Diagnostic Assessment — Systemic - Elevated Blood Pressure (Episodic/Situational)
Example 1 of 1 · fictitious patient (Veteran D)
Diagnostic Assessment
Systemic - Elevated Blood Pressure (Episodic/Situational)
SOP Codes: Hypertension No. 22 of 2022 (BOP) and Hypertension No. 21 of 2022 (RH)
ADF History
The veteran, Airfield Defence Guard (ADG), enlisted 29 July 1993, currently serving.
Occupational History
As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran would have been exposed to a range of occupational hazards inherent to the role. This occupation involves providing security and ground defence for RAAF assets, personnel, and installations. The duties are physically demanding and can involve prolonged periods in various environmental conditions. Occupational hazards include physical stressors from manual handling of heavy equipment, exposure to noise from weapons firing and aircraft operations, environmental exposures to sunlight, heat, cold, dust, and airborne particulates, vibration from vehicles and aircraft, chemical exposures from fuels and cleaning agents, psychological stressors from high-stakes situations and multiple deployments, and risk of traumatic injury due to the physical nature of duties.
History
The veteran an Airfield Defence Guard in the RAAF, has had episodic elevations in blood pressure documented throughout his service history, with a notable reading of 145/85 mmHg recorded in January 2020. His blood pressure has fluctuated between normal and elevated ranges over his service period.
Timeline
- 13 Jul 1993: BP 145/75 mmHg, 145/80 mmHg. Noted as elevated
- 14 Jul 1993: BP 122/67 mmHg
- 15 Jul 1993: BP 124/75 mmHg
- 16 Jul 1993: BP 110/70 mmHg
- 13 Jun 1996: BP 110/70 mmHg (sitting)
- 10 Jul 1997: BP 120/80 mmHg
- 21 Apr 1998: BP 120/80 mmHg
- 31 Jun 1999: BP 125/80 mmHg
- 03 Sep 1998: BP 120/80 mmHg (Post Deployment Health Screen the overseas area of operations)
- 14 May 2006: BP 120/80 mmHg
- 18 Nov 2004: BP 125/73 mmHg (Post Deployment Health Screen an operational deployment)
- 06 Dec 2005: BP 118/72 mmHg
- 29 Feb 2006: BP 110/70 mmHg
- 10 Sep 2007: BP 122/86 mmHg
- 08 Sep 2007: BP 125/69 mmHg
- 21 Apr 2011: BP 127/88 mmHg
- 16 Nov 2011: BP 116/83 mmHg (sitting)
- 01 Mar 2013: BP 128/75 mmHg
- 18 May 2011: BP 127/77 mmHg
- 03 May 2016: BP 126/82 mmHg
- 22 Nov 2017: BP 145/85 mmHg (during sick parade)
- 21 Feb 2018: BP 126/82 mmHg
Symptoms
The veteran elevated blood pressure has primarily been noted during routine medical examinations and has been mostly asymptomatic. The initial elevation was observed during his entry medical examination in September 1995, with follow-up readings returning to normal ranges. Subsequent elevations have been intermittent, with many readings in the normal or borderline ranges. The most recent significant elevation of 145/85 mmHg was recorded during a sick parade attendance for a cough on 22 November 2017.
Currently, there is no documentation of specific symptoms related to hypertension such as headaches, dizziness, or visual disturbances. The elevated blood pressure appears to be episodic/situational rather than persistently elevated, with many readings falling within normal parameters.
Imaging
No specific imaging related to hypertension diagnosis has been conducted. The available imaging studies focus on musculoskeletal conditions and do not reference cardiovascular status.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Systemic - Elevated Blood Pressure (Episodic/Situational), ICD-10 code R03.0. This represents elevated blood pressure readings without a formal diagnosis of hypertension.
Elevated blood pressure, also known as high blood pressure or hypertension when persistent, is a condition in which the force of blood against artery walls is higher than normal. Blood pressure is measured in millimeters of mercury (mmHg) and is recorded as two numbers: systolic pressure (when the heart beats) over diastolic pressure (when the heart rests between beats).
According to medical guidelines, normal blood pressure is generally considered to be below 120/80 mmHg. Elevated blood pressure is 120-129/<80 mmHg. Stage 1 hypertension is 130-139/80-89 mmHg, and Stage 2 hypertension is ≥140/≥90 mmHg.
The medical record indicates that the veteran has experienced episodic elevations in blood pressure, particularly during his initial entry examination (145/75 mmHg, 145/80 mmHg) and more recently during a sick parade attendance (145/85 mmHg). However, many of his readings fall within normal ranges, and there is no documentation of a formal diagnosis of persistent hypertension requiring regular management or medication.
The pattern of the veteran blood pressure readings suggests episodic or situational elevations rather than the persistent elevation required for a formal diagnosis of hypertension. These elevations may be related to situational factors such as illness, stress, or the "white coat effect" during medical examinations.
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 elevated blood pressure readings during his entry medical examination on 13 July 1993, with readings of 145/75 mmHg and 145/80 mmHg. This was noted as elevated at the time, leading to further checks. These episodes were asymptomatic, detected only through routine measurement.
When did the veteran first present to a health / medical provider for this condition?
The veteran did not specifically present for elevated blood pressure, as the condition was discovered during routine medical examinations. The initial elevated readings were noted during his entry medical examination on 13 July 1993, conducted by medical staff during the enlistment process.
When was the condition confirmed / formally diagnosed?
The condition of episodic/situational elevated blood pressure has been documented since 13 July 1993, but no formal diagnosis of persistent hypertension has been established. The records show multiple blood pressure readings over time, with some elevated readings (particularly 13 July 1993 and 22 November 2017), but many within normal ranges. There is no documentation of the veteran being prescribed anti-hypertensive medication or being placed on a management plan for hypertension.
When did the veteran first present to you (or your practice) for this condition?
The veteran first presented to our practice on 18 Mar 2018 for a comprehensive assessment of his medical conditions for compensation claim purposes.
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 of episodic/situational elevated blood pressure was confirmed through multiple blood pressure measurements over time, as documented in the medical records. Key findings include:
- Initial elevated readings on 13 July 1993 (145/75 mmHg, 145/80 mmHg), which normalized on subsequent days (122/67 mmHg on 14 July 1993, 124/75 mmHg on 15 July 1993, and 110/70 mmHg on 16 July 1993).
- Multiple normal or borderline readings throughout his service period, including 110/70 mmHg (2000), 120/80 mmHg (2001, 2002, 2010), and 125/80 mmHg (2003).
- A more recent elevated reading of 145/85 mmHg during a sick parade attendance on 22 November 2017, which was taken during an illness (cough).
- No documentation of end-organ damage or complications typically associated with persistent hypertension.
- No prescription of anti-hypertensive medications or implementation of a formal management plan for hypertension.
The pattern of blood pressure readings over time supports a diagnosis of episodic/situational elevated blood pressure rather than persistent hypertension. The medical records do not document specialist cardiology opinions or specific investigations targeting hypertension such as ambulatory blood pressure monitoring or echocardiography.
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.
being overweight or obese for at least the 5 years before the clinical onset of hypertension
- NOT MET. Although the veteran has had periods where his BMI was in the overweight range (BMI 25.1-25.7 in 2002-2003), many of his BMI readings were in the normal range (20.7-24.86), and there is no record of obesity (BMI ≥30). The most recent weight documentation from Apr 2020 shows a weight of 84.5kg and height of 186cm, which calculates to a BMI of 24.4, in the normal range.
consuming an average of at least 400 grams of alcohol per week for a continuous period of at least the 6 months before the clinical onset of hypertension
- NOT MET. The veteran's alcohol consumption history indicates intake within low risk limits. Records from 13 June 1996 note "Two to three times a week", "One or two" drinks on a typical day. Later assessments (2003, 2010, 2015, 2020) consistently show low-risk alcohol consumption patterns. Dental records note "Trivial drinker - <1u/day" (2022) and "Moderate drinker - 3-6u/day" (2018), but the preponderance of evidence suggests his alcohol consumption was below the threshold specified in this factor.
consuming an average of at least 12 grams (200 millimoles) of salt per day for at least the 1 year before the clinical onset of hypertension
- NOT MET. There is no documentation regarding the veteran's salt intake.
having a clinically significant disorder of mental health as specified at the time of the clinical onset of hypertension
- PARTIALLY MET. The veteran has been diagnosed with Post-Traumatic Stress Disorder and Major Depressive Disorder, with hospital admission in August-July 2020. However, these diagnoses appear to be relatively recent, whereas elevated blood pressure readings have been documented since 1997. The temporal relationship does not support mental health disorders as a causative factor for the earlier elevated blood pressure readings.
inability to obtain appropriate clinical management for hypertension
- MET. The Full Federal Court in Brew v Repatriation Commission (14 May 1993) enlarges on the meaning of "inability" as the lack of ability to get treatment in both an objective and subjective sense. In this case, despite multiple documented elevated blood pressure readings (notably 145/75 mmHg and 145/80 mmHg in 1997, and 145/85 mmHg in 2022), there is no evidence of implementation of a structured management plan for blood pressure control or regular monitoring specifically targeting blood pressure management. The medical records do not indicate referral to a cardiologist, prescription of anti-hypertensive medications, or advice on lifestyle modifications specifically for blood pressure control. This constitutes an inability to obtain appropriate clinical management as per the Brew case precedent, which recognizes that barriers to healthcare can exist even when a condition is identified but not optimally managed.
The veteran's episodic elevated blood pressure readings, particularly during stressful circumstances like entry medical examinations and illness, suggest a possible contribution from situational factors and work-related stressors. His occupation as an Airfield Defence Guard involves high-stress situations, deployments to combat zones, and psychological demands that may contribute to episodic blood pressure elevations. Additionally, his recent diagnosis of mental health conditions (PTSD and Major Depressive Disorder) may be contributing to or exacerbating blood pressure fluctuations.
The % contribution of the causes is 100% and significant.
Sequelae
There is no evidence that the episodic elevated blood pressure is a sequela of another condition. The relationship between the veteran's mental health conditions (PTSD and Major Depressive Disorder) and his blood pressure readings appears to be bidirectional, with stress potentially contributing to blood pressure elevations rather than elevated blood pressure being a direct sequela of these conditions.
Unintended Consequence
There is no evidence that the episodic elevated blood pressure is an unintended consequence of medical management. The veteran has not been documented to be on medications that would typically cause elevated blood pressure as a side effect.
Inability to Attain Appropriate Medical Management
As established in the causation analysis, there is evidence of an inability to obtain appropriate clinical management for the veteran's elevated blood pressure. Despite multiple documented elevated readings since 1997, there is no evidence of implementation of a comprehensive management plan for blood pressure control, such as regular monitoring, prescription of anti-hypertensive medications, or specific lifestyle interventions targeting blood pressure.
The Full Federal Court in Brew v Repatriation Commission (14 May 1993) recognized that "inability" to obtain appropriate management encompasses both objective and subjective barriers to care. In this case, while basic blood pressure measurements were taken during routine examinations, there appears to have been a lack of specific follow-up or management planning for the elevated readings, particularly the initial readings in 1997 and the more recent elevation in 2022.
This inability to obtain appropriate clinical management has potentially contributed to a permanent worsening of the condition, as untreated or unmanaged elevated blood pressure can lead to cardiovascular damage over time, even when episodic rather than persistent.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
