This is a schema chart about a patient named Mr. Zhang, a middle-aged farmer with Systemic atherosclerosis, whose diagnosis and treatment in a hospital by a specialist doctor are fully illustrated in this schema-chart and diagram. The main treatment for this patient was implantation of a stent in his right coronary artery. The initial diagnosis was hypertensive crisis, but after tests, the doctor realized that the more accurate diagnosis was Systemic atherosclerosis. This schema-chart is designed by Mohammadsaleh Moallem

1. Clinical manifestations
Uncle Zhang
A healthy middle-aged
Case flowchart
Strong & tanned skin farmer
History & Origin Recurrence of disease Hospitalization Medical Examination Diagnose Treatment
Blood plaques
Cause Stenosis
He smokes 1pack of cigarettes
daily and consumes 250 ml of
wine once a week.
Experienced SOB
Chest tightness
Good sleep pattern
His symptoms were
relieved after rest
Cerebral infarction
and high BP
He felt uncomfortable
after climate change
Chest tightness
Shortness of breath
With no Chest and arm pain
Sever Hypertension
His BP: 234/108 mmHg
The blood pressure of the four limbs of uncle Zhang:
Dr. Liu quickly measured the blood pressure of the four limbs
of uncle Zhang. The left upper limb was 229 / 115mm Hg. Blood
pressure of both lower limbs could not be measured. Bilateral
symmetrical pulsation of femoral artery can be felt. No vascular
murmur was heard in the neck during auscultation. The heart
sounds and the heart rhythm were normal. Systolic blowing
murmur was slightly heard at the navel.
Doctor have mentioned that: patient's blood pressure is too
high and something dangerous could happen at any time!
He was comfortable even with his high BP
However the speed of his speech had increased.
Preliminary diagnose
A hypertensive crisis
which could be
Essential hypertension
or Secondary hypertension
This disease could lead to
The complications:
1. Heart attack or stroke.
2. Aneurysm.
3. Heart failure.
4. Weakened & narrowed blood vessels in kidneys.
5. Thickened, narrowed blood vessels in the eyes.
6. Metabolic syndrome.
7. Trouble with memory or understanding.
8. Dementia.
Blood test result
BNP: 1604 pg /mL
Homocysteine: 38.8 μmol / L
Creatinine: 99 μmol / L
ALT: 7 U/L
ALB: 39.2 U/L
Cho: 2.72 mmol/L
APOB: 0.54 g/L
High
Low
Carotid Ultrasound
showed the formation of bilateral
carotid plaques.
Ultrasonic Cardiogram
a. The segmental motion of the left ventricular
wall was not good
b. The left ventricle had centrifugal hypertrophy
c. The left ventricular filling was abnormal
CT Scan of RCA
A local stenosis is found in the proximal
segment of the right coronary artery; the
degree of stenosis is about 80%.
CT Scan of Renal vessels
The local diameter of the celiac trunk is
relatively thick; a small calcification is
observed at the lower edge of the left renal
artery root, and an eccentric small plaque is
formed in the proximal segment with slight
stenosis of the lumen; slighter stenosis is in
the root of the right renal artery.
ECG
more prominent ST depression
in lead I (p = 0.001)
ST elevation in V1 (p = 0.002)
ST depression (≤ 0 mm) in I
ST elevation (> 0.5 mm) in V1
Angiography
The opening stenosis of the first diagonal branches (D1) was 40%,
The stenosis of middle segment of right coronary artery (RCA) was 85%.
The middle lumen of left anterior descending branch was not smooth.
TIMI blood flow
Grade 3 (complete perfusion)
Differential
Diagnose
Systemic
atherosclerosis
High homocysteine
levels in the blood
can damage the
lining of the arteries.
Without treatment, elevated
homocysteine increases the
risks for dementia, heart
disease and stroke.
ST depression
RCA stenosis
CAD
Implementing
stent into RCA
A stent was implanted in the middle segment of RCA
Aspirin
Prevent blood clots from forming in arteries
Clopidogrel
It is an antiplatelet drug; it works by
blocking platelets from sticking together.
Rosuvastatin
It helps lower LDL cholesterol in the blood.
They draw cholesterol out of plaque and
stabilize plaque.
Betaloc
Metoprolol are Beta blockers lower HR,
which reduces the strain on the heart. They
also reduce BP.
Candesartan
It’s an angiotensin receptor blocker, reduces
cardiovascular risk in high-risk patients with
CAD
Spironolactone
Lowering high BP & helps prevent strokes
Nicorandil
It’s a vasodilator drug used to treat angina.
Isosorbide mononitrate
It works by relaxing the blood vessels and
increasing the supply of blood and oxygen
to the heart while reducing its workload.
The Result of prescribed drugs
Uncle Zhang’s BP decreased
to 150 / 85 mmHg gradually.
PBL3 O5
Flowchart
November, 2021
Teacher
Prof. Li yan 李妍老师
Students
张美丽
默汉
郭雨 艾里
哈沙 李安
思得 张笛夕
露华
Ghazal
Saleh
Harsha
Rainy Alireza
Niloufar
LeeAnn
Dikshita
Srii