Pulmonary puzzle

A 70-year-old Caucasian man was transferred back to New Zealand from an Italian hospital having been admitted there 6 weeks earlier with acute dyspnoea. There was no associated cough or fever and, despite antibiotic treatment, he remained dyspnoeic at rest with persistent orthopnoea. His left shoulder had been weak for over 10 years but he had recently noticed weakness in the right shoulder and arm. He had moderate chronic obstructive lung disease secondary to smoking. On examination he had a short neck, with limited range of movement in all directions, and a body mass index of 32. His respiratory rate was 24/min, oxygen saturation 80% on air. The chest was mildly hyperinflated but expansion was decreased and lung bases were dull to percussion with decreased breath sounds. There were no signs …