Lung nodule - film edge

Case contributed by Ian Bickle
Diagnosis almost certain


Left shoulder pain. No history of trauma. Joint abnormality?

Patient Data

Age: 65 years
Gender: Female

No bone or joint abnormality.

Minor left apical fibrosis.

2 cm nodule in the right upper lobe just inferior to the right first anterior rib.


2 cm well defined opacity in the right upper lobe between the 1 and 2nd rib ends.

Minor left apical fibrosis.

Normal mediastinal contours.

Heart size normal.

Case Discussion

A good case to highlight one's approach to plain radiography reporting.

  1. Basic, but for a purpose: yes it is now considered a basic investigation, but give the radiograph respect. They do herald pathology.
  2. Clinical query blindness: do not just focus on the immediate clinical query. Check all that is given. 
  3. Film edge: ignoring the film edge is potentially dangerous. Images have to start and stop somewhere.
  4. Projection bias: Yes it's not a film to look at the chest. Yes, this could potentially be an artifact from positioning, but don't ignore it. Do something to prove or repute concerns, like an appropriate projection for clarification.
  5. Gut instinct: If it makes you feel uncomfortable on first sight it probably is something.
  6. Satisfaction of search error: one identifies shoulder OA and left apical fibrosis, and then stops actively reviewing the image

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