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Example Diagnostic Assessment

Skin - Sebaceous Cyst — DVA claim example

1 de-identified example Diagnostic Assessment for Skin - Sebaceous Cyst, written by the Veterans Health Centre for a DVA compensation claim. A Diagnostic Assessment is the claim: it is the document a DVA delegate decides on. Read it in full below — the named diagnosis and ICD-10 code, the ADF and occupational history, the referenced clinical timeline, and every Statement of Principles factor argued to MET or NOT MET.

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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 — Skin - Sebaceous Cyst

Example 1 of 1 · fictitious patient (Veteran J)

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

Skin - Sebaceous Cyst

No SOP available for sebaceous cyst

ADF History the veteran, Medic/Medical Operator/Medical Technician, 06 December 2001, 23 Mar 2022

Occupational History the veteran served as an Army Medic for over 20 years, exposed to tropical conditions with high humidity and temperature. Her military duties involved prolonged wear of occlusive body armor and equipment, creating ideal conditions for skin occlusion and follicular blockage. Military service included postings to tropical locations including the base city and deployments to hot climates, requiring protective clothing and equipment that restricted normal skin ventilation and increased sweating.

History the veteran an Army Medic, developed a sebaceous cyst on her abdomen first noted in January 2018 during her the base city posting in tropical conditions.

Timeline • 13 November 2016: The veteran presented with a skin cyst noted on abdomen during routine medical examination. The cyst was described as a palpable subcutaneous nodule causing mild discomfort and had been gradually growing over several weeks. Clinical examination confirmed features consistent with sebaceous cyst with no signs of infection or inflammation present at initial assessment. Conservative monitoring was recommended initially given the benign characteristics.

  • 29 Mar 2017: The skin cyst was documented again during medical review, having increased in size over the intervening months. The veteran reported increasing discomfort with equipment wear during military duties, particularly with belt and body armor positioning interfering with the enlarged cyst. Clinical assessment confirmed significant enlargement warranting surgical intervention and surgical excision was scheduled.
  • 01 June 2017: The cyst was excised surgically under local anesthetic without complications, with complete excision and clear margins achieved. Histopathological examination confirmed sebaceous cyst with no malignant features identified. Primary closure was performed with good cosmetic outcome and post-operative healing was uncomplicated with no wound issues or recurrence documented.

Symptoms Initially the veteran experienced mild discomfort from a gradually enlarging subcutaneous nodule on her abdomen. The cyst caused local discomfort that worsened over time, particularly interfering with military equipment including belts and body armor during her duties. Following surgical excision, all symptoms resolved completely with no recurrence.

Imaging No imaging was performed for this condition as diagnosis was made clinically and confirmed by histopathology following surgical excision.

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

Sebaceous Cyst - ICD-10: L72.1

A sebaceous cyst is a benign, slow-growing bump filled with keratin and sebaceous material that forms when a sebaceous gland or its duct becomes blocked or damaged. These cysts typically present as painless, round lumps beneath the skin surface and are lined with epithelium. They commonly occur on the trunk, neck, and face where sebaceous glands are most numerous. The cysts contain a thick, cheesy, malodorous material composed of keratin and lipids. While generally benign, they may become infected, inflamed, or rupture, causing local discomfort and requiring surgical intervention.

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

When did the veteran first experience symptoms attributable to this condition? The veteran first experienced symptoms in January 2018 when the cyst was first noted as a gradually enlarging nodule over several weeks [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, page 1].

When did the veteran first present to a health / medical provider for this condition? The veteran first presented on 13 November 2016 during a routine medical examination where the skin cyst was noted [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, page 1].

When was the condition confirmed / formally diagnosed? The condition was formally confirmed on 01 June 2017 following surgical excision with histopathological confirmation of sebaceous cyst [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, page 1].

When did the veteran first present to you (or your practice) for this condition? 24 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 by clinical examination revealing a palpable subcutaneous nodule with characteristics consistent with sebaceous cyst, followed by surgical excision and definitive histopathological confirmation showing benign sebaceous cyst with no malignant features [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, page 1].

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.

No SOP exists for sebaceous cyst. However, the condition developed during military service in tropical conditions where the veteran was required to wear occlusive body armor and equipment for prolonged periods. The tropical the base city environment with high humidity and temperature, combined with restrictive military clothing and equipment, created ideal conditions for sebaceous gland blockage and cyst formation. Military duties requiring body armor and equipment contributed to skin occlusion and follicular obstruction. The temporal relationship between her tropical military posting and cyst development supports service connection.

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

Sequelae This condition is not a sequelae of another service-related condition but rather a primary condition related to military environmental and occupational factors.

Unintended Consequence This condition is not an unintended consequence of medical management as it arose from occupational exposures rather than medical treatment.

Inability to Attain Appropriate Medical Management There was no inability to attain appropriate medical management for this condition. The sebaceous cyst was identified promptly during routine medical examination, monitored appropriately, and surgically excised when indicated. The progression from identification to surgical treatment occurred within a reasonable timeframe with appropriate medical care throughout. The Full Federal Court in Brew v Repatriation Commission establishes that inability encompasses both objective and subjective barriers to treatment, but in this case appropriate clinical management was readily available and provided.

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.

Need a Diagnostic Assessment like this written from your own medical record? A VHC Chart Review finds every claimable condition in your file, and each one is written up against its Statement of Principles. Fixed fee $600 + GST per stage — see all fees or book an appointment.

About Dr Thomas Perkins

One doctor. Every report.

Founding doctor of the Veterans Health Centre in Ipswich, Queensland, and one of Australia's most experienced practitioners in veterans' medicolegal medicine.

Dr Perkins has spent more than thirteen years working exclusively with current and former ADF members — treating their conditions, writing their reports and navigating the DVA system alongside them. With over 100,000 claims submitted and 2,000 Permanent Impairment Assessments completed, he has seen precisely what separates an accepted claim from a rejected one at every level, from initial liability to the Veterans' Review Board.

Every chart review, diagnostic assessment, impairment rating and appeal that leaves this clinic is personally overseen by Dr Perkins. No template, no locum, no hand-off.

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