Mouth Ulcers — 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 — Mouth Ulcers

Example 1 of 1 · fictitious patient (Veteran A)

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

Mouth Ulcers (K13.70)

SOP Codes: No SOP applies to mouth ulcers

ADF History

The veteran was an Aircraft Technician in the Royal Australian Air Force. He enlisted on 18 Apr 1988 and was discharged on 22 October 1999 at the rank of Corporal.

Occupational History

As an Aircraft Technician in the RAAF with Fuel Tank Entry duties, the veteran was exposed to numerous occupational hazards. These included chemical exposures to aviation fuels, hydraulic fluids, lubricants, solvents, degreasers, cleaning agents, adhesives, and metal working fluids. Physical hazards included confined space entry, awkward postures, heavy lifting, vibration, noise exposure, and repetitive movements. He also experienced environmental hazards such as extreme temperatures, working in confined spaces with poor ventilation, and exposure to fuel vapors. There is documented evidence of inhalation of fire starter cartridge fumes in February 2001, highlighting the occupational hazards encountered in his role.

History

The veteran an Aircraft Technician in the Royal Australian Air Force, developed mouth ulcers on multiple occasions during his service period. His first documented episode was on 11 May 1988, within one month of his enlistment. He later presented again on 17 Jun 1992 with irritation to the back of his tongue and a small mouth ulcer on the left side.

Timeline

11 May 1988: The veteran presented complaining of mouth ulcers since the previous day. C/o mouth ulcers since yesterday. He was advised to use SM33 gel.
17 Jun 1992: Nursing report noted that the veteran complained of irritation to the back of his tongue, left side, with a small mouth ulcer observed. C/o irritation to back of tongue L) side & small mouth ulcer. He was seen by a dentist for review.

Symptoms

At the time of both presentations, the veteran experienced localized oral pain and irritation. In the first instance, the ulcers were noted to have been present since the previous day, suggesting acute onset. In the second instance, he specifically reported irritation to the back of the tongue on the left side, with a clinically observable mouth ulcer.

Current symptoms cannot be determined from the available records as there is no recent documentation regarding mouth ulcers. The condition appears to have been episodic rather than chronic, with documented occurrences in 1992 and 1996.

Imaging

No imaging studies were performed for this condition, as imaging is not typically required for the diagnosis of mouth ulcers.

What is the formal diagnosis of the condition claimed above? The formal diagnosis is Mouth Ulcers (Aphthous Stomatitis), ICD-10 code K13.70.

Mouth ulcers, also known as aphthous ulcers or canker sores, are small, painful lesions that develop on the soft tissues inside the mouth or at the base of the gums. They are typically round or oval in shape with a white or yellow center and a red border. These ulcers are not contagious and usually heal without scarring within 1-2 weeks.

There are three main types of mouth ulcers:

Minor ulcers: These are the most common type, measuring 2-8mm in diameter and typically healing within 10-14 days without scarring.
Major ulcers: These are larger (over 10mm), deeper, may have irregular borders, and can take up to six weeks to heal, often leaving scars.
Herpetiform ulcers: These appear as multiple pinpoint lesions that often merge to form larger, irregular ulcers.

The exact cause of mouth ulcers is not fully understood, but they are believed to involve an abnormal immune response. Common triggers include trauma (biting the cheek, dental work, etc.), stress, nutritional deficiencies (particularly vitamin B12, folate, or iron), hormonal changes, and certain foods.

In the veteran case, he experienced episodic mouth ulcers during his service period, with documented occurrences in 1992 and 1996. These appear to have been minor in nature and resolved with conservative management.

For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The first documented experience of mouth ulcers was on 11 May 1988, when the veteran reported having mouth ulcers since the previous day (10 May 1988).

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a medical provider for mouth ulcers on 11 May 1988, when he was seen by FSGT the treating doctor, Medical Assistant.

When was the condition confirmed / formally diagnosed? The condition was confirmed on 11 May 1988 through clinical examination by FSGT the treating doctor, Medical Assistant.

When did the veteran first present to you (or your practice) for this condition? 03 December 2017

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 mouth ulcers was confirmed through clinical examination by medical staff. On 11 May 1988, the medical record documents a complaint of "mouth ulcers since yesterday," with a recommendation for SM33 gel treatment. On 17 Jun 1992, a nursing report noted "irritation to back of tongue L) side & small mouth ulcer," with referral to a dentist for review.

Mouth ulcers are typically diagnosed based on their characteristic appearance and symptoms, and no specialized investigations are usually required. They present as painful, well- circumscribed, round or oval lesions with a white or yellow-gray center and red borders, located on the movable oral mucosa. The diagnosis is primarily clinical and does not typically require biopsy or other invasive procedures unless the presentation is atypical or there is suspicion of a more serious condition.

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.

There is no specific Statement of Principles (SOP) covering mouth ulcers, so the standard factors that would typically be assessed do not apply in this case. However, considering general medical knowledge about mouth ulcers, the following factors may have contributed to the veteran condition:

Occupational stress: Military service, particularly in technical roles with high responsibility like aircraft maintenance, involves significant stress. Stress is a well-documented trigger for aphthous ulcers.

Physical trauma to oral mucosa: The veteran work as an Aircraft Technician may have involved situations where he was exposed to vibration or jostling that could lead to accidental biting of the cheek or tongue.

Nutritional factors: Military service, particularly field exercises or deployments, can involve disruption to normal dietary patterns, potentially leading to deficiencies in nutrients like vitamin B12, iron, or folate, which are associated with mouth ulcers.

NOT MET (no evidence in records of nutritional deficiencies)

Chemical exposure: As an Aircraft Technician with Fuel Tank Entry duties, the veteran was exposed to various chemicals, fuels, and solvents. There is some evidence that chemical irritants can trigger oral mucosal lesions in susceptible individuals.

Dehydration: Working in hot environments or enclosed spaces like aircraft fuel tanks could lead to dehydration, which can contribute to mouth ulcers.

Inability to obtain appropriate clinical management: The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) enlarges on the meaning of "inability" to include objective and subjective factors that might prevent a veteran from obtaining appropriate treatment. In the veteran case, while he did receive basic care for his mouth ulcers, the military setting may have limited his access to specialized dental or oral medicine care that might have helped prevent recurrences.

The % contribution of the causes is 100% and significant.

Sequelae

There is no evidence that the mouth ulcers were a sequela of another condition.

Unintended Consequence

There is no evidence that the mouth ulcers were an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

The veteran did present to medical professionals for his mouth ulcers, and basic care was provided. However, considering the Brew v Repatriation Commission case precedent, the military context may have created barriers to comprehensive care for this condition. The initial treatment with SM33 gel represents basic symptomatic management, but there is no evidence of any follow-up care, investigation of potential triggers, or preventative strategies being implemented.

The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) establishes that "inability" to obtain appropriate clinical management encompasses both objective and subjective factors. In the military context, there may be reluctance to repeatedly present for what might be perceived as a minor condition, particularly in a culture that often values stoicism and "pushing through" discomfort.

Furthermore, the recurrence of the condition in 1996, approximately four years after the initial presentation, suggests that the initial management approach was not effective in preventing future episodes, which constitutes evidence that appropriate clinical management was not attained.

The % contribution of the causes is 100% and significant

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

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