Chest
Pulmonary and Critical Care PearlsAn Unusual Cause of Dyspnea in a 77-Year-Old Man
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Physical Examination
Vital signs were normal except for an increased respiratory rate of 24 breaths/min. An examination of the lungs revealed reduced breath sounds over the right lower zone. Close observation of the breathing pattern revealed neither paradoxical abdominal wall movement nor obvious decreased expansion of the right side of the chest in the supine position. A neurologic examination revealed muscle weakness in the right upper extremity, atrophy of the intrinsic right hand muscles, and paresthesias in a
Laboratory Findings
The WBC count was 7.78 × 103 cells/μL, with 60% neutrophils, 31% lymphocytes, 5% monocytes, and 3% basophils. The hemoglobin level was 16.8 g/dL, and the hematocrit was 51.6%. The platelet count was 213 × 103 cells/μL. Other laboratory investigations performed at hospital admission included measurement of electrolyte levels, renal and liver function tests, and measurement of blood sugar levels, the results of which were all within normal limits. Results of arterial blood gas analysis on room
Diagnosis: Hemidiaphragmatic paralysis due to cervical spondylosis, diagnosed by MRI scan
MRI scan with fast-spin echo, T1-weighted and proton density-weighted sagittal images (Fig 2) revealed advanced degenerative changes at the C3-C4, C4-C5, C5-C6, and C6-C7 levels, with posterior disk protrusions and posterior osteophytes. At the C4-C5 level, an intraspinal high-density area was seen on proton density-weighted images, which is consistent with myelopathy (Fig 2). There was also evidence of concomitant degenerative lateral spinal canal stenosis. Degenerative changes, posterior disk
Clinical Pearls
- 1.
The most common cause of unilateral diaphragmatic paralysis is a malignancy that invades the mediastinum; however, it rarely can be caused by cervical spondylosis.
- 2.
Lateralization and distribution of neurologic deficit (ie, nerve root involvement) may suggest the cause of diaphragmatic elevation in the proper clinical setting.
- 3.
Patients with unilateral diaphragmatic paralysis without underlying lung disease are usually asymptomatic at rest but may have dyspnea and decreased exercise
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