Dense bulky right hilum.

Despite the relatively subtle plain radiograph appearances, the subsequent CT revealed an advanced right hilar lung malignancy (T4,N2,M1c).

This is one of the hardest abnormalities to identify on chest x-ray amongst the hundreds or thousands of x-rays one will have to report to find just one of these.

Another key practicable aspect is to not be prolific over caller. This inconveniences patients, introduces unnecessary anxiety, adds to the burden (both financial and work volume) of healthcare systems and referrers lose faith in the value of chest x-ray and go straight to CT chest for any indication.

 Use any old imaging if available to check first before suggesting CT.