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Clinical presentation
A 63-year-old retired radiologist was on vacation in Atlantic City. He had a mild upper respiratory tract infection approximately 1 week earlier. While in his hotel room, he noted the acute onset of orthopnea. He went to a local emergency room. In the ED, he reported orthopnea and dyspnea when bending over, but he could walk about two blocks on level ground. He denied cough, fever, wheezing, or sputum production. Review of systems was only notable for bilateral shoulder pain.

Past medical history
His past history included Hansen disease treated in the 1950s, prostate cancer, coronary disease, and diabetes.

Social history
He is originally from the Philippines, married, has three grown children, and no history of tobacco use.

Family history
Heart disease and diabetes

Medications
Medications included atenolol, finasteride, irbesartan, aspirin, metformin, ezetimibe/simvastatin, and fluoxetine

Physical examination

• Vital signs: BP = 130/80 mm Hg; heart rate = 80 bpm; respiratory rate = 30/min
• Appears comfortable but dyspneic when supine
• HEENT: negative
• Neck: No JVD, + use of accessory muscles
• Chest: small lung volumes, no diaphragm movement, clear
• Heart: reg, no murmurs/gallops
• Abd: + abdominal paradox
• Ext: negative
• Neuro: CN intact, strength 5/5, DTRs 2+

Figure 1.Chest radiograph.

The chest radiograph was read as showing bibasilar atelectasis (Fig 1). The patient was treated with moxifloxacin for 10 days for a presumed pneumonia or bronchitis. His symptoms did not improve; after 1 month, he went to a pulmonologist.

Pulmonary function tests
Upright FVC = 1.31 (30%); FEV₁ = 0.85 (27%); FEV₁/FVC = 78. His supine FVC was 0.4 L. TLC = 3.18 (52%); RV = 1.84 (104%); MIP = -33 (30%); MEP = 164 (81%)

Diaphragm fluoroscopy was performed that showed no inspiratory movement of the diaphragm. Nerve conduction studies of the phrenic nerve showed markedly reduced compound muscle amplitude consistent with phrenic nerve injury.