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2103268042
Gender
No
Patient Name a;:ffi Gaya\ny
Female l1y'
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CabiniBed : p(Cabin.1013)
Address Village: Surmagate,District: Mobile :
0111721g197/0120963
Assign Doctor
Sadar,,
Sylhet,Area/Thana: Sylhet
79g6
Prof. Dr. Md. Matiur Rahman MBBS, FCps (Medicine)
MD (Neurorogy)
MOi) DeA

_tliagresis:
- I.ACUTEISCHEMrCSTROKE (24/3/2L) T t-Lt+t
2. DEMENTIA
3. PD
4. OA( Both Knee)

Case Summary. I

Mrs Gayathry Roy, 7! years oid diagno.sed case of perkinsonism

presented with the complaints of
suriden feeling of weakness followed by unable
to stand_since morning. She also complaints of
tremor for 6-7 years which increased foi 1 year and forgetfulness
for 1.-2 years and both knee joint
pain' with proper examination and investigations
we diagnosed as above and treated accordingly.
Now patient's condition is improving so we gave her
discharge with advice. we wish him all the
best.
StaIru_on&rUissron:
BP: 140190 mmhg, p:BZ b
/mins, T:98 F, RBS: 7 .6 mmol/l, SpOZ: 960/o
Anemia, jaundice, edema, dehydration were absent
N/s/E: GCS:15/15, HPF: Intact, cN: lntact, sensory: lntact,
Mp:5/5 in all 4limbs, cogwheel: +ve,
Bradykinesia: +ve
ierks: Knee(B/L)- rntact, Ankre: Diminished (B/L), pranter:
Frexor (B/L)
otherr systemic examination reveals no abnormalities
TREATMENT oN ADMISSIoN: Conservative

[-,. I{0-3/2q4_ - *,r,,G;ry

z ' 24/o3/202i *p --
"_ (Fasting)
surm Lp,a p.iit.
_-_ __ Serum Creatinine : 1.0g me/dL

lli'l
I l Serum Lipid profile (Fasting) : , Total
Cholesterol : 150 mg/dl , HDL Cholesterol
30 mg/dL , LDL Cholesterol : 1.15 mg/dL
,
:

Triglycerides : 90 meldL
3 24/03/2021 r)Ft TSH : 0.56 UtU/mL
lq
l-_-]_
l5
z+/W_ /2 02
24/03 /2 02 1,
I URrNE R/E Pus cells : 2 - 4/HpF, RBC : Nil
t" Complete Blood Count (CBC ) Haemoglobin (Hb%): t2.O gm/dt , ESR (Auto
I
! analyzer) : 48 mm , RBC (Total Count) : 4.26
million/cmm , WBC (TotalCount) : 11,000
/cmm , Differential Count : , platelet Count :
6 Serum Electrolytes Sodium :1,41,mmo|/L , potassium ,+S
1-
01107 079117, Diagnostic: 01707 0j97 6mmol/L , Chloride : 110 mmol/L ,T-CO2:20
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Treatment on Discharge:
1" TAB. ECOSPRIN 75 mg...........,....0+1+0................After mea1...................Cont
2. TAB. ATOVA 20 mg.....,..............0+0+1.................Before meat.................Cont
3. TAB. CODOPA 110 mg...........,.1+1+1............After mea1...........Cont...........(5.F.2L12121, Dose ^24l3l2tl
4. TAB. CINARON 15 mg..............1+1+1....................After mea1.................1 Month
5. TAB, QUIET 25 mg....................0+0+1.....................After mea1...................Cont
, 6. cAP. ExELoN 1.5 mg.................1+0+1 ..After mea1.....................cont {s.F.tol3lz1l
7. CAP. SERGEL 20 mg...................1+0+1...,................Before mea1...................Cont
8. INDO A SUPPOSITORY 1OO mg.....................1 stick per rectat..............2 times............3 DAYS

Status on Discharge:
BP 11,0/7 0 mmhg, P:81 b/mins, T:98 F, RBS: 7.1mmol/l,SPOZ: 980/o
Anemia, jaundice, edema, dehydration were absent
N/S/E: GCS:15/L5, HPF: lntact, CN: lntact, Sensory: lntact, MP:5/5 in all 4limbs, Cogwheel: +ve,
Bradykinesis; +v€, Jerks: Knee(B/L)- lntact, Ankle: Diminished 1b711, elanter: Flexor (B/L)
MS system: Crackling both knee, SLR: - ve
Other systemic examination reveals no abnormalities

Advice:
L. Take medication regularly
2. Follow up after 1 month

\-,/-
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Print Time & Date: 27 /03/2021,1-0:07 AM M,b-?\
-r'L+ [ledical officer
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Mount Adora Hospital
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Biochemical Repoft rtilfiililtill|t illltililt]iltlliltil]tilltilililflil]ill

No :2L03L52202 (D18847)
Bill Received i24-o3-2a21. 12:1"3 PM Print : 2sl3/2021 1.1:42:15AM
Name : Goyathy Ray Gender : Female Age : 71 Yrs
Refd. By : Prof" Dr. Md. Matiur Rahman MBBS, FCPS (Medicine)MD (Neurology) Cabin:Cabin-1013
Specimen : Blood Mobile:01717278197/0170963

lfian€ you_/or 6emg tvltfi i,4/ount At{ora -ilbqeitaf

Iesf(s) performed by S/EMEiIS Dimension EXL with LM

Parameter Result Reference Value

Serum Lipid Profile (Fasting)

Total Cholesterol 150 mg/dl <200 mg/dL

HDL Cholesterol 30 mg/dl >35 mg/dL

LDL Cholesterol 1 '15 mg/dl <130 mg/dL

Triglycerides 90 mg/dl <150 mg/dl

... End of Report .....

a\
R umar Das B.Sc (Hons)
*o
Md. SaifulAlam
Medical Technoloqist
N/ount Adora irosflital M.Sc (Biochemistry & Molecular Biotogy)
Biochemist
Biochemistry and lmmunology Division
llepttrr printed bt, ,\AYEnhH Mount Adora Hospital

Akhalia, Sylhet. Information: 0 1 707 01 91 17, Diagnostic: 011 07 01 91 16

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lD No. 21031522.02 rece,ve 24,'03,202' l il 58 ,r[,,1 Pr nt 24tA3i2A21 06:46 PM

Patient's Name MRS.GOYATHY RAY
Age 71Y Sex
Refd. by PROF. DR, MD, MATTUR RAHMAN MBBS. FCPS (MED), MD (NEUROLoGY)

MRI OF BRAIN
T lianQlouJor tlic courte.sl o;l: tfii.s reJ'erraf

IECHNIaUET
T1 sE sagittal, Ti sE Axial, T2 FSE Axial, FLAIR Axral, T1 SE coronal, T2 GRE Axial,
DW Axial & ADC Axial.

Findinqsi
Hyperintense signal changes with effacement of subjacent sulci on T2 & FLAIR images are
noted at right frontal parafalcine region, The lesions show festricted diftusion on DW &
low ADC values.
Several discrete foci of high signal intensity on T2 & FLAIR images in subcortical & deep white
matter region of cerebral hemispheres.
3rd & both lateral ventricles are miidly dilated.
Cerebral sulci & fissures & basal cisterns are deep & widened.
The midline structures are not shifted.
Pltuitary region: No lesion at para, supra or intrasellar region,
No focal abnormality is detected in the brainstem or cerebellum.
Orbit: Both eyeballs, extraocular muscles, optic nerves & other retrobulbar structures are
normal.
PNS; No aLrnormalrty is noted in paranasal sinuses.

ITqPBESSIqNi
. Acute infarcts at right ACA terrilsJy.
. Mild age compatible cerebral atrophy with microvascular chronic white
matter ischaem ic changes.

Dr, Mcl. $aelrul Amin

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E-mail: adoraho.nital6 omril corn \f,\r \^'m^rnr

Page 1" of L
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BillNo 2103152202 (D18817)
Name
Date : 241A312021 Print Date 24t3t2021 6..48.,24Pt/t
Goyathy Ray
Gender : Female Age 71 Yrs
Refd By Prof" Dr Md. Matiur Rahman MBBS, FCpS
(Medicine) MD (Neurotogy)
Specimen Urine
Cabin Cabin-1013 Mobile
Relevant estimation were curried out
by Fully Automatecl Llrine Anulysis
system Bioway 3000 &checked
PHYSTCAL EXAMTNATTON Manuully

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Colour or--
@roru
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" Straw .

Albumin ;
Appearence : Clear Nil
rpecific Gravity 1 oo5 j19r, . Nit
Ketones :
PH .. L0 Nii
Urobilinogen ; Nil
Bilirubin . Nil

Ascorbic Acid
. Nil

EpithelialCells .2-311pF Nitrite : Nil

R.B.C : Nit
PusCells Z_4tHpF
Granular Casts : Nil
Hyaline Casts . Nil
RBC Casts . Nit

ealcium-Oxalate . Nil
rriple Phosphate . Nil
Amorphous phosphate : Nil

Trichonomonas Vaginals .
Nil
Spermatozoa . Nii
Yeast ' Nil

'c{Vld Dr"qudFarhana Rahman

Medical Technologist MBBS M" phit(path
)
Mount Adora Hospitai Sylhet Consultant
lVount Adora Hospital, Sylhet
Report prrnted by .. robrul

Akhalia, Sylhet. Inform ation: 017 07 Oj 97 lj, Diagnostic: Tlj 07 01 97 1 6

E-mail: adorahosoital@
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Mount Adora Hospital

DEPARTMENT OF RADIOLOGY & IMAGING

lD. No. : 2103351892 Receive:24l0312021 11:05 AM Print:2410312021 11:53 AM
Patient's Name : GOYATI ROY
Age '. 71Y Sex : F
Refd. by : Outdoor, Mount Adora Hospital, Akhalia

X-RAY OF CHESI P/A (prGrTAL)

Diaphragm Both hemidiaphragm are normal in position.

C-P angles are clear.
Heart Enlarged in T.D.

Lung Pulmonary vessels are prominent,

4

Bony thorax Reveals no abnormality.

Comments Cardiomegaly.

Sugg. Echo for further evaluation.

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Dr. l-1d, Farhad l-{ossain
IJBBS ARlr.rr 1"11, rLiSl'.1t.1U:
riti ianred irairrinrl r:n t-.1 & l,'lRl
Ass|:lrrate Frofessrr (Radiol*qi, ,1 lntaqlnqj
S!IhEt li{oilens llr:diraI L0lIegI Hr-rsptt*I

This report has been electronically signed Page 1 of 1

Akhalia, Sylhet. Information: 01 707 01 97 17, Diagnostic: 011 07 07 97 16

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HAEMAroLocy REpoRr llllllllllllllllllillllllllllllllllillllllllilllllllilillfil
Bill No 2L03152202 (D18847) Received i24'03'2021' 12:L3PM Print : 24/3/2021 04:53:11PM

Name Goyathy Ray Gender : Female Age : 71Yrs

Refd. By Prof. Dr. Md, Matiur Rahman MBBS, FCPS (Medicine)MD (Neurology) Cabin:Cabin-10L3

Specimen Blood Mobile t 01717

_278197/0170963
lrtan€ you-for being vtrrt -Mount A[ora 3{oqaitaf
Relevant estimations were carried out by Automated Haematology Analyzer Pentra DX Nexus

Parameter Result Reference Value

Haemoglobin (Hb%) 12.0 gm/dl Adult male: 15.0 t2.0, Female: 13.5.0 11.5
At Birth: 13.5-19.5, 3 Days: 14.5-22.5
1 Month: 11-17 , 2-6 Months: 9.5-13.5
2-6 Years: 11-14,6-12 Years: '1 1.5-15.5
ESR (Auto analyzer) 48 mm Male: 2-30 mm/1 st hr
Female: 2-3Bmm/1 st hr
RBC (Total Count) 4.26 million/cmm Male : 5.0 t0.5. Female: 4.3 10.5

PCV/HCT 36.9 % Male. 40-48, Female: 34-45

MCV 86.0 fL 86 fL (r 10)

MCH 28.2 p9 29.5 ps (t2.5)

MCHC 32.6 g/dl 32.5 stdt(!2)

RDW 12.9 Yo 12.8 (! 1.2)

White Blood Cells

VI/BC (TotalCount) 11,000 /cmm Child: 5,000-25,000, Adult: 4,000 -11,000

Differential Count

Neutrophils 66% Child: 20-50, Adult 40-75

L-ymphocyte 2g ok Child: 40-75, Adult: 20-40

0k
Monocyte 04 2-1jYo
ak
Eosinophil 02% 1-6
0k
tsasophil 00% 0-1

Platelet Count
Platelet (Total Count) 2,20,000 /cmm 1,50,000-4,00,000

MPV . B.B fL 8.0-9.5

..'." End of Report "..".

m^arDas
Medical Technologist
Dr. Suchanda Ray
MBBS M. Phil (Pathology)
Consultant Pathologist
Mount Adora Hospital
Mount Adora Hospital

Re2ort Pl intetl b\' ; 511,1H,11'.1)l

Akhalia, Sylhet. Information: 01707 019711, Diagnostic: 01707 079716

E-mail : adorahosnital (E smail com www mountadnra cnm
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DE ARTMENT OF RADIOLOGY & IMAGING
lD. No. 2103351892 Receve24i03i2021rc4aN't1 ?rint 24fi312a211149AM
Name GOYATHY ROY
Patient's
Age ' 71Y Sex : M
Refd by . Outdoor, Mount Adora Hospital, Akhalia

Clinical information:
Left sided weakness

Technique:
Multiple axial, coronal and sagittal reconstruction non-contrast CT
scan were performed.
Findings:
There is degenerative cortical atrophy

Small hypodense areas noted at right centrum semiovale region.

Venii'icles and extraventlcular CSF spaces are prominent.

No significant midline shift is noted

FIuid density area noted in sellar region - causing compression of

pituitary inferiorly
.
No focal abnormality is noted in the brain stem and cerebellum.

C-P angles are unremarkable

lmpression: Right sided tiny cerebral infarcts.

Degenerative cortical atrophy.
Suggestive of Empty sella.

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, nr. fuld. Farhad Hossain

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