MEDICINE ELOG

Thursday 9 February 2023

Internship assessment

This blog is made based on my experience that showcases my competency and pitfalls

UNIT duties—-First 15 days (12/12/22-26/12/22)

Last 16 days (27/1/23-11/2/23)

>I would check the vitals of my patients and update SOAP notes Daily morning

>Have taken samples and took the patients for required investigations (CECT,USG ABDOMEN,XRAYS AND RECENTLY GOT IVP DONE FOR A URETHRAL STRICTURE CASE)

>have done ascitic tap on a patient

On OP DAY

>I have checked vitals of every patient

>Examined for reflexes, postural hypotension, Romberg’s sign

>Have learnt basic management protocol for sob, chest pain and headaches

Here are the blogs I made during my unit duties

https://166sasirakasinadhuni.blogspot.com/2022/12/80year-old-with-fever-burning.html

https://166sasirakasinadhuni.blogspot.com/2022/12/13-year-old-with-gross-haematuria-and.html

https://166sasirakasinadhuni.blogspot.com/2023/01/27year-old-with-bl-pedal-edema-facial.html

https://166sasirakasinadhuni.blogspot.com/2022/12/60year-old-female-brought-to-casuality.html

https://166sasirakasinadhuni.blogspot.com/2023/02/68yf-with-sob.html

ICU AND AMC DUTIES (27/12/22-31/12/22 and on 6/1/23,7/1/23)

>My first and foremost important work in ICU AND AMC was to monitor the vitals of patients timely ( varying from hourly basis to 2nd hourly)

>Have Taken about 5 ABGs and many samples for lab investigations.

>Have Learnt how to manage in critical situations

>I have Assisted in intubation for 1 patient

> Ryles have been put for 4 patients

> Foleys have been put for 7patients

>Have given RT feeds

> have helped the patient for ambulation

NEPHRO DUTY (1/1/23-5/1/23)

>monitored patients who came for dialysis

>Handled Day care patients who came for dialysis.

> Learnt about dialysis machine , central line care and fistula importance

>Have given NTG to 1 patient and have monitored the patient meticulously

> Have learnt how to maintain patients BP and GRBS while dialysis is going on

> Have Learnt about drugs used in hypo and hypertension

> here is the link to the blog of an icu patient who underwent dialysis :

https://166sasirakasinadhuni.blogspot.com/2023/01/24ym-with-sob.html

WARD DUTIES (8/1/23-11/1/23)

> Have updated soap notes of patients

>Helped my co interns in updating soap notes

>Have taken samples

>was present for rounds and presented the cases

>with the help of my Co intern , i have completed all the works assigned

PSYCHIATRY DUTY (12/1/23-26/1/23)

>Learned about importance of history taking

>vitals monitoring done for OP patients

Examples like :

1. Schizophrenia

2.OCD

3.ALCOHOL DEPENDENCE SYNDROME

4. TOBBACO DEPENDENCE SYNDROME

> learnt about the medications given to the patients and their side effects

> have seen and learnt from pgs regarding how they handle patients in DAC

>Have had a catatonic schizophrenic patient admitted, for whom I have monitored and learned how BENZODIAZEPINES worked in this patient.

Tuesday 7 February 2023

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

COMPLAINTS AND DURATION:

Pt c/o cough: 6 months

Shortness of breath= 4-5 months

HOPI:

-Patient was apparently normal untill 6months back.

then developed productive cough, insidious in onset gradually progressive with white colored mucoid sputum , relieved on taking medication and aggrevated later I.e., cough Increased mostly at night time around 3-4AM

Shortness of breath: 4-5 monthly, insidious in onset and gradually progressed to grade-IV now. Increases on walking for few steps.
Orthopnoea present.
feels better on lying to lateral side.
Pt also gives h/o PND

PAST HISTORY:

H/o decreased appetite: 4 months.

no h/o fever/ burning micturition/ pain abdomen / chest pain/ palpitations

No Decreased urine output/ pedal edema.

Not a k/c/o DM/HTN/TB/ Epilepsy / CVA / CAD/ thyroid diseases

- H/o fall 2 years back -> Right antle # - POP applied.

PERSONAL HISTORY:

Normal appetite, mixed diet with regular bowel and bladder habits and addiction of smoking

2-3beedis/day started 8years back ,stopped 2 years back

GENERAL EXAMINATION:

PT IS C/C/C

PALLOR: PRESENT

NO PEDAL EDEMA,ICTERUS,CYANOSIS,CLUBBING,

LYMPHADENOPATHY

VITALS ON ADMISSION:

PR-98 BPM

BP- 130/80MM HG

RR- 40 CPM

SPO2- 92% AT RA

GRBS - 133mg/dl

SYSTEMIC EXAMINATION:

1) PER ABDOMEN:

INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.

PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.

ASCULTATION: BOWEL SOUNDS - HEARD

2)RESPIRATORY SYSTEM:

INSPECTION: SHAPE OF THE CHEST IS ELLIPTICAL. B/L SYMMETRICAL. BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL VOCAL FREMITUS IS NORMAL

PERCUSSION: RESONANT BIL

ASCULTATION: BAE + , NVBS HEARD

3) CVS:

INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION: APEX BEAT FELT IN LEFT 5TH ICS. NO THRILLS AND PARASTERNAL HEAVES.

ASCULTATION: S1S2 +,NO MURMURS

4) CNS:

PATIENT WAS C/C/C.

HIGHER MENTAL FUNCTIONS- INTACT

GCS - E4V5M6

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM-NORMAL,

MOTOR SYSTEM:

TONE- NORMAL,

POWER- 5/5 IN ALL LIMBS REFLEXES:

B/L REFLEXES: BICEPS - 2+, TRICEPS-2+, SUPINATOR + , KNEE - 2+, ANKLE - 2+

INVESTIGATIONS :

ECG

CXR

Sputum culture

DIAGNOSIS:

SOB UNDER EVALUATION

?PULMONARY KOCHS

TREATMENT:

1.Nebulisation with DUOLIN 4th hrly

BUDECORT 8th hrly

2.Syp: ARCORYL-LS

2TBSP TID.

3.T LEVOCETRIZINE PO BD

8AM —————-8Pm

4.T. PAN 40mg PO OD

7am —x——x

5.SYRUP CREMAFFIN PO HS 10ml

Wednesday 1 February 2023

60year old female brought to casuality in unresponsive state

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

PATIENT WAS BROUGHT TO CASUALITY IN UNRESPONSIVE STATE.

PATIEN WAS APPARENTLY ASYMPTOMATIC 3 YEARS BACK THEN SHE DEVELOPED GENERALISED WEAKNESS FOR WHICH SHE VISITED LOCAL HOSPITAL AND WAS DIAGNOSED WITH TYPE 2 DM. SINCE THEN PATIENT WAS ON IRREGULAR MEDICATION. TODAY MORNING PATIENT ATTENDERS NOTICED THAT PATIENT WAS IN UNRESPONSIVE STATE AND WAS UNABLE TO WAKEUP FROM SLEEP AND WAS TAKEN TO LOCAL RMP (HIGH SUGARS 600 MG/DL WAS OBSERVED) AND WAS REFERRED TO OUR HOSPITAL IN UNRESPONSIVE STATE, HER GCS - E1V1M6.

NO H/O ABNORMAL MOVEMENTS, HEADACHE,VOMITING. K/C/O DM2 SINCE 3 YRS AND ON IRREGULAR MEDICATION.

NOT K/C/O HTN,ASTHMA, CAD, EPILEPSY. PERSONAL HISTORY :

APPETITE - NORMAL

DIET - MIXED

BOWEL AND BLADDER - REGULAR

SLEEP - ADEQUATE

ADDICTIONS : OCCASIONAL TODDY-ONCE A WEEK

TOBACCO(BEEDI) FROM 20 YEARS, STOPPED 3 YEARS AGO

GENERAL EXAMINATION :

NO PALLOR, ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY,PEDAL EDEMA

VITALS ON ADMISSION:

TEMP- 101 F

PR-90 BPM

BP- 100/70MM HG

RR- 20 CPM

SPO2- 97% AT RA

GRBS - 226 MG/DL

SYSTEMIC EXAMINATION:

1) PER ABDOMEN:

INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.

ASCULTATION: BOWEL SOUNDS - HEARD

2)RESPIRATORY SYSTEM:

INSPECTION:SHAPE OF THE CHEST IS ELLIPTICAL,B/L SYMMETRICAL.BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL .VOCAL FREMITUS IS NORMAL

PERCUSSION: RESONANT B/L

ASCULTATION: BAE + , NVBS HEARD

3) CVS:

INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

PALPATION: APEX BEAT FELT IN LEFT 5TH ICS.NO THRILLS AND PARASTERNAL HEAVES.

ASCULTATION: S1S2 +,NO MURMURS

4) CNS:

GCS - E1V1M6

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM- NORMAL,

MOTOR SYSTEM: TONE- NORMAL, POWER- 0/5 IN RIGHT UL AND LL , 2/5 IN LEFT UL AND LL REFLEXES : BICEPS - 1+ , TRICEPS-1+ , SUPINATOR - 1+ ,KNEE - 1+ , ANKLE - 1+

Investigations:

1)HEMOGRAM:

29/01/23

HB : 13.0 mg/dl

PCV : 24.8%

TLC : 13500 CELLS/CUMM PLAT: 1.8 LAKH/CUMM 30/01/23

HB : 11.1 mg/dl

PCV : 34.5%

TLC : 13400 CELLS/CUMM PLT : 1.7 LAKH/CUMM 31/01/23

HB : 10.6 mg/dl

PCV: 33.1 %

TLC : 6900 CELLS/CUMM PLT : 1.7 LAKH/CUMM

01/012/23

HB : 10.8 mg/dl

PCV : 33.3%

TLC : 6700 CELLS/CUMM

PLT : 2.1 LAKH/CUMM

ABG ON 28-01-2023 (04:15:PM)

PH 4.50

PCO2 30.4

PO2 76.6

HCO3 24.0

St.HCO3 : 26.3

BEB : 2.2

BEecf : 1.2

TCO2 : 46.0

O2 Sat : 95.7

O2 Count : 19.5

Serum creatinine :1.2mg/dl

PHOSPHOROUS 28-01-2023:-2.0 mg/dl

HBsAg-RAPID: Negative

HIV : Negative

ANTI HCV : Negative

BLOOD UREA : 28- 56 mg/dl

SERUM ELECTROLYTES —

SODIUM ; POTASSIUM ; CHLORIDE ; CALCIUM

143 mEq/L ; 3.0 mEq/L ; 105 mEq/L ;1.05 mmol/L

LFT:

Total Bilurubin :1.07 mg/dl

DB: 0.20 mg/dl

AST:24 IU/L

ALT: 13 IU/L

ALP: 143 IU/L

TP:6.2 gm/dl

ALB:3.0 gm/dl

A/G: 0.89

2)USG ABDOMEN: NO SONOLOGICAL ABNORMALITY DETECTED 3)USG NECK: TRIRADS 3 LESION IN RIGHT LOBE OF THYROID

TRIRADS 2 LESION IN LEFT LOBE OF THYROID 4)BLOOD C/S : NO GROWTH SEEN

5)URINE C/S : E.COLI ISOLATED.

6)2D ECHO : NO RWMA , CONCENTRIC LVH+

TRIVIAL TR+/MR+/AR+

NO AS, MS

EF=62%

GOOD LV SYSTOLIC FUNCTION, DIASTOLIC DYSFUNCTION +, NO PE,PAH.

Diagnosis:

? SEPTIC ENCEPHALOPATHY (SECONDARY TO UROSEPSIS) WITH HYPERGLYCEMIA (RESOLVED) WITH TYPE 2 DM

Treatment :

1.IVF - NS@ 75ML/HR

2.INJ.PIPTAZ 4.5 GM IV/TID

3.T NITROFURONTOIN 100 MG PO/BD

4.INJ PAN 40 MG IV OD

5.INJ KCL 20 MEQ IN 100 ML NS

6.INJ MAGNESIUM 1 AMP IN 100 ML NS

7.T DOLO 650 MG PO/TID

8.SYP POTCHLOR 10 ML PO/TID

9.INJ HAI S/C ACCORDING TO GRBS

Sunday 29 January 2023

27year old with b/L pedal edema, facial puffiness and sob

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

PATIENT CAME TO CASUALITY WITH C/O

B/L PEDAL DEMA - 20 DAYS

FACIAL PUFFINESS - 20 DAYS

BREATHLESSNESS - 1 DAY

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 YEARS BACK THEN WAS DIAGNOSED WITH DM-1 AND IS ON INSULIN MITARD (20U-X-16U).SHE HAD 2 EPISODES OF WEAKNESS, UNCONTROLLED SUGARS FOR WHICH SHE WAS ADMITTED FOR A DAY &DISCHARGED ( 1ST EPISODE 5YEARS BACK AND 2ND EPISODE 3 YEARS BACK RESPECTIVELY).ON NOV

2022 PATIENT WAS TAKEN TO GOVT HOSPITAL I/v/O SOB AND WAS DIAGNOSED WITH DENOVO HYPERTENSION, UNCONTROLLED SUGARS ( STARTED ON ? HTN MEDICATION).ON 2ND JAN 2023, SHE HAD EPISODES OF VOMITINGS, LOOSE STOOLS AND WAS ADMITTED IN AIIMS & WAS DIAGNOSED WITH PANCYTOPENIA ,DIABETIC NEPHROPATHY, DILATED CARDIOMYOPATHY,HTN ,VIT D DEFICIENCY RIGHT EYE PSEDUOPHAKIA AND LEFT EYE IMSC WITH HYPERPIGMENTED LESION ON RIGHT FOOT (?

CALLOSITY).6 DAYS BACK SHE DEVELOPED PEDAL EDEMA AND SOB WHICH WAS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE (GRADE 2 TO 4) ASSOCIATED WITH ORTHOPNOEA AND WAS BROUGHT TO OUR HOSPITAL AS HER SYMPTOMS DIDN'T SUBSIDE.

PAST HISTORY:

K/C/O DM TYPE 1 SINCE 10 YEARS AND IS ON INSULIN

K/C/O HTN FROM 2 MONTHS AND ON T TELMA+CLINIDIPINE AND T METXL

H/O OF RIGHT EYE CATARACT SURGERY: 8 YEARS BACK

PERSONAL HISTORY:

APPETITE - NORMAL

DIET - MIXED

BOWEL AND BLADDER - REGULAR

SLEEP - ADEQUATE

GENERAL EXAMINATION:

PT IS C/C/C

PALLOR: PRESENT

PEDAL EDEMA - PRESENT,PITTING TYPE, TILL KNEE NO ICTERUS,CYANOSIS,CLUBBING,

LYMPHADENOPATHY

VITALS ON ADMISSION:

PR-113 BPM

BP- 220/120MM HG

RR- 26 CPM

SPO2- 72% AT RA

GRBS - HIGH

SYSTEMIC EXAMINATION:

1) PER ABDOMEN:

INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.

PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.

ASCULTATION: BOWEL SOUNDS - HEARD

2)RESPIRATORY SYSTEM:

INSPECTION: SHAPE OF THE CHEST IS ELLIPTICAL. B/L SYMMETRICAL. BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL VOCAL FREMITUS IS NORMAL

PERCUSSION: RESONANT BIL

ASCULTATION: BAE + , NVBS HEARD

3) CVS:

INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION: APEX BEAT FELT IN LEFT 5TH ICS. NO THRILLS AND PARASTERNAL HEAVES.

ASCULTATION: S1S2 +,NO MURMURS

4) CNS:

PATIENT WAS C/C/C.

HIGHER MENTAL FUNCTIONS- INTACT

GCS - E4V5M6

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM-NORMAL,

MOTOR SYSTEM: TONE- NORMAL, POWER- 5/5 IN ALL LIMBS REFLEXES: BICEPS - 2+, TRICEPS-2+, SUPINATOR + , KNEE - 2+, ANKLE - 2+

Diagnosis:

TYPE 1 DM WITH UNCONTROLLED SUGARS (RESOLVING)

WITH HYPERTENSIVE EMERGENCY (RESOLVED)

?NEPHROTIC SYNDROME

WITH HFpEF (EF:66%)

BICYTOPENIA SECONDARY TO B12 DEFICIENCY

ANEMIA OF CHRONIC DISEASE

HEPATIC HEMANGIOMA

HTN SINCE 2 MONTHS &DM SINCE 20 YEARS NON PROLIFERATIVE DIABETIC RETINOPATHY]

Treatment:

1.IVF NS @ 30 ML/HR

2.STRICT DIABETIC DIET

3.INJ LASIX 40 MG IV BD

4.T TELMA 40 MG PO BD

5.T CLINIDIPINE 10 MG PO BD

6.T METXL 25 MG PO OD

7.T DYTOR PLUS PO OD

8.T NICARDIA 20 MG PO BD

9.INJ HAI ACCORDING TO GRBS

10.INJ GLARGINE 10 U @ 10 PM

11.T THYRONORM 25 MCG PO OD

BRIEF COURSE IN HOSPITAL: (6/2/23) PATIENT WAS BROUGHT TO THE HOSPITAL WITH ABOVE COMPLAINTS AND NECESSARY INVESTIGATIONS WERE DONE, HER SUGARS WERE FOUND TO BE HIGH AND BP BEING 220/110MMHG ON PRESENTATION AND WAS TREATED SYMPTOMATICALLY. REFRRALS WERE TAKEN FROM ENDOCRINOLOGIST I//O HIGH SUGARS,NEPHROLOGIST I/V/O HIGH CREATININE AND OPTHALMOLOGIST INIO DIABETIC &HYPERTENSIVE RETINOPATHY CHANGES.INITIALLY FOR HYPERTENSION,SHE WAS TREATED WITH T. TELMA 40MG + CLORTHALIDONE 12.5MG AND T.METXL 25MG AND LATER ON WAS FIXED ON T.NICARDIA 20MG PO/BD(8AM-X-8PM) AND ON ADVISE OF NEPHROLOGIST INJ ERYTHROPOIETIN 2000 UNITS S/C WAS GIVEN. THYRONORM 25MCG WAS STARTED I//O HYPOTHYROIDISM ON 4/2/23 AND PATIENT WAS DISCHARGED UNDER HEMODYNAMICALLY STABLE CONDITION.

Patient has been in constant touch with our doctor’s via PAJR group

Here’s the conversation from today(19/2/23)

Ragi mudda na ??

With jaggery...

That's too much sugar! Please avoid Jaggery 😳

Tuesday 3 January 2023

INTERNSHIP ASSESSMENT ROLL NO.49 to 72

Roll no.49

https://39nagarjuna.blogspot.com/?m=1

Roll no.50

Roll no.51

https://meghanag51.blogspot.com/

Roll no.52

http://52rahulsai.blogspot.com/2023/01/this-is-online-e-log-book-to-discuss.html

Roll no.53

http://akash688.blogspot.com/

Roll no.54

https://44jsrinath.blogspot.com/?m=1

Roll no.55

https://vignatha45.blogspot.com/

Roll no.56

https://jatinsharma56.blogspot.com/?m=1

Roll no.57

https://jaya47.blogspot.com/2022/12/sob-evaluation.html?m=1

Roll no.58

https://sreshtaj.blogspot.com/

Roll no.59

https://prasunakreddy.blogspot.com/

Roll no.60

http://lasyamithrakandregula.blogspot.com/

Roll no.61

https://medhakesani.blogspot.com/?m=1

Roll no.62

Roll no.63

https://supriyakammari53.blogspot.com/2022/12/my-learning-points-in-nephrology-from.html

Roll no.64

https://54tejasreekandregula.blogspot.com/

Roll no.65

https://sannithreddykasala.blogspot.com/

Roll no.66

https://166sasirakasinadhuni.blogspot.com/?m=1

Roll no.67

https://kausalyavarma.blogspot.com/2022/12/52-year-old-male-with-abdominal.html

Roll no.68

https://60shirisha.blogspot.com/

Roll no.69

https://61tejarshini.blogspot.com/2022/12/general-medicine-case-discussion.html

Roll no.70

https://konakallavyshnavi.blogspot.com/

Roll no.71

https://63konakanchihyndavi.blogspot.com/

Roll no.72

https://www.keshithakonda.blogspot.com/

Monday 2 January 2023

24Y/M WITH SOB

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

A 24 year old male daily wage labourer came to the OPD with a chief complaints of decreased urine output, shortness of breath and vomitings since 4 days.

HOPI

Patient was apparently asymptomatic 8 days back then he developed severe vomitings due to an excessive binge drinking without any consumption of food. The vomitings were non bilious, non blood stained, non foul smelling, watery and occurred immediately after consumption of food or liquids.

Patient developed oral ulcerations later that day. He was taken to a local hospital where medication was provided. 4 days ago he had complaints of shortness of breath (Grade 4) and decreased urine output with blood in the urine. On taking him to a local hospital, dialysis was advised after which he was admitted to our hospital. 2 days ago the patient was observed to develop a white coating in the mouth and over the tongue( dermatology opinion taken).