Diagnostic Assessment — Right Middle Finger - Wart
Example 1 of 1 · fictitious patient
Diagnostic Assessment Right Middle Finger — Wart BOP Code: 8 of 2023 (Warts) RH Code: 7 of 2023 (Warts)
ADF History
The veteran, date of birth [withheld], Australian Army, Rifleman, 11 January 1988 to 27 October 1994
History
The veteran had warts on both hands and wrists during ADF service.
The documentation of warts on "both hands and wrists" on 27 March 1990 encompasses the right hand including the right middle finger.
A single wart on the right middle finger was specifically documented on 28 March 1990, when liquid nitrogen was applied to it.
The diathermy on 12 April 1992 specifically documented left-sided warts (left 5th finger, middle finger, wrist), which may indicate that the right-sided warts had resolved with the initial liquid nitrogen treatment in March 1990
Timeline
27 Mar 1990 — Warts on both hands and wrists recorded at an infantry battalion and referred for liquid nitrogen, which was applied on 28 March 1990. "Warts of hands and wrists" 28 Mar 1990 — Liquid nitrogen applied to warts: one on the right middle finger, two on the left thenar eminence and four on the left wrist. "x1 wart (Rt) middle finger" 1 3.
Diagnosis, dates, confirmation: Right Middle Finger Wart — Viral Wart (ICD-10: B07.8).
Onset prior to 27 March 1990.
Confirmed clinically on 27 March 1990 as part of bilateral hand and wrist warts [CHART REVIEW document], and specifically on 28 March 1990, when liquid nitrogen was applied to a single wart on the right middle finger [CHART REVIEW document].
DRCA legislation.
100% service-related
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 9 April 2008 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Warts, No.
8 of 2023) Factor 9(1): having direct physical contact with another person s cutaneous warts, within the 12 months before the clinical onset of warts — MET - Cutaneous warts are acquired from another person's wart virus, chiefly by direct skin contact, and are common among adolescents and young adults.
In the 12 months before 27 March 1990 the veteran, as a young adult and 18, lived and worked in close quarters with other young sailors on the survey ship an infantry battalion and then in an infantry battalion, working lines and handling steel cables and survey equipment alongside them; in such work and communal living, direct skin contact with shipmates' hands, without any barrier, is routine.
No specific contact is recorded, but that is not evidence that it did not occur, and it is reasonable to infer direct physical contact with another person's cutaneous warts within that period.
Factor 9(2): for warts affecting the cervix uteri only, having penetrative sexual intercourse with a person with genital warts within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the cervix uteri and cannot apply to the veteran, who is a man.
Factor 9(3): for warts affecting the anogenital region only, having contact with the anogenital warts of another person within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to warts affecting the anogenital region; the veteran's wart in this assessment affects the right middle finger.
Factor 9(4): for warts affecting the oral cavity or the larynx only, having oral sex with a person with anogenital warts within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the oral cavity or larynx; the veteran's wart in this assessment affects the right middle finger.
Factor 9(5): for plantar warts only, using communal showering or bathing facilities within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to plantar warts; the veteran's wart in this assessment affects the right middle finger, not the sole of the foot.
Factor 9(6): for warts on the hands only, using shared gloves or shared utensils on more days than not for 3 months in the preparation of meat, poultry or fish for consumption, within the 12 months before the clinical onset of warts — NOT MET - Although the right middle finger is on the hand, there is no record that the veteran prepared meat, poultry or fish with shared gloves or utensils, and his recorded duties as a Rifleman and Rifleman do not include galley work.
Factor 9(7): being in an immunocompromised state as specified at the time of the clinical onset of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation, and nothing in his history suggests substantially lowered immune function when the wart appeared in or before March 1990.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Warts, No.
7 of 2023) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): having direct physical contact with another person s cutaneous warts, within the 20 months before the clinical onset of warts — MET - In the 20 months before 27 March 1990 the veteran, as a young adult to 18, lived in shared accommodation as a recruit and trainee at naval establishments and then served in close quarters on the survey ship an infantry battalion and in an infantry battalion, working lines and cables alongside other young sailors, among whom cutaneous warts are common.
Direct skin contact with shipmates, without any barrier, is routine in that setting, and although no specific contact is recorded, it is reasonable to infer direct physical contact with another person's cutaneous warts within that period.
Factor 9(2): for warts affecting the cervix uteri only, having penetrative sexual intercourse with a person with genital warts within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the cervix uteri and cannot apply to the veteran, who is a man.
Factor 9(3): for warts affecting the anogenital region only, having contact with the anogenital warts of another person within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to warts affecting the anogenital region; the veteran's wart in this assessment affects the right middle finger.
Factor 9(4): for warts affecting the oral cavity or the larynx only, having oral sex with a person with anogenital warts within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the oral cavity or larynx; the veteran's wart in this assessment affects the right middle finger.
Factor 9(5): for plantar warts only, using communal showering or bathing facilities within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to plantar warts; the veteran's wart in this assessment affects the right middle finger, not the sole of the foot.
Factor 9(6): for warts on the hands only, using shared gloves or shared utensils on more days than not for 3 months in the preparation of meat, poultry or fish for consumption, within the 20 months before the clinical onset of warts — NOT MET - Although the right middle finger is on the hand, there is no record that the veteran prepared meat, poultry or fish with shared gloves or utensils, and his recorded duties as a Rifleman and Rifleman do not include galley work.
Factor 9(7): being in an immunocompromised state as specified at the time of the clinical onset of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation, and nothing in his history suggests substantially lowered immune function when the wart appeared in or before March 1990.
Other Plausible Links to Service the veteran acquired and spread his warts while serving as a young Rifleman and Rifleman, living in close quarters on survey ships and at naval establishments with shared messes, ablutions and equipment.
His recorded duties included rope work and working ships' lines, lifting steel cables and cable drums (April 1989), scrubbing decks and diving on tide poles (1989), largely in the hot, humid climate of north Queensland.
Wet, abraded skin is more easily infected by the wart virus, which persists on shared ropes, tools and wet surfaces, and the wart clinic held by the sick bay of an infantry battalion in July 1991 suggests that warts were common in the Rifleman.
These conditions of service plausibly contributed to the infection of his hands.
The right middle finger wart appeared alongside warts on the left hand and wrist, where the infection had been established since at least May 1989; spread between the hands by contact is a recognised mechanism, and the right middle finger is exposed to the same friction and minor injuries as the left in rope and cable work.
On that basis the wart is most probably an extension of an in-service wart infection.
Conclusion the veteran's right middle finger wart is a human papillomavirus infection acquired during his naval service, most probably through direct contact with other personnel's warts in the close living and working conditions of ships and naval establishments (factor 9(1)) and by spread from his own in-service warts of the left hand and wrist, favoured by hands kept wet and abraded by rope work, deck work and diving.
It was treated with liquid nitrogen on 28 March 1990 and is not recorded again.
The wart therefore arose in the course of his service and was contributed to by its conditions.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's right middle finger wart is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset (on or before 27 March 1990) aggravated it or contributed to it in a material degree.
The wart was treated with liquid nitrogen on 28 March 1990 and is not recorded again.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Warts, No.
8 of 2023) Factor 9(8): being in an immunocompromised state as specified at the time of the clinical worsening of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation after March 1990, and nothing in his history suggests substantially lowered immune function at that time.
Factor 9(9): inability to obtain appropriate clinical management for warts — NOT MET - The single wart on the right middle finger was treated with liquid nitrogen on 28 March 1990, the day after it was recorded, and no right-sided wart appears again: the wart clinic in July 1991 recorded only left-sided warts, and the surgeon in April 1992 recorded and treated warts only on the left hand and wrist and the penis, which suggests that it had resolved.
Assessed objectively and subjectively under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there is no evidence that an inability to obtain appropriate clinical management worsened this wart.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Warts, No.
7 of 2023) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(8): being in an immunocompromised state as specified at the time of the clinical worsening of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation after March 1990, and nothing in his history suggests substantially lowered immune function at that time.
Factor 9(9): inability to obtain appropriate clinical management for warts — NOT MET - The right middle finger wart was treated with liquid nitrogen on 28 March 1990, the day after it was recorded, and later examinations in July 1991 and April 1992 recorded warts only on the left side and, in April 1992, the penis; there is no evidence that an inability to obtain appropriate clinical management, assessed as explained in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), worsened it
Sequelae, Unintended Consequence, Inability
No sequelae are documented, and the condition is not an unintended consequence of medical management.
Inability to attain appropriate medical management — NOT MET: the single wart on the right middle finger was treated with liquid nitrogen on 28 March 1990, the day after it was recorded, and no right-sided wart is recorded at the wart clinic in July 1991 or by the surgeon in April 1992, which suggests that it resolved
Date of Clinical Onset
Right middle finger wart is an infective condition.
Its date of clinical onset is the date on which it first appeared, which is no later than the date on which it was first recorded in the service medical records.
Later treatment, investigation or imaging does not alter the date of clinical onset.
First documented: 27 March 1990 — warts of the hands and wrists, with liquid nitrogen applied to a wart on the right middle finger the next day [ [CHART REVIEW document], pages 69 70].
As the condition was already present when it was first documented, its clinical onset was no later than that date.
Date of clinical onset: on or before 27 March 1990.
This date falls within the veteran's ADF service (11 January 1988 27 October 1994).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
