Diagnostic Assessment — Left Wrist - Wart
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Wrist — Wart BOP Code: 8 of 2023 (Warts) RH Code: 7 of 2023 (Warts)
ADF History
The veteran, date of birth [withheld], Royal Australian Air Force, Supply Operator, 23 March 1987 to 6 January 1994
History
The veteran had warts on the left wrist during ADF service.
On 6 August 1988 at a support squadron, a large wart on the left wrist, which continued to bump against objects and had its top bumped off that day, was excised under local anaesthetic and closed with three 4/0 nylon sutures.
Four warts on the left wrist were treated with liquid nitrogen on 7 June 1989, and the left wrist was specifically documented as one of the sites treated with diathermy on 23 June 1991
Timeline
06 Aug 1988 — Large wart on the left wrist excised under local anaesthetic at a support squadron and closed with three 4/0 nylon sutures, for review.
The wart continued to bump against objects and had its top bumped off that day. "R/O wart (L) wrist" 06 Jun 1989 — Warts on both hands and wrists recorded at a support squadron and referred for liquid nitrogen, which was applied on 7 June 1989. "Warts of hands and wrists" 07 Jun 1989 — Liquid nitrogen applied to warts: one on the right middle finger, two on the left thenar eminence and four on the left wrist. "x4 (L) wrist" 23 Jun 1991 — Diathermy of warts on left wrist, left 5th finger (x2), and middle finger (x1) performed under GA at RANH a support squadron by the treating doctor. "Diathermy wrist (warts)" 1 3.
Diagnosis, dates, confirmation: Left Wrist Wart — Viral Wart (ICD-10: B07.8).
Onset prior to 6 August 1988.
First presented and confirmed clinically on 6 August 1988, when a large wart on the left wrist was excised under local anaesthetic at a support squadron [CHART REVIEW document].
Warts of the hands and wrists were documented on 6 June 1989, with liquid nitrogen applied to four warts on the left wrist on 7 June 1989 [ [CHART REVIEW document], pages 69 70], and the left wrist warts were treated surgically on 23 June 1991 [ [CHART REVIEW document], pages 112 113].
DRCA legislation.
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 20 June 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.
In the 12 months before 6 August 1988 the veteran, as a young adult and 17, was a Supply Operator at a support squadron, living in shared accommodation and playing rugby league (a scrum collapse on 21 August 1987), and then served on the survey ship a support squadron, working lines and steel cables with shipmates; scrums, tackles and shared manual work bring the hands and wrists into direct skin contact with others without any barrier.
His first wart must have come from another person's wart virus, and although no contact is recorded, it is reasonable to infer direct physical contact with another person's cutaneous warts in 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 wrist.
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 wrist.
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 wrist, 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 wrist, 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 wart appeared in or before August 1988.
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 6 August 1988 the veteran enlisted as an adult Supply Operator, lived in shared accommodation at a support squadron and a support squadron, played rugby league in 1987 (rugby injuries are recorded in April, July and September 1987), and served on the survey ship a support squadron, working lines and cables with shipmates.
These activities involve repeated direct skin contact of the hands and wrists with other adolescents and young men, among whom warts are common, 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 wrist.
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 wrist.
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 wrist, 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 wrist, 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 wart appeared in or before August 1988.
Other Plausible Links to Service the veteran's first wart appeared while he was a Supply Operator and then a Supply Operator on the survey ship a support squadron, living in shared accommodation with communal ablutions and playing rugby league (1987).
In a support squadron his duties included working lines, lifting steel cables and cable drums (July 1988) and diving on tide poles (1988), in the hot, humid climate of north Queensland.
Skin that is repeatedly wet and abraded is more easily infected by the wart virus, which also persists on shared ropes, tools and wet surfaces.
These conditions of service plausibly contributed to the acquisition and establishment of the infection at his left wrist.
The Daily Medical Record of 6 August 1988 notes that the large wart on his left wrist kept bumping against objects and had its top knocked off that day, while he was serving in a support squadron.
Repeated trauma to a wart releases virus into the surrounding broken skin and is a recognised way in which warts spread locally; four warts were present at the same wrist by 7 June 1989, and warts later appeared on his left hand, fingers and arm.
The knocks to the wart in the course of shipboard life therefore plausibly contributed to its recurrence and spread.
Conclusion the veteran's left wrist wart, the first of his recorded warts, is a human papillomavirus infection acquired during his naval service, most probably through direct skin contact with other recruits' and sailors' warts in shared accommodation, rugby league and shipboard work (factor 9(1)), favoured by skin kept wet and abraded by rope and cable work and diving.
Repeated knocks to the wart and isolated, incomplete treatment (factor 9(9)) allowed warts to recur and multiply at the wrist until diathermy under general anaesthetic on 23 June 1991.
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 wrist 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 6 August 1988) aggravated it or contributed to it in a material degree.
After excision on 6 August 1988, four warts had recurred at the wrist by June 1989, and warts there persisted despite liquid nitrogen in June 1989 and October 1990 until diathermy under general anaesthetic on 23 June 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 wrist warts recurred between 1988 and 1991; the Celestone-V cream used on his cracked heels in October 1988 is a topical steroid that does not substantially suppress immune responses.
Factor 9(9): inability to obtain appropriate clinical management for warts — MET - The left wrist wart excised in a support squadron on 6 August 1988 was listed for review, but none is recorded while he continued survey work at sea, and by 7 June 1989 four warts had recurred at the wrist.
They received one liquid nitrogen session, although cryotherapy normally needs repeated sessions every two to three weeks, and no further treatment is recorded for 16 months, which included a May 1990 command signal suspecting malingering; after two sessions in October 1990 and a support squadron's voyage in early 1991, they required diathermy under general anaesthetic on 23 June 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 wrist warts recurred between 1988 and 1991; the Celestone-V cream used on his cracked heels in October 1988 is a topical steroid that does not substantially suppress immune responses.
Factor 9(9): inability to obtain appropriate clinical management for warts — MET - After excision of the left wrist wart in a support squadron on 6 August 1988, with no recorded review, four warts recurred at the wrist by June 1989, received one liquid nitrogen session, had no recorded treatment for 16 months (a period that included a May 1990 command signal suspecting malingering) and, after two sessions in October 1990 and a support squadron's voyage in early 1991, required diathermy under general anaesthetic on 23 June 1991.
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 wrist 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: 6 August 1988 — excision of a large wart on the left wrist at a support squadron [CHART REVIEW document].
The later records, including the further treatment on 7 June 1989 and 23 June 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 6 August 1988.
This date falls within the veteran's ADF service (23 March 1987 6 January 1994).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
