PPS Critical Illness Form

PPS Critical Illness Form Patient Details: Full Name: Sarah Jane Smith Date of Birth: 15/03/1975 Policy Number: PI-7890123-A Date of Diagnosis: 01 November 2024 Diagnosis: Acute Myocardial Infarction (Heart Attack) Clinical Information: History of Present Illness: Mrs. Smith, a 49-year-old female, presented to the emergency department on 28/10/2024 with sudden onset of severe central chest pain radiating to her left arm, accompanied by shortness of breath and profuse sweating. Symptoms began approximately 2 hours prior to presentation. She reports no prior history of similar pain. She is a known smoker (20 pack-years) and has a family history of ischaemic heart disease (father had an MI at age 55). Relevant Past Medical History: * Hypertension, diagnosed 5 years ago, managed with Lisinopril 10mg OD. * Hypercholesterolaemia, diagnosed 3 years ago, managed with Atorvastatin 20mg OD. * No known allergies. Investigations: * ECG: ST-segment elevation in leads II, III, aVF consistent with inferoposterior myocardial infarction. * Troponin I: Elevated at 120 ng/mL (normal < 0.04 ng/mL). * Echocardiogram (29/10/2024): Left ventricular ejection fraction estimated at 40%, regional wall motion abnormalities noted in the inferior and posterior walls. * Coronary Angiography (29/10/2024): Revealed significant triple vessel disease, including a 90% stenosis in the right coronary artery, 70% stenosis in the left anterior descending artery, and 50% stenosis in the circumflex artery. Treatment: * Immediate angioplasty and stenting of the right coronary artery performed on 29/10/2024. * Started on dual antiplatelet therapy (Aspirin and Clopidogrel), beta-blocker (Bisoprolol), ACE inhibitor (Ramipril), and high-dose statin (Rosuvastatin). * Cardiac rehabilitation programme commenced. Prognosis: Patient is currently stable post-procedure. Expected to make a good recovery with ongoing medical management and lifestyle modifications. Long-term prognosis will depend on adherence to medication and cardiac rehabilitation. Risk of future cardiovascular events remains. Is the patient currently receiving ongoing medical care for this condition? Yes. If yes, please provide details of treating specialists and ongoing management plan: * Cardiology follow-up with Dr. Anya Sharma (Consultant Cardiologist) every 3 months. * Regular GP follow-up for medication review and risk factor management. * Participation in a 12-week cardiac rehabilitation programme. Impact on Daily Living: Initially, the patient experienced significant limitation in physical activity and daily tasks due to chest pain and fatigue. Post-discharge, she is gradually improving but still requires assistance with heavy lifting and strenuous activities. She is unable to return to her physically demanding job as a cleaner in the short term. Expected to be off work for at least 3-6 months. Declaration: I confirm that the information provided above is accurate and complete to the best of my knowledge. Signature of Attending Physician: "Dr. Thomas Kelly" Date: 01 November 2024 Medical Council Registration Number: 1234567