Chest pain accounts for approximately 7.6 million annual visits to emergency departments (ED) in the United States and can include a broad differential1. The workup warranted includes extensive testing with the goal of demonstrating a reassuring cardiopulmonary status. When preliminary chest pain workup is negative, the subtle features of common primary symptoms can provide insight into other less common etiologies. This case looks to highlight the rare presentation of a relatively healthy middle age male with complaint of chest pain and shortness of breath, worsened with exertion and supine position. When standard cardiopulmonary workup was negative, further specialty testing was pivotal to identify a rare and potentially life threatening cause to his symptoms in the form of diaphragmatic paralysis. Frequently asymptomatic, presenting symptoms can vary in severity from common dyspnea, shortness of breath, and orthopnea to acute respiratory failure. Consideration of rare causes, such as diaphragmatic paralysis, is important to ensure accurate evaluation and identification of this physiologic defect.