Chest Pain OSCE - Anxiety / Panic Attack

Case Overview

• Age/Sex: 18/F
• Occupation: University student (first year)
• Setting: Emergency Department during exam period
• Chief complaint: "Chest pain"

Patient Script

Who I Am

I'm an 18-year-old university student in the middle of exam week.

What Brings Me In

I have a sudden sharp chest pain and I feel very short of breath and panicky.

My Story

I was studying in the library when, about 20 minutes ago, I suddenly felt a tight, sharp pain in the centre of my chest and my heart started pounding. I felt very short of breath, light-headed, sweaty and my hands went tingly. The episode came on very quickly and felt overwhelming — I thought I might faint or have a heart attack. The worst of it lasted about 15 minutes, and it’s eased a bit since I sat down, but I still feel anxious and a bit shaky. I had a similar but milder episode about a week ago that lasted 5–10 minutes while I was revising. I’ve been under a lot of stress for the last two weeks with exams.

I drank two energy drinks this morning and had a strong coffee. I vape occasionally (a few puffs last weekend). I used to have mild childhood asthma but haven’t needed an inhaler for years. My mother thinks I might be "just anxious," but my grandfather had heart problems in his 50s and I’m worried this might be serious.

My Medical Background

• Past medical history: mild childhood asthma (no inhaler for several years)
• Medications: combined oral contraceptive pill (taken daily)
• Allergies: none known
• Social: lives in halls, smoking: very occasional vaping only, drinks 1–2 coffees/energy drinks per day during exams, no regular alcohol use, sexually active with one partner, uses condoms sometimes
• Family: grandfather had a heart attack in his 50s; mother has anxiety

What I Think & Worry About

• I think this could be a heart problem because my grandfather had a heart attack and my chest really hurt.
• I’m worried I might faint or have something seriously wrong before my exams and fail.
• I also think maybe it’s just stress, but I’m scared it’s more than that.

If You Ask Me About Other Symptoms...

• Pain: It’s a sharp central chest pain, not worse on movement, not clearly worse on breathing now.
• Palpitations: Yes — heart racing, felt like it was pounding.
• Breathlessness: Yes — felt very short of breath during the episode, now a bit better but still breathing fast.
• Dizziness/syncope: Felt light-headed but didn’t faint.
• Cough/sputum/fever: No.
• Leg pain/swelling: No.
• Recent long travel/immobility: No.
• Recent trauma: No.
• Medication changes: None except taking my usual pill.
• Menstrual history: Periods regular, last period 2 weeks ago.
• Other: My hands and lips tingled during the episode; I felt very hot and sweaty.

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Clinical Summary

Examination

• General: alert, visibly anxious, pacing hands
• Vitals: HR 110 bpm (regular), BP 118/72 mmHg, RR 24/min, SpO2 98% on room air, Temp 36.7°C
• Cardiac exam: normal S1/S2, no murmurs
• Respiratory exam: clear breath sounds bilaterally, no wheeze
• Chest wall: no focal tenderness reproducible with palpation
• Neuro: cranial nerves grossly intact, no focal deficit
• Other: mild tremor of hands, dry mouth, pupils slightly dilated

Investigations

• ECG: sinus tachycardia 110 bpm (no ST-segment elevation or ischemic changes)
• Troponin I: 0.01 ng/mL (reference <0.04) (not elevated)
• Chest X-ray: clear lungs, normal cardiac silhouette (no consolidation or pneumothorax)
• Capillary/ABG (if done): pH 7.48, pCO2 28 mmHg, pO2 95 mmHg, HCO3- 22 mEq/L (consistent with respiratory alkalosis)
• Pregnancy test (urine): negative
• Finger-stick glucose: 5.4 mmol/L (normal)

Diagnosis

Primary diagnosis:

• Panic attack / acute anxiety episode (supported by sudden onset chest tightness, palpitations, shortness of breath, tingling, sense of impending doom, clear precipitant of exam stress, normal cardiac/respiratory investigations, and respiratory alkalosis on ABG)

Differential diagnoses and reasoning:

• Pulmonary embolism — less likely: age 18, SpO2 normal, no risk factors or leg signs, normal CXR, low pre-test probability (but would consider if ongoing hypoxia or raised D-dimer)
• Acute coronary syndrome — very unlikely given age, absence of ECG ischemic changes, and normal troponin
• Asthma exacerbation — unlikely: no wheeze, no prior recent inhaler use, normal oxygenation
• Costochondritis — less likely: pain is not reproducible on palpation
• Hyperthyroidism or stimulant intoxication (caffeine/energy drinks) — could contribute; history of recent high caffeine intake is a possible precipitant

Management

• Immediate:
  • Provide a calm, quiet environment; sit the patient down and reassure her.
  • Controlled breathing technique (e.g., slow diaphragmatic breathing, 6 breaths/min) and grounding strategies.
  • Offer water; encourage removal from exam/study setting; reduce stimulant intake (caffeine/energy drinks) for now.
  • If severe ongoing panic/anxiety: consider a short-acting benzodiazepine (e.g., lorazepam 0.5–1 mg PO/IV) as a single dose after assessing risk of sedation and airway; document shared decision-making.
• Investigation-based reassurance:
  • Explain ECG, troponin and chest X-ray results to rule out acute cardiac/pulmonary causes.
  • Review ABG showing respiratory alkalosis consistent with hyperventilation.
• Disposition and follow-up:
  • If symptoms resolve and observations remain stable, discharge with safety-netting and arranged follow-up with primary care or university health services within 1 week.
  • Provide information about psychological interventions (referral for cognitive behavioural therapy) and discuss stress-management techniques and sleep hygiene.
  • Consider referral to psychiatry/psychology if recurrent attacks or significant functional impairment; consider SSRI if panic disorder established and persistent.
  • Advise avoidance/reduction of caffeine and other stimulants; discuss vaping cessation.
  • Explain red flags for return to ED: recurrent severe chest pain, syncope, persistent breathlessness, new focal neurology, or abnormal vital signs.

Key Learning Points

• Panic attacks can present with prominent chest pain, palpitations, dyspnoea and paraesthesia that mimic life-threatening causes; always first exclude acute cardiac and pulmonary pathology with targeted assessment (ECG, troponin, O2 saturation) before attributing symptoms to anxiety.

• Hyperventilation from panic produces respiratory alkalosis (low pCO2) and symptoms such as light-headedness and tingling; simple breathing control and reassurance are effective immediate treatments.

• In young patients with low risk for cardiovascular disease, consider psychosocial triggers (exam stress, stimulants) and arrange appropriate follow-up for psychological support while safety-netting for red flags.