Case presentation
A 72 years old lady presented to the outpatient department with a history of on and off epigastric discomfort, burping, and water brash for one year. She also complained of occasional dyspnoea after food intake, not severe enough to restrict daily activities. She was being managed in the line of acid peptic disorder. She gave no history of cough, orthopnoea, tachypnoea, chest pain. She denied any history of previous surgery or trauma. However, she had a past history of Tuberculosis infection 25 years back, for which she had received antitubercular medications. She does not consume alcohol but has been smoking for 25 years with a pack-year of 6.25.
Her general physical examination was normal with stable vital signs. On chest examination, there was decreased movement on the right side inframammary area. Tactile vocal fremitus and breath sounds were also reduced on the right side. Respiratory rate was normal with no signs of respiratory distress.
Routine investigations showed no abnormalities. X-ray of the chest revealed a focal upward bulge in the contour of the right hemidiaphragm at the medial aspect, with no herniation of abdominal content into the right hemithorax. (Figure 1) Also, a lobulated radiopaque lesion was noted in the medial aspect of the lower lung zone, the caudal aspect of which was extending below the right diaphragmatic dome. The lesion was likely a calcified granulomatous lesion. Plain CT of the chest (Mediastinal Window) in coronal (Figure 2) and sagittal planes(Figure 3) showed focal thinning of the right hemidiaphragm in the anterior aspect without obvious diaphragmatic defect. The adjacent right lobe of the liver appeared to bulge into the thinned portion. Based on the radiological findings, diagnosis of eventration of right hemidiaphragm was made.
The case was thoroughly assessed and evaluated by a team of experts at our center and with no immediate need for surgical intervention; she was managed conservatively and reviewed on regular follow-up visits. A physiotherapy consultation was done. Counseling for smoking cessation was also done.