Reference Determination Content
Suggested draft · fictitious patient
Left Forearm - Infected Insect Bite/Cellulitis
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 July 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 3 July 2025;
- An X-ray reports (operation report and microbiology screening report) by the orthopaedic surgeon and radiologist, dated 14 August 2004;
- A lymphoscintigraphy report by the nuclear medicine physician, dated 16 June 2005;
- A periodic health examination and pathology by the medical officer, Garrison health centre, dated 14 March 2006;
- A treatment record by the deployed medical officer, Solomon Islands, dated 2 January 2007;
- A treatment record by the deployed medical officer, Solomon Islands, dated 15 January 2007;
- A patrol report by the section commander, dated 21 January 2007;
- A treatment record by the unit medic, Patrol post, Solomon Islands, dated 21 January 2007;
- An admission record (ultrasound and microbiology reports) by the deployed medical facility, Solomon Islands, dated 25 January 2007;
- A post-deployment health assessment by the medical officer, Garrison health centre, dated 20 March 2007.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
11 January 1997 and 5 June 2014
Left Forearm - Infected Insect Bite/Cellulitis
You have stated that your condition was caused by:
- having a break in the skin of the affected site, from an insect or other arthropod bite, a cut, an abrasion or excoriation, within the 7 days before the clinical onset of cellulitis
- being exposed to a hot and humid tropical environment for at least the 7 days before the clinical onset of cellulitis
- being unable to wash, bathe or change clothing for periods of at least 72 hours, while the skin of the affected site was wet or soiled, within the 14 days before the clinical onset of cellulitis
- having an inflammatory dermatosis or superficial skin infection, such as dermatitis, eczema or tinea, of the affected site at the time of the clinical onset of cellulitis
- having lymphoedema or impaired lymphatic drainage of the affected limb at the time of the clinical onset of cellulitis
- having diabetes mellitus at the time of the clinical onset of cellulitis
- being obese at the time of the clinical onset of cellulitis
- taking an immunosuppressive drug, including a systemic corticosteroid at a dose of at least 7.5 milligrams of prednisolone per day or equivalent, for at least the 2 weeks within the 1 month before the clinical onset of cellulitis
- being colonised with Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus, at the time of the clinical onset of cellulitis
- having a previous surgical wound or traumatic injury of the affected limb that has disrupted the skin, subcutaneous tissue or lymphatics, before the clinical onset of cellulitis
Diagnosis: Infected Insect Bite/Cellulitis
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 3 July 2025, and is supported by a patrol report by the section commander, dated 21 January 2007.
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 a break in the skin of the affected site, from an insect or other arthropod bite, a cut, an abrasion or excoriation, within the 7 days before the clinical onset of cellulitis
- being exposed to a hot and humid tropical environment for at least the 7 days before the clinical onset of cellulitis
- being unable to wash, bathe or change clothing for periods of at least 72 hours, while the skin of the affected site was wet or soiled, within the 14 days before the clinical onset of cellulitis
- having an inflammatory dermatosis or superficial skin infection, such as dermatitis, eczema or tinea, of the affected site at the time of the clinical onset of cellulitis
- having lymphoedema or impaired lymphatic drainage of the affected limb at the time of the clinical onset of cellulitis
- having diabetes mellitus at the time of the clinical onset of cellulitis
- being obese at the time of the clinical onset of cellulitis
- taking an immunosuppressive drug, including a systemic corticosteroid at a dose of at least 7.5 milligrams of prednisolone per day or equivalent, for at least the 2 weeks within the 1 month before the clinical onset of cellulitis
- being colonised with Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus, at the time of the clinical onset of cellulitis
- having a previous surgical wound or traumatic injury of the affected limb that has disrupted the skin, subcutaneous tissue or lymphatics, before the clinical onset of cellulitis
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 a painful, hot, red, swollen area on the left forearm around scratched insect bites, with fever, shivers and malaise on 21 January 2007.
The diagnosis was made clinically by the medic on 21 January 2007, who recorded a hot, red, swollen and tender area of 10 by 6 cm centred on excoriated insect bites on the left forearm, with fever of 38.6 degrees. These are the classic clinical features of cellulitis.
This has then led to further investigations and the diagnosis of your condition of Infected Insect Bite/Cellulitis. I have accepted your condition of Infected Insect Bite/Cellulitis.
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 21 January 2007.
Left Forearm - Infected Insect Bite/Cellulitis (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 July 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 3 July 2025;
- An X-ray reports (operation report and microbiology screening report) by the orthopaedic surgeon and radiologist, dated 14 August 2004;
- A lymphoscintigraphy report by the nuclear medicine physician, dated 16 June 2005;
- A periodic health examination and pathology by the medical officer, Garrison health centre, dated 14 March 2006;
- A treatment record by the deployed medical officer, Solomon Islands, dated 2 January 2007;
- A treatment record by the deployed medical officer, Solomon Islands, dated 15 January 2007;
- A patrol report by the section commander, dated 21 January 2007;
- A treatment record by the unit medic, Patrol post, Solomon Islands, dated 21 January 2007;
- An admission record (ultrasound and microbiology reports) by the deployed medical facility, Solomon Islands, dated 25 January 2007;
- A post-deployment health assessment by the medical officer, Garrison health centre, dated 20 March 2007.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
11 January 1997 and 5 June 2014
Left Forearm - Infected Insect Bite/Cellulitis (Worsening)
You have stated that the worsening of your condition was caused by:
- having diabetes mellitus with poor glycaemic control at the time of the clinical worsening of cellulitis
- continuing exposure to a hot and humid environment, with inability to keep the affected site clean and dry, after the clinical onset and before the clinical worsening of cellulitis
- taking an immunosuppressive drug, including a systemic corticosteroid, at the time of the clinical worsening of cellulitis
- inability to obtain appropriate clinical management for cellulitis
Diagnosis: Infected Insect Bite/Cellulitis (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 3 July 2025, and is supported by a patrol report by the section commander, dated 21 January 2007.
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 diabetes mellitus with poor glycaemic control at the time of the clinical worsening of cellulitis
- continuing exposure to a hot and humid environment, with inability to keep the affected site clean and dry, after the clinical onset and before the clinical worsening of cellulitis
- taking an immunosuppressive drug, including a systemic corticosteroid, at the time of the clinical worsening of cellulitis
- inability to obtain appropriate clinical management for cellulitis
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 a painful, hot, red, swollen area on the left forearm around scratched insect bites, with fever, shivers and malaise on 21 January 2007.
The diagnosis was made clinically by the medic on 21 January 2007, who recorded a hot, red, swollen and tender area of 10 by 6 cm centred on excoriated insect bites on the left forearm, with fever of 38.6 degrees. These are the classic clinical features of cellulitis.
After the condition arose, it was worsened during your service. At the documented worsening on 25 January 2007 your blood glucose was 17.8 mmol/L and you required insulin, your diabetes having been destabilised by the infection and the prednisolone prescribed in theatre. From onset on 21 January 2007 to evacuation on 25 January 2007 you remained at the remote patrol post in tropical heat, humidity and rain, with limited water and no means of keeping the infected forearm clean, dry and elevated, while waiting for evacuation on non-warlike service. You were still taking tapering prednisolone, prescribed in theatre for the plant dermatitis, until 30 January 2007, and was taking it when the cellulitis worsened to an abscess with lymphangitis on 25 January 2007. Appropriate management of cellulitis in a diabetic, immunosuppressed patient with lymphoedema is prompt oral or intravenous antibiotics, elevation and early review.
This has then led to further investigations and the diagnosis of your condition of Infected Insect Bite/Cellulitis (Worsening). I have accepted your condition of Infected Insect Bite/Cellulitis (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 25 January 2007.
