Respiratory - Pharyngitis — 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 — Respiratory - Pharyngitis

Example 1 of 1 · fictitious patient (Veteran C)

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

Respiratory – Pharyngitis (J02.9)

Balance of Probabilities SOP: No specific SOP exists for Pharyngitis. Analogous factors from Sinusitis SOP No. 74 of 2018 apply. Reasonable Hypothesis SOP: No specific SOP exists for Pharyngitis. Analogous factors from Sinusitis SOP No. 73 of 2018 apply.

ADF History

The veteran, Communications and Information Systems Controller, enlisted 28 July 1986, discharged 22 Mar 2003.

Occupational History

Communications and Information Systems Controllers work in communal military environments and deployment settings with increased exposure to respiratory pathogens and environmental irritants. Deployments to austere environments expose personnel to dust, particulate matter, and infectious agents that can cause pharyngeal inflammation. The role involves working in confined spaces with multiple personnel and exposure to harsh environmental conditions during operations.

History

The veteran a Communications and Information Systems Controller in the RAAF, developed recurrent pharyngitis due to pathogen exposure in communal military settings and environmental exposures during deployment, particularly exacerbated following his an overseas area of operations deployment.

Timeline

06 Sep 1996: The veteran presented with a sore throat, diagnosed as pharyngitis, with pain impacting swallowing and speaking, linked to service-related exposures. The clinical presentation included throat discomfort with no specific examination findings documented, suggesting a clinical diagnosis. The condition was managed with symptomatic treatment, with no complications reported, indicating a self-limiting course.
05 May 1994: The veteran presented with a sore throat, diagnosed as pharyngitis, with pain on swallowing and speaking, likely from communal exposure during service. The clinical presentation included throat inflammation, with no allergies noted, allowing safe antibiotic use. Erythromycin 400 mg twice daily for 5 days was prescribed, indicating possible bacterial etiology. No specific examination findings were documented, suggesting a clinical diagnosis based on symptoms.
Nov 2005: The veteran presented with a sore throat post-an overseas area of operations deployment, diagnosed as pharyngitis with inflamed adenoids on ENT examination, linked to deployment-related environmental exposures. The clinical presentation included pain on swallowing, yawning, sneezing, and talking loudly, significantly impacting normal functions. The condition was managed with painkillers and antibiotics initially, followed by ENT referral for persistent symptoms. The ENT examination confirmed adenoid inflammation, suggesting a chronic or recurrent issue requiring ongoing management.

Symptoms

At the time of initial presentations, the veteran experienced throat pain, difficulty swallowing, pain with yawning and speaking, and throat irritation. The November 2005 episode was particularly severe with functional impact on daily activities. Following deployments, symptoms were more persistent and required specialist ENT evaluation. Currently, from the chart review, no ongoing pharyngitis symptoms are reported, indicating resolution of acute episodes.

Imaging

No specific imaging was performed for pharyngitis diagnosis.

1. What is the formal diagnosis of the condition claimed above?

Pharyngitis (ICD-10 J02.9). No specific DVA SOP exists for Pharyngitis. Analogous factors from Sinusitis SOP No. 74 of 2018 (Balance of Probabilities) and No. 73 of 2018 (Reasonable Hypothesis) may be considered.

Pharyngitis is inflammation of the pharynx (throat) that causes a sore throat. It is most commonly caused by viral infections but can also be bacterial. The condition is characterized by throat pain, difficulty swallowing, throat irritation, and may be accompanied by fever and systemic symptoms. Most cases are self-limiting, though bacterial pharyngitis may require antibiotic treatment.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition? The veteran first experienced pharyngitis symptoms on 05 May 1994 [Clinical Notes Page 5, CLAIMS.pdf], with earlier presentation on 06 September 1996 [ANTHONY GERARD FRANCIS HOPCRAFT Details Sheet, UMR - FILE REVIEW.pdf, Page 18].

When did the veteran first present to a health / medical provider for this condition? The veteran first presented on 05 May 1994 to medical officer for throat pain [Clinical Notes Page 5, CLAIMS.pdf] and again on 06 September 1996 [ANTHONY GERARD FRANCIS HOPCRAFT Details Sheet, UMR - FILE REVIEW.pdf, Page 18].

When was the condition confirmed / formally diagnosed? The condition was confirmed on 05 May 1994 by attending medical officer who prescribed erythromycin treatment [Clinical Notes Page 5, CLAIMS.pdf], and in November 2005 by ENT specialist who confirmed inflamed adenoids [Australian Government Department of Veterans' Affairs Injury or Disease Details Sheet, UMR 1-100.pdf, Page 2].

When did the veteran first present to you (or your practice) for this condition? 21 January 2015

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 was confirmed through clinical presentation of throat pain, difficulty swallowing, and pharyngeal inflammation. Key symptoms included pain on swallowing, yawning, sneezing, and talking loudly. The November 2005 episode was confirmed by ENT specialist examination revealing inflamed adenoids [Australian Government Department of Veterans' Affairs Injury or Disease Details Sheet, UMR 1-100.pdf, Page 2]. Treatment response to erythromycin in 2000 supported bacterial pharyngitis diagnosis [Clinical Notes Page 5, CLAIMS.pdf].

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.

Having a viral, bacterial or fungal respiratory tract infection at the time of the clinical onset of pharyngitis

MET. The veteran was diagnosed with pharyngitis requiring antibiotic treatment in multiple episodes, indicating infectious etiology with clinical evidence of pathogen involvement.

Exposure to environmental irritants and pathogens in deployment settings

MET. The veteran's November 2005 pharyngitis was specifically linked to an overseas area of operations deployment exposure to dust, particulate matter, and environmental conditions that exacerbated throat inflammation and required ENT specialist intervention.

Being required to work and live in communal environments making transmission of respiratory pathogens likely

MET. The veteran was required to work and live in communal military environments, barracks, and shared facilities, making transmission of respiratory pathogens within this environment likely. The recurrent nature of pharyngitis episodes supports ongoing exposure risk in military settings.

Inability to obtain appropriate clinical management for pharyngitis

NOT MET. The veteran received appropriate clinical management including antibiotic therapy when indicated (erythromycin), specialist ENT referral for persistent symptoms, and symptomatic management. No evidence of barriers to healthcare access.

Sequelae

This condition is not a sequelae of another known condition.

Unintended Consequence

This condition is not an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

This factor is NOT MET. The veteran received appropriate clinical management for pharyngitis including antibiotic therapy when clinically indicated (erythromycin 400mg twice daily for 5 days), specialist ENT referral for persistent post-deployment symptoms, and symptomatic management. The treatment provided was appropriate for the standards and knowledge of the time. The ENT examination confirmed adenoid inflammation and provided specialized care. There is no evidence of inability to access appropriate medical management. The Full Federal Court in Brew v Repatriation Commission (19 July 1990) established that inability encompasses both objective and subjective barriers to treatment, but in this case appropriate treatment was readily available and provided, including specialist consultation when required.

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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