Shadow Health Focused Exams: Complete Guide to Chest Pain, Cough, Abdominal Pain and Special Populations
11 min read In this guide
- What Shadow Health focused exams are and how they differ from full system exams
- Shadow Health Focused Exam: Chest Pain, with the cardiovascular assessment
- Shadow Health Focused Exam: Cough, with the respiratory assessment
- Shadow Health Focused Exam: Abdominal Pain, with the abdominal assessment
- Shadow Health special populations focused exams (children, pregnancy, older adults)
- Four practice case studies with key questions and findings
What is a Shadow Health focused exam?
A focused exam is a problem-centered assessment of a patient who comes in with a specific complaint, such as chest pain, cough or abdominal pain. Unlike a comprehensive health assessment, which covers every body system, a focused exam targets the systems most related to the chief complaint and the conditions that could explain it. Shadow Health’s Health Assessment collection includes focused exams such as cough, chest pain and abdominal pain, and graduate collections include focused, episodic and telehealth visits (Elsevier, n.d.).
Focused exams test clinical reasoning more than memorization. You must quickly decide which questions and exam techniques matter, recognize red flags, and think about possible causes, the same way a nurse triages a patient in an emergency department or clinic. For the basics of DCE scoring, documentation and the Lab Pass, see our Shadow Health DCE: Complete Student Guide.
A five-step approach to any focused exam
- Clarify the chief complaint using OLDCARTS: onset, location, duration, characteristics, aggravating and relieving factors, timing and severity.
- Screen for red flags that need urgent action.
- Ask targeted history questions: related systems, risk factors, medications, allergies, family and social history.
- Perform a targeted physical exam of the involved systems, plus vital signs.
- Synthesize: list the most likely and most dangerous possibilities, educate the patient and document clearly.
Shadow Health Focused Exam: Chest Pain
Chest pain is high-stakes because it can signal life-threatening conditions such as acute coronary syndrome, pulmonary embolism or aortic dissection, but it can also come from muscles, the esophagus, the lungs or anxiety. Your first job is to rule out an emergency.
Key subjective questions
- OLDCARTS: when it started, exact location, pressure vs. sharp vs. burning, radiation to the arm, jaw or back, duration, what makes it worse (exertion, breathing, eating, movement) or better (rest, nitroglycerin, antacids)
- Associated symptoms: shortness of breath, sweating, nausea, palpitations, dizziness, fainting, cough, fever, leg swelling
- Cardiovascular risk factors: hypertension, diabetes, high cholesterol, smoking, obesity, inactivity, family history of early heart disease
- Medications, including stimulants and recent drug use; recent travel, surgery or immobility (pulmonary embolism risk)
Shadow Health cardiovascular assessment
- Vital signs: blood pressure in both arms if dissection is a concern, heart rate and rhythm, oxygen saturation.
- Inspection: general appearance (distress, diaphoresis), jugular venous distention, skin color, chest wall.
- Palpation: point of maximal impulse, chest wall tenderness, peripheral pulses, capillary refill, edema.
- Auscultation: heart sounds at the aortic, pulmonic, Erb’s point, tricuspid and mitral areas with the diaphragm and bell; listen for S3, S4, murmurs and rubs; auscultate the carotids for bruits.
- Auscultate the lungs as well, because many chest pain causes are respiratory.
Practice case: chest pain
Original practice case for learning; not a Shadow Health answer key.
Patient: Robert Kim, 58, accountant. “My chest has been tight when I walk up the stairs at work.”
Subjective: pressure-like central chest tightness for two weeks, comes on after climbing two flights of stairs, lasts about 5 minutes, relieved by rest, 4/10, sometimes spreads to the left shoulder. Mild shortness of breath with the episodes. Smoked one pack a day for 30 years; hypertension and high cholesterol; father had a heart attack at 55. Denies pain at rest, fainting or leg swelling.
Objective: BP 148/90, HR 88 regular, RR 18, SpO2 97%. No distress. S1 and S2 normal; no murmurs, gallops or rubs. Lungs clear. No chest wall tenderness. Peripheral pulses 2+ and equal. No edema.
Clinical reasoning: exertional chest pressure relieved by rest with multiple risk factors is consistent with stable angina and must be reported promptly for further cardiac evaluation. Teach him to stop activity and call 911 if pain occurs at rest, lasts more than a few minutes or is accompanied by sweating or shortness of breath, and begin education on smoking cessation.
Shadow Health Focused Exam: Cough
Cough is one of the most common reasons people seek care. Causes range from viral infections and allergies to asthma, pneumonia, gastroesophageal reflux, medication side effects (such as ACE inhibitors), smoking-related disease and, rarely, cancer or tuberculosis.
Key subjective questions
- Onset and duration: acute (under 3 weeks), subacute (3–8 weeks) or chronic (over 8 weeks)
- Dry or productive; sputum color, amount and any blood
- Timing: worse at night, in the morning, with exercise, cold air or lying down
- Associated symptoms: fever, chills, shortness of breath, wheezing, chest pain, runny nose, sore throat, heartburn, weight loss, night sweats
- Triggers: smoke, pets, dust, pollen, workplace exposures; sick contacts; travel
- History of asthma, COPD, allergies, reflux; smoking and vaping; medications such as ACE inhibitors; immunizations
Shadow Health respiratory assessment
- Inspection: respiratory rate and effort, use of accessory muscles, chest shape, skin and nail color, clubbing.
- Palpation: chest expansion, tactile fremitus, tenderness.
- Percussion: resonance vs. dullness (consolidation, effusion) or hyperresonance (air trapping).
- Auscultation: anterior, lateral and posterior lung fields side to side; identify vesicular, bronchial and bronchovesicular sounds and adventitious sounds such as crackles, wheezes and rhonchi.
- Oxygen saturation and, if relevant, peak flow.
Practice case: cough
Patient: Leila Ahmed, 27, graduate student. “I can’t stop coughing, especially at night.”
Subjective: dry cough for 10 days after a cold; worse at night and when running in cold air; chest tightness and mild wheezing; childhood asthma, no inhaler for years; lives with a cat; seasonal allergies. Denies fever, blood in sputum or weight loss. Nonsmoker.
Objective: T 98.6°F, RR 20, SpO2 96%, HR 90. Mild expiratory wheezes bilaterally, prolonged expiration, no crackles. Resonant to percussion. Mild nasal congestion.
Clinical reasoning: findings suggest an asthma exacerbation triggered by a viral infection, with allergens possibly contributing. Report findings; anticipate a rescue inhaler and an asthma action plan; teach inhaler technique, trigger avoidance and warning signs such as difficulty speaking or bluish lips.
Shadow Health Focused Exam: Abdominal Pain
Abdominal pain can come from the stomach, bowel, gallbladder, liver, pancreas, appendix, kidneys, bladder or reproductive organs. Location and associated symptoms are key clues.
Key subjective questions
- OLDCARTS, especially location (point to it), migration of pain, and relation to meals
- Associated symptoms: nausea, vomiting, diarrhea, constipation, blood in stool or vomit, black stools, fever, appetite change, jaundice
- Urinary symptoms: burning, frequency, blood in urine, flank pain
- For people who menstruate: last menstrual period, possibility of pregnancy, vaginal bleeding or discharge
- Diet, alcohol, NSAID use, past abdominal surgeries, history of ulcers, gallstones or inflammatory bowel disease
Shadow Health abdominal assessment
- Inspection: contour, symmetry, scars, distention, visible pulsations, skin color.
- Auscultation first: bowel sounds in all four quadrants before percussion or palpation; listen for bruits over the aorta and renal arteries.
- Percussion: tympany vs. dullness, liver span, costovertebral angle tenderness.
- Palpation: light, then deep, palpating the painful area last; check for guarding, rigidity, masses and rebound tenderness; special signs such as Murphy’s sign (gallbladder) and McBurney’s point tenderness (appendix).
Practice case: abdominal pain
Patient: Ana Ruiz, 34, teacher. “My stomach has hurt since last night and now it’s on the right side.”
Subjective: pain began around the navel 14 hours ago and moved to the right lower abdomen; constant, sharp, 7/10, worse with walking and coughing; nausea, one episode of vomiting, poor appetite. Last menstrual period two weeks ago; denies vaginal bleeding or urinary symptoms.
Objective: T 100.6°F, HR 104, BP 118/74. Lying still, guarding. Bowel sounds hypoactive. Tenderness at McBurney’s point with rebound tenderness; no CVA tenderness.
Clinical reasoning: periumbilical pain migrating to the right lower quadrant, fever, anorexia and rebound tenderness are classic signs of acute appendicitis; this requires urgent reporting. Keep her NPO as ordered, monitor vital signs and pain, and rule out pregnancy-related causes as ordered.
Shadow Health special populations focused exams
Focused exams in pediatrics, maternal health and gerontology require you to adapt your questions, techniques and interpretation.
| Population | Key adaptations |
|---|---|
| Children | Interview the caregiver and the child at their developmental level; ask about birth history, growth, immunizations and development; use age-appropriate vital sign ranges; examine the least invasive areas first; watch for signs of respiratory distress such as retractions and nasal flaring |
| Pregnancy | Gestational age, prenatal care, fetal movement, vaginal bleeding or fluid, headaches and visual changes (preeclampsia), contractions; remember that common symptoms such as nausea or back pain can mask serious problems |
| Older adults | Atypical presentations (infection or heart attack with confusion or fatigue instead of fever or chest pain), polypharmacy, falls, cognition, function and daily activities, hearing and vision, and social support |
| People with limited English or health literacy | Use interpreters, plain language and teach-back; confirm understanding of instructions |
Practice case: special population (pediatric)
Patient: Noah, 6, brought by his father. “He’s been coughing and breathing fast since yesterday.”
Subjective (from father): runny nose for three days, then fever to 102°F and cough; eating and drinking less; urinating less often than usual. Immunizations up to date. No history of asthma.
Objective: T 101.8°F, RR 34 (elevated for age), HR 124, SpO2 93%. Mild subcostal retractions; crackles in the right lower lobe; dullness to percussion in the same area.
Clinical reasoning: fever, tachypnea, retractions, low oxygen saturation and focal crackles suggest pneumonia with respiratory distress; report immediately. Monitor oxygenation and hydration, and teach the father about fever management and signs of worsening breathing.
Shadow Health pain assessment in focused exams
Pain is part of almost every focused exam. Assess it consistently using a validated scale (numeric 0–10 for adults, FACES for young children, PAINAD for adults with dementia), and always document location, quality, intensity, timing, and what helps or worsens it. Our Shadow Health Musculoskeletal Assessment guide includes a full Shadow Health pain assessment guide.
Common mistakes in focused exams
- Jumping to a diagnosis without ruling out dangerous causes
- Forgetting related systems, such as the lungs in chest pain or the urinary and reproductive systems in abdominal pain
- Not asking about medications, allergies and risk factors
- Palpating the painful area first, which causes guarding and an unreliable exam
- Missing education opportunities, such as smoking cessation or warning signs
- Documenting vague findings without pertinent negatives
Sample focused exam documentation (chest pain case)
Subjective: 58-year-old male reports exertional substernal chest tightness × 2 weeks, 4/10, pressure-like, occasionally radiating to left shoulder, lasting about 5 minutes, relieved by rest; associated mild dyspnea. Risk factors: 30 pack-year smoking history, hypertension, hyperlipidemia, father with MI at 55. Denies pain at rest, syncope, palpitations, diaphoresis or lower-extremity edema.
Objective: BP 148/90, HR 88 and regular, RR 18, SpO2 97% on room air. No acute distress. S1, S2 present; no murmurs, gallops or rubs. No JVD. Lungs clear to auscultation bilaterally. Chest wall nontender. Radial and pedal pulses 2+ bilaterally; capillary refill less than 3 seconds; no edema.
Frequently asked questions
How long does a Shadow Health focused exam take?
Most focused exams take 45 to 90 minutes, including the interview, physical exam, documentation and post-exam questions. Allow extra time for your first attempt so you are not rushed into skipping follow-up questions.
What is the difference between a focused exam and a comprehensive assessment?
A comprehensive assessment covers every body system and the full health history, usually for a new or well patient. A focused exam targets the chief complaint and the systems most related to it, plus vital signs and key risk factors, and emphasizes ruling out dangerous causes.
How do I avoid missing findings in the chest pain focused exam?
Use OLDCARTS for the pain, then ask about associated symptoms, cardiovascular risk factors, medications and pulmonary embolism risk. Examine both the heart and the lungs, check pulses and edema, and teach warning signs before closing the interview.
Continue the series: Shadow Health Neurological Assessment and How to Write a Shadow Health Reflection.
Deep-dive Shadow Health guides
- Shadow Health Focused Exam: Chest Pain and Cardiovascular Assessment
- Shadow Health Focused Exam: Cough and Respiratory Assessment
- Shadow Health Focused Exam: Abdominal Pain and Abdominal Assessment
- Shadow Health Special Populations Focused Exams
- Shadow Health Documentation: How to Document Your Assessment
References
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.
Elsevier. (n.d.). Shadow Health: Undergraduate. https://www.elsevier.com/products/shadow-health/undergraduate
Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.
