Diagnostic Assessment — Right Ribs - External Bruise
Example 1 of 1 · fictitious patient
Diagnostic Assessment Right Ribs — External Bruise BOP Code: 44 of 2024 (Traumatic Contusion or Haematoma) RH Code: 43 of 2024 (Traumatic Contusion or Haematoma)
ADF History
The veteran, date of birth [withheld], Royal Australian Air Force, Airfield Defence Guard, 25 September 1985 to 11 July 1992
History
The veteran sustained bruised right ribs posteriorly on 27 July 1990 when he slipped on a wet polished floor at FIMA Alexandria/an airbase whilst deck polishing.
He landed on the polisher, striking his back and right ribs.
The right ribs were tender posteriorly at approximately T10 T12 region
Timeline
27 Jul 1990 — ABSR the veteran, as a young adult, slipped on a wet polished floor at FIMA Alexandria/an airbase whilst deck polishing.
He landed on the polisher, striking his back.
Examination demonstrated tender right ribs posteriorly at approximately T10 T12 region.
An X-ray of ribs and L5 spine was requested.
This presentation also documented chronic low back pain since MVA 1987 with tenderness at L4 5 S1. "Bruised right ribs"
Symptoms
At the time of injury, the veteran experienced pain and tenderness over the right ribs posteriorly at the T10 T12 level following the slip and fall onto the floor polisher
Imaging
27 Jul 1990 — X-ray right ribs requested to exclude fracture.
Result not documented in available records
1. What is the formal diagnosis of the condition claimed above?
Right Ribs External Bruise / Contusion (ICD-10: S20.411A).
A rib contusion involves bruising of the intercostal soft tissues and periosteum from direct impact
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 27 July 1990 [ [CHART REVIEW document], pages 8 9; [CHART REVIEW document], Page 12] When did the veteran first present to a health / medical provider for this condition? 27 July 1990 When was the condition confirmed / formally diagnosed? 27 July 1990 When did the veteran first present to you (or your practice) for this condition? 5 February 2017
3. How was this diagnosis confirmed?
Clinical diagnosis by the medical officer (S.
Neill) at an airbase based on tenderness over the right ribs posteriorly at T10 T12 following a documented slip and fall [ [CHART REVIEW document], pages 8 9]
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 23 December 2005 (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 Traumatic Contusion or Haematoma, No.
44 of 2024) Factor 9(1): having trauma involving the affected site within the 24 hours before clinical onset — MET - At about 11.00 am on 27 July 1990, while scrubbing a deck with soapy water before laying polish at the Fleet Intermediate Maintenance Activity (FIMA), Alexandria, the veteran slipped and landed on the floor polisher, injuring his back (Daily Injury Records of 27 July 1990).
The medical officer diagnosed bruised right posterior ribs, with tenderness over the 9th to 12th ribs, and ordered x-rays of the ribs and lumbosacral spine; no rib fracture was recorded.
The fall onto the polisher was trauma involving the right posterior ribs, the affected site, on the day the bruising began, and so within the 24 hours before clinical onset.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Traumatic Contusion or Haematoma, No.
43 of 2024) 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 trauma involving the affected site within the 24 hours before clinical onset — MET - the veteran's fall onto the floor polisher while scrubbing a deck at FIMA Alexandria on 27 July 1990 was trauma involving his right posterior ribs, where bruising and tenderness over the 9th to 12th ribs were found, on the day the bruising began and so within the 24 hours before clinical onset.
Other Plausible Links to Service The injury arose out of, and in the course of, the veteran's employment as a member.
The compensation copy of the Daily Injury Record (PM 278) of 27 July 1990 records that he was on duty, that the nature of the duty was deck polishing and scrubbing, and that at 11.00 am at FIMA Alexandria he 'slipped on a wet soapy water whilst scrubbing the deck prior to laying polish, and landed on polisher injuring back'.
Scrubbing and polishing decks are routine Airfield Defence Guard's duties, and the fall was a direct consequence of them.
Conclusion The bruising of the veteran's right posterior ribs was caused by his fall onto the floor polisher on 27 July 1990, while he was scrubbing and polishing a deck on duty at FIMA Alexandria; this is trauma involving the affected site at the onset of the bruising, meeting factor 9(1) of both Statements of Principles, and no rib fracture was recorded.
The injury arose out of and in the course of his service, and no other cause is identified.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the bruising of the veteran's right posterior ribs is found not to have arisen out of his service, the following factor addresses whether it was worsened after its clinical onset on 27 July 1990.
He remained in service, on light duties for the associated back injury in the following weeks, until his discharge on 11 July 1992.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Traumatic Contusion or Haematoma, No.
44 of 2024) Factor 9(2): inability to obtain appropriate clinical management for traumatic contusion or haematoma before clinical worsening — NOT MET - Assessed objectively and subjectively as Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J) requires, there was no inability: the injury was examined promptly and x-rays were ordered, and the veteran was reviewed on 31 July 1990, referred to an orthopaedic surgeon and given physiotherapy and light duties; the bruising resolved without further presentation.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Traumatic Contusion or Haematoma, No.
43 of 2024) 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(2): inability to obtain appropriate clinical management for traumatic contusion or haematoma before clinical worsening — NOT MET - Applying Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there was no objective or subjective inability: the injury was examined, x-rayed and followed up promptly, and the bruising resolved without further presentation
Sequelae
No specific sequelae documented
Unintended Consequence
Not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
There was no inability to obtain appropriate clinical management.
The injury was examined promptly and X-rays were ordered, and the veteran was reviewed on 31 July 1990, referred to an orthopaedic surgeon and given physiotherapy and light duties; the bruising resolved without further presentation.
Assessed objectively and subjectively as required by Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this factor is NOT MET
Date of Clinical Onset
Right ribs external bruise is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: 27 July 1990 — fall onto a floor polisher at an airbase, with bruising and tenderness of the right posterior ribs [ [CHART REVIEW document], pages 8 9; [CHART REVIEW document]].
Date of clinical onset: 27 July 1990.
This date falls within the veteran's ADF service (25 September 1985 11 July 1992).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
