Prof. Bal Krishna Khanna was the
Professor and Head of the Department of Tuberculosis and Chest Diseases in King
George’s Medical College when we were doing our M.B.B.S. He was a very strict
disciplinarian and a very hard task master. We students were mortally afraid of
him. He would never start teaching a fresh chapter or discussing a new case
until he had thoroughly quizzed the entire class, starting from the back
benchers, about the last taught chapter or about the patient discussed the day
before. The rules were petty simple, correct answer, which was an answer that
could satisfy him, which in turn was very rare, would mean that the student can
sit or he or she would remain standing for the rest of the class. An
exceptionally stupid answer would result in standing of the chair. So, it was
not at all uncommon to find majority of the students standing in his class.
Prof Khanna was an exceptionally good teacher, and reputed, even long after his retirement, as the last word in pulmonary medicine. He was M.D in three subjects - Pharmacology, Medicine and Pulmonary Medicine & Tuberculosis. His understanding of the diseases of the lungs was outstanding and thorough and Prof. O.P. Tandon of Medicine would invite him to every Postgraduate Clinic in which a patient with pulmonary disease was being presented and discussed. His would teach eliciting of physical signs of pulmonary diseases with great care and the details he could pick up in auscultation with his stethoscope were simply unbelievable. Different types of crepitations, ronchis at different stages of the respiratory cycle, broncheal breathing over the smallest area of consolidation, could never escape his stethoscope. He, Dr. M.S. Agnihotri, Dr. P.K. Mukherjee and Dr. Zafar Zameel formed a formidable quartet of all exceptionally good teachers, but Prof. Khanna was the most feared and still the most sought after.
He was a visionary
academician and an inspiring guide and had a profound influence on generations
of students. He had a gentle squint, and
that made him a dangerous invigilator during our written examinations. His gaze
would be very deceptive and many students got caught while attempting to pass a
chit or prompt a friend, because we thought he was not looking towards us!
He went on to become the Principal of our Medical College when I was doing my M.Ch in Plastic Surgery. He was always just, and always guided by the merit of the student while making key decisions. In March 1998, my one year Pool Job in Plastic Surgery department was coming to an end, and my then Head of the Department was not inclined to give me an extension. During this year long tenure I had participated in undergraduate and postgraduate teachings, conducted elective and emergency surgeries, published 6 papers in indexed journals and was awarded the prestigious Peet Prize by the Association of Plastic Surgeons of India. So, my mentor, Prof. S.K. Bhatnagar asked me to write to the Principal pleading my case and asked me to annex the photocopies of all 6 papers and the certificate of the Peet Prize and my log book. Within 24 hours I got the recommendation for extension for one more year!
When one becomes the Principal, one often acquires a fan club of teachers around, but Prof. Khanna had none. He once famously asked a senior teacher, who was visiting his office a bit too often, "Don't you have some work to do in your department, because I have a lot!" He was a true Guru of the guru–shishya
tradition, where knowledge, discipline, and values were passed on for a lifetime
to enrich the students. His students have become pioneers in the field of
Pulmonary Medicine, and headed departments and institutions all over the world, and one of them, my senior Prof. Rajendra Prasad, was recently decorated with Padmashree!.
I am today sharing with you a case discussion in which he patiently listened to the history and clinical examination of a patient of Tubercular Empyema Thoracis. Then he started teaching:
Types of Empyema Thoracis
Empyema thoracis can be classified into
different types based on the stage and characteristics of the condition. The
stages of empyema include exudative, fibrinopurulent, and organizing stages.
·
The
exudative stage is characterized by the presence of fluid in the pleural space.
·
In
the fibrinopurulent stage, there is an accumulation of pus and fibrin within
the pleural cavity.
·
The
organizing stage of empyema involves the formation of a thick pleural peel.
Other categorizations of empyema may include
acute, chronic, loculated, or complicated empyema.
Acute empyema develops rapidly and may be
associated with an infection.
Risk
Factors
· Chronic
respiratory conditions like COPD can increase the risk of developing empyema
thoracis due to compromised lung function.
- Smoking tobacco is
a significant risk factor for empyema thoracis, as it weakens the immune
system and damages lung tissues.
- Having a history
of pneumonia can predispose individuals to developing empyema thoracis by
increasing the likelihood of bacterial invasion in the pleural space.
- Immunocompromised
individuals, such as those on cortisone or undergoing chemotherapy, are at
higher risk of empyema thoracis due to weakened immune responses.
- Conditions that
impair normal swallowing reflexes, like neurological disorders or
structural abnormalities, can lead to aspiration pneumonia and subsequent
empyema thoracis.
Investigations
· Hematocrit
· Blood Sugar Fasting and Post prandial
· Blood urea & Serum Creatnine
· X-rays Chest PA
· Examination of Pleural fluid for bacterial culture
· Pleural biopsy
Treatment
· Anti tubercular treatment
· Inter costal drainage (ICD) with under water seal
· Atibiotics to treat super added infection
· Decortication - Chronic empyema is often characterized by thickened visceral and parietal peels which hamper the ability of the affected lung to re-expand and requires this definitive surgical intervention. Open thoracotomy is followed by removal of thickeded and calcified visceral pleura followed by ICD. The lung expands and recreates its pleura
· Plombage – This is an ancient technique, mentioned only to be ridiculed. After cleaning the pleural cavity of pus, it is washed with antibiotic solution and filled with ping pong balls to fill the dead space. Foreign body infection is a big problem.
Now he turned to the backbenchers and asked them to approach the patient one by one and say what the person presenting the case had missed. After 5 people had returned to their back benches to remain standing for the rest of the class, the 6th student said “foul smelling breath Sir, halitosis”
Good! He exclaimed, and then started his teaching.
Halitosis is persistent bad breath. Smoking, eating food with onion
and garlic can also cause bad breath but that is transient. Chronic smokers can
have halitosis too. Poor oral hygiene is a very common cause of halitosis but bad
breath doesn’t necessary mean poor hygiene, but it could be the symptom of an
untreated disease. The smell of your patient's breath can tell you an awful lot about
different health issues he/she might have and which type of specialist would help him/her most.
1. Acid Reflux or Heartburn – Sour Smell
If your breath smells sour, then there
is a condition associated with it – acid reflux. In order to control this smell
and make it disappear, you’ll have to take control of your condition first.
Also, changing your diet and excluding trigger foods such as garlic, alcohol,
spicy food, and coffee may help.
2. Gum
Disease – Rotting Teeth Smell
If you have a rotten tooth, then your
breath will certainly be letting you know that something is wrong. If this is
the case, then you need to make an appointment with the dentist. Gingivitis and
periodontitis are the two main conditions associated with rotting teeth and bad
odor from your mouth.
3. Stomach
Cancer – Metallic Taste and Smell
A metallic taste in your mouth with a
similar breath odor is a typical sign of advanced stomach cancer. However,
it must be noted that certain medications can sometimes give similar smelling
breath.
4. Diabetes
– Fruity Smell
A fruity smell from your mouth wouldn’t
be considered much of a problem if it weren’t for the fact that it’s a symptom
of a much more serious issue. Such an odor only appears when a person is about
to develop a diabetic ketoacidosis. Make an appointment with an endocrinologist
if you notice that you have fruity breath.
5. Lung
Cancer – Rotting Smell
Lung cancer is known to produce a
certain odor in the breath that is often described as a rotting smell.
Therefore, if your breath has changed and is smelling of something rotten, it’s
time to visit the doctor.
6. Kidney
Failure – A Fishy Smell
If you have a fishy smell when you
exhale then it might mean that you have kidney failure. This disease is very
serious, so putting off visiting the doctor is out of the question.
7. Lactose
Intolerance – Sour Milk Smell
A sour milk smell is a definite sign of
lactose intolerance, meaning your body can’t break down the protein in milk.
Other symptoms include cramping and diarrhea.
8. Liver
Failure – Moldy and Sweet Smell
A sweet mold-like smell means that your
liver is not working well. Another symptom of this condition is the yellowing
of your skin and the whites of your eyes. If you notice this, schedule an
appointment with your doctor immediately.
9.
Tonsil Stones – Dirty Diaper Smell
Tonsil stones accumulate in your throat
on the tonsils, giving you breath that some people described as smelling like
dirty diapers. One way to treat this condition is to visit a doctor – they’ll
use a special medical instrument to get rid of the calcium and bacteria that
has accumulated in your tonsils.
10. Head
& Neck cancer
Cancer tongue, floor of mouth, alveolus,
oro-pharynx all produce halitosis.
The fact that he would surely ask the causes of halitosis in his next class compelled
us to learn them by heart, and be ready for his interrogation.
