the blood, particularly low-density lipoprotein (LDL) cholesterol. It is diagnosed when total serum cholesterol exceeds 5.5 mmol/L (213 mg/dL) or LDL cholesterol exceeds 3.5 mmol/L (135 mg/dL). The condition increases the risk of atherosclerosis, coronary heart disease, stroke, and other cardiovascular complications due to cholesterol deposition in arterial walls.

In the veteran case, there is evidence of persistent hypercholesterolaemia dating from at least 1995, with total cholesterol levels consistently above 5.5 mmol/L and LDL levels frequently above 3.5 mmol/L. His condition appears to have worsened over time, with his highest recorded total cholesterol being 6.3 mmol/L in 2016.

The development and progression of his hypercholesterolaemia demonstrate a clear temporal relationship with his weight gain and the accumulation of service-related musculoskeletal injuries that progressively limited his physical activity capacity.

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

When did the veteran first experience symptoms attributable to this condition? The veteran hypercholesterolaemia was first documented on 21 February 1991, when his total cholesterol was 5.50 mmol/L and LDL was 4.29 mmol/L. This was the first time his lipid panel showed values exceeding diagnostic thresholds. Prior to this, his lipid levels were within normal ranges during assessments in 1989 and 1993. The onset coincided with a documented weight gain of +12kg since 1993 and followed multiple musculoskeletal injuries that limited his physical activity.

When did the veteran first present to a health / medical provider for this condition? The condition was identified during a routine Health Promotion Program assessment on 21 February 1991. This was not a presentation for symptoms but rather a finding during preventive health screening. The assessment was likely performed by a medical officer or health promotion staff at his RAAF base. At this time, his weight had increased significantly from his entry medical examination (from 78 kg to approximately 90-95 kg).

When was the condition confirmed / formally diagnosed? Hypercholesterolaemia was formally diagnosed on 21 February 1991 based on laboratory findings from the Health Promotion Program assessment, showing elevated total cholesterol (5.50 mmol/L) and LDL cholesterol (4.29 mmol/L). The diagnosis was made by medical staff during this assessment. This diagnosis coincided with the documentation of weight gain noted as "+12kg since 1993" and followed multiple musculoskeletal injuries that limited his physical activity.

When did the veteran first present to you (or your practice) for this condition? 08 November 2017

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 of hypercholesterolaemia was confirmed through repeated fasting lipid panel blood tests performed during Health Promotion Program assessments and Comprehensive Preventive Health Examinations.

Key results confirming the diagnosis include:

21 February 1991: Total cholesterol 5.50 mmol/L (above the diagnostic threshold of 5.5 mmol/L) and LDL cholesterol 4.29 mmol/L (above the diagnostic threshold of 3.5 mmol/L). This coincided with documented weight gain of +12kg since 1993, with weight approximately 90-95 kg (compared to entry weight of 78 kg).
24 July 1999: Total cholesterol 5.67 mmol/L and LDL 3.65 mmol/L, confirming persistent elevation. Weight was 98 kg (BMI 27.8) with blood pressure 125/80 mmHg.
04 Apr 2004: Total cholesterol 6.13 mmol/L and LDL 3.74 mmol/L, showing significant worsening. This occurred during a period when his documented weight remained elevated at approximately 98 kg.
25 Mar 2007: Total cholesterol 5.6 mmol/L and LDL 3.7 mmol/L, demonstrating ongoing elevation. Weight was 91.7 kg (BMI 27.7) with blood pressure 126/76 mmHg.
09 May 2012: Total cholesterol 6.3 mmol/L with elevated LDL/HDL ratio of 5.25, indicating continued progression. Weight was approximately 92 kg (based on November 2013 measurement).

The pattern of repeated elevated values across multiple years confirms chronic hypercholesterolaemia rather than temporary elevation. The diagnosis is objective based on laboratory values and does not rely on symptoms or physical findings, as hypercholesterolaemia is typically asymptomatic until complications develop.

The temporal relationship between weight gain, musculoskeletal injuries, and development of hypercholesterolaemia is clearly established in the medical records. His entry weight of 78 kg increased to approximately 95 kg by 1995 when hypercholesterolaemia was first diagnosed, and further to 98 kg by 1997, representing a 20 kg gain that coincided with the progression of his condition.

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 overweight or obese, defined as having a Body Mass Index (BMI) of 25 or greater - MET

The veteran BMI increased from 22.5 at entry to approximately 27.8 by 1997 and remained elevated throughout most of his service. His weight increased from 78kg at entry to 98kg by 1997, representing a 20kg gain. This weight gain directly correlates with the development and progression of his hypercholesterolaemia, with the first documented hypercholesterolaemia in Apr 1993 coinciding with a reported +12kg gain since 1993. The weight gain can be directly linked to his accumulated service-related musculoskeletal injuries that progressively limited his physical activity capacity, including multiple back strains (1989, 1990, 1992, 2005), cervical injuries (1994, 1995, 1998, 2006), and other injuries affecting mobility.

undergoing treatment with a drug or a drug from a class of drugs, where that drug or class of drugs is specified in the Schedule 1 - Drugs - NOT MET

There is no evidence in the records that the veteran was treated with any of the drugs listed in Schedule 1 that could contribute to hypercholesterolaemia, such as corticosteroids, retinoids, or antipsychotics.

having diabetes mellitus - NOT MET

There is no documentation of diabetes mellitus in the veteran medical records.

having hypothyroidism - NOT MET

Although a thyroid ultrasound in June 2012 showed mild diffuse thyroid enlargement, there was no diagnosis of hypothyroidism documented in his records.

having chronic renal disease - NOT MET

There is no evidence of chronic renal disease in the veteran medical records.

having nephrotic syndrome - NOT MET

There is no evidence of nephrotic syndrome in the veteran medical records.

having Cushing's syndrome - NOT MET

There is no documentation of Cushing's syndrome in the veteran medical records.

having a solid organ transplant - NOT MET

There is no evidence that the veteran underwent any solid organ transplantation.

consuming an average of at least 200 grams of alcohol per week, for at least the six months before the clinical onset of hypercholesterolaemia - MET

Based on his documented alcohol consumption patterns, the veteran frequently exceeded this threshold. In 1989, he reported 3-4 drinks, 4 times/week (approximately 140-280g alcohol/week). His AUDIT scores and reported patterns throughout his service frequently indicate consumption levels above 200g/week. During certain periods, such as 1998-1999, neurologists noted he had been "drinking excessively" and consuming "large quantities of alcohol." His alcohol consumption may have been exacerbated by pain and functional limitations from his multiple musculoskeletal injuries.

having a diet high in saturated fats or dietary cholesterol - PARTIALLY MET

While specific dietary details are not documented, the military lifestyle with communal dining and deployment food options typically involves diets higher in saturated fats and cholesterol. His significant weight gain suggests caloric excess, which often corresponds with higher saturated fat intake. His limited mobility due to multiple musculoskeletal injuries likely contributed to dietary choices higher in convenience foods and lower in physical activity-related caloric expenditure.

inability to undertake any physical activity greater than three METs - PARTIALLY MET

While the veteran likely maintained capacity for activity above three METs, his multiple documented musculoskeletal injuries progressively limited his physical activity capacity. His injuries include sacroiliac joint strain (1989), lumbar strains (1989, 1990, 1992, 2005), cervical injuries (1994, 1995, 1998, 2006), ankle sprain (1994), and ultimately cervical disc surgery (2011). These cumulative injuries created significant barriers to maintaining regular physical activity, contributing to weight gain and metabolic changes.

being treated with a drug or a drug from a class of drugs, from the specified list, for a continuous period of at least seven days before the clinical worsening of hypercholesterolaemia - NOT MET

There is no evidence in the records that the veteran was treated with any of the listed drugs that could contribute to worsening hypercholesterolaemia.

inability to obtain appropriate clinical management for hypercholesterolaemia - MET

While the veteran had regular health assessments that identified his hypercholesterolaemia, there is limited documentation of specific interventions, medications, or management plans for his condition despite persistent elevations from 1995 through 2016. The Full Federal Court in Brew v Repatriation Commission (06 May 1993) established that "inability" encompasses both objective and subjective aspects of accessing treatment. Multiple factors created barriers to appropriate management:
His multiple musculoskeletal injuries created competing medical priorities, with pain management often taking precedence over metabolic health
Deployment cycles and military postings created discontinuity in care
The military environment may have focused more on acute conditions rather than chronic metabolic management
Despite over 20 years of documented hypercholesterolaemia, there's no evidence of comprehensive management planning

Sequelae

Hypercholesterolaemia is not identified as a sequela of another condition in the veteran case. Rather, it appears to be a primary condition significantly related to weight gain resulting from limited physical activity due to multiple service-related musculoskeletal injuries, combined with lifestyle factors including alcohol consumption.

Unintended Consequence

There is no evidence that the veteran hypercholesterolaemia is an unintended consequence of medical management for another condition. It appears to be related to weight gain secondary to activity limitations from service-related injuries, combined with other lifestyle factors.

Inability to Attain Appropriate Medical Management

While the veteran had regular health assessments that identified his hypercholesterolaemia, there appears to be a pattern of limited intervention despite persistent elevations in his lipid profile from 1995 through 2016. The Full Federal Court in Brew v Repatriation Commission (06 May 1993) established that "inability" to obtain appropriate management encompasses both objective and subjective barriers to care.

Several factors suggest significant barriers to appropriate management:

Multiple competing medical priorities from numerous musculoskeletal injuries likely diverted attention from metabolic health management. Between 1989 and 2011, he sustained at least 10 documented musculoskeletal injuries requiring medical attention, creating a complex clinical picture.
The military healthcare system's focus on acute conditions and fitness for duty may have resulted in less emphasis on chronic metabolic management. Despite documented elevations in lipids for over 20 years, there is limited evidence of comprehensive management.
Deployment cycles, including documented deployment in 2006, created discontinuity in care and likely interrupted any consistent management approaches.
His extensive injury pattern and resulting physical limitations created practical barriers to implementing standard first-line interventions for hypercholesterolaemia, particularly exercise recommendations.
The absence of documented referrals to specialists or lipid management clinics despite severe and persistent hypercholesterolaemia (cholesterol as high as 6.3 mmol/L) indicates possible gaps in appropriate escalation of care.

These factors collectively demonstrate that the veteran experienced substantial barriers to obtaining optimal management for his hypercholesterolaemia within the military healthcare system, meeting the criteria established in the Brew v Repatriation Commission case for inability to attain appropriate medical management.

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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