Medicine — Urgent Referral to Cardiology for Exertional Chest Pain
A GP refers a 55-year-old woman with new exertional chest pain, new ST changes on ECG and a significant cardiovascular risk cluster urgently to cardiology. This proficient case embeds two clinical distractors — a recent right shoulder problem and a resolved viral illness — that must be cut cleanly to keep the letter focused and within the word limit.
Letter type
Referral
Write to
Cardiologist
Target length
180–200 words
The case notes
Patient: Mrs Elena Vasquez, 55 years old, secondary school teacher
Presenting complaint: 3-week history of central chest pressure on exertion; radiates to left jaw; settles with rest within 10 minutes; occurring daily
ECG: ST depression 1 mm in leads V4–V6 at rest; new compared to ECG 8 months ago
Risk factors: Hypertension (amlodipine 5 mg), T2DM (metformin), BMI 31, ex-smoker (15 pack-years, quit 5 years ago), father — MI age 57
Examination: BP 148/90, HR 82, chest clear, no signs of heart failure; mild right shoulder tenderness on palpation (separate musculoskeletal problem, long-standing)
Bloods: HbA1c 68 mmol/mol; total cholesterol 6.1 mmol/L, LDL 4.1 mmol/L; troponin negative on two occasions 6 hours apart
Incidental: Saw GP 4 weeks ago with a viral URTI — resolved fully; prescribed cetirizine; no connection to current symptoms
Current medication: Amlodipine 5 mg, metformin 1 g BD; cetirizine course completed
Task: Write an urgent referral letter to cardiologist Dr Marcus Lee requesting assessment for probable angina, including the relevant clinical findings and risk profile.
Writing task
Write an urgent referral letter to cardiologist Dr Marcus Lee requesting assessment for probable angina, including the relevant clinical findings and risk profile.
What to include, what to cut
The hardest mark to win is selection. The same case notes contain decision-relevant facts and distractors. Here is what an examiner expects to see in a Grade B letter for this scenario, and what should be left out.
Include
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The new ST changes compared to the previous ECG 8 months ago
An objective change that transforms this from a symptom-only referral into an urgent cardiac one. The cardiologist cannot triage urgency accurately without knowing the change is new.
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The symptom pattern: central, exertional, jaw radiation, relief at rest
This is a classic stable angina presentation. Stating the exact pattern lets the cardiologist plan the investigation pathway before seeing the patient.
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The cardiovascular risk cluster: HTN, T2DM, ex-smoker, elevated LDL, family history
All five risk factors belong together. Combined with ST changes, they justify urgent rather than routine referral. Group them efficiently in one sentence.
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Troponin negative twice and no signs of heart failure
These negative findings were specifically sought and justify urgent outpatient — not emergency — referral, framing the clinical decision correctly.
Leave out
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The right shoulder tenderness
A documented separate musculoskeletal problem with no cardiac relevance. The single clearest distractor in this case — including it suggests the writer cannot distinguish relevant from incidental.
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The viral URTI and cetirizine four weeks ago
Pre-dates the symptoms, was a different problem, and has fully resolved. Including it is the classic proficient-level trap: note detail that looks like it could be relevant, but is not.
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Cetirizine in the current medication list
The course is completed and the condition resolved. The medication list contains what the recipient needs for ongoing management — not a historical drug record.
Criterion in focus · Conciseness & Clarity
Proficient cases embed clinical distractors — the shoulder pain, the viral illness — that look relevant but are not. Under 2026 marking, including a distractor costs Conciseness & Clarity, weakens Content, and dilutes Purpose. The hallmark of a proficient candidate is cutting incidental findings without hesitation.
Now write the letter — and find out what is blocking your Grade B
Write a 180–200 words referral letter from these notes, paste it into the free checker for an instant read, then submit it for a human grade against all six criteria. Dr Mariam's team returns line-by-line feedback, from $12.