Reference Determination Content
Suggested draft · fictitious patient
Abdomen - Acute Appendicitis
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 3 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 3 April 2025;
- A pre-deployment medical by the medical officer, dated 20 May 2009;
- A patrol base medical record (knee injury) by the medic, Afghanistan, dated 20 August 2009;
- A patrol base medical record and stool culture by the medic and regimental medical officer, Afghanistan, dated 28 August 2009;
- A regimental Medical Officer review and throat swab by the afghanistan, dated 2 September 2009;
- A patrol base medical record (abdominal injury) by the medic, Afghanistan, dated 10 September 2009;
- A patrol base medical record and evacuation request by the medic, Afghanistan, dated 14 September 2009;
- A CT report (operation report and histopathology) by Role 3 hospital, Afghanistan, dated 16 September 2009;
- A CT and interventional radiology report by the radiologist, dated 30 October 2009;
- A hospital admission and CT abdomen by the general surgeon, dated 7 March 2012.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
6 February 2006 and 12 December 2014
Abdomen - Acute Appendicitis
You have stated that your condition was caused by:
- having obstruction of the lumen of the appendix by a faecolith at the time of the clinical onset of acute appendicitis
- having an enteric bacterial infection, including infection with Yersinia, Campylobacter, Salmonella or Shigella species, within the 4 weeks before the clinical onset of acute appendicitis
- having an infestation of the bowel with a parasite, including Enterobius vermicularis, Ascaris lumbricoides, Schistosoma species or Entamoeba histolytica, at the time of the clinical onset of acute appendicitis
- having a systemic viral infection, including adenovirus, Epstein-Barr virus or measles virus infection, within the 4 weeks before the clinical onset of acute appendicitis
- consuming a diet low in dietary fibre, as the main source of nutrition, for at least the 4 weeks before the clinical onset of acute appendicitis
- having constipation for at least the 2 weeks before the clinical onset of acute appendicitis
- having blunt trauma to the right lower quadrant of the abdomen within the 7 days before the clinical onset of acute appendicitis
- ingesting a foreign body which lodges in the lumen of the appendix before the clinical onset of acute appendicitis
- taking an opioid drug that causes constipation for at least the 7 days before the clinical onset of acute appendicitis
Diagnosis: Acute Appendicitis
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 3 April 2025, and is supported by a CT report (operation report and histopathology) by Role 3 hospital, Afghanistan, dated 16 September 2009.
I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:
Reasonable Hypothesis - no Statement of Principles determined for this condition
which requires the evidence to connect the condition with service.
I am satisfied that the evidence establishes the following link to your service:
- having obstruction of the lumen of the appendix by a faecolith at the time of the clinical onset of acute appendicitis
- having an enteric bacterial infection, including infection with Yersinia, Campylobacter, Salmonella or Shigella species, within the 4 weeks before the clinical onset of acute appendicitis
- having an infestation of the bowel with a parasite, including Enterobius vermicularis, Ascaris lumbricoides, Schistosoma species or Entamoeba histolytica, at the time of the clinical onset of acute appendicitis
- having a systemic viral infection, including adenovirus, Epstein-Barr virus or measles virus infection, within the 4 weeks before the clinical onset of acute appendicitis
- consuming a diet low in dietary fibre, as the main source of nutrition, for at least the 4 weeks before the clinical onset of acute appendicitis
- having constipation for at least the 2 weeks before the clinical onset of acute appendicitis
- having blunt trauma to the right lower quadrant of the abdomen within the 7 days before the clinical onset of acute appendicitis
- ingesting a foreign body which lodges in the lumen of the appendix before the clinical onset of acute appendicitis
- taking an opioid drug that causes constipation for at least the 7 days before the clinical onset of acute appendicitis
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with central abdominal pain moving to the right iliac fossa, anorexia, nausea, vomiting and fever, with pain on walking and coughing on 14 September 2009.
The diagnosis was made clinically on 14 September 2009 from migratory abdominal pain localising to the right iliac fossa, anorexia, nausea, fever and right iliac fossa tenderness, and confirmed on 16 September 2009 by CT, which showed a dilated inflamed appendix with a faecolith, perforation and an abscess, and at open appendicectomy.
This has then led to further investigations and the diagnosis of your condition of Acute Appendicitis. I have accepted your condition of Acute Appendicitis.
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that this condition is related to your wartime service.
I have therefore accepted that this condition is related to your service with effect from 14 September 2009.
Abdomen - Acute Appendicitis (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 3 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 3 April 2025;
- A pre-deployment medical by the medical officer, dated 20 May 2009;
- A patrol base medical record (knee injury) by the medic, Afghanistan, dated 20 August 2009;
- A patrol base medical record and stool culture by the medic and regimental medical officer, Afghanistan, dated 28 August 2009;
- A regimental Medical Officer review and throat swab by the afghanistan, dated 2 September 2009;
- A patrol base medical record (abdominal injury) by the medic, Afghanistan, dated 10 September 2009;
- A patrol base medical record and evacuation request by the medic, Afghanistan, dated 14 September 2009;
- A CT report (operation report and histopathology) by Role 3 hospital, Afghanistan, dated 16 September 2009;
- A CT and interventional radiology report by the radiologist, dated 30 October 2009;
- A hospital admission and CT abdomen by the general surgeon, dated 7 March 2012.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
6 February 2006 and 12 December 2014
Abdomen - Acute Appendicitis (Worsening)
You have stated that the worsening of your condition was caused by:
- being treated with an opioid analgesic or an antibiotic that masks the signs of acute appendicitis, at the time of the clinical worsening of acute appendicitis
- smoking at least 5 pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of acute appendicitis
- inability to obtain appropriate clinical management for acute appendicitis
Diagnosis: Acute Appendicitis (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 3 April 2025, and is supported by a CT report (operation report and histopathology) by Role 3 hospital, Afghanistan, dated 16 September 2009.
I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:
Reasonable Hypothesis - no Statement of Principles determined for this condition
which requires the evidence to connect the condition with service.
I am satisfied that the evidence establishes the following link to your service:
- being treated with an opioid analgesic or an antibiotic that masks the signs of acute appendicitis, at the time of the clinical worsening of acute appendicitis
- smoking at least 5 pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of acute appendicitis
- inability to obtain appropriate clinical management for acute appendicitis
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with central abdominal pain moving to the right iliac fossa, anorexia, nausea, vomiting and fever, with pain on walking and coughing on 14 September 2009.
The diagnosis was made clinically on 14 September 2009 from migratory abdominal pain localising to the right iliac fossa, anorexia, nausea, fever and right iliac fossa tenderness, and confirmed on 16 September 2009 by CT, which showed a dilated inflamed appendix with a faecolith, perforation and an abscess, and at open appendicectomy.
After the condition arose, it was worsened during your service. When you presented on 14 September 2009 the medic, without a medical officer present, gave you intramuscular morphine 10 mg for pain and oral amoxicillin with clavulanic acid for presumed recurrent gastroenteritis. You began smoking at 15 and smoked about 20 cigarettes a day, increasing to 30 a day on deployment, where cigarettes were cheap and smoking filled the hours on piquet. At onset on 14 September 2009 you were at a forward patrol base on warlike service with a medic and no medical officer, imaging or surgical capability.
This has then led to further investigations and the diagnosis of your condition of Acute Appendicitis (Worsening). I have accepted your condition of Acute Appendicitis (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that the worsening of this condition is related to your wartime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 16 September 2009.
