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 Hand - Possible Scaphoid Fracture
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 Hand - Possible Scaphoid Fracture
Balance of Probabilities: Fracture SOP (Instrument No. 63 of 2024)
Reasonable Hypothesis: Fracture SOP (Instrument No. 64 of 2024)
ADF History
The veteran, Aircraft Technician (ATECH/AMECH), enlisted approximately June 1986, discharge date not explicitly stated but ongoing service indicated up to at least 2021.
Occupational History
As an Aircraft Technician in the Royal Australian Air Force, the veteran the veteran was responsible for maintenance, repair, and servicing of aircraft and associated systems. This role involved working in high-risk environments such as flight lines, engine bays, and maintenance hangars, with exposure to various occupational hazards and environmental stressors. Military service also required participation in physical fitness activities and sports for team building and conditioning.
History
The veteran an Aircraft Technician in the RAAF, sustained a possible scaphoid fracture on 19 May 1990 from a fall during a sport, a recreational activity encouraged for military fitness. The injury occurred during his service and was diagnosed on the same date with a query diagnosis pending imaging.
Timeline
- 19 May 1990: The veteran presented with right wrist pain and swelling following a fall during a sport, a recreational activity encouraged in the RAAF. The pain was localized to the scaphoid region, with tenderness on palpation. Clinical examination raised a query scaphoid fracture, managed with a cast and X-rays ordered. The injury was likely due to hyperextension or impact from the fall, consistent with sports-related trauma. This presentation highlights the occupational requirement for physical fitness, which contributed to the injury. The condition was managed conservatively, with no confirmed fracture documented.
Symptoms
At the time of injury, the veteran experienced acute right wrist pain localized to the scaphoid region, with swelling and tenderness on palpation. The symptoms developed immediately following the fall during sport. The injury was managed with casting and the symptoms resolved with conservative treatment.
Imaging
19 May 1990: X-rays ordered for query scaphoid fracture, managed with cast application.
1. What is the formal diagnosis of the condition claimed above?
Query scaphoid fracture of the right hand. DVA SOP: Fracture (Instrument No. 63 of 2024). ICD-10: S62.0 (Fracture of scaphoid bone of hand).
A scaphoid fracture is a break in the scaphoid bone, one of the small bones in the wrist on the thumb side. The scaphoid bone has a poor blood supply, making it prone to healing complications. These fractures commonly occur from falls onto an outstretched hand, particularly during sports activities. The diagnosis was queried based on clinical presentation and mechanism of injury, with conservative management initiated.
The temporal relationship shows an acute injury occurring on 19 May 1990 during a service-encouraged sporting activity, with immediate clinical assessment and management.
When did the veteran first experience symptoms attributable to this condition?
The veteran first experienced symptoms on 19 May 1990 following a fall during sport.
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented to a medical provider on 19 May 1990 following the injury.
When was the condition confirmed / formally diagnosed?
The condition was diagnosed as a query scaphoid fracture on 19 May 1990 by the attending medical officer, with X-rays ordered and conservative management with casting initiated.
When did the veteran first present to you (or your practice) for this condition?
13 Apr 2018.
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 based on clinical examination revealing pain and swelling localized to the scaphoid region following a fall. The mechanism of injury (fall during sport) and clinical presentation led to a query diagnosis of scaphoid fracture. X-rays were ordered and conservative management with casting was initiated. The injury was managed as a presumptive scaphoid fracture given the high index of suspicion.
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 significant physical force applied to or through the affected bone at the time of clinical onset - MET. The veteran sustained the injury during a fall while participating in sport, with significant force applied through the wrist and scaphoid bone, consistent with the mechanism for scaphoid fractures.
Inability to obtain appropriate clinical management - NOT MET. The injury was promptly assessed and managed conservatively with casting, which is appropriate initial management for suspected scaphoid fractures.
Note: This condition occurred on 19 May 1990, which is before 26 February 1998 and did not occur on warlike deployment, therefore it comes under DRCA legislation. Under DRCA, the test is whether the injury arose out of or in the course of employment. The injury occurred during a sporting activity encouraged for military fitness and team building, which is considered part of military service requirements.
Sequelae
This condition is not a sequelae of another known condition but represents an acute traumatic injury sustained during service-encouraged activities.
Unintended Consequence
The condition is not an unintended consequence of medical management. No procedures or medications contributed to this condition.
Inability to Attain Appropriate Medical Management
NOT MET. The injury received prompt medical attention with appropriate clinical assessment, X-ray investigation, and conservative management with casting. There were no barriers to obtaining appropriate medical care for this acute injury.
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 Hand - Possible Scaphoid Fracture
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 Hand - Possible Scaphoid Fracture
Balance of Probabilities: Fracture SOP (Instrument No. 63 of 2024)
Reasonable Hypothesis: Fracture SOP (Instrument No. 64 of 2024)
ADF History
The veteran, Aircraft Technician (ATECH/AMECH), enlisted approximately June 1986, discharge date not explicitly stated but ongoing service indicated up to at least 2021.
Occupational History
As an Aircraft Technician in the Royal Australian Air Force, the veteran the veteran was responsible for maintenance, repair, and servicing of aircraft and associated systems. This role involved working in high-risk environments such as flight lines, engine bays, and maintenance hangars, with exposure to various occupational hazards and environmental stressors. Military service also required participation in physical fitness activities and sports for team building and conditioning.
History
The veteran an Aircraft Technician in the RAAF, sustained a possible scaphoid fracture on 19 May 1990 from a fall during a sport, a recreational activity encouraged for military fitness. The injury occurred during his service and was diagnosed on the same date with a query diagnosis pending imaging.
Timeline
- 19 May 1990: The veteran presented with right wrist pain and swelling following a fall during a sport, a recreational activity encouraged in the RAAF. The pain was localized to the scaphoid region, with tenderness on palpation. Clinical examination raised a query scaphoid fracture, managed with a cast and X-rays ordered. The injury was likely due to hyperextension or impact from the fall, consistent with sports-related trauma. This presentation highlights the occupational requirement for physical fitness, which contributed to the injury. The condition was managed conservatively, with no confirmed fracture documented.
Symptoms
At the time of injury, the veteran experienced acute right wrist pain localized to the scaphoid region, with swelling and tenderness on palpation. The symptoms developed immediately following the fall during sport. The injury was managed with casting and the symptoms resolved with conservative treatment.
Imaging
19 May 1990: X-rays ordered for query scaphoid fracture, managed with cast application.
1. What is the formal diagnosis of the condition claimed above?
Query scaphoid fracture of the right hand. DVA SOP: Fracture (Instrument No. 63 of 2024). ICD-10: S62.0 (Fracture of scaphoid bone of hand).
A scaphoid fracture is a break in the scaphoid bone, one of the small bones in the wrist on the thumb side. The scaphoid bone has a poor blood supply, making it prone to healing complications. These fractures commonly occur from falls onto an outstretched hand, particularly during sports activities. The diagnosis was queried based on clinical presentation and mechanism of injury, with conservative management initiated.
The temporal relationship shows an acute injury occurring on 19 May 1990 during a service-encouraged sporting activity, with immediate clinical assessment and management.
When did the veteran first experience symptoms attributable to this condition?
The veteran first experienced symptoms on 19 May 1990 following a fall during sport.
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented to a medical provider on 19 May 1990 following the injury.
When was the condition confirmed / formally diagnosed?
The condition was diagnosed as a query scaphoid fracture on 19 May 1990 by the attending medical officer, with X-rays ordered and conservative management with casting initiated.
When did the veteran first present to you (or your practice) for this condition?
13 Apr 2018.
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 based on clinical examination revealing pain and swelling localized to the scaphoid region following a fall. The mechanism of injury (fall during sport) and clinical presentation led to a query diagnosis of scaphoid fracture. X-rays were ordered and conservative management with casting was initiated. The injury was managed as a presumptive scaphoid fracture given the high index of suspicion.
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 significant physical force applied to or through the affected bone at the time of clinical onset - MET. The veteran sustained the injury during a fall while participating in sport, with significant force applied through the wrist and scaphoid bone, consistent with the mechanism for scaphoid fractures.
Inability to obtain appropriate clinical management - NOT MET. The injury was promptly assessed and managed conservatively with casting, which is appropriate initial management for suspected scaphoid fractures.
Note: This condition occurred on 19 May 1990, which is before 26 February 1998 and did not occur on warlike deployment, therefore it comes under DRCA legislation. Under DRCA, the test is whether the injury arose out of or in the course of employment. The injury occurred during a sporting activity encouraged for military fitness and team building, which is considered part of military service requirements.
Sequelae
This condition is not a sequelae of another known condition but represents an acute traumatic injury sustained during service-encouraged activities.
Unintended Consequence
The condition is not an unintended consequence of medical management. No procedures or medications contributed to this condition.
Inability to Attain Appropriate Medical Management
NOT MET. The injury received prompt medical attention with appropriate clinical assessment, X-ray investigation, and conservative management with casting. There were no barriers to obtaining appropriate medical care for this acute injury.
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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