Mid Back - Dysplastic Naevus — DVA claim example (Diagnostic Assessment)

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Mid Back - Dysplastic Naevus

Example 1 of 1 · fictitious patient (Veteran D)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Mid Back - Dysplastic Naevus

There is no SOP for Dysplastic Naevus. However, considering the causal relationship between sun exposure and dysplastic naevi (similar to solar keratosis SOP No. 79 of 2021 for Reasonable Hypothesis and No. 80 of 2021 for Balance of Probabilities), service connection can be established by analogy.

ADF History

The veteran, Airfield Defence Guard, enlisted 29 July 1993, currently serving.

Occupational History

As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran would have been exposed to a range of occupational hazards inherent to the role. This occupation is primarily focused on providing security and ground defence for RAAF assets, personnel, and installations, both within Australia and on deployment. Environmental exposures are common, including prolonged exposure to sunlight (UV radiation), heat, cold, dust, and potentially other airborne particulates depending on the location of training or deployment. The Health Surveillance Questionnaire from 31 June 1999 specifically notes "The use of weapons and exposure to the sun" as part of his work area description. Physical stressors include manual handling of heavy equipment, including weapons, ammunition, and field gear, often over uneven terrain and for extended durations.

History

The veteran an Airfield Defence Guard in the RAAF, was diagnosed with a dysplastic naevus on his mid back on 25 May 2016 during a routine skin check. The lesion was identified during a dermatological examination and was subsequently removed via shave excision. Throughout his military service spanning more than 20 years, the veteran accumulated substantial sun exposure due to his occupational duties.

Timeline

12 Jul 1993: During enlistment Medical History Questionnaire, the veteran answered "No" to "Skin problems," indicating no significant pre-existing skin conditions were reported at the time of joining the RAAF.
31 Jun 1999: Health Surveillance Questionnaire specifically noted "exposure to the sun" as part of the veteran work area description, confirming occupational UV radiation exposure, a known risk factor for the development of dysplastic naevi.
29 Jul 1993 - Present: Throughout his military service spanning more than 20 years, the veteran accumulated approximately 26,396.4 weighted sunlight hours based on his postings and deployments. His primary posting at the RAAF base (latitude weighting factor 0.75) and multiple deployments to various locations including an overseas area of operations, Papua New Guinea, and the an overseas area of operations resulted in significant cumulative sun exposure.
25 May 2016: The veteran was reviewed by the treating doctor Lau, Dermatologist, who identified and "shave excised a dysplastic naevus from his mid back". The dermatologist noted that no further follow-up was required for this specific lesion.

Symptoms

The dysplastic naevus on the veteran mid back was identified during a dermatological examination rather than due to symptoms reported by the patient. The medical record does not indicate that the veteran experienced any symptoms specifically attributable to the dysplastic naevus. There is no documentation of pain, itching, bleeding, or changes in appearance that prompted him to seek medical attention for this specific lesion.

Currently, the veteran does not appear to have any ongoing symptoms related to the dysplastic naevus as it was completely excised and no follow-up was required.

Imaging

25 May 2016: No imaging studies specifically for the dysplastic naevus are documented in the medical records. The diagnosis was made through clinical examination by a dermatologist, followed by histopathological confirmation after shave excision.

1. What is the formal diagnosis of the condition claimed above? Mid Back - Dysplastic Naevus, ICD-10 code D22.5 (Melanocytic naevi of trunk).

A dysplastic naevus (atypical mole) is a benign melanocytic lesion that shows architectural disorder and cytological atypia. These lesions represent an intermediate step between common acquired naevi and melanoma in the spectrum of melanocytic neoplasia. Dysplastic naevi are clinically characterized by size greater than 5mm, irregular borders, variable pigmentation, and asymmetry. Histologically, they demonstrate architectural disorder with asymmetry, subepidermal fibroplasia, and cytological atypia of melanocytes.

Dysplastic naevi are significant because they can be precursors to melanoma and also serve as markers for increased melanoma risk. Individuals with multiple dysplastic naevi have a higher risk of developing melanoma compared to the general population. Management typically involves complete excision of suspicious lesions and regular dermatological surveillance.

2. For each diagnosis identified, please also provide the following dates: "When did the veteran first experience symptoms attributable to this condition?" The exact date when the dysplastic naevus first developed cannot be determined from the available medical records. Dysplastic naevi typically develop gradually and are often asymptomatic. There is no documentation of the veteran reporting any symptoms specifically attributable to this lesion prior to its discovery during a dermatological examination on 25 May 2016.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a health provider regarding this specific condition on 25 May 2016, when he was seen by the treating doctor Lau, Dermatologist. The documentation indicates that the consultation was for a general skin examination rather than specifically for the dysplastic naevus, which was discovered during the examination.

When was the condition confirmed / formally diagnosed? The dysplastic naevus was formally diagnosed on 25 May 2016 by the treating doctor Lau, Dermatologist, who identified the lesion during examination and performed a shave excision. The diagnosis was likely confirmed by histopathological examination following the excision, although the specific pathology report details are not provided in the available medical records.

When did the veteran first present to you (or your practice) for this condition? 16 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 of dysplastic naevus was confirmed through clinical examination by a dermatologist (the treating doctor Lau) on 25 May 2016, followed by histopathological confirmation after shave excision of the lesion from the veteran mid back. The specific histopathological features confirming the diagnosis of dysplastic naevus are not detailed in the available medical records, but would typically include architectural disorder, cytological atypia of melanocytes, and subepidermal fibroplasia.

The lesion was identified during a dermatological examination rather than due to symptoms reported by the patient. The medical record does not indicate any specific symptoms attributable to the dysplastic naevus prior to its discovery.

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.

While there is no specific SOP for dysplastic naevus, I will analyze the case using the solar keratosis SOP as an analogous framework, as both conditions share ultraviolet radiation as a primary causative factor:

Exposure to ultraviolet radiation

MET
The veteran has had significant occupational exposure to sunlight throughout his military career spanning over 20 years. His calculated weighted sunlight hours total approximately 26,396.4 hours, based on his postings and deployments. This far exceeds the thresholds established in the Solar Keratosis SOP (2,250 hours for Reasonable Hypothesis and 4,500 hours for Balance of Probabilities). His primary posting at the RAAF base (latitude weighting factor 0.75) and multiple deployments to various locations resulted in substantial cumulative UV exposure. The Health Surveillance Questionnaire from 31 June 1999 specifically notes "exposure to the sun" as part of his work area description.

Genetic predisposition

NOT MET
There is no documentation of a family history of dysplastic naevi or melanoma in the veteran medical records.

Fair skin phenotype

INDETERMINATE
The veteran specific skin type is not documented in the available medical records. Fair-skinned individuals (Fitzpatrick skin types I and II) are at higher risk for developing dysplastic naevi and melanoma.

History of sunburns, especially during childhood and adolescence

INDETERMINATE
There is no documentation regarding history of sunburns in the veteran medical records.

Inability to obtain appropriate clinical management

NOT MET
There is no evidence suggesting the veteran was unable to obtain appropriate clinical management for his skin health. When the dysplastic naevus was identified, it was promptly excised by a dermatologist.

As per the Full Federal Court in Brew v Repatriation Commission (14 May 1993), there is no evidence of objective or subjective barriers that would have prevented the veteran from seeking treatment for skin concerns. He had access to medical care, and when the lesion was identified, it was promptly managed.

Sequelae

The dysplastic naevus is not a sequela of another condition. It is a primary condition related to a combination of genetic factors and environmental exposures, particularly ultraviolet radiation.

Unintended Consequence

The dysplastic naevus is not an unintended consequence of medical management. There is no evidence in the medical records that it developed as a result of any medical treatment provided to the veteran.

Inability to Attain Appropriate Medical Management

There is no evidence of an inability to attain appropriate medical management for this condition. When the dysplastic naevus was identified during a dermatological examination on 25 May 2016, it was promptly addressed with shave excision. The dermatologist noted that no further follow-up was required for this specific lesion.

The % contribution of the causes is 100% and significant

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

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