Importance of Clinical History in Radiology

rad clinical history

The situation:

A dear grandmother walked into her local urgent care center with minor breathing problems and an intermittent cough. She had been diagnosed with pneumonia 3 weeks prior at a different location. The physician at the local urgent care performed a chest x-ray to determine the severity of her symptoms. The full clinical history of the patient was not available/provided to the radiologist.

The Result:

Since the full clinical history was not provided to the radiologist, he could not compare the current x-ray with the x-ray from three weeks prior. This put both the patient and the radiologist at a disadvantage and resulted with the physician prescribing additional antibiotics, which were not necessary, due to the fact that her condition has improved.

Why is access to history and clinical information important for your radiologist?

  • Radiologists are at a disadvantage because they cannot see the patient physically
  • In order to properly review the films, the radiologist must draw a full picture or mechanism of injury to properly interpret the images seen.
  • If a radiologist has no history or clinical history, he is not focusing on the areas of interest for the given examination.
  • Example: If a radiologist is reading a chest x-ray and there is no history providing that this was a follow up exam, then the radiologist cannot properly compare the resolution of any type of pneumonia or infiltrate.