Respiratory - Upper Respiratory Tract Infection — 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 - Upper Respiratory Tract Infection

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 – Upper Respiratory Tract Infection (J06.9)

Balance of Probabilities SOP: No specific SOP exists for URTI. Analogous factors from Sinusitis SOP No. 74 of 2018 apply. Reasonable Hypothesis SOP: No specific SOP exists for URTI. 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 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 respiratory infections.

History

The veteran a Communications and Information Systems Controller in the RAAF, developed upper respiratory tract infections due to exposure to pathogens in communal military environments during his service from 1992 to 2009.

Timeline

03 Aug 1994: The veteran presented with nasal congestion, sputum production, and a red throat, diagnosed as viral URTI, likely from communal exposure during service. The clinical presentation included acute respiratory symptoms with markedly red throat and mildly enlarged tender glands, indicating local inflammation. The condition was managed with Codral, increased fluids, and rest, with no fever suggesting a mild infection.
19 Dec 1992: The veteran was admitted with a five-day history of worsening upper respiratory tract infection symptoms, requiring inpatient management likely from communal or deployment-related exposure. The clinical presentation included severe nasal congestion and respiratory discomfort warranting antibiotics (Augmentin Duo Forte) and symptomatic treatment, with chest X-ray and blood tests normal, ruling out pneumonia.

Symptoms

At the time of injury, the veteran experienced acute onset of nasal congestion, sputum production, throat irritation, and upper respiratory discomfort. Following the infections, symptoms resolved with conservative management but demonstrated recurrent pattern consistent with communal exposure risks. Currently, from the chart review, no ongoing URTI symptoms are reported, indicating complete resolution of acute episodes.

Imaging

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

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

Upper Respiratory Tract Infection (ICD-10 J06.9). No specific DVA SOP exists for URTI. Analogous factors from Sinusitis SOP No. 74 of 2018 (Balance of Probabilities) and No. 73 of 2018 (Reasonable Hypothesis) may be considered.

Upper respiratory tract infection is inflammation of the upper respiratory tract, including the nose, throat, pharynx, and associated structures, typically caused by viral pathogens but may be bacterial. The condition is characterized by nasal congestion, rhinorrhea, sore throat, cough, and general malaise, usually self-limiting within 7-10 days.

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 URTI symptoms on 19 December 1992 [PM371 Inpatient Record Summary, UMR - FILE REVIEW.pdf, Page 12] and subsequently on 03 August 1994 [Clinical Notes Page 4, CLAIMS.pdf].

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] and again on 03 August 1994 to medical officer [Clinical Notes Page 4, CLAIMS.pdf].

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 [PM371 Inpatient Record Summary, UMR - FILE REVIEW.pdf, Page 12] and on 03 August 1994 by attending medical officer [Clinical Notes Page 4, CLAIMS.pdf].

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 respiratory symptoms including nasal congestion, sputum production, red throat, and systemic symptoms. Key investigations included chest X-ray and full blood count which were normal, ruling out lower respiratory involvement [PM371 Inpatient Record Summary, UMR - FILE REVIEW.pdf, Page 12]. Clinical assessment by military medical officers confirmed viral upper respiratory tract infection based on typical symptomatology and physical examination findings [Clinical Notes Page 4, 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 upper respiratory tract infection

MET. The veteran was diagnosed with viral URTI on clinical presentation, confirming the presence of respiratory tract infection at onset.

Being in close contact with individuals in communal living arrangements increasing pathogen transmission

MET. The veteran was required to work and live in communal military environments, barracks, and shared facilities, significantly increasing exposure to respiratory pathogens compared to civilian populations.

Inability to obtain appropriate clinical management for upper respiratory tract infection

NOT MET. The veteran received appropriate clinical management including inpatient care when indicated, symptomatic treatment, and monitoring. 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 URTI including inpatient care when symptoms were severe, appropriate investigations to rule out complications, symptomatic treatment, and follow-up 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.

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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