BEDSIDE TEACHING ROUND WITH PROF. C.G. AGARWAL

 

Prof. C G Agrawal was our teacher in Medicine, when we were doing our MBBS in King George's Medical College in Lucknow. Even today, decades after his retirement, he remains a highly skilled and well known Physician in Lucknow. His home in Niralanagar still attracts patients from all over the state and even from surrounding states and Nepal. He remains the last word in diabetology and his patients almost worship him.

 

Dr. Agarwal completed MBBS in 1966 and MD - Medicine from King George Medical College, Lucknow in 1970. He is a very respected member of Association of Physicians of India, Indian Medical Association (IMA) and American College of Chest Physicians. Decorated with Gold Medal in MD, Dr. Agrawal has also been conferred with Certificate of Honour in 1966. He is a Diplomat American Board of Int. Medicine (1972) from Harvard in the U.S.

 

Prof. Agarwal was a very young teacher, fresh from his overseas training, when we were studying Medicine. He was quite a charismatic person, with lots of stories to attract our attention and convey his message. So, whenever, during his lectures, he would hear a hum he would stop and break into one of his stories, how he met Gregory Peck or how once in Heathrow, while waiting for his flight, Elizabeth Taylor helped him to pick up the tie he was wearing that day! These stories were enough to regain our complete attention, and then he would continue with the lesson being taught. We, the students, were literally in awe of him, and many would spend the next weekend searching for a tie like his one!

 

Today, I am reminded of a morning ward teaching round, in which four from our batch were allotted two patients by his Senior Resident, on the prior evening, to present before him, one of bronchiectasis and one of hypotension. Dr. Agarwal walked in the Medicine ward, cheerful as ever. I presented the patient who had bronchiectasis.

 

Bronchiectasis is a condition where repeated infections cause the bronchus and its branches to widen or develop pouches. It makes it hard to clear mucus out of the lungs and can cause frequent repeat infections. Coughing a lot with pus and mucus is the main symptom of bronchiectasis. 

 

After this presentation by us he asked us to examine the patient in his presence and then he showed us how the coarse and leathery crepitations of Bronchiectasis sound and how they are distinctly different from the fine crepitations of CHF, which he demonstrated in another patient. The coarse crepitations of Bronchiectasis were low pitched, longer and early inspiratory sounds, whereas the fine crepitations in the CHF patient were high pitched, brief and late inspiratory sounds.

 

The CHF patient too was coughing, and so was our patient of Bronchiectasis but he showed us how the sputum or phlegm they were bringing out was so very different. The CHF patient had pinkish thin frothy sputum, which, he told us, was a sign of pulmonary edema. Our patient was bringing out thick tenacious yellow coloured sputum, which was a feature of infection. 

 

Fine crepitations are caused by the reopening of small airways and alveoli that have collapsed due to fluid or inflammation. The rapid equalization of pressure during inspiration leads to the characteristic crackling sound. These sounds are similar to the sound of hair being rubbed between your fingers near your ear, he explained.

Coarse crepitations, on the other hand, are caused by air passing through larger airways that contain fluid or mucus. So, they indicate presence of secretions in large airways. The intermittent opening of these airways produces the characteristic sound. These sounds resemble bubbling or the sound of Velcro being pulled apart. In our patient of Bronchiectasis these sounds were very coarse, and almost leathery.

 

Dr. Agarwal then went on to explain that when we are ill, especially if it is an illness that involves a hacking cough, it is not uncommon to cough up phlegm, or sputum. The color of this mucus phlegm can tell us a lot about the pathogens that have caused the infection. The body is a mucus-making machine, producing around 1 to 1.5 liters of this gel-like substance every single day, even when you're healthy, he explained.  In health, phlegm/mucus is mostly clear and minimal. If you are coughing up significant amounts of phlegm you could have an infection or allergies.

Phlegm is produced by our patient because his respiratory tract has become inflamed, which leads to the coughing. The phlegm can be of different colours and each of these convey a message to the physician:

 

White or Gray Phlegm 

If your patient is coughing up white or gray phlegm then this could be a sign of an upper respiratory tract infection or sinus congestion.

Normally, paranasal sinuses don’t drip, but when there's inflammation, either viral or bacterial, it can cause a drip from the sinus into your throat. This post nasal drip will make your patient caugh when he tries to sleep.

Coughing up gray phlegm could be a sign that your body is trying to rid itself of resin or tars that have accumulated as a result of excessive smoking or inhalation of air pollutants like smog or dust. 

 

Green or Dark Yellow Phlegm 

Coughing up thick and dark yellow phlegm could be a sign of a viral or bacterial infection, or a lower respiratory tract infection. Usually, this occurs when the body's immune system sends white blood cells, the neutrophils, to the area of infection. These cells contain a green protein, which, when present in large numbers, give the mucus a greenish tint. 

 

Brown phlegm 

Smokers tend to produce more brown phlegm, which often comes out mixed with saliva in a grainy texture. Smoking can cause the phlegm to turn brown because of the resin, tar and other particulate matter in cigarettes, which the body is trying to expel. If you don't smoke and are coughing up brown phlegm, it could be down to the food and drink that you're consuming - Chocolate, coffee, and red wine to name but a few.

Pink Phlegm 

Coughing up pink phlegm could be a sign of a pulmonary edema, or Congestive Heart Failure, as we saw in the other patient. When seen in small amounts, it can also be a sign of bleeding because of repeated coughing. This type of phlegm can sometimes have a frothy texture - this is especially common in those who have pre-existing heart problems. 

 

Bloody Phlegm 

Blood in the phlegm is known as haemoptysis, while streaks of blood in phlegm is a benign sign of bronchitis. Coughing up a large quantity of bloody phlegm could be a sign of tuberculosis, pneumonia, cancer, or pulmonary embolism. 

 

So, Dr. Agarwal concluded that the nature, the amount and the colour of the phlegm is vital to come to a clinical diagnosis. 

 

Our group now walked to the next patient. My colleague presented the lady as a patient of hypotension. This was a new admission, still being investigated and so after examining the patient, and finding no major clinical signs to demonstrate, Dr. Agarwal gave us an idea of how to approach a patient of hypotension.

A reading of less than 90/60 mm HG is considered hypotension. Everyone’s blood pressure drops occasionally and doesn’t cause any noticeable symptoms, he said. For example, the transition from a sitting or lying down position to a standing up one can cause a drop in blood pressure.  This is postural hypotension or orthostatic hypotension.

However, certain conditions can cause prolonged periods of hypotension that can be harmful:

·         Significant blood loss due to an injury – oligovolumic shock

·         poor circulation due to a heart condition

·         pregnancy

·         dieting to lose weight

·         infections of the bloodstream - septicemia

·         anaphylactic shock

·         diabetes - baroreflex dysfunction of diabetic neuropathy

·         thyroid disease.

Furthermore, certain medications such as beta-blockers, erectile dysfunction drugs, and antidepressants can also cause hypotension.

When the blood pressure drops, baroreceptors (nerve endings within the carotid arteries and heart) respond by sending signals to the brain to increase the heartbeat and constrict (narrow) blood vessels to raise blood pressure. A faulty baroreflex prevents adequate raising of the heart rate and constriction of blood vessels when standing, leading to a sustained drop in blood pressure.

 

Having persistent low blood pressure is harmful. If the blood pressure gets severely low, the body will not receive enough oxygen to carry out normal functions. A decrease in oxygen levels can lead to impaired functioning of the heart and brain as well as cause difficulty breathing. In certain cases, people suffering from low blood pressure can lose consciousness or go into shock.

 

Signs & Symptoms of Hypotension

 

1. Dizziness or Light-Headedness - A low blood pressure causes poor blood flow to the brain. This decreases the oxygen supply to the brain and makes you feel dizzy and light-headed. This is often associated with a sudden change in position, such as standing up to quickly or waking up in the morning.

2. Fatigue - Low blood pressure will affect your patient’s energy levels, causing fatigue. The flow of blood throughout the body plays a key role in the production of energy as it provides the body with oxygen and other necessary nutrients. The mitochondria with cells require nutrients for energy production. When there is a disruption in the blood flow due to a decrease in blood pressure, it disrupts the energy creation process, which in turn causes fatigue and tiredness.

3. Rapid Heart Rate or tachycardia - Poor blood flow to the heart causes it to contract irregularly. If the heart is not getting the required amount of blood, it tries to compensate for this by beating faster. This can cause the pulse and breathing to speed up, and even a frequent change in body temperature.

4. Cold, Clammy Skin - Having cold, clammy and pale skin is another sign of low blood pressure, especially when it’s also accompanied by a rapid heartbeat and shallow breathing. This occurs when there’s not enough blood circulating in your body due to a drop in blood pressure.

5. Lack of Concentration - Due to a decrease in blood pressure, blood is not being moved to the brain at a normal rate. As a result, the brain cells are not getting the required oxygen and nourishment that they need to function properly. This makes it hard to concentrate. If you start to feel foggy and can’t concentrate on what you’re doing despite trying hard, get your blood pressure checked.

6. Unusual Thirst - Being unusually thirsty means that you’re dehydrated, which can at times cause your blood pressure to drop. In fact, this is your body’s way of telling you that you need to add more water to your blood, in an attempt to raise your blood pressure.

7. Blurred Vision - The lack of oxygen in the blood resulting from a drop in blood pressure affects eye movements significantly. Suddenly experiencing blurry vision can be scary, and the effect can be long-lasting or permanent, as this can be caused by glaucoma, myopia, retinal detachment, and a migraine too.

 

 

Treatments for Hypotension

•       Drink plenty of water to avoid a drop in blood pressure due to dehydration. 

·         Intravenous fluids / blood transfusion

•       Do not cross your legs when you sit. 

•       Avoid standing up quickly from a sitting or sleeping position.

•       Get enough sleep so you always feel refreshed. 

•       Eat foods rich in essential vitamins B12 and folic acid to prevent anemia. 

•       Avoid smoking and drinking in excess, as both can cause poor circulation. 

•       Learn your triggers and try to avoid them

 

This is how our morning teaching round with Dr. C.G. Agarwal ended. Dr. Agarwal is a great communicator and there are many videos in YouTube to testify for the same. He graced our Golden Jubilee reunion in December 2025. We pray to God for his long and productive life.