THE CASE OF ABNORMAL CHEST X-RAY

      I often get consultations for the abnormal x-ray . Sometimes it is 'nothing ' , sometimes it is a cancer.and sometimes we need to do tests to find out what we are dealing with . Sometimes we have to do things to 'prove ' that there is nothing. or at least nothing sincere.
      I saw this patient in the office for the abnormal x-ray. He was 28 years old Vietnamese male who was seen by his primary care physician. He was complaining of the cough. So the physician did chest x-ray,and it was abnormal . It showed the 'congestion 'and so he gave him an antibiotic. Patient did not have fever, and did not get any better. So the MD did follow up x-ray, It continued to show the congestion . . So now he ordered a CT scan of the chest and send him to a cardiologist. The CT scan showed significant congestion in both the lungs . The cardiologist did an echo cardiogram --an ultrasound of the heart. He told the family that the heart was  OK and he needed to see a lung specialist. So now he came to me . He had Down's syndrome and was quite a bit mentally challenged. He physically looked OK , but was not educated and was not working and had significantly reduced IQ. So I was talking to the brother , with whom he lived .
     I examined him  . The over all examination was normal, except that he had a murmur . He was also having some cough and had very small sputum .  I looked at the x-ray and looked the CT scan . Though it was abnormal, I did not think it was showing 'pneumonia ' . I thought that it was consistent with 'congestive heart failure ' . When the heart does not pump out enough , then it 'backs' up in the lungs and x-ray will show increased congestion in the lungs . This time my thought was little different. With his Down's syndrome In which congenital heart defects are common , I was thinking of 'hole in the septum ' that separates the right and the left sided chambers. It either could be between upper chambers (called ASD ) or lower chambers (called VSD ) . When I  told the brother the possibility of this diagnosis, he said that cardiologist  told them that there was nothing wrong with his heart . I told him to go to a pediatric cardiologist, even though he was not a child.
     He agreed , did go to the pediatric cardiologist, who did again a echo cardiogram. IT was positive for the ASD and he did a cardiac catheterizing and it did confirm the diagnosis of ASD .
    He was referred to a pediatric cardiac surgeon. Unfortunately patient's father refused the surgery as he felt that there was no reason to 'prolong '.