Diagnostic Assessment — Left Hand - Laceration
Example 1 of 1 · fictitious patient (Veteran I)
Diagnostic Assessment
Left Hand - Laceration
SOP Balance of Probabilities: Cut, Stab, Abrasion and Laceration (No. 36 of 2025) SOP Reasonable Hypothesis: Cut, Stab, Abrasion and Laceration (No. 37 of 2025)
ADF History
The veteran, Aircraft Technician (ATECH/AMECH), enlisted approximately June 1986, discharge date not explicitly stated but ongoing service indicated up to at least 2021.
Occupational History
As an Aircraft Technician in the Royal Australian Air Force, the veteran was exposed to numerous occupational hazards including work in high-risk environments such as flight lines, engine bays, and maintenance hangars. His role involved working with hazardous materials, heavy lifting, repetitive motions, and exposure to various environmental stressors. The position required both occupational duties and participation in recreational activities encouraged for military fitness and team cohesion.
History
The veteran an Aircraft Technician in the RAAF, sustained a left hand laceration on 17 Apr 1992 during a fall at Litchfield National Park, likely during a recreational activity associated with military service.
Timeline
- 17 Apr 1992: The veteran presented with a deep laceration to the left palm following a fall at Litchfield National Park during what was likely a recreational activity during RAAF service. The wound was bleeding with no associated fractures or neurological deficits noted. Clinical assessment confirmed laceration and the injury was managed with sutures and dressings. The laceration was due to impact with a sharp surface during the fall, consistent with outdoor activities commonly encouraged in military culture for fitness and team cohesion.
Symptoms
At the time of injury, the veteran experienced immediate pain and bleeding from the left palm laceration. The wound required suturing due to its depth. There were no associated fractures or neurological deficits. The condition resolved with appropriate treatment and no long-term complications were documented.
Imaging
No imaging was documented for this condition as it was a soft tissue injury managed with clinical assessment and wound care.
1. What is the formal diagnosis of the condition claimed above?
Left palm laceration, ICD-10 code S61.4, covered under the Statement of Principles for Cut, Stab, Abrasion and Laceration (No. 36 & 37 of 2025).
A laceration is defined as an injury that interrupts the continuity of the epidermis or other external tissue and causes a wound. Lacerations may or may not penetrate to subcutaneous tissues and underlying structures. They result from direct trauma causing tearing of tissue, typically requiring wound closure through suturing, adhesive strips, or other closure methods depending on depth and location.
This represents a single acute traumatic injury with complete healing following appropriate treatment.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
17 Apr 1992 [CHART REVIEW - TOM.docx, Page 38]
When did the veteran first present to a health / medical provider for this condition?
17 Apr 1992, presenting to military medical personnel for treatment of the laceration [CHART REVIEW - TOM.docx, Page 38]
When was the condition confirmed / formally diagnosed?
17 Apr 1992, diagnosed clinically by medical officer through examination of the wound [CHART REVIEW - TOM.docx, Page 38]
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 was confirmed through clinical examination revealing a deep laceration to the left palm with active bleeding. The wound was assessed for depth, nerve function, and vascular integrity. No fractures or neurological deficits were identified. The laceration was treated with sutures and dressings, confirming the clinical diagnosis. [CHART REVIEW - TOM.docx, Page 38]
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.
Having direct physical trauma to the affected site at the time of the cut, stab, abrasion or laceration - MET
- The veteran sustained direct trauma to the left palm during a fall at Litchfield National Park on 17 Apr 1992, resulting in contact with a sharp surface causing the laceration. This recreational activity was part of the military lifestyle and culture that encourages outdoor activities for fitness and team building.
Inability to obtain appropriate clinical management for cut, stab, abrasion or laceration before clinical worsening - NOT MET
- The veteran received immediate and appropriate clinical management with wound cleaning, suturing, and dressings on the same day as the injury. There was no delay in treatment or clinical worsening.
Sequelae
This condition is not a sequelae of another known condition. It represents a primary traumatic injury.
Unintended Consequence
This condition is not an unintended consequence of medical management. It resulted from recreational trauma during a fall.
Inability to Attain Appropriate Medical Management
This factor is not met. The veteran received immediate and appropriate medical treatment for his laceration on the day of injury. The wound was properly cleaned, sutured, and dressed according to standard wound care protocols. There were no barriers to accessing healthcare, and the treatment provided was appropriate for the injury sustained. The Full Federal Court in Brew v Repatriation Commission establishes that inability encompasses both objective and subjective barriers to treatment, but in this case, immediate appropriate care was provided without delay or obstruction.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
