Diagnostic Assessment — Left Arm - Warts
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Arm — Warts BOP Code: 8 of 2023 (Warts) RH Code: 7 of 2023 (Warts)
ADF History
The veteran, date of birth [withheld], Australian Army, Combat Engineer, 6 July 1990 to 21 April 1997
History
The veteran had warts on both hands and wrists during ADF service, with the documented distribution on "both hands and wrists" on 19 September 1992 encompassing the wrist and forearm area of the left arm.
Warts on the left arm were specifically documented at the a field engineer regiment wart clinic on 16 January 1994 (warts of the left hand and arm, x5) and 23 January 1994 (warts of the left arm and wrist), and were treated with liquid nitrogen on both occasions
Timeline
19 Sep 1992 — Warts on both hands and wrists recorded at a field engineer regiment and referred for liquid nitrogen, which was applied on 20 September 1992.
The widespread distribution of warts across "both hands and wrists" is consistent with involvement of adjacent areas including the left arm. "Warts of hands and wrists" 16 Jan 1994 — Wart clinic at a field engineer regiment: liquid nitrogen applied to warts of the left hand and arm (x5) and the left little finger. "(L) hand & arm x 5" 23 Jan 1994 — Wart clinic at a field engineer regiment: liquid nitrogen applied again to warts of the left arm and wrist and the left little finger. "(L) arm & wrist" 06 Oct 1994 — Diathermy of warts on left hand and wrist under GA at RANH a field engineer regiment. "Diathermy warts"
1. What is the formal diagnosis of the condition claimed above?
Left Arm Warts — Viral Warts (ICD-10: B07.8).
Acquired during ADF service.
2 3.
Dates, confirmation: As per Left Hand Warts above.
Onset on or before 16 January 1994 (warts of the hands and wrists had been recorded from 19 September 1992).
Warts on the left arm were specifically documented and treated with liquid nitrogen at the a field engineer regiment wart clinic on 15 and 23 January 1994.
DRCA legislation applies.
Warts acquired in communal service environment.
The % contribution of the causes is 100% and significant
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 3 October 2010 (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 young adults.
In the 12 months before 16 January 1994 the veteran served in a field engineer regiment, at a field engineer regiment and, from 18 November 1993, in a field engineer regiment, living and working among other sailors; the sick bay of a field engineer regiment held a wart clinic in January 1994, which suggests that warts were common among the people around him.
Direct skin contact with shipmates, without any barrier, is routine in shipboard work and communal living, 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 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 arm.
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 arm.
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 arm, 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 - This factor applies only to warts on the hands; the veteran's warts in this assessment affect the left arm, and there is no record that he prepared meat, poultry or fish with shared gloves or utensils.
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 1994.
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 1994 the veteran served in a field engineer regiment, at a field engineer regiment and, from 18 November 1993, in a field engineer regiment, living and working in close quarters with other sailors; the sick bay of a field engineer regiment held a wart clinic in January 1994, which suggests that warts were common among the people around him.
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 arm.
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 arm.
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 arm, 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 - This factor applies only to warts on the hands; the veteran's warts in this assessment affect the left arm, and there is no record that he prepared meat, poultry or fish with shared gloves or utensils.
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 1994.
Other Plausible Links to Service the veteran acquired and spread his warts while serving as a young Combat Engineer and Combat Engineer, 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 (October 1991), scrubbing decks and diving on tide poles (1991), 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 a field engineer regiment in January 1994 suggests that warts were common in the Combat Engineer.
These conditions of service plausibly contributed to the infection of his hands, wrist and arm.
The left arm warts are most probably an extension of the wart infection already established in service on his left hand and wrist, where warts were recorded from November 1991 and September 1992.
Warts spread to adjacent skin by autoinoculation, particularly through scratches and abrasions of the kind caused by rope and cable work, and the arm warts appeared on the same side as the earlier warts, his dominant left side.
On that basis the arm warts are a consequence of an in-service condition.
Conclusion the veteran's left arm warts are a human papillomavirus infection acquired during his naval service, most probably by spread from his established in-service warts of the left hand and wrist and through direct contact with other personnel's warts in the close living and working conditions of ships and naval establishments (factor 9(1)), favoured by skin kept wet and abraded by rope work, deck work and diving.
They were treated promptly at the a field engineer regiment wart clinic in January 1994 and are not recorded again.
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 arm 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 1994) aggravated them or contributed to them in a material degree.
The arm warts were treated with liquid nitrogen on 15 and 23 January 1994 and are not recorded again; they were not among the warts treated by diathermy on 6 October 1994.
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 after January 1994, and nothing in his history suggests substantially lowered immune function at that time.
Factor 9(9): inability to obtain appropriate clinical management for warts — NOT MET - The left arm warts were treated with liquid nitrogen at the a field engineer regiment wart clinic on the day they were first recorded, 16 January 1994, and again on 23 January 1994; they are not recorded again, and the surgeon who examined him on 3 October 1994 and operated on 6 October 1994 recorded and treated warts only on the left fingers and wrist and the penis.
Assessed objectively and subjectively under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there is no evidence that an inability to obtain appropriate clinical management worsened the arm warts.
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 after January 1994, and nothing in his history suggests substantially lowered immune function at that time.
Factor 9(9): inability to obtain appropriate clinical management for warts — NOT MET - The left arm warts were treated with liquid nitrogen on the day they were first recorded, 16 January 1994, and again a week later, and they are not among the warts recorded and treated in October 1994; there is no evidence that an inability to obtain appropriate clinical management, assessed as explained in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), worsened them
Sequelae, Unintended Consequence, Inability to Attain Appropriate Medical Management
No sequelae are documented, and the condition is not an unintended consequence of medical management.
Inability to attain appropriate medical management — NOT MET: the left arm warts were treated with liquid nitrogen at the a field engineer regiment wart clinic on the day they were first recorded, 16 January 1994, and again on 23 January 1994; they are not recorded again and were not among the warts found and treated by the surgeon in October 1994
Date of Clinical Onset
Left arm 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 1994 — warts of the left hand and arm treated with liquid nitrogen at the a field engineer regiment wart clinic (warts of the hands and wrists had been documented from 19 September 1992) [ [CHART REVIEW document], pages 53, 70].
The later records, including the diathermy of 6 October 1994, 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 1994.
This date falls within the veteran's ADF service (6 July 1990 21 April 1997).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
