a 75-year - old female presented to the chest clinic of our hospital with a history of a cough with mucoid expectoration , episodic dyspnea with wheeze of 1 month duration .
she did not have any symptoms of chest pain , hemoptysis , recurrent fever , weight loss , reflux , or symptoms of postnasal drip .
she did not give any past history of atopy or asthma , and her family history was also negative for same . general examination revealed that she had pallor .
her chest x - ray is shown in figure 1 . what is the abnormality seen ?
chest x - ray posteroanterior view showing elevated hemidiaphragm on the right , with a retrocardiac opacity on the left side
diaphragmatic eventration is congenital in nature and is due to incomplete muscularization of the diaphragm with a thin membranous sheet replacing normal diaphragmatic muscle . over a period of time , this region stretches and thins out , and on inspiration does not contract normally .
radiologically , elevation of the affected portion of the diaphragm is usually seen as a smooth hump , while the remainder of the hemidiaphragm contour is normal .
hiatus hernias occur when there is a herniation of abdominal contents through the esophageal hiatus of the diaphragm into the thoracic cavity .
usually , both these defects are seen in isolation . however , combination of both an eventration and hiatus hernia occurring together is a very rare entity , and a thorough literature search showed only three previous such cases .
the coronal reconstructed 64 slice computerized tomogram showed eventration of right hemidiaphragm with liver occupying the right lower hemithorax .
widening of the esophageal diaphragmatic hiatus with herniation of stomach and perigastric fat was also seen [ figure 2 ] .
coronal reconstructed 64 slice computed tomography image showing eventration of right hemidiaphragm with liver occupying the right lower hemithorax .
widening of the esophageal diaphragmatic hiatus with herniation of stomach and perigastric fat is also seen her spirometry showed a mild reversible airflow obstruction .
she was managed conservatively considering her age and her respiratory symptoms resolved significantly after the institution of inhaled corticosteroids .
 although diaphragmatic anomalies such as an eventration and hiatus hernia are commonly encountered in incidental chest x - ray imaging , the presence of concomitant multiple anomalies is extremely rare . 
 this is all the more true in adults . 
 herein , we present the case of a 75-year - old female , while undergoing a routine chest x - ray imaging , was found to have eventration of right hemidiaphragm along with a hiatus hernia as well . 
THE CASE
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