P02.003 Incidental findings

Incidental findings, also known as incidentalomas, are unexpected results that are discovered unintentionally during medical examinations or procedures conducted for other reasons. These findings can arise in various diagnostic tests, including imaging studies, laboratory tests, and physical examinations. For students preparing for the Professional and Linguistic Assessments Board (PLAB) exam, understanding how to approach and manage incidental findings is crucial.

Definition: Incidental findings are abnormalities that are discovered unexpectedly and are not related to the patient’s current symptoms or the primary reason for the test.

Common Scenarios:

• Radiological Incidentalomas: Detected during imaging studies such as CT scans, MRIs, or X-rays. Common examples include adrenal nodules, thyroid nodules, and liver lesions.
• Laboratory Incidentalomas: Abnormal laboratory results found during routine blood tests, such as elevated liver enzymes or unexpected electrolyte imbalances.
• Physical Examination Incidentalomas: Unexpected findings during physical exams, such as an asymptomatic heart murmur or an enlarged thyroid.

Approach to Incidental Findings:

1. Assessment of Clinical Significance:
   • Determine whether the finding is benign or potentially serious.
   • Consider the patient’s age, medical history, and risk factors.
2. Further Investigation:
   • Decide if additional tests are necessary to characterize the incidental finding.
   • Use appropriate diagnostic modalities based on the nature of the finding (e.g., biopsy, follow-up imaging).
3. Consultation and Referral:
   • Involve specialists if the incidental finding is beyond the primary care physician’s expertise.
   • Refer to endocrinologists, oncologists, or surgeons as needed.
4. Patient Communication:
   • Discuss the incidental finding with the patient, explaining its significance and the planned approach.
   • Address patient concerns and provide reassurance if the finding is benign.
5. Follow-Up:
   • Schedule follow-up appointments to monitor the incidental findings, if necessary.
   • Ensure appropriate documentation of the findings and follow-up plans.

Common Incidental Findings and Their Management:

Clinical Relevance: Incidental findings can sometimes lead to the early detection of potentially serious conditions, but they can also cause unnecessary anxiety and lead to invasive procedures that might not be needed. Therefore, a balanced and evidence-based approach is essential in managing these findings.

Points to Remember:

• Always assess the clinical relevance of an incidental finding based on the patient’s overall health and risk factors.
• Communicate clearly with patients about the nature of the incidental finding and the planned course of action.
• Involve specialists when the incidental finding requires expertise beyond general practice.
• Ensure proper documentation and follow-up to monitor incidental findings over time.

Bibliography:

1. Chen, L. P., & Coakley, F. V. (2015). Incidental Findings in Imaging: A Practical Guide for Clinicians. Springer.
2. Berland, L. L., & Silverman, S. G. (2010). Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. Journal of the American College of Radiology, 7(10), 754-773.
3. Hoang, J. K., et al. (2017). ACR neck imaging reporting and data system (NI-RADS). Journal of the American College of Radiology, 14(8), 953-959.
4. Ioannidis, J. P., & Lau, J. (2001). The impact of high-risk cases on large clinical trials. Journal of the American Medical Association, 285(3), 284-288.