60 year old female with convulsions

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Date of admission: 13/09/23

A female patient aged 60 years, farmer by occupation, resident of nalgonda, hindu by religion belonging to low socioeconomic status came to opd with chief complaints of 

• Involuntary hand movements and loss of consciousness 

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 20 years back, then one day when she was working in the field, she accidentally fell on the ground and injured her back of the head for which she went to a local hospital and got treated. 

15 years ago, while she was working in the field, she suddenly developed an episode of involuntary movements of hands and loss of consciousness was present which lasted for about 2-3min and then after regaining the consciousness she does not seem to remember the events. Then she was taken to the local hospital and she was prescribed with medication. 

5 years ago, the patient had similar episode which she had 10 years back. 

The patient also had similar complaints of 5-6 episodes during these years i.e., involuntary movements of hand but there was no loss of consciousness

Present day: She had come to the hospital for cataract surgery, she was undergoing some tests and she had breakfast and a cup of tea, then she was sitting on the bed, then she suddenly developed similar episode that she had in the past i.e., involuntary hand movements and loss of consciousness for about 2-3mins and after regaining the consciousness she does not seem to remember the events. 

She fell on the ground when she lost her consciousness and injured her lower lip. 

PAST HISTORY:

Not a known case of DM , HTN , Asthma , TB , CAD 

No previous admissions in the hospital 

PERSONAL HISTORY:

The patient is married, has 2 children.

Was Previously a farmer but now she is a homemaker.

Daily routine:

Previously, she uses to wake up early, go to the fields and work.

She used to come back home, has lunch and goes back to field in the evening. She used to work and come back by night, has dinner, does household work and sleep. 

Now,  She wakes up in the morning, cleans the house, cooks and has breakfast .

She does household chores and has lunch.

The she just takes rest at home.

FAMILY HISTORY:

Not relevant 

GENERAL EXAMINATION:

Patient is moderately built and nourished  

Absence of  pallor,Icterus, Clubbing, Cyanosis, Pedal edema, lymphadenopathy 

VITALS:

1.Temperature: Afebrile 

2.Pulse rate: 79 beats per min

3.Respiratory rate: 20 cycles per min 

4.BP: 140/80 mm Hg

5.SpO2: 99%@Room air 

6.GRBS: 110mg  %