Chest Pain OSCE - GERD / Acid Reflux

Diagnosis: GERD / Acid Reflux

Case Overview

  • Age/Sex: 25-year-old female
  • Occupation: Office administrator
  • Setting: Primary care / urgent care clinic
  • Chief complaint: "Chest pain"

Patient Script

Who I Am

I'm 25, I work in an office doing a lot of computer work and lately I've been quite stressed about a project.

What Brings Me In

I've been getting chest pain off and on for the last couple of weeks and it's worrying me — I wanted to get it checked out.

My Story

About two weeks ago I started noticing a burning sensation behind my breastbone after meals. At first it was just an occasional odd feeling, but in the last three days it's been more frequent and uncomfortable. The pain is a burning/acid feeling in the middle of my chest, usually comes on after I eat, especially if I lie down or bend over, and sometimes I taste a sour/bitter fluid in my mouth after it happens. I tried some antacid tablets (Tums) yesterday and it helped within 10–20 minutes. The pain is not worse with walking or climbing stairs and it doesn't feel like a heavy pressure crushing my chest — it feels more like a burn.

I also get tense and a bit shaky when I'm stressed and sometimes my heart seems to race, but the chest burning is a separate feeling. I had a cold about a month ago but that resolved. I take the combined oral contraceptive pill. I drink coffee most mornings (about 2–3 cups) and sometimes I eat late at night if I'm working late. I don't smoke; I drink alcohol socially on weekends.

My Medical Background

  • Past medical history: no chronic illnesses, no asthma
  • Medications: combined oral contraceptive pill; occasionally ibuprofen for headaches; took antacid tablets once yesterday (helped)
  • Allergies: none known
  • Social: lives with partner, office job with long hours, drinks 1–2 beers on weekends, drinks coffee daily, does not smoke
  • Family history: father had a heart attack at 52 (hes alive and well now)

What I Think & Worry About

  • I think it might be something I ate or that my stomach is upset.
  • I'm worried it could be something serious with my heart because chest pain sounds scary.
  • I'm also worried it might get worse at night and wake me up.

If You Ask Me About Other Symptoms...

  • Pain character: "Burning" in the middle of my chest, sometimes goes up the throat.
  • Radiation: sometimes a bit up toward my throat, not to my arm or jaw.
  • Timing/triggers: worse after big meals, when I lie down, or if I bend over; often happens after dinner.
  • Relieving factors: antacids help; sitting up helps; pain not relieved by rest because it is not related to exertion.
  • Shortness of breath: I get a little breathless when anxious, but not with the chest burning.
  • Palpitations: sometimes I notice a fast heartbeat when I'm stressed — lasts a minute or two.
  • Sweating: no heavy sweating with these episodes.
  • Fever/cough: no fever now; I had a brief cold a month ago which resolved.
  • Vomiting/diarrhea: no vomiting; no change in bowel habits.
  • Weight/appetite: appetite normal; no unintentional weight loss.
  • Swallowing: no painful swallowing, but occasionally food feels like it "comes back up" (regurgitation).
  • Menstrual: periods regular; not pregnant.

Clinical Summary

Examination

  • General: alert, anxious-appearing but comfortable at rest
  • Vitals: HR 78 bpm, regular; BP 118/72 mmHg; RR 14/min; SpO2 99% on air; Temp 36.7°C
  • Cardiac exam: normal S1/S2, no murmurs, no gallop
  • Respiratory exam: clear bilaterally, no wheeze or crackles
  • Chest wall: no reproducible tenderness over costochondral joints
  • Abdominal: soft, non-distended; mild epigastric tenderness to deep palpation
  • Other: no peripheral edema, no signs of acute distress

Investigations

  • ECG: sinus rhythm 78 bpm, PR 160 ms, QRS normal, no ST-segment elevation or depression, no ischemic T-wave changes (no acute ischemia)
  • Troponin I: 0.01 ng/mL (below institutional cutoff for myocardial injury) on initial sample
  • Chest X-ray: heart size normal; lungs clear; no consolidation or pneumothorax
  • Full blood count: WBC 7.4 x10^9/L (normal)
  • CRP: 1 mg/L (normal)
  • If symptoms persist or are atypical: consider 24-hour pH monitoring or upper GI endoscopy

Diagnosis

  • Primary diagnosis: Gastroesophageal reflux disease (GERD)/acid reflux

    • Supporting evidence: history of burning retrosternal pain that is worse after meals and when lying down, sour regurgitation, symptomatic improvement with antacids, normal cardiac exam and investigations (ECG, troponin) and epigastric tenderness on exam.

  • Differential diagnoses and reasoning:

    • Costochondritis: less likely because pain is burning and related to meals and posture rather than focal reproducible chest wall tenderness.
    • Panic/anxiety-related chest pain: anxiety may contribute (palpitations present) but the clear relation to meals and relief with antacids favors GERD.
    • Cardiac ischemia (acute coronary syndrome): unlikely given young age, typical reflux features, normal ECG and troponin; family history is a red herring but does not fit current presentation.
    • Peptic ulcer disease/gastritis: possible but pain pattern and regurgitation favor reflux; NSAID use is intermittent and could contribute to dyspepsia.
    • Esophageal spasm: less likely but could present with chest pain; lacks classic dysphagia or severe episodic pain.

Management

  • Immediate:

    • Reassure the patient regarding low likelihood of cardiac cause based on history, normal ECG and troponin, while advising return if symptoms worsen (e.g., syncope, severe shortness of breath, chest pain radiating to arm/jaw, diaphoresis).

  • Symptomatic therapy and short-term plan:

    • Empirical trial of a proton pump inhibitor (e.g., omeprazole 20 mg once daily) for 4–8 weeks.
    • Antacids (e.g., alginate-based or calcium carbonate) as needed for breakthrough symptoms.
    • Advise lifestyle measures: avoid large/late meals, reduce caffeine and alcohol, avoid lying down for 2–3 hours after eating, elevate head of bed if nocturnal symptoms, weight loss if overweight.

  • Safety-netting and follow-up:

    • Arrange review in 4 weeks to assess response to PPI; if symptoms markedly improved, continue PPI for full course then consider step-down therapy.
    • If no improvement or alarm features develop (dysphagia, odynophagia, unintentional weight loss, recurrent vomiting, GI bleeding), refer for gastroenterology assessment and consider endoscopy and H. pylori testing.
    • Consider ambulatory 24-hour pH impedance monitoring or esophageal manometry if diagnosis remains unclear or if atypical features.

Key Learning Points

  • Typical GERD presents with retrosternal burning pain related to meals and posture, often with regurgitation and improvement with antacids — an empirical PPI trial is a reasonable first-line diagnostic and therapeutic step in low-risk patients.

  • Always assess for red flags (dysphagia, weight loss, bleeding) and cardiac features; perform ECG and troponin as appropriate to exclude acute coronary syndrome when chest pain is the presenting symptom.

  • Take note of red herrings (anxiety, family history of heart disease, recent minor viral illness, intermittent NSAID use) and use history, targeted exam, and basic investigations to differentiate causes.

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