Diagnostic Assessment — Left Hand - Warts
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Hand — Warts BOP Code: 8 of 2023 (Warts) RH Code: 7 of 2023 (Warts)
ADF History
The veteran, date of birth [withheld], Royal Australian Air Force, Aircraft Technician, 30 November 1980 to 16 September 1987
History
The veteran had warts on the left hand during ADF service, recorded on 14 February 1983 and treated with liquid nitrogen on 15 February 1983 and at the a maintenance squadron wart clinic on 12 June 1984 (warts of the left hand and arm, x5), and documented again on the surgical referral on 27 February 1985.
The left hand warts were among the widespread warts on both hands and wrists
Timeline
14 Feb 1983 — Warts on both hands and wrists recorded at a maintenance squadron and referred for liquid nitrogen, which was applied on 15 February 1983. "Warts of hands and wrists" 12 Jun 1984 — Wart clinic at a maintenance squadron: liquid nitrogen applied to warts of the left hand and arm (x5) and the left little finger. "(L) hand & arm x 5" 27 Feb 1985 — Surgical referral to the treating doctor.
Brown at a maintenance squadron.
Multiple warts on shaft of penis and warts on left hand noted. "Warts on left hand" 02 Mar 1985 — Diathermy of warts on left 5th finger, middle finger, and wrist under GA at RANH a maintenance squadron. "Diathermy warts"
1. What is the formal diagnosis of the condition claimed above?
Left Hand Warts — Viral Warts (ICD-10: B07.8).
Acquired during ADF service in the communal service environment
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Prior to 14 February 1983 [CHART REVIEW document] When did the veteran first present to a health / medical provider for this condition? 14 February 1983 When was the condition confirmed / formally diagnosed? 14 February 1983 When did the veteran first present to you (or your practice) for this condition? 12 April 2022
3. How was this diagnosis confirmed?
Clinical diagnosis on 14 February 1983, 12 June 1984 (a maintenance squadron wart clinic: warts of the left hand and arm, x5, treated with liquid nitrogen) and 27 February 1985 [ [CHART REVIEW document], pages 53, 70, 114]
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 27 February 2001 (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 14 February 1983 the veteran, as a young adult and 18, lived and worked in close quarters with other young sailors on the survey ship a maintenance squadron and then in a maintenance squadron, 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 hand.
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 hand.
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 hand, 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 warts are on the left hand, there is no record that the veteran prepared meat, poultry or fish with shared gloves or utensils, and his recorded duties as an Aircraft Technician and Aircraft Technician 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 February 1983.
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 14 February 1983 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 a maintenance squadron and in a maintenance squadron, 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 hand.
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 hand.
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 hand, 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 warts are on the left hand, there is no record that the veteran prepared meat, poultry or fish with shared gloves or utensils, and his recorded duties as an Aircraft Technician and Aircraft Technician 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 February 1983.
Other Plausible Links to Service the veteran acquired and spread his warts while serving as a young Aircraft Technician and Aircraft Technician, 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 (March 1982), scrubbing decks and diving on tide poles (1982), 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 maintenance squadron in June 1984 suggests that warts were common in the Aircraft Technician.
These conditions of service plausibly contributed to the infection of his hands and fingers.
The left hand warts are most probably an extension of the wart infection that began at the left wrist, where a large wart that kept bumping against objects while he served in a maintenance squadron was excised on 16 April 1982; by February 1983 there were warts on both hands and wrists, including two on the left thenar eminence, and by 1984 and 1985 warts had appeared on the left little and middle fingers and the left arm.
Warts spread to nearby skin by autoinoculation, particularly through small cuts and abrasions, and their concentration on his dominant left hand, which takes most of the load and minor injuries of manual work, fits this pattern.
Conclusion the veteran's left hand 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 multiplied and spread through isolated, incomplete courses of cryotherapy (factor 9(9)) and required diathermy under general anaesthetic on 2 March 1985.
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 hand 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 14 February 1983) aggravated them or contributed to them in a material degree.
The left hand warts multiplied and spread after liquid nitrogen in February 1983 and June 1984 and required diathermy under general anaesthetic on 2 March 1985.
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 1983 and 1985, 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 - Warts on the left hand (two on the thenar eminence) received one liquid nitrogen session on 15 February 1983 with no recorded review, although cryotherapy normally needs repeated sessions every two to three weeks until clearance.
No further treatment is recorded for 16 months, which included a January 1984 command signal suspecting malingering, and by 12 June 1984 five warts affected the left hand and arm, as well as the little finger; after two sessions that month and a maintenance squadron's voyage in early 1985, warts of the left hand required diathermy under general anaesthetic on 2 March 1985.
Assessed objectively and subjectively under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this amounts 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 1983 and 1985, 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 left hand warts received one liquid nitrogen session in February 1983 and no further recorded treatment for 16 months, which included a January 1984 command signal suspecting malingering; by June 1984 there were five warts on the left hand and arm, and after two further sessions and a maintenance squadron's voyage in early 1985 they required diathermy under general anaesthetic on 2 March 1985.
Isolated treatments without specialist referral for two years 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
Not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
Warts on the left hand received a single liquid nitrogen session on 15 February 1983 with no recorded review for 16 months, a period that included a January 1984 command signal suspecting him of malingering; by June 1984 there were five warts on the left hand and arm, and after two further sessions and a maintenance squadron's voyage in early 1985 they required diathermy under general anaesthetic on 2 March 1985.
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 hand 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: 14 February 1983 — warts of the hands and wrists referred for liquid nitrogen [CHART REVIEW document].
The later records, including the wart clinic treatment of 12 June 1984 and the diathermy of 2 March 1985, 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 14 February 1983.
This date falls within the veteran's ADF service (30 November 1980 16 September 1987).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
