Shadow Health Focused Exam: Chest Pain and Cardiovascular Assessment Guide (with Practice Case)
10 min read In this guide
- What the Shadow Health Focused Exam: Chest Pain tests
- The subjective questions that uncover the most findings
- A step-by-step Shadow Health cardiovascular assessment
- Red flags and common causes of chest pain
- A practice case with atypical symptoms, plus sample documentation
- Patient education, common mistakes and FAQs
Why the chest pain focused exam matters
Chest pain is one of the most common and most frightening complaints nurses encounter. It can come from the heart, lungs, aorta, esophagus, stomach, chest wall, skin (shingles) or anxiety. Some causes are harmless, but others, such as acute coronary syndrome, pulmonary embolism and aortic dissection, are life-threatening and time-sensitive. The Shadow Health Focused Exam: Chest Pain tests whether you can gather the right history quickly, perform a focused cardiovascular assessment and recognize when a patient needs urgent help (Jarvis & Eckhardt, 2024).
For a quick overview of all focused exams, see our Shadow Health Focused Exams: Complete Guide. This article goes deeper into chest pain and the cardiovascular exam.
Step 1: Start safely
- Introduce yourself, confirm the patient’s identity and explain the purpose of the visit.
- Look at the patient: Are they in distress, pale, sweating or short of breath? If the patient appears unstable, real-world care shifts immediately to emergency response.
- Obtain vital signs early: blood pressure, heart rate and rhythm, respiratory rate, temperature and oxygen saturation.
Step 2: Subjective data for chest pain
| Area | Sample questions | Why it matters |
|---|---|---|
| Onset | “When did it start? What were you doing?” | Exertional onset suggests cardiac ischemia; sudden onset at rest may suggest dissection or embolism |
| Location and radiation | “Show me where it hurts. Does it spread to your arm, jaw, neck or back?” | Radiation to the arm or jaw suggests cardiac pain; tearing pain to the back suggests dissection |
| Duration and timing | “How long does it last? Is it constant?” | Seconds-long pain is rarely cardiac; pain over 20 minutes at rest is concerning |
| Characteristics | “Is it pressure, squeezing, sharp, burning or stabbing?” | Pressure suggests ischemia; sharp pain worse with breathing suggests pleuritic or pericardial causes; burning suggests reflux |
| Aggravating factors | “Does exertion, breathing, eating, lying down or pressing on your chest make it worse?” | Pain reproduced by pressing suggests chest wall pain |
| Relieving factors | “Does rest, sitting forward, antacids or nitroglycerin help?” | Relief with rest suggests angina; leaning forward suggests pericarditis |
| Severity | “On a scale of 0 to 10?” | Tracks change; severity alone does not rule out serious causes |
| Associated symptoms | “Any shortness of breath, sweating, nausea, dizziness, palpitations, fainting, cough, fever or leg swelling?” | Clusters of symptoms point to specific causes |
Risk factors and history
- Hypertension, diabetes, high cholesterol, smoking or vaping, obesity, physical inactivity
- Family history of heart disease at a young age (men under 55, women under 65)
- Previous heart attack, stents, bypass surgery, heart failure or arrhythmia
- Recent surgery, long travel, immobility, cancer, hormonal contraception or pregnancy (pulmonary embolism risk)
- Cocaine or stimulant use
- Medications, including any recent changes, and allergies
- Stress, sleep and diet
Step 3: The Shadow Health cardiovascular assessment
Inspection
- General appearance: distress, diaphoresis, pallor, cyanosis
- Jugular venous distention with the head of the bed at 30–45 degrees
- Chest wall: symmetry, visible pulsations, lifts or heaves
- Extremities: color, hair distribution, edema, skin changes
Palpation
- Point of maximal impulse (PMI) at about the fifth intercostal space, midclavicular line
- Chest wall tenderness (to identify musculoskeletal pain)
- Carotid, radial, femoral, popliteal, dorsalis pedis and posterior tibial pulses, graded 0–4+ and compared side to side
- Capillary refill and edema (graded 1+ to 4+ if pitting)
Auscultation
Listen with the diaphragm and then the bell at five areas, remembered with “APE To Man” (Ball et al., 2023):
| Area | Location |
|---|---|
| Aortic | Second intercostal space, right sternal border |
| Pulmonic | Second intercostal space, left sternal border |
| Erb’s point | Third intercostal space, left sternal border |
| Tricuspid | Fourth or fifth intercostal space, left sternal border |
| Mitral (apex) | Fifth intercostal space, midclavicular line |
Identify S1 and S2, rate and rhythm, and listen for extra sounds: S3 (may indicate heart failure in adults), S4 (stiff ventricle, often with hypertension), murmurs (grade 1–6, timing, location, radiation) and pericardial friction rub. Auscultate the carotid arteries for bruits. Because many causes of chest pain are respiratory, always auscultate the lungs too.
Red flags in chest pain
Report immediately: chest pressure at rest or lasting longer than a few minutes; pain with sweating, nausea, shortness of breath or fainting; sudden tearing pain radiating to the back; sudden pleuritic pain with shortness of breath and fast heart rate, especially after travel or surgery; low blood pressure, new irregular rhythm, low oxygen saturation or a new murmur.
Common causes of chest pain
| Cause | Typical features |
|---|---|
| Stable angina | Exertional pressure, relieved by rest within minutes |
| Acute coronary syndrome | Pressure at rest or prolonged, radiation, sweating, nausea, shortness of breath; may be atypical in women, older adults and people with diabetes |
| Pulmonary embolism | Sudden pleuritic pain, shortness of breath, tachycardia, risk factors for clots |
| Aortic dissection | Sudden severe tearing pain to the back, blood pressure difference between arms |
| Pericarditis | Sharp pain worse lying flat, better leaning forward; friction rub |
| Pneumonia or pleurisy | Pleuritic pain with fever, cough, crackles |
| Gastroesophageal reflux | Burning after meals or lying down, sour taste, relief with antacids |
| Costochondritis or muscle strain | Localized pain reproduced by pressing on the chest wall |
| Anxiety or panic | Chest tightness with fear, rapid breathing, tingling; a diagnosis of exclusion |
Practice case: atypical presentation
Original practice case for learning; not taken from Shadow Health and not an answer key.
Patient: Patricia Owens, 61, school librarian. “I just feel off. My jaw aches and I’m exhausted.”
Subjective: for the past three days she has had episodes of aching in the jaw and upper chest “like indigestion” lasting 10–15 minutes, brought on by walking to her car and once while resting; unusual fatigue; nausea; shortness of breath climbing stairs. Type 2 diabetes for 12 years; hypertension; former smoker (quit 5 years ago, 25 pack-years). Mother had a heart attack at 60. Takes metformin, lisinopril and atorvastatin. Denies fever, cough, recent travel or leg swelling. She says, “I didn’t think it was my heart because it doesn’t really hurt.”
Objective: BP 156/94, HR 98 regular, RR 20, SpO2 95%, T 98.2°F. Appears tired and mildly anxious; skin slightly clammy. No JVD. S1, S2 present; S4 heard at apex; no murmurs or rub. Lungs clear. Chest wall nontender. Pulses 2+ and equal. No edema.
Clinical reasoning
- Recognize cues: jaw and upper chest discomfort with exertion and at rest, fatigue, nausea, dyspnea, clamminess, diabetes, hypertension, smoking history, family history, S4.
- Analyze: women, older adults and people with diabetes often have atypical symptoms of myocardial ischemia, such as fatigue, nausea and jaw discomfort, rather than crushing chest pain. Symptoms at rest raise concern for acute coronary syndrome.
- Prioritize and act: this is urgent. Report immediately, anticipate an ECG and cardiac evaluation per protocol, keep her at rest and monitor vital signs and oxygen saturation.
- Teach: heart attack symptoms can be subtle; call 911 rather than driving herself if symptoms recur or last more than a few minutes (American Heart Association [AHA], n.d.).
Sample documentation
Subjective: 61-year-old female reports intermittent jaw and upper chest aching “like indigestion” × 3 days, lasting 10–15 minutes, triggered by exertion and once at rest; associated fatigue, nausea and exertional dyspnea. History of type 2 diabetes, hypertension and 25 pack-year former smoking (quit 5 years ago); mother with MI at 60. Medications: metformin, lisinopril, atorvastatin. Denies fever, cough, recent travel, syncope or lower-extremity edema.
Objective: BP 156/94, HR 98 regular, RR 20, SpO2 95% on room air, T 98.2°F. Appears fatigued and anxious; skin cool and slightly clammy. No JVD. S1, S2 present with S4 at apex; no murmurs or rubs. Lungs clear to auscultation bilaterally. Chest wall nontender to palpation. Radial and pedal pulses 2+ bilaterally; capillary refill less than 3 seconds; no edema. Findings reported to provider immediately.
Patient education opportunities
- Warning signs of a heart attack, including atypical symptoms, and when to call 911
- Smoking cessation and avoiding secondhand smoke
- Blood pressure, cholesterol and blood glucose control
- Heart-healthy eating, physical activity and weight management
- Correct use of nitroglycerin, if prescribed
- Medication adherence and reporting side effects
Common mistakes in the chest pain focused exam
- Dismissing symptoms that do not “sound cardiac,” especially in women, older adults and patients with diabetes
- Forgetting to ask about pulmonary embolism risk factors
- Skipping lung auscultation, peripheral pulses or edema
- Not palpating the chest wall to check for reproducible pain
- Missing family history and stimulant use
- Failing to teach warning signs and when to seek emergency care
Sample interview flow for the chest pain exam
Example questions you might type, in a logical order. Adapt the wording to each patient.
- “Hello, I’m [name], the nurse who will be examining you today. Can you confirm your name and date of birth?”
- “What brings you in today?”
- “When did the chest discomfort start, and what were you doing?”
- “Can you point to where you feel it? Does it move anywhere, like your arm, jaw, neck or back?”
- “How would you describe it: pressure, squeezing, sharp, burning or something else?”
- “How long does each episode last, and how often does it happen?”
- “What makes it worse? What makes it better?”
- “Have you had shortness of breath, sweating, nausea, dizziness, fainting or a racing heartbeat?”
- “Any cough, fever, leg swelling, recent travel or surgery?”
- “Do you have high blood pressure, diabetes or high cholesterol? Do you smoke or vape?”
- “Has anyone in your family had heart disease, especially at a young age?”
- “What medications do you take, including over-the-counter products and supplements? Any allergies?”
- “This must be worrying for you. What concerns you most?”
- “Is there anything else you’d like to tell me?”
Chest pain exam checklist
- Vital signs, including oxygen saturation and, when indicated, blood pressure in both arms
- OLDCARTS for the pain and associated symptoms
- Cardiac risk factors and pulmonary embolism risk factors
- Inspect for distress, JVD, chest wall changes and edema
- Palpate PMI, chest wall, pulses, capillary refill and edema
- Auscultate five cardiac areas with diaphragm and bell, plus carotids and lungs
- Teach warning signs and when to call 911
- Document pertinent positives, negatives and that abnormal findings were reported
Frequently asked questions
Do I need to check blood pressure in both arms?
It is good practice when chest pain is severe or radiates to the back, because a large difference between arms can suggest aortic dissection. Follow your assignment instructions and course guidance.
How do I tell S1 from S2?
S1 (“lub”) marks closure of the mitral and tricuspid valves and is loudest at the apex; it occurs with the carotid pulse. S2 (“dub”) marks closure of the aortic and pulmonic valves and is loudest at the base of the heart.
Is it enough to listen to the heart only at the apex?
No. Listen at all five areas with both the diaphragm and the bell, and listen to the lungs, carotids and peripheral pulses as well.
What should I do if a Shadow Health patient describes symptoms of a heart attack?
Recognize it as an emergency in your documentation and reflection: report the findings immediately, explain what you would anticipate (such as an ECG and cardiac evaluation) and teach the patient to call 911 rather than drive themselves if symptoms recur.
How do I document a heart murmur?
Describe its timing (systolic or diastolic), grade (1–6), location where it is loudest, radiation, pitch and quality, for example “grade 2/6 systolic murmur, loudest at the apex, radiating to the axilla.”
More in the series: Shadow Health Focused Exam: Cough, Shadow Health Focused Exam: Abdominal Pain and Shadow Health Documentation.
References
American Heart Association. (n.d.). Warning signs of a heart attack. https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier.
Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.
