Using a Hypotheticodeductive Reasoning Approach to Identify Coronary Artery Stenosis and Myocardial Ischemia in a Patient With Upper Arm, Scapular, and Wrist Pain

BACKGROUND: A 58-year-old male with left upper extremity pain presented for second opinion via video teleconferencing secondary to his physician’s recommendation for potential rotator cuff surgery. CASE PRESENTATION: He reported subacute variable left upper extremity pain. He denied questioning targeting the cardiopulmonary symptoms but also denied movement-based aggravating factors of the cervical spine and shoulder. OUTCOME: A movement-based exam targeting potential cervical and shoulder differential diagnoses failed to elicit symptoms. The physical therapist advocated for referral by the primary care provider to a cardiologist to rule out an underlying cardiac etiology. Per-recommendation stress electrocardiogram (EKG) testing reproduced his symptoms and caused abnormal EKG behavior, leading to angiography and stenting. FOLLOW-UP: At follow-up 48 hours, 1 week, and 4 weeks after stent placement, the patient reported complete resolution of symptoms. DISCUSSION: This case underscores the importance of ruling out competing differential diagnoses, the role the physical therapist can have in entry-point care, and the value that telehealth-based services can have in patient triage. JOSPT Cases 2025;5(1):57-65. Epub 22 January 2025. doi:10.2519/josptcases.2025.0104