Diagnostic Assessment — Left Middle Finger - Wart
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Middle Finger — Wart BOP Code: 8 of 2023 (Warts) RH Code: 7 of 2023 (Warts)
ADF History
The veteran, date of birth [withheld], Royal Australian Navy, Steward, 23 February 1987 to 9 December 1993
History
The veteran had a wart on the left middle finger during ADF service.
This was specifically documented as one of the warts treated with diathermy under general anaesthetic on 26 May 1991 at RANH a supply ship
Timeline
09 May 1989 — Warts on both hands and wrists recorded at a supply ship and referred for liquid nitrogen, which was applied on 10 May 1989. "Warts of hands and wrists" 26 May 1991 — Diathermy of warts on left middle finger (x1), left 5th finger (x2), and wrist performed under GA at RANH a supply ship by the treating doctor. "Diathermy middle finger x1"
1. What is the formal diagnosis of the condition claimed above?
Left Middle Finger Wart — Viral Wart (ICD-10: B07.8).
Acquired during ADF service.
Dates: Symptom onset: prior to 9 May 1989.
First presentation: 9 May 1989.
Diagnosis confirmed: 9 May 1989 [CHART REVIEW document].
First presentation to practice: 5 July 2018.
Confirmed: Clinically on 9 May 1989 and surgically on 26 May 1991 [ [CHART REVIEW document], pages 70, 112 113].
Causes: DRCA legislation.
Acquired in communal naval environment.
100% service- related
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 23 May 2007 (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 9 May 1989 the veteran, as a young adult and 18, lived and worked in close quarters with other young sailors on the survey ship a supply ship and then in a supply ship, 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 wart in this assessment affects the left middle 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 wart in this assessment affects the left middle 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 wart in this assessment affects the left middle 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 middle 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 a Steward and Steward 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 wart appeared in or before May 1989.
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 9 May 1989 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 supply ship and in a supply ship, 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 wart in this assessment affects the left middle 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 wart in this assessment affects the left middle 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 wart in this assessment affects the left middle 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 middle 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 a Steward and Steward 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 wart appeared in or before May 1989.
Other Plausible Links to Service the veteran acquired and spread his warts while serving as a young Steward and Steward, 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 (June 1988), scrubbing decks and diving on tide poles (1988), 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 supply ship in September 1990 suggests that warts were common in the Steward.
These conditions of service plausibly contributed to the infection of his hands and fingers.
The left middle finger wart is 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 a supply ship, was excised on 9 July 1988, and by May 1989 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 wart is a consequence of an in-service condition.
Conclusion the veteran's left middle finger wart is 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.
It persisted through isolated, incomplete courses of cryotherapy for his left hand warts (factor 9(9)) until it was removed by diathermy under general anaesthetic on 26 May 1991.
The wart therefore arose in the course of his service and was contributed to by its conditions.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's left middle finger wart is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset (on or before 9 May 1989) aggravated it or contributed to it in a material degree.
The wart persisted until it was removed by diathermy under general anaesthetic on 26 May 1991.
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 wart persisted between 1989 and 1991, 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 middle finger wart, taken to have been present by 9 May 1989, was not among the warts treated on 10 May 1989, and no treatment specific to it is recorded until diathermy under general anaesthetic on 26 May 1991, unless it was among the left hand warts treated in September 1990.
Cryotherapy normally needs repeated sessions every two to three weeks, but the left hand warts received isolated sessions only, with no follow-up for 16 months, which included an April 1990 command signal suspecting malingering, and none after a supply ship's voyage in early 1991.
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 wart persisted between 1989 and 1991, 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 middle finger wart, taken to have been present by May 1989, had no treatment specific to it recorded until diathermy under general anaesthetic on 26 May 1991, while the left hand warts received only isolated cryotherapy sessions in May 1989 and September 1990, with a 16-month gap that included an April 1990 command signal suspecting malingering.
This amounts to an inability to obtain appropriate clinical management as explained in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J)
Sequelae, Unintended Consequence, Inability
As per Left 5th Finger Warts
Date of Clinical Onset
Left middle finger wart is an infective condition.
Its date of clinical onset is the date on which it first appeared, which is no later than the date on which it was first recorded in the service medical records.
Later treatment, investigation or imaging does not alter the date of clinical onset.
First documented: 9 May 1989 — warts of the hands and wrists referred for liquid nitrogen [CHART REVIEW document].
The later records, including the diathermy of the left middle finger wart on 26 May 1991, 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 9 May 1989.
This date falls within the veteran's ADF service (23 February 1987 9 December 1993).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
