This is a great example to remember using the ABC’s when reviewing films. A for alignment, B for bone quality, C for cartilage/joint and in this case the most important S for soft-tissues. When looking at a shoulder film one must always remember to consider other sources of pain referral to the shoulder. Never forget to look at the soft-tissues, especially the lungs. Also, remember that pathology may hide in corners.
So, what can we take away from the two shoulder views? The alignment appears normal. There is no evidence of any fractures or other bone destructive processes and the joint spaces appear adequate. Did you notice the increased opacity in the apex of the lung? It may be a subtle finding and you may have dismissed this as idiopathic apical pleural thickening. Seeing the increased opacity along with a long-standing history of smoking, the patient’s age and presentation with a cough should have led you to take a chest film. The chest film is shown in Figure 2.
Figure 2: Chest radiograph shows a large (7 cm) mass in the right upper lung field. There is no evidence of cavitation, calcification or rib destruction at this time. The mass has caused tracheal deviation to the left.
Question 5: What is your working diagnosis at this time?