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Example Diagnostic Assessment

Thoracic Strain — DVA claim example

1 de-identified example Diagnostic Assessment for Thoracic Strain, 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 — Thoracic Strain

Example 1 of 1 · fictitious patient (Veteran I)

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

Thoracic Strain

SOP Codes: Balance of Probabilities - Sprain and Strain (No. 28 of 2020); Reasonable Hypothesis - Sprain and Strain (No. 27 of 2020)

ADF History

The veteran, Aircraft Technician (ATECH/AMECH), approximately June 1986, ongoing service indicated up to at least 2021.

Occupational History

As an Aircraft Technician in the Royal Australian Air Force, the veteran the veteran was responsible for the maintenance, repair, and servicing of aircraft and associated systems. This role involved working in high-risk environments such as flight lines, engine bays, and maintenance hangars, exposing him to significant physical demands including heavy lifting, repetitive movements, awkward postures, and prolonged standing. The occupation required frequent manual handling of aircraft components, tools, and equipment, creating substantial ergonomic stressors on the musculoskeletal system, particularly the spine and supporting structures.

History

The veteran an Aircraft Technician in the RAAF, sustained an acute thoracic back strain on 18 Apr 1991 while lifting furniture. The incident occurred during what was likely a service-related relocation or personal activity influenced by military lifestyle demands.

Timeline

  • 18 Apr 1991: The veteran presented with acute thoracic back pain following lifting furniture, likely during a service-related move or personal activity. The pain was localized to the thoracic region, with no radiation or neurological symptoms noted. Clinical examination confirmed thoracic strain, managed with reassurance and urinalysis to exclude renal causes. The injury was attributed to improper lifting technique or overexertion, consistent with the physical demands of military life. This presentation reflects the occupational and lifestyle demands of service, where heavy lifting is common in both occupational duties and frequent military relocations. The condition resolved with conservative management, with no documented chronic sequelae.

Symptoms

At the time of injury, the veteran experienced acute localized thoracic back pain with no radiating symptoms or neurological deficits. The pain was mechanical in nature, exacerbated by movement and relieved by rest. No current symptoms are documented in relation to this acute thoracic strain, indicating complete resolution with conservative management.

Imaging

No imaging was documented for this acute thoracic strain episode.

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

Thoracic strain, DVA SOP Sprain and Strain (Instrument No. 27 & 28 of 2017/2020), ICD-10 code S23.3.

Thoracic strain is an injury involving the tearing or stretching of muscles or tendons in the thoracic (mid-back) region, associated with the onset of pain and tenderness at the injury site within 24 hours following the injury. This condition typically results from sudden forceful movements, lifting heavy objects with poor technique, or overexertion of the thoracic musculature. The thoracic spine is generally more stable than the cervical or lumbar regions due to rib cage support, making strains in this area often related to specific traumatic incidents or significant physical stress.

This represents a single acute episode with no evidence of chronic or recurrent thoracic conditions.

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

When did the veteran first experience symptoms attributable to this condition?

18 Apr 1991 [CHART REVIEW.docx; CR - GEMINI.docx, Page 42]

When did the veteran first present to a health / medical provider for this condition?

18 Apr 1991, presented to military medical officer [CHART REVIEW.docx; CR - GEMINI.docx, Page 42]

When was the condition confirmed / formally diagnosed?

18 Apr 1991, diagnosed as thoracic strain by military medical officer through clinical examination [CHART REVIEW.docx; CR - GEMINI.docx, Page 42]

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

08 November 2017

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 through clinical examination by military medical personnel on 18 Apr 1991. Key symptoms included acute onset thoracic back pain following a lifting incident, with localized tenderness and no neurological deficits. The pain was mechanical in nature, consistent with muscular strain. Urinalysis was performed to exclude renal causes of back pain, which was normal. No imaging was required given the acute nature and typical presentation of muscular strain. The condition responded appropriately to conservative management with rest and reassurance. [CHART REVIEW.docx; CR - GEMINI.docx, Page 42]

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.

Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon - MET

  • The veteran sustained the thoracic strain while lifting furniture on 18 Apr 1991, which constitutes forceful use of thoracic muscles and tendons. This incident occurred during service when such physical activities were common due to frequent military relocations and the physical demands of military lifestyle.

Inability to obtain appropriate clinical management for sprain or strain - NOT MET

  • The veteran received immediate and appropriate clinical management for the acute thoracic strain, including clinical assessment, conservative management with rest, and urinalysis to exclude other causes. The condition resolved completely with appropriate care.

Note: This condition occurred after 26 February 1998 during peacetime service, so MRCA factors apply.

Sequelae

This thoracic strain is not a sequelae of another known condition. It represents an acute, isolated injury related to a specific lifting incident.

Unintended Consequence

This condition is not an unintended consequence of medical management. No procedures or medications were administered that contributed to this condition.

Inability to Attain Appropriate Medical Management

This factor is NOT MET. The veteran received immediate and appropriate medical attention for the acute thoracic strain on 18 Apr 1991. Clinical assessment was performed, appropriate conservative management was provided, and investigations (urinalysis) were conducted to exclude other pathology. The condition resolved completely with appropriate care, indicating that medical management was both timely and effective. There were no barriers to healthcare access, and the Full Federal Court precedent in Brew v Repatriation Commission does not apply in this case as appropriate clinical management was readily available and provided.

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

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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