A 28 year old man presents with difficulty in breathing and orthopnea since last 30 days .
He had been treated for pneumonia 2 months ago .
At the moment he denies any sputum production , but at times gets right sided chest pain.
He is afebrile, and oxygen saturation is 97 percent on air.
A chest X ray is done which is shown below:
1. What is the most likely Diagnosis? / Findings on chest X - ray?
2. What are the causes of this condition?
3. Which further investigations should be performed?
4. What are the treatment options of this condition?
5. What are differential diagnosis of this condition?
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1. 1. What is the most likely Diagnosis? / Findings on chest X - ray? :
Chest X ray findings include elevated Right hemi-diaphragm .
Most likely Diagnosis is Right sided phrenic nerve palsy.
2. Causes of phrenic nerve palsy:
This occurs due to lesions anywhere along the course of the phrenic nerve as it travels from the neck to pierce the diaphragm adjacent to the pericardium.
Causes include :
idiopathic or post viral.
Other causes include:
Inflammatory causes :
Pneumonia
Pleurisy
Empyema
Herpes zoster infection.
Direct Compression;
Aortic aneurysm
Cervical osteophytes.
Neuromuscular Disease:
Chronic inflammatory demyelinating polyradiculopathy.
Trauma and Iatrogenic:
Penetrating injury
Chiropractic manipulation
Malignancy :
Pulmonary metastasis.
Bronchogenic carcinoma.
3. Which further investigations should be performed?
Fluoroscopic examination of the diaphragm ( sniff test).
CT chest : helps to identify the cause of phrenic nerve palsy eg pneumonia, haematoma ,space occupying lesions etc.
MRI can help in evaluation of Pancoast tumors.
Conduction and electromyographic studies.
4 Treatment options:
Deep breathing and hold the breath.
Treatment of underlying cause.
Diaphragmatic pacing in case of symptomatic unilateral cases or bilateral involvement.
5. Differential Diagnosis of Phrenic nerve palsy:
Masses / collections pushing the diaphragm up from below:
Hepatic mass
Sub phrenic collection
Intra abdominal fat
Reduced volume of lung pulling the diaphragm up:
Lobectomy
Radiation induced fibrosis.
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