Respiratory - Sinusitis — 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 - Sinusitis

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 – Sinusitis (J01.9)

Balance of Probabilities SOP: Sinusitis SOP No. 74 of 2018 Reasonable Hypothesis SOP: Sinusitis SOP No. 73 of 2018

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 with increased exposure to respiratory pathogens through shared facilities, barracks accommodation, close quarters training, and deployment conditions. The role involves working in confined spaces with multiple personnel, increasing transmission risk of viral and bacterial infections that can lead to secondary sinusitis.

History

The veteran a Communications and Information Systems Controller in the RAAF, developed sinusitis secondary to viral upper respiratory tract infection likely contracted in communal military environments during his service.

Timeline

19 Dec 1992: The veteran was admitted with sinusitis alongside a URTI, presenting with worsening respiratory symptoms over five days, likely from communal exposure during service. The clinical presentation included nasal congestion, sputum, and sinus discomfort requiring inpatient care at 2HSB. Physical examination findings warranted antibiotics (Augmentin Duo Forte), Codral, and Cepacol lozenges, indicating significant sinus inflammation. Chest X-ray and full blood count were normal, ruling out lower respiratory involvement, with discharge on 20 December 1992 following symptom resolution.

Symptoms

At the time of onset, the veteran experienced nasal congestion, sinus pressure and discomfort, purulent discharge, and systemic symptoms requiring inpatient management. Following treatment, symptoms resolved with antibiotic therapy and symptomatic management. Currently, from the chart review, no ongoing sinusitis symptoms are reported, indicating complete resolution of the acute episode.

Imaging

19 Dec 1992: Chest X-ray and full blood count were normal, ruling out lower respiratory involvement

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

Sinusitis (ICD-10 J01.9), DVA SOP No. 74 of 2018 (Balance of Probabilities) and DVA SOP No. 73 of 2018 (Reasonable Hypothesis).

Sinusitis (or rhinosinusitis) is inflammation of the nasal cavity and the paranasal sinuses, which may be acute, recurrent acute, subacute or chronic. Acute sinusitis is almost always due to viral infection but may become secondarily infected with bacteria. The condition is characterized by nasal blockage or congestion, nasal discharge (anterior or postnasal drip), facial pain or pressure, reduction or loss of smell, and fluid within the sinuses.

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 sinusitis symptoms on 19 December 1992 [PM371 Inpatient Record Summary, UMR - FILE REVIEW.pdf, Page 12].

When did the veteran first present to a health / medical provider for this condition? The veteran first presented on 19 December 1992 to military medical officers requiring inpatient management [PM371 Inpatient Record Summary, UMR - FILE REVIEW.pdf, Page 12].

When was the condition confirmed / formally diagnosed? The condition was confirmed on 19 December 1992 by military medical officer based on clinical presentation and symptoms requiring antibiotic treatment [PM371 Inpatient Record Summary, UMR - FILE REVIEW.pdf, Page 12].

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 acute sinusitis symptoms including nasal congestion, sinus pressure, and purulent discharge in the context of upper respiratory tract infection. Clinical assessment by military medical officers confirmed bacterial sinusitis requiring antibiotic therapy with Augmentin Duo Forte. Investigations included chest X-ray and full blood count which were normal [PM371 Inpatient Record Summary, UMR - FILE REVIEW.pdf, Page 12].

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 sinusitis

MET. The veteran was diagnosed with sinusitis secondary to upper respiratory tract infection, with clinical evidence of infective process requiring antibiotic treatment.

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. On a daily basis, he encountered several orders of magnitude more people in the workplace than outside work, making transmission of the pathogen within the workplace more likely on balance of probabilities.

Inability to obtain appropriate clinical management for sinusitis

NOT MET. The veteran received appropriate clinical management including inpatient care, appropriate antibiotic therapy (Augmentin Duo Forte), symptomatic treatment, and monitoring until resolution. No evidence of barriers to healthcare access.

Sequelae

This condition is not a sequelae of another known condition, although it developed secondary to upper respiratory tract infection.

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 sinusitis including prompt inpatient care when indicated, appropriate antibiotic therapy with Augmentin Duo Forte, symptomatic treatment with Codral and Cepacol, and monitoring until resolution. The treatment was appropriate for the standards and knowledge of the time. 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 promptly.

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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