Sinusitis (j01/ — DVA claim example (Diagnostic Assessment)

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 — Sinusitis (j01/

Example 1 of 1 · fictitious patient (Veteran N)

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

Sinusitis (J01/J32)

SOP Codes: Balance of Probabilities - Instrument No. 74 of 2018; Reasonable Hypothesis - Instrument No. 75 of 2018

ADF History

The veteran, Chef, enlisted 09 January 2009, discharged 27 Mar 2016.

Occupational History

Military chefs are exposed to various occupational hazards that may predispose to sinusitis including close quarters living conditions facilitating transmission of respiratory infections, exposure to cooking fumes and vapors in kitchen environments, potential allergens from food preparation, and environmental irritants during field exercises and training activities.

History

The veteran the veteran a military chef, developed acute sinusitis during his military service in August 2014. The condition appears related to recurrent upper respiratory tract infections and occupational exposures during his military service from 2013 to 2020.

Timeline

03 July 2012 - the veteran presented with symptoms of acute sinusitis including blocked nose and green discharge from the nose with a slight cough. He appeared systemically well without fever and was seeking appropriate treatment. Physical examination revealed afebrile status with normal ear examination, clear chest, and slightly red throat without significant systemic signs.
03 Jun 2013 - the veteran presented feeling unwell with reports of sinus congestion, sore throat and feeling generally out of sorts. He denied fevers, nausea, vomiting or being otherwise systemically unwell. Physical examination revealed tender frontal sinuses bilaterally, erythema of tympanic membranes bilaterally, and erythema and swelling of tonsils without pus.

Symptoms

Acute symptoms during service included nasal blockage, purulent nasal discharge, facial pain and pressure over frontal sinuses, and associated upper respiratory symptoms. The episodes were characterized by nasal congestion with green discharge and sinus tenderness on examination. Current symptoms from medical assessment indicate ongoing susceptibility to sinus inflammation and potential chronic sinusitis symptoms.

Imaging

No specific imaging was performed for sinusitis during the documented episodes.

1. What is the formal diagnosis of the condition claimed above?

Sinusitis (Acute and Chronic), DVA SOP Instrument No. 74 of 2018 (Balance of Probabilities), ICD-10 codes J01 (Acute Sinusitis) and J32 (Chronic Sinusitis).

Sinusitis is inflammation of the nasal cavity and paranasal sinuses characterized by nasal blockage or congestion, nasal discharge, facial pain or pressure, reduction or loss of smell, and fluid within the sinuses. It includes both acute and chronic forms.

The temporal relationship shows acute episodes during military service with potential progression to chronic symptoms.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition? 03 July 2012 (first documented acute sinusitis episode).

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to military medical personnel on 03 July 2012 for acute sinusitis symptoms.

When was the condition confirmed / formally diagnosed? The condition was confirmed and formally diagnosed on 03 July 2012 by military medical personnel who assessed the clinical presentation as consistent with acute sinusitis.

When did the veteran first present to you (or your practice) for this condition? 19 July 2018.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed through clinical assessment by military medical personnel. Key symptoms included blocked nose, green nasal discharge, and slight cough. Physical examination revealed afebrile status, normal ear examination, clear chest, and slightly red throat. Subsequent episode in 2017 showed tender frontal sinuses bilaterally and erythema of tympanic membranes, confirming recurrent sinus inflammation.

4. What do you consider to be the cause(s) of the condition in this veteran?

Factor 9(2): Having a viral, bacterial or fungal respiratory tract infection at the time of the clinical onset of sinusitis - the veteran had documented recurrent upper respiratory tract infections during military service, with acute sinusitis developing in the context of ongoing respiratory symptoms. MET - Multiple documented episodes of upper respiratory tract infections preceded and accompanied the sinusitis episodes.

Factor 9(3): Being in an immunocompromised state as specified at the time of the clinical onset of sinusitis - Military service stress and documented mental health conditions may have contributed to immune suppression. NOT MET - No specific immunocompromised state as defined in the SOP was documented.

Factor 9(6): Smoking at least one pack-year of cigarettes before clinical onset - No smoking history is documented in the available records. NOT MET - No evidence of smoking history meeting the threshold.

Factor 9(7): Being exposed to second-hand smoke for at least 1000 hours - Military environment may have involved second-hand smoke exposure, but specific duration is not quantified. NOT MET - Insufficient evidence to meet the specific hour threshold.

Factor 9(20): Inability to obtain appropriate clinical management for sinusitis - Recurrent episodes without comprehensive investigation or specialist referral. MET - Multiple presentations with conservative management only, without ENT referral or imaging studies.

Sequelae

This condition may be considered a sequelae of recurrent upper respiratory tract infections during military service.

Unintended Consequence

This condition is not considered an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

The recurrent episodes of sinusitis were managed conservatively without comprehensive investigation, ENT specialist referral, or imaging studies. The Full Federal Court in Brew v Repatriation Commission established that inability includes both objective and subjective barriers to treatment. The lack of specialist referral and comprehensive management for recurrent sinusitis represents an inability to attain appropriate medical management that may have contributed to chronic symptoms and permanent worsening of the condition.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

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