Scenario date: 3 March 2024
You are a GP examining a 58-year-old male patient, Mr Robert Chen.
Writing Task:
Using the information in the case notes, write a urgent referral to Dr Sarah Nguyen, cardiologist, at City Heart Centre, 45 Cardigan Street, Melbourne.
In your answer:
- Expand the relevant notes into complete sentences
- Do not use note form
- Use letter format
- Clearly convey urgency
The body of the letter should be approximately 180–200 words words.
Patient Details:
| Name: | Robert Chen (Mr) |
| DOB: | 12 Nov 1965 |
| Height: 178cm Weight: 92kg BMI: 29.0 BP: 148/92 HR: 78 bpm |
| Social History: | Retired engineer; Married, 3 adult children; Ex-smoker – quit 2010 (20 pack-year history); Alcohol: 3–4 standard drinks/week; Sedentary lifestyle since retirement (2022) |
| Substance Intake: | Nil illicit |
| Allergies: | Penicillin (rash); shellfish |
| Family History: | - Father – myocardial infarction age 62, deceased
- Mother – type 2 diabetes, hypertension
- Brother – coronary artery disease, stented age 55
|
Previous Medical History:
- Hypertension – diagnosed 2015, on ramipril 5mg
- Hypercholesterolaemia – on atorvastatin 40mg
- Type 2 diabetes – diagnosed 2019, metformin 500mg BD
- Gout – allopurinol 300mg
- 2018 appendicectomy
3 Mar 2024
- Presenting complaint: exertional chest pain, onset 6 weeks ago
- Pain: retrosternal, dull/pressure, radiates to left arm and jaw
- Triggered by walking >200m or climbing stairs
- Relieved within 5 min rest
- 1–2 episodes/week, increasing in frequency
- No rest pain, no nocturnal symptoms
- Associated: mild dyspnoea on exertion
- No palpitations, no syncope
- Recent ECG: ST depression V4–V6 at rest
- Troponin: normal
- HEART score 6/10 — intermediate risk
Plan:
- • Urgent cardiology referral for stress testing ± coronary angiography
- • Add aspirin 100mg daily
- • GTN spray PRN (prescribed, with instructions)
- • Strict activity restriction pending review
- • Optimise glycaemic control – endocrinology review