Diagnostic Assessment — Right Mandible - Seborrheic Keratosis
Example 1 of 1 · fictitious patient (Veteran M)
Diagnostic Assessment
Right Mandible - Seborrheic Keratosis
SOP Codes: Balance of Probabilities No. 20 of 2024, Reasonable Hypothesis No. 19 of 2024
ADF History
Name: The veteran, Date of Birth: [withheld] Occupation: Avionics Technician, Enlistment Date: 06 September 2003, Discharge Date: 19 Mar 2019.
Occupational History
As an Avionics Technician in the Royal Australian Air Force, the veteran was exposed to significant occupational sun exposure during aircraft maintenance work. His role required regular outdoor work on aircraft flight lines at RAAF bases, particularly at the RAAF base in the the territory, which is located in the tropical zone at approximately 14.5° South latitude. This geographic location subjects personnel to intense solar radiation throughout the year with minimal seasonal variation in ultraviolet radiation intensity. Avionics technicians routinely work outdoors on flight lines and aircraft surfaces that reflect UV radiation, creating ongoing dermatological exposure risks.
History
The veteran an Avionics Technician in the Royal Australian Air Force, developed a seborrheic keratosis on his right mandible during his military service. The lesion was first formally assessed by a plastic surgeon in July 2010 as part of a comprehensive skin examination that included multiple facial lesions requiring specialist evaluation due to their location and cosmetic significance.
Timeline
- 12 Apr 2009 - the veteran presented for review of skin lesions including one on his right mandible. The right mandibular lesion was described as small, light brown, measuring 2mm x 3mm, flat in appearance, and appeared clinically benign. Given the facial location and patient concerns, referral to a plastic surgeon was recommended for formal assessment and potential excision. This represented the first documented medical assessment of the right mandibular lesion.
- 12 May 2009 - Plastic surgeon the treating doctor performed clinical assessment and shave biopsy of the right mandibular lesion under local anaesthetic. The lesion was assessed as "?Seb K (Seborrheic Keratosis)" based on clinical appearance. The procedure was completed successfully with the specimen sent for histopathological analysis. Follow-up was arranged for histopathology results review.
- 18 May 2009 - Histopathology results were received confirming the right chin lesion was "consistent with lentigo simplex". The specimen showed sun-damaged skin with no evidence of atypia or malignancy. The surgical margins were clear and no further treatment was required. The results confirmed benign solar-related skin changes and the veteran was reassured regarding the benign nature of the lesion.
Symptoms
At the time of initial assessment in June 2010, the veteran presented with a small, light brown lesion on the right mandible measuring 2mm x 3mm that was flat in appearance. The lesion was noted to appear clinically benign but required formal assessment due to its facial location. From the available medical documentation, there is no specific mention of associated symptoms such as itching, irritation, or bleeding from this lesion. The primary concerns appeared to be the visible appearance and appropriate clinical evaluation.
Imaging
No specific imaging studies were documented for this lesion. The diagnosis was made on clinical assessment by the plastic surgeon followed by histopathological examination.
1. What is the formal diagnosis of the condition claimed above?
Seborrheic Keratosis (Lentigo Simplex), Right Mandible, DVA SOP Code Balance of Probabilities No. 20 of 2024, Reasonable Hypothesis No. 19 of 2024, ICD-10 code L82.
Seborrheic keratosis is a benign intra-epidermal skin tumour arising from the proliferation of basaloid keratinocytes with histopathological architecture of a papilloma with a flat base and a hyperkeratotic crown. Lentigo simplex is included within the SOP definition of seborrheic keratosis as a variant form. These lesions are among the most common benign skin tumours in adults, typically appearing as well-demarcated, pigmented lesions. They are strongly associated with chronic sun exposure and increase in frequency with age. Lentigo simplex specifically refers to benign melanocytic lesions characterized by increased melanin production in the basal layer of the epidermis, commonly resulting from cumulative sun exposure.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? The exact onset date is not documented, but the lesion was present by June 2010 when first assessed [CHART REVIEW Page 63].
When did the veteran first present to a health / medical provider for this condition? 12 Apr 2009 - The veteran presented to medical personnel for assessment of the right mandibular lesion [CHART REVIEW Page 63].
When was the condition confirmed / formally diagnosed? 18 May 2009 - The condition was formally diagnosed following histopathological examination by the pathologist (the treating doctor) showing lentigo simplex [CHART REVIEW Page 64].
When did the veteran first present to you (or your practice) for this condition? 05 Apr 2021.
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 a combination of specialist plastic surgeon assessment and histopathological examination [CHART REVIEW Page 63, Page 64]. Initially, plastic surgeon the treating doctor clinically assessed the lesion as possibly seborrheic keratosis and performed a shave biopsy under local anaesthetic. The key diagnostic confirmation came from histopathological examination by pathologist the treating doctor on 18 May 2009, which showed the lesion was "consistent with lentigo simplex" with sun-damaged skin and no evidence of atypia or malignancy. The surgical margins were clear, confirming complete excision of benign solar-related skin changes.
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 sunlight exposure to unprotected skin at the affected site for at least 2,250 hours while in a tropical area, or having equivalent sunlight exposure in other latitude zones - MET
- The veteran served primarily at the RAAF base (14.5° South latitude) in the tropical zone from November 2004 to May 2020, accumulating 22,320 weighted sunlight hours based on documented outdoor work exposure of approximately half of each shift on the flight line. This significantly exceeds the 2,250-hour threshold required under the SOP.
For the the treating doctor-Trélat sign only, having a malignancy excluding non-melanotic malignant neoplasm of the skin, within 1 year before clinical onset - NOT MET
- This factor only applies to the treating doctor-Trélat sign (sudden onset of >20 new seborrheic keratoses within 6 months), which is not applicable to this single lesion presentation.
Taking a course of dabrafenib or vemurafenib for the treatment of cancer within 1 year before clinical onset - NOT MET
- No documentation of the veteran receiving these specific cancer medications in the medical records.
Inability to obtain appropriate clinical management for seborrheic keratosis before clinical worsening - NOT MET
- The lesion was appropriately assessed by medical personnel and subsequently by a specialist plastic surgeon with histopathological confirmation, demonstrating appropriate clinical management without barriers to care.
Sequelae
This condition is not considered a sequelae of another known condition. Seborrheic keratosis (lentigo simplex variant) is a primary benign skin lesion related to chronic sun exposure.
Unintended Consequence
This condition is not considered an unintended consequence of medical management. No procedures or medications were documented that would have resulted in the development of seborrheic keratosis.
Inability to Attain Appropriate Medical Management
The condition does not meet the criteria for inability to attain appropriate medical management. The veteran was appropriately assessed by medical personnel in June 2010 and subsequently referred to a specialist plastic surgeon for formal evaluation and histopathological confirmation. The timeline from initial presentation to definitive diagnosis and management was appropriate and timely. There is no evidence of barriers to healthcare access or inappropriate management that would have led to permanent worsening of the condition. The Full Federal Court in Brew v Repatriation Commission (01 May 1996) establishes that "inability" encompasses both objective and subjective barriers to treatment, but in this case, appropriate specialist care with histopathological confirmation was provided in a timely manner.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
