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Heart on the wrong side.

A man aged 19 years presented to a general practitioner (GP) with a one-day history of urinary frequency. There was no associated dysuria, macroscopic haematuria or urethral discharge. His history was unremarkable for previous urological conditions and sexual activity. On examination he was afebrile at 36.7°C. His abdomen was soft with no palpable masses, and examination of his genitalia was normal. A digital rectal examination was not performed. A urine dipstick indicated the presence of nitrites, leucocytes, blood and protein. A provisional diagnosis of urinary tract infection was made. The specimen was sent for microscopy, culture and sensitivities (MCS). The patient was prescribed trimethoprim 300 mg daily for seven days and advised he would need a follow-up appointment to discuss the MCS results and to arrange ultrasonography of his kidneys, ureters and bladder. 
Incidentally, the GP noticed that the patient had a marfanoid appearance and obtained consent to examine for this. The patient’s height was 195.5 cm and weight was 64.3 kg, giving a body mass index of 16.82 kg/m2. He had long limbs with low muscle volume and long digits with hyperextendable joints. Inspection of the anterior chest revealed pectus carinatum and, to the GP’s surprise, a bounding apex beat on the right side of the chest within the fifth intercostal space. The patient’s left hemithorax was dull to percussion and had no breath sounds to auscultation. He was not tachypnoeic and had no increased work of breathing. It was noted that the patient was diaphoretic. 
On further questioning, the patient admitted to worsening exertional dyspnoea for one month with associated orthopnoea when sleeping on his right side. He had also had a non-productive cough for the same duration. He had not sought medical advice for these symptoms as he attributed them to smoking, having smoked five cigarettes daily for the previous 1–2 years. He had not had any weight loss, had not travelled internationally and did not use recreational drugs. His alcohol intake was minimal. 
The GP expressed concern about a sinister thoracic pathological process and requested the patient have a chest X-ray performed that afternoon. Despite telephone call reminders, the patient delayed the X-ray (Figure 1) until the following week because of commitments, and in this time he had increased exertional dyspnoea.