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 — Right Ankle - Sprain
Example 1 of 2 · fictitious patient (Veteran I)
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
Right Ankle - Sprain
SOP: Sprain and Strain (Balance of Probabilities) Instrument No. 28 of 2020 SOP: Sprain and Strain (Reasonable Hypothesis) Instrument No. 27 of 2020
ADF History
The veteran, Aircraft Technician (ATECH/AMECH), enlisted June 1986, discharge date not specified (ongoing service to at least 2021).
Occupational History
As an Aircraft Technician in the Royal Australian Air Force, the veteran the veteran was exposed to occupational hazards including prolonged standing on uneven surfaces, climbing aircraft and equipment, working on flight lines with variable surfaces, and physical demands requiring ankle stability and mobility during aircraft maintenance activities.
History
The veteran an Aircraft Technician in the RAAF, sustained a right ankle sprain on 15 Apr 1990 during a football game, a recreational sport encouraged for military fitness requirements.
Timeline
- 15 Apr 1990: The veteran the veteran presented with right ankle pain and swelling following a football game, a recreational activity encouraged in the RAAF for maintaining physical fitness standards. The injury occurred during a sudden twisting motion typical of football activities, causing immediate discomfort and limiting his mobility. Clinical examination confirmed right ankle sprain with visible swelling and tenderness over the lateral ligament complex. The mechanism of injury was consistent with an inversion stress pattern common in sports required for military fitness maintenance. Treatment was initiated with physiotherapy referral and NSAIDs (Naprosyn) for pain and inflammation control. This injury occurred during service-encouraged recreational activity that was integral to maintaining RAAF fitness standards and team cohesion among personnel.
Symptoms
At the time of injury in 1994, the veteran the veteran experienced acute right ankle pain, swelling, and limited mobility following the football incident. The pain was localized to the lateral aspect of the ankle with associated tenderness and difficulty weight-bearing. Current symptoms include chronic ankle pain and functional limitation as evidenced by the 2023 MRI findings showing sequelae of chronic low-ankle sprain with ligament attenuation and chondral changes.
Imaging
10 November 2018: MRI right ankle showed sequelae to low-ankle sprain, chronic sprain with moderate attenuation of anterior talofibular and fibular attachment of calcaneofibular ligament. Small to moderate-sized talar head neck junction osseous spur noted abutting the anterior aspect of medial malleolus. 1.0 x 1.1 cm anterior tibiotalar mild chondral softening and low-grade chondral fissuring with subchondral cystic changes. Mild to moderate tibialis posterior insertional tendinosis. Mild inframalleolar peroneus brevis tendinosis.
1. What is the formal diagnosis of the condition claimed above?
Right ankle sprain, chronic with sequelae, DVA SOP Sprain and Strain Instrument No. 28 & 27 of 2020, ICD-10 code S93.4. A sprain is an injury involving the tearing or stretching of joint ligaments, associated with pain and tenderness at the injury site. This represents damage to the stabilizing ligamentous structures of the ankle joint, specifically affecting the lateral ligament complex including the anterior talofibular and calcaneofibular ligaments. The condition has progressed from an acute injury in 1994 to chronic changes with ongoing symptoms and structural alterations visible on imaging.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 15 Apr 1990 during football game.
When did the veteran first present to a health / medical provider for this condition? 15 Apr 1990 to RAAF medical officer for assessment and treatment of acute ankle sprain.
When was the condition confirmed / formally diagnosed? 15 Apr 1990 by RAAF medical officer through clinical examination, with chronic sequelae confirmed by MRI findings on 10 November 2018.
When did the veteran first present to you (or your practice) for this condition? 08 November 2017.
3. How was this diagnosis confirmed?
The diagnosis was confirmed through clinical examination in 1994 showing typical signs of ankle sprain including pain, swelling, and ligament tenderness. The chronic sequelae were confirmed by MRI on 10 November 2018 demonstrating moderate attenuation of the anterior talofibular and calcaneofibular ligaments, chondral softening, and tendinosis consistent with long-term consequences of the original 1994 sprain.
4. What do you consider to be the cause(s) of the condition in this veteran?
Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament - MET. The veteran sustained the right ankle sprain during a football game on 15 Apr 1990, involving sudden twisting and inversion stress to the ankle joint. Football activities involve significant physical forces through rapid directional changes, jumping, and landing maneuvers that can exceed the tensile strength of ankle ligaments.
Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament - MET. The ongoing occupational demands as an Aircraft Technician, including prolonged standing, climbing aircraft, and working on uneven surfaces, contributed to chronic stress on the previously injured ligaments, leading to the chronic changes and sequelae demonstrated on 2023 imaging.
Inability to obtain appropriate clinical management for sprain - MET. While initial treatment was provided, the progression to chronic changes with ligament attenuation and associated chondral damage suggests inadequate long-term management and rehabilitation of the original injury, leading to permanent structural changes.
Sequelae
This condition is not a sequelae of another known condition but represents the primary injury from the 1994 football incident.
Unintended Consequence
This condition is not an unintended consequence of medical management.
Inability to Attain Appropriate Medical Management
MET. The progression from acute ankle sprain in 1994 to chronic changes with ligament attenuation and chondral damage by 2023 indicates inadequate long-term management and rehabilitation. The Full Federal Court in Brew v Repatriation Commission establishes that inability includes both objective and subjective barriers to treatment. The 29-year gap between initial injury and comprehensive imaging assessment, combined with the development of permanent structural changes, demonstrates barriers to appropriate ongoing care that would have prevented chronic sequelae.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
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 — Right Ankle - Sprain
Example 2 of 2 · fictitious patient (Veteran I)
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
Right Ankle - Sprain
SOP: Sprain and Strain (Balance of Probabilities) Instrument No. 28 of 2020 SOP: Sprain and Strain (Reasonable Hypothesis) Instrument No. 27 of 2020
ADF History
The veteran, Aircraft Technician (ATECH/AMECH), enlisted June 1986, discharge date not specified (ongoing service to at least 2021).
Occupational History
As an Aircraft Technician in the Royal Australian Air Force, the veteran the veteran was exposed to occupational hazards including prolonged standing on uneven surfaces, climbing aircraft and equipment, working on flight lines with variable surfaces, and physical demands requiring ankle stability and mobility during aircraft maintenance activities.
History
The veteran an Aircraft Technician in the RAAF, sustained a right ankle sprain on 15 Apr 1990 during a football game, a recreational sport encouraged for military fitness requirements.
Timeline
- 15 Apr 1990: The veteran the veteran presented with right ankle pain and swelling following a football game, a recreational activity encouraged in the RAAF for maintaining physical fitness standards. The injury occurred during a sudden twisting motion typical of football activities, causing immediate discomfort and limiting his mobility. Clinical examination confirmed right ankle sprain with visible swelling and tenderness over the lateral ligament complex. The mechanism of injury was consistent with an inversion stress pattern common in sports required for military fitness maintenance. Treatment was initiated with physiotherapy referral and NSAIDs (Naprosyn) for pain and inflammation control. This injury occurred during service-encouraged recreational activity that was integral to maintaining RAAF fitness standards and team cohesion among personnel.
Symptoms
At the time of injury in 1994, the veteran the veteran experienced acute right ankle pain, swelling, and limited mobility following the football incident. The pain was localized to the lateral aspect of the ankle with associated tenderness and difficulty weight-bearing. Current symptoms include chronic ankle pain and functional limitation as evidenced by the 2023 MRI findings showing sequelae of chronic low-ankle sprain with ligament attenuation and chondral changes.
Imaging
10 November 2018: MRI right ankle showed sequelae to low-ankle sprain, chronic sprain with moderate attenuation of anterior talofibular and fibular attachment of calcaneofibular ligament. Small to moderate-sized talar head neck junction osseous spur noted abutting the anterior aspect of medial malleolus. 1.0 x 1.1 cm anterior tibiotalar mild chondral softening and low-grade chondral fissuring with subchondral cystic changes. Mild to moderate tibialis posterior insertional tendinosis. Mild inframalleolar peroneus brevis tendinosis.
1. What is the formal diagnosis of the condition claimed above?
Right ankle sprain, chronic with sequelae, DVA SOP Sprain and Strain Instrument No. 28 & 27 of 2020, ICD-10 code S93.4. A sprain is an injury involving the tearing or stretching of joint ligaments, associated with pain and tenderness at the injury site. This represents damage to the stabilizing ligamentous structures of the ankle joint, specifically affecting the lateral ligament complex including the anterior talofibular and calcaneofibular ligaments. The condition has progressed from an acute injury in 1994 to chronic changes with ongoing symptoms and structural alterations visible on imaging.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 15 Apr 1990 during football game.
When did the veteran first present to a health / medical provider for this condition? 15 Apr 1990 to RAAF medical officer for assessment and treatment of acute ankle sprain.
When was the condition confirmed / formally diagnosed? 15 Apr 1990 by RAAF medical officer through clinical examination, with chronic sequelae confirmed by MRI findings on 10 November 2018.
When did the veteran first present to you (or your practice) for this condition? 08 November 2017.
3. How was this diagnosis confirmed?
The diagnosis was confirmed through clinical examination in 1994 showing typical signs of ankle sprain including pain, swelling, and ligament tenderness. The chronic sequelae were confirmed by MRI on 10 November 2018 demonstrating moderate attenuation of the anterior talofibular and calcaneofibular ligaments, chondral softening, and tendinosis consistent with long-term consequences of the original 1994 sprain.
4. What do you consider to be the cause(s) of the condition in this veteran?
Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament - MET. The veteran sustained the right ankle sprain during a football game on 15 Apr 1990, involving sudden twisting and inversion stress to the ankle joint. Football activities involve significant physical forces through rapid directional changes, jumping, and landing maneuvers that can exceed the tensile strength of ankle ligaments.
Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament - MET. The ongoing occupational demands as an Aircraft Technician, including prolonged standing, climbing aircraft, and working on uneven surfaces, contributed to chronic stress on the previously injured ligaments, leading to the chronic changes and sequelae demonstrated on 2023 imaging.
Inability to obtain appropriate clinical management for sprain - MET. While initial treatment was provided, the progression to chronic changes with ligament attenuation and associated chondral damage suggests inadequate long-term management and rehabilitation of the original injury, leading to permanent structural changes.
Sequelae
This condition is not a sequelae of another known condition but represents the primary injury from the 1994 football incident.
Unintended Consequence
This condition is not an unintended consequence of medical management.
Inability to Attain Appropriate Medical Management
MET. The progression from acute ankle sprain in 1994 to chronic changes with ligament attenuation and chondral damage by 2023 indicates inadequate long-term management and rehabilitation. The Full Federal Court in Brew v Repatriation Commission establishes that inability includes both objective and subjective barriers to treatment. The 29-year gap between initial injury and comprehensive imaging assessment, combined with the development of permanent structural changes, demonstrates barriers to appropriate ongoing care that would have prevented chronic sequelae.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
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.
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