Heather Powell Shadow Health — Chest Pain & ACS Assessment Walkthrough

Heather Powell presents to the ED with chest pain that started 2 hours ago at rest. She is diaphoretic, pale and anxious. Her history includes hypertension, hyperlipidemia and a significant smoking history — three of the major modifiable cardiac risk factors. This combination, alongside the presentation at rest, immediately raises the suspicion for Acute Coronary Syndrome.

The assessment tests your ability to rapidly recognise a high-risk cardiac presentation, conduct a structured history and initiate the correct diagnostic workup without delay.

O — Onset: Sudden onset 2 hours ago at rest while watching television. No precipitating activity.

P — Provocative/Palliative: Worsened with exertion. Sublingual nitroglycerin provided partial but incomplete relief.

Q — Quality: Pressure-like, crushing, squeezing. Patients with ACS classically describe this as an elephant sitting on their chest.

R — Region/Radiation: Substernal, radiating to the left arm and jaw. Left arm and jaw radiation is a classic ACS pattern.

S — Severity: 8/10 at rest. 10/10 with any movement.

T — Timing: Constant since onset 2 hours ago. No prior similar episodes.

U — Understanding: Patient is frightened and asking if she is having a heart attack. Address her concerns empathetically while initiating the workup.

The 12-lead EKG shows ST depression in leads V4-V6 — consistent with subendocardial ischaemia in the anterior lateral territory. There is no ST elevation, which means this presentation is classified as NSTEMI or unstable angina pending troponin results.

Troponin I returns at 0.08 ng/mL — elevated above the normal threshold (typically >0.04 ng/mL). An elevated troponin in the context of chest pain and ST changes confirms myocardial injury. Diagnosis: NSTEMI.

A common mistake is failing to document the EKG leads systematically and instead only noting the most abnormal finding. Shadow Health expects documentation of all 12 leads including rhythm, rate, axis, intervals and any ST/T-wave changes in each territory.

Once ACS is confirmed or strongly suspected, the management documentation must cover: aspirin 325mg administered, sublingual nitroglycerin given, IV access established, continuous cardiac monitoring initiated, oxygen if O2 sat below 94%, cardiology consultation placed and NPO status.

The TIMI risk score calculation — which predicts 14-day risk of death, MI or urgent revascularisation — should be documented. Heather scores a TIMI of 4 (intermediate-high risk), indicating early invasive strategy is appropriate.

Patient education must address: what is happening, what tests are being done, what medications are being given and why, and the importance of not eating or drinking in case intervention is needed.

Get the completed Heather Powell Shadow Health files

Includes the full interview transcript, OPQRSTU pain evaluation, 12-lead EKG documentation (ST depression V4-V6), troponin interpretation, TIMI score calculation, and ACS protocol documentation. Written by a board-certified PMHNP-BC.