Chest Pain OSCE - Costochondritis | Free OSCE Practice

Case Overview

Age/Sex: 25-year-old male
Occupation: Personal trainer / gym instructor (athletic)
Setting: Primary care / urgent care clinic
Chief complaint: "Chest pain"

Patient Script

Who I Am

I'm a 25-year-old guy who works as a personal trainer and I lift weights most days.

What Brings Me In

I've had a sore spot on the front of my chest for a couple of days and it hurts when I press on it and when I bench press — I'm a bit worried it's serious.

My Story

Two days ago I felt a sharp twinge on the left side of my chest after doing a heavy bench-press session at the gym. The pain has been there since then — it's usually mild to moderate (about 3–4/10) but gets worse if I push on the area or do certain movements with my arms. It is also a bit worse when I take a deep breath sometimes. There was a mild cold about one week ago with a sore throat and runny nose, but that settled. I don't have any fever now. The pain does not spread to my jaw or left arm, and I haven't fainted or felt sweaty. I used to get anxious before competitions and once had a panic attack a couple of years ago, but this pain feels different — more like a musculoskeletal niggle. I pressed on my chest this morning and it really hurt over the left side of my sternum.

My Medical Background

Past medical history: none of significance
Medications: none routinely; sometimes takes ibuprofen or paracetamol after workouts
Allergies: none known
Social history: non-smoker, drinks alcohol socially (1–2 drinks on weekends), occasional cannabis months ago, trains 5–6 times/week
Family history: father had a heart attack in his 50s (not young), otherwise no early cardiac disease

What I Think & Worry About

I think it might be something I pulled in the gym or maybe just inflammation from my workout.
I'm worried it could be something serious like a heart problem because chest pain sounds scary and my dad had a heart attack.
I want to be sure it's safe for me to keep training and to know what to do so it doesn't become worse.

If You Ask Me About Other Symptoms...

Pain character: sharp/stabbing when I press on it, otherwise a dull ache at rest
Onset/timing: started 2 days ago immediately after heavy bench pressing
Radiation: no pain radiating to jaw, arm, neck, or back
Exertional symptoms: I can still run and lift at lower weights; no collapse or syncope with exercise
Associated: mild shortness of breath when I sprint (usual for me), no palpitations right now
Recent infection: had a mild cold 1 week ago (sore throat, runny nose) that resolved in a few days
Reproducibility: pressing over the left costal margin / upper sternum reproduces the pain
Red herrings / distractors: briefly bumped my chest on a gym machine two weeks ago but it didn't hurt then; sometimes I get anxious in competitions; occasionally took a pre-workout supplement last week

Clinical Summary

Examination

General: alert, comfortable at rest
Vitals: BP 118/72 mmHg, HR 76 bpm (regular), RR 14/min, SpO2 99% on air, Temp 36.7°C
Inspection: no chest wall bruising or visible swelling
Palpation: focal tenderness over the left parasternal area at the 3rd–5th costochondral junctions (reproducible pain) with no palpable swelling
Movement: pain reproduced by resisted chest wall movement (pressing palms together, deep inspiration aggravates slightly)
Cardiovascular: normal heart sounds, no murmurs, no pericardial rub
Respiratory: clear breath sounds bilaterally, no crackles or wheeze
Neuro: no focal deficits

Investigations

ECG: Normal sinus rhythm 76 bpm, PR 160 ms, QRS normal, no ST-segment elevation or depression, no pathological Q waves (no ischemic changes)
Troponin I: <0.01 ng/mL (normal reference <0.04 ng/mL) (not suggestive of myocardial injury)
Chest X-ray: Clear lung fields, normal cardiac silhouette (no acute cardiopulmonary process)
CRP: 2 mg/L (reference 0–5 mg/L) (not suggestive of systemic inflammation)
Optional (if done): CBC normal (WCC within normal limits)

Diagnosis

Primary: Costochondritis (musculoskeletal chest wall pain) — supported by localized, reproducible tenderness at the left costochondral junctions, relation to recent heavy bench-pressing, pleuritic component with movement/deep inspiration, normal ECG and troponin, and young low-risk profile.
Differentials:
- Muscular strain of pectoralis major/minor — possible given weightlifting; distinguished by more diffuse muscle pain and pain with active contraction rather than focal joint tenderness
- Tietze syndrome — similar presentation but usually with visible swelling of the costochondral joint (absent here)
- Pericarditis — typically positional chest pain, diffuse ST elevation or PR depression on ECG, possible pericardial rub (not present)
- Pulmonary embolism / pneumothorax — less likely given normal oxygenation, clear chest X-ray, low pre-test probability and no pleuritic severe dyspnea
- Acute coronary syndrome — unlikely in a healthy 25-year-old with normal ECG/troponin and non-exertional nature of the pain; family history not in a very young relative
- Pleurisy from recent viral URTI — possible but usually associated with systemic signs and more pleuritic pain with respiration and cough (patient's URTI resolved)

Management

Reassure patient about low likelihood of cardiac cause given history, normal ECG and troponin.
Analgesia: start NSAID (e.g., ibuprofen 400 mg every 6–8 hours as needed, or naproxen 500 mg then 250 mg twice daily as tolerated) and paracetamol as adjunct; advise to take with food and avoid if contraindications.
Local measures: rest from heavy pressing and bench-type exercises for 1–2 weeks, ice/heat to the area, and gentle stretching/graded return to activity as pain allows.
Advise that symptoms often improve over days to weeks; if pain persists beyond 2–4 weeks consider referral to sports medicine or physiotherapy.
Safety netting: return immediately if severe worsening chest pain, radiation to jaw/left arm, syncope, persistent shortness of breath, diaphoresis, or if fevers develop.
Follow-up: review with primary care in 1 week if not improving or sooner if red flag symptoms; no routine further cardiac testing required unless clinical picture changes.

Key Learning Points

Localized chest wall pain that is reproducible on palpation strongly suggests a musculoskeletal cause such as costochondritis rather than cardiac ischemia.
In young, low-risk patients with non-suspicious history and normal ECG/troponin, musculoskeletal chest pain can be managed conservatively with NSAIDs, activity modification, and safety-netting.
Always screen for red flags (radiation, syncope, diaphoresis, significant dyspnea) and use ECG/troponin to exclude cardiac causes when clinical concern exists; watch for mimics such as Tietze syndrome, pericarditis, and pulmonary causes.