Diagnostic Assessment — Left 5th Finger - Warts
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left 5th Finger — Warts BOP Code: 8 of 2023 (Warts) RH Code: 7 of 2023 (Warts)
ADF History
The veteran, date of birth [withheld], served in the Royal Australian Air Force as an Airfield Defence Guard from 1 November 1977 to 17 August 1984
Occupational History
As a naval serviceman, the veteran worked in a communal living and working environment aboard service vessels and at shore establishments.
Shared living quarters, communal showers, and manual handling of equipment in wet conditions are recognised risk factors for the acquisition and spread of viral warts (human papillomavirus)
History
The veteran had warts affecting the left 5th finger during ADF service.
Warts on both hands and wrists were first recorded on 16 January 1980 at an airbase and treated with liquid nitrogen on 17 January 1980.
Warts on the left little finger were specifically documented and treated with liquid nitrogen at the an airbase wart clinic on 15 and 21 May 1981.
On 1 February 1982, diathermy of warts on the left 5th finger (x2) was performed under general anaesthetic at RANH an airbase by the treating doctor
Timeline
16 Jan 1980 — Warts on both hands and wrists recorded at an airbase and referred for liquid nitrogen, which was applied on 17 January 1980.
The left 5th finger warts were among the warts distributed across both hands and wrists at this presentation. "Warts of hands and wrists" 14 May 1981 — Wart clinic at an airbase: liquid nitrogen applied to warts of the left hand and arm (x5) and the left little finger. "(L) little finger liquid nitrogen applied" 21 May 1981 — Wart clinic at an airbase: liquid nitrogen applied again to warts of the left arm and wrist and the left little finger. "(L) little finger Applied liquid nitrogen" 01 Feb 1982 — Diathermy of warts on the left 5th finger (x2), middle finger (x1), and wrist performed under general anaesthetic at RANH an airbase by the treating doctor.
The admission record documents two separate warts on the left 5th finger requiring surgical diathermy. "Diathermy left 5th finger x2"
Symptoms
The veteran had visible warts on the left 5th finger that persisted despite initial liquid nitrogen treatment in January 1980 and further liquid nitrogen treatment at the an airbase wart clinic on 15 and 21 May 1981, requiring surgical diathermy under general anaesthetic in February 1982, two years after the initial treatment
Imaging
No imaging related to this condition
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left 5th Finger Warts — Viral Warts (ICD-10: B07.8).
Viral warts (verrucae) are benign epithelial proliferations caused by human papillomavirus (HPV) infection.
They are transmitted by direct contact or through contaminated surfaces in communal environments
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Prior to 16 January 1980 [CHART REVIEW document] When did the veteran first present to a health / medical provider for this condition? 16 January 1980 When was the condition confirmed / formally diagnosed? 16 January 1980 When did the veteran first present to you (or your practice) for this condition? 14 March 2019
3. How was this diagnosis confirmed?
The diagnosis was confirmed on clinical grounds by the attending medical officers.
Warts were recorded on examination on 16 January 1980 and treated with liquid nitrogen the next day.
Warts on the left little finger were recorded and treated with liquid nitrogen at the an airbase wart clinic on 15 and 21 May 1981 [ [CHART REVIEW document], pages 52 53].
Persistent warts on the left 5th finger (x2) were treated with diathermy under general anaesthetic on 1 February 1982 [ [CHART REVIEW document], pages 112 113]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 29 January 1998 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Warts, No.
8 of 2023) Factor 9(1): having direct physical contact with another person s cutaneous warts, within the 12 months before the clinical onset of warts — MET - Cutaneous warts are acquired from another person's wart virus, chiefly by direct skin contact, and are common among adolescents and young adults.
In the 12 months before 16 January 1980 the veteran, as a young adult and 18, lived and worked in close quarters with other young sailors on the survey ship an airbase and then in an airbase, working lines and handling steel cables and survey equipment alongside them; in such work and communal living, direct skin contact with shipmates' hands, without any barrier, is routine.
No specific contact is recorded, but that is not evidence that it did not occur, and it is reasonable to infer direct physical contact with another person's cutaneous warts within that period.
Factor 9(2): for warts affecting the cervix uteri only, having penetrative sexual intercourse with a person with genital warts within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the cervix uteri and cannot apply to the veteran, who is a man.
Factor 9(3): for warts affecting the anogenital region only, having contact with the anogenital warts of another person within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to warts affecting the anogenital region; the veteran's warts in this assessment affect the left fifth finger.
Factor 9(4): for warts affecting the oral cavity or the larynx only, having oral sex with a person with anogenital warts within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the oral cavity or larynx; the veteran's warts in this assessment affect the left fifth finger.
Factor 9(5): for plantar warts only, using communal showering or bathing facilities within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to plantar warts; the veteran's warts in this assessment affect the left fifth finger, not the sole of the foot.
Factor 9(6): for warts on the hands only, using shared gloves or shared utensils on more days than not for 3 months in the preparation of meat, poultry or fish for consumption, within the 12 months before the clinical onset of warts — NOT MET - Although the left fifth finger is on the hand, there is no record that the veteran prepared meat, poultry or fish with shared gloves or utensils, and his recorded duties as an Airfield Defence Guard and Airfield Defence Guard do not include galley work.
Factor 9(7): being in an immunocompromised state as specified at the time of the clinical onset of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation, and nothing in his history suggests substantially lowered immune function when the warts appeared in or before January 1980.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Warts, No.
7 of 2023) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): having direct physical contact with another person s cutaneous warts, within the 20 months before the clinical onset of warts — MET - In the 20 months before 16 January 1980 the veteran, as a young adult to 18, lived in shared accommodation as a recruit and trainee at naval establishments and then served in close quarters on the survey ship an airbase and in an airbase, working lines and cables alongside other young sailors, among whom cutaneous warts are common.
Direct skin contact with shipmates, without any barrier, is routine in that setting, and although no specific contact is recorded, it is reasonable to infer direct physical contact with another person's cutaneous warts within that period.
Factor 9(2): for warts affecting the cervix uteri only, having penetrative sexual intercourse with a person with genital warts within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the cervix uteri and cannot apply to the veteran, who is a man.
Factor 9(3): for warts affecting the anogenital region only, having contact with the anogenital warts of another person within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to warts affecting the anogenital region; the veteran's warts in this assessment affect the left fifth finger.
Factor 9(4): for warts affecting the oral cavity or the larynx only, having oral sex with a person with anogenital warts within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the oral cavity or larynx; the veteran's warts in this assessment affect the left fifth finger.
Factor 9(5): for plantar warts only, using communal showering or bathing facilities within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to plantar warts; the veteran's warts in this assessment affect the left fifth finger, not the sole of the foot.
Factor 9(6): for warts on the hands only, using shared gloves or shared utensils on more days than not for 3 months in the preparation of meat, poultry or fish for consumption, within the 20 months before the clinical onset of warts — NOT MET - Although the left fifth finger is on the hand, there is no record that the veteran prepared meat, poultry or fish with shared gloves or utensils, and his recorded duties as an Airfield Defence Guard and Airfield Defence Guard do not include galley work.
Factor 9(7): being in an immunocompromised state as specified at the time of the clinical onset of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation, and nothing in his history suggests substantially lowered immune function when the warts appeared in or before January 1980.
Other Plausible Links to Service the veteran acquired and spread his warts while serving as a young Airfield Defence Guard and Airfield Defence Guard, living in close quarters on survey ships and at naval establishments with shared messes, ablutions and equipment.
His recorded duties included rope work and working ships' lines, lifting steel cables and cable drums (February 1979), scrubbing decks and diving on tide poles (1979), largely in the hot, humid climate of north Queensland.
Wet, abraded skin is more easily infected by the wart virus, which persists on shared ropes, tools and wet surfaces, and the wart clinic held by the sick bay of an airbase in May 1981 suggests that warts were common in the Airfield Defence Guard.
These conditions of service plausibly contributed to the infection of his hands and fingers.
The left fifth finger warts are most probably an extension of a wart infection already established in service: a large wart on the left wrist, which kept bumping against objects while he served in an airbase, was excised on 18 March 1979, and by January 1980 there were warts on both hands and wrists.
Warts spread to nearby skin by autoinoculation, particularly through small cuts and abrasions, and the concentration of his warts on the left hand, his dominant hand, which takes most of the load and minor injuries of manual work, fits this pattern.
On that basis the finger warts are a consequence of an in-service condition.
Conclusion the veteran's left fifth finger warts are a human papillomavirus infection acquired during his naval service, most probably through direct contact with other personnel's warts in the close living and working conditions of ships and naval establishments (factor 9(1)) and by spread from his own earlier in-service warts, favoured by hands kept wet and abraded by rope work, deck work and diving.
They persisted through isolated, incomplete courses of cryotherapy (factor 9(9)) and required diathermy under general anaesthetic on 1 February 1982.
The warts therefore arose in the course of his service and were contributed to by its conditions.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's left fifth finger warts are found not to have arisen out of his service, the following factors address whether service rendered after their clinical onset (on or before 16 January 1980) aggravated them or contributed to them in a material degree.
The warts persisted after liquid nitrogen at the an airbase wart clinic in May 1981, and two warts on the finger required diathermy under general anaesthetic on 1 February 1982.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Warts, No.
8 of 2023) Factor 9(8): being in an immunocompromised state as specified at the time of the clinical worsening of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation while the warts persisted and spread between 1980 and 1982, and nothing in his history suggests substantially lowered immune function at that time.
Factor 9(9): inability to obtain appropriate clinical management for warts — MET - The warts of the hands and wrists recorded on 16 January 1980 received one liquid nitrogen session, which did not include the little finger, although cryotherapy normally needs repeated sessions every two to three weeks until clearance.
No follow-up is recorded for 16 months, which included a December 1980 command signal suspecting malingering; the little finger was first treated at the an airbase wart clinic on 15 and 21 May 1981, and after the ship's voyage in early 1982 two warts on it required diathermy under general anaesthetic on 1 February 1982.
Assessed objectively and subjectively under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), these isolated treatments without specialist referral amount to an inability to obtain appropriate clinical management.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Warts, No.
7 of 2023) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(8): being in an immunocompromised state as specified at the time of the clinical worsening of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation while the warts persisted and spread between 1980 and 1982, and nothing in his history suggests substantially lowered immune function at that time.
Factor 9(9): inability to obtain appropriate clinical management for warts — MET - After the warts of the hands and wrists were recorded on 16 January 1980, the left little finger had no recorded treatment until two liquid nitrogen sessions at the an airbase wart clinic in May 1981, and two warts on it then persisted through the ship's voyage in early 1982 until diathermy under general anaesthetic on 1 February 1982.
Isolated treatments without specialist referral for two years, including a period under a December 1980 command signal suspecting malingering, amount to an inability to obtain appropriate clinical management as explained in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J)
Sequelae
No specific sequelae documented
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
The warts of the hands and wrists received a single liquid nitrogen session on 17 January 1980, which did not include the little finger, with no follow-up for 16 months, a period that included a December 1980 command signal suspecting him of malingering.
The little finger was first treated at the an airbase wart clinic in May 1981, and after an airbase's voyage in early 1982 two warts on it required diathermy under general anaesthetic on 1 February 1982.
Assessed objectively and subjectively under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this is an inability to obtain appropriate clinical management — MET
Date of Clinical Onset
Left 5th finger warts are an infective condition.
Their date of clinical onset is the date on which they first appeared, which is no later than the date on which they were first recorded in the service medical records.
Later treatment, investigation or imaging does not alter the date of clinical onset.
First documented: 16 January 1980 — warts of the hands and wrists referred for liquid nitrogen [CHART REVIEW document].
The later records, including the wart clinic treatment of 15 and 21 May 1981 and the diathermy of 1 February 1982, do not alter the date of clinical onset.
As the condition was already present when it was first documented, its clinical onset was no later than that date.
Date of clinical onset: on or before 16 January 1980.
This date falls within the veteran's ADF service (1 November 1977 17 August 1984).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
