HISTORY: J.T. is a 46-year-old male avid recreational golfer who presented to the University of Chicago Sports Medicine Clinic with a chief complaint of intermittent left anterior chest pain for three months. The onset of his pain first occurred after carrying some heavy boxes. The first episode lasted for 10–14 days including some mild nighttime pain. The pain was dull and achy in nature and radiated posteriorly around to his back and up to his left shoulder. The pain was exacerbated during golf and was relieved somewhat by ice, rest and stretching. He denied sternal chest pain, crushing or sharp pain, arrhythmia's, palpitations, shortness of breath, cough, fevers, night sweats, sinus symptoms, weight loss, fatigue, or relationship of pain to meals. Since the first episode he has had 3–5 recurrent episodes of similar symptoms. Two of these episodes occurred with right anterior chest pain radiating to the right anterior shoulder, and one episode of left sided chest pain radiating to the left upper abdominal quadrant. PMH: negative. MEDICATIONS: Tylenol PM, ibuprofen 600 mg po prn, and an unknown muscle relaxant prn. ALLERGIES: PCN. SPORTS: frequent golf, skiing and occasional tennis. Prior to his referral to our Sports Medicine Center his internist had obtained a normal EKG, CBC, Chem 20, and TSH. PHYSICAL EXAMINATION: well developed male in no apparent distress. BP: normal, Pulse = 66, RR = 16. Normal cervical neck and shoulder exams. Heent: negative. CV: S1 S2 normal, RRR without murmur. Lungs BCTA. Abdomen benign, no masses no HSM. No lymphadenopathy noted. Musculoskeletal exam revealed tenderness to palpation along left ribs 6–12 and internal/external oblique muscles extending from anterior mid-clavicular line to just posterior to mid-axillary line. DIFFERENTIAL DIAGNOSIS: Muscle Strain of intercostal muscles Stress fracture(s) ribs Costochondritis Cardiogenic chest pain: ischemia, arrhythmia Pulmonary: pleurisy, pneumonia Gastrointestinal: GERD/PUD Neoplasm: primary versus metastatic TESTS AND RESULTS: Chest Radiograph: normal chest ESR = 28 CRP: positive Bone Scan obtained 2 weeks later revealed a markedly abnormal scan. The delayed blood pooling images revealed increased uptake in the right costochondral junctions of ribs 9–11. On the left, punctate areas of increased nuclide activity at ribs 6, 7, and 10. Posteriorly, increased activity was noted throughout the body of the 9th rib. The 7th and 5th ribs were also abnormal. Peripherally, reactive areas were noted in the proximal right humerus. Finally, abnormal activity was noted in the right frontal orbit. FINAL/WORKING DIAGNOSIS: Metastatic Disease versus Multiple Myeloma TREATMENT AND OUTCOMES: Additional testing was performed including a repeat CBC with a hemoglobin now of 11.4 and platelets of 112,000. A CT scan of his chest/abdomen/pelvis revealed spenomegaly of 16 cm, multiple lytic lesions in spine, ribs and left acetabulum, no lymphadenopathy. A qualitative immunoelectrophoresis revealed a monoclonal pattern. A subsequent bone marrow aspiration confirmed multiple myeloma. The patient has undergone treatment with an oncologist and is currently considering a bone marrow transplant.