Filem Cahaya X Dada Pediatrik: Sail Sign

This entry was written with a sense of achievement.

My group leader was on MC last wednesday so it is only natural that I stepped in temporarily untuk menggantikan dia or else my A1 (I love how this group number sounds motivating, cam ayam A1) group will be astray. Seperti dijanjikan, our Bed Side Teaching (BST) that day was held after office hour, 5 pm, which (except for me) is a second on-call stayback of this week for the rest of my group. Last Tuesday (as every week) is a mandatory on-call, at which I absent.

We didn't clerk any case to be presented because we have such hectic back-to-back day. I mean seriously packed day. We were in Pediatric Ward since 8 to 11 a.m. clerking; followed by Case Presentation class at 11 to 1. Followed by Case Presentation supplementary class. Followed by Bed Side Teaching. We only manage to stop for late-lunch and solat at 4 p.m. I was told about the requirement to clerk after that, which is 15 minutes before our BST with Dr. Lau. Okey that super-convenient, I might as well just flipped through BHT and present neuro case (e.g. Febrile Fit) impromptu but God I am not that mentally prepared and was exhausted and not competent enough.

So when Dr Lau came and asked "Have you clerked any case?" to which our answer is solid "No!" and expecting sudden outburst of disappointment projection in forms of multiple demotivating words. But no she didn't. Instead we were strolling around the ward looking for appropriate neuro case. Cek dengan member A2 yang sangat super rajin clerk semua case kat ward, they told me there's a Simple turned Complex Febrile Fit tapi that patient is not in a good condition to be clerked sebab ada UNIVERSAL PRECAUTION sign diletakkan kat katil dia. Maybe that patient was deemed to explode anytime soon. Omaigod, I am so mean.

So or beloved doctor was chitchating around while we were busy looking out best candidate for BST. Tapi tiba-tiba Dr. Lau called us into the playroom sambil kat tangan ada chest x-ray.

Damn! Our Achilles tendon.

Lightbox dinaikkan atas meja dan dipasang. Chest X-ray diklip. The question is.

"Anyone of you know how to read chest X-ray?"

Sambil tengok satu sama lain. "A bit" muka tetap gabra sambil mencuba mengendong every bit ego yang ada.

"So who wants to read this film. Any volunteer?"

I looked around the room. There are six of us. No one looked keen to volunteer. Goodness gracious. The last time I systematically read x-ray was during my BMS Practical in IPR. The last class on chest x-ray was with Dr. Thandar, friday last week. Itu pun separuh blur, separuh mengantuk and total lost in translation (or pronounciation).

Reluctantly, sebab nak jaga air muka, I volunteered. Mapuh. Kene pun kenelah, at least ada volunteer dari takde langsung. What I remembered about chest X-ray in adult adalah ABCDEF. What it stands for are most doubtfully remembered.

So step by step:

TIPS 1:

First thing first, identification;

Aku masih ingat lagi macamana Prof Datin Aziah of IPR taught us how to present a chest xray

"This is an xray film of __________ taken on ________. This is emm..." stuck. Supposedly kat film ada tulis AP (anterior posterior) or PA (posterior anterior) but this one just tulis 'Supine'. Given it a pediatrik case, I said "This is an AP film with adequate exposure."

"How do you know exposure is adequate?" lepas tu Dr Lau tanya kat the rest of the group whether that film has a good exposure. Mostly disagree. But actually it is a good exposure. Sigh. Macamana nak tahu that film is a good exposure.

Dr Lau memberi tips...

TIPS 2:

- Kalau film underexposed, the image will be mostly white or radio-opaque

- Kalau film overexposed, the image will be mostly black or radio-lucent.

- Adequate exposure is when you can see the spine just well.

After that Dr. Lau suruh aku continue terangkan pasal chest X-ray.

TIPS 3:

"ABCDEF"

Airway - Trachea should be midline. Check for rotational variation.

Bones - Check for ribs, clavicles and other shoulder bones.

Cardiomediastinal Silhoutte - Cardiothoracic ratio less than 50 to 55%. Use paper trick if you have no measuring tape in handy.

Diaphragm - Sharp costophrenic and cardiophrenic angles.

I think I explained each one of it good enough but I stuck down to 'E'. Tak ingat apekebendenya E itu.

E is for Expanded Lung

There is something fishy about the right side upper lobe of the lung. That film is just as similar as below. But the opacity is rather extended throughout the upper lobe lung field.

"What do you think it is?" Dr Lau asked me.

"I think it can be consolidation, pneumonia maybe?" then suddenly it strike me ding ding ding...

"Or maybe it can be thymus." I gave my second choice. Still doubtfully. She smiled.

"Who else think it is thymus?" she asked around. Nobody agrees.

One of my friend go such extent claiming "It can't be thymus because thymus is small", I was smacking my head in my imagination. Gosh, they didn't remember about thymus. It is large in newborn, and regressing upon growing up.

Everybody agreed with my first answer that it is pneumonia.

The ultimatum is.

"It IS thymus. Remember the classic 'Sail Sign'." at which point it struck me again from the last class with Dr. Thandar, yup, I remember reading from her slide about 'Sail Sign'. Oh.

Well it turned out to be that that is the reason she brought the chest film to discuss about thymus. She said rarely can be found a thymus that big. That was such a good film she wanted to share with us as an ice-breaking session before we went for BST topic that day, a tricky and challenging Neurological Examination.

Well that was such a great experience I'll treasured. To actually interpreting pediatric chest xray that I have no knowledge about in front of a specialist. My subsconscious again surprised me. I actually read about interpreting chest xray long time ago from Medscape and some random encounter (including Dr. Thandar's lecture). But somehow, this subconscious manage to store something I don't even know. Tricky this creature is.

Here's the link CLICK HERE

...and F is Foreign Bodies - check for chest tube, endotracheal (ET) tube, nasogastric tube (NGT), ECG wires, central lines, pacemakers.