Angina pectoris is very unusual in this age group. The character of the distress is typically described as a substernal pressure or tightness that is precipitated by exertion or emotional stress, lasts less than ten minutes and is relieved by rest or nitroglycerin. While the distress may occur in the shoulder and arm, it is not associated with focal tenderness. A completely normal examination does not rule out the diagnosis of angina pectoris.