Influenza

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 — Influenza

Example 1 of 1 · fictitious patient (Veteran P)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

SOP Codes: Balance of Probabilities: No. 45 of 2017 Reasonable Hypothesis: No. 46 of 2017

ADF History

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

Occupational History

As a Warehouse Operator in the Australian Army, the veteran would have been exposed to communal living conditions typical of military environments, increasing risk of infectious disease transmission. Military personnel live in close quarters, share facilities, and work in environments where respiratory infections can spread rapidly through populations. The occupation involves regular contact with other personnel and shared equipment, creating opportunities for viral transmission.

History

The veteran a Warehouse Operator with the Australian Army, developed influenza in March 2013 during his military service. The condition occurred during routine military duties and required medical assessment and temporary duty restrictions.

Timeline

24 Feb 2012 - the veteran presented with significant flu-like illness with "extremely lethargic with a headache and runny nose" with onset two days prior. He reported being "unable to sleep at all last night as he felt like he was getting hot flushes and sweats" indicating systemic symptoms consistent with influenza. Physical examination showed he "looks genuinely unwell" with stable vital signs but clear evidence of viral illness. The condition was diagnosed as "Influenza"and managed with supportive care including bed rest, increased fluid intake, and symptomatic medications. He was placed on restricted duties for recovery and to prevent transmission to other personnel.

Symptoms

At the time of injury, the veteran experienced typical influenza symptoms including lethargy, headache, runny nose, hot flushes, sweats, and general malaise. He appeared genuinely unwell on examination with systemic viral illness symptoms. The condition resolved with conservative management and supportive care.

Imaging

No imaging was performed for this condition.

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

Influenza (J11.1) DVA SOP Code: No. 45 of 2017 (Balance of Probabilities) ICD-10 Code: J11.1

Influenza is an acute respiratory tract infection caused by influenza viruses (types A, B, or C). It is characterized by the sudden onset of fever, cough, headache, muscle aches, fatigue, and respiratory symptoms. The condition typically lasts 7-10 days and can range from mild to severe illness. Influenza is highly contagious and spreads through respiratory droplets when infected individuals cough, sneeze, or talk. The viral infection affects the respiratory system and can cause systemic symptoms including fever, chills, body aches, and profound fatigue.

This represents a single acute episode of influenza occurring during military service.

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

When did the veteran first experience symptoms attributable to this condition? 22 February 2012 (two days prior to presentation on 24 February 2012) [CHART REVIEW.docx]

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

When was the condition confirmed / formally diagnosed? 24 February 2012 - diagnosed as "Influenza" by military medical officer [CHART REVIEW.docx]

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

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

The diagnosis was confirmed based on clinical presentation and symptom pattern consistent with influenza. Key symptoms included extreme lethargy, headache, runny nose, hot flushes, sweats, and general malaise with acute onset. Physical examination revealed a patient who appeared genuinely unwell with viral illness. No specific laboratory investigations were performed as diagnosis was made on clinical grounds. The temporal pattern and symptom constellation were typical of influenza infection [CHART REVIEW.docx].

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

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

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

Inability to obtain influenza vaccination between ten days and six months before the clinical onset of influenza - MET

No documentation of influenza vaccination prior to onset of illness, constituting inability to obtain appropriate preventive measures.

Inability to obtain appropriate clinical management for influenza - MET

While basic supportive care was provided, there is no evidence of antiviral therapy or comprehensive clinical management being offered during the acute phase of illness.

Sequelae

This condition is not a sequelae of another known condition.

Unintended Consequence

This condition is not an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

There was an inability to attain appropriate medical management for this condition. The Full Federal Court in Brew v Repatriation Commission (12 July 1996) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. While supportive care was provided, there is no evidence that antiviral therapy was offered or considered, which would constitute appropriate clinical management for influenza. This constitutes an inability to get appropriate medical management and the factor is MET. This causes a permanent worsening of the condition by potentially prolonging the duration and severity of symptoms.

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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