Murmur Auscultations and Peri/Endocarditis

Question 1

Systolic murmur heard at 5th interspace (L sternum). High pitched, holosystolic, Blowing. Worse on inspiration

Answer 1

Tricuspid Regurg

Question 2

Diastolic murmur heard at 5th interspace (L sternum). Low pitched, rumbling, worse on inspiration

Answer 2

Tricuspid stenosis

Question 3

Systolic murmur heard at 2nd interspace/upper right sternal border. Medium pitch, harsh. Decreased on valsalva, IHG
Increased on squat

Answer 3

Aortic stenosis

Question 4

Diastolic murmur heard at 2nd interspace, right sternum. High pitched, Blowing, increased with IHG/squat. Decreased with valsalva

Answer 4

Aortic regurgitation

Question 5

Diastolic murmur heard at 5th interspace, MCL (at the PMI). Low pitched, Rumbling
S1 loud, S2 split, OS heard

Answer 5

Mitral stenosis

Question 6

Systolic murmur heard at 5th interspace, MCL. Musical quality, Increased click to S2 during Valsalva, increased during IHG.

Answer 6

MVP

Question 7

Systolic murmur heard at 5th interspace, MCL. Holosystolic, High pitched, Blowing, increased during IHG.

Answer 7

Mitral Regurg

Question 8

Systolic murmur heard at 2nd interspace, Left sternum. Medium pitched, harsh quality

Answer 8

Pulmonic stenosis

Question 9

Diastolic murmur heard at 2nd interspace, left sternum. High pitched, blowing

Answer 9

Pulmonic regurg

Question 10

Systolic murmur, increased (less VR) during valsava, decreased during squat.

Answer 10

HOCM

Question 11

Holosystolic murmur that is increased with IHG

Answer 11

VSD

Question 12

What is the best test to order to diagnose valvular disease?

Answer 12

Echo is definitive
12-lead EKG will identify sequelae
24 HOlter for arrhythmias

Question 13

What botanicals can lower HR in tachycardic patients?

Answer 13

Lycopus, Bryonia, Cactus

Question 14

Patients with metastatic cancer are likely to develop R/L sided lesions?

Answer 14

R sided lesions

Question 15

Patients who have gotten radiations are more likely to develop what valvular condition?

Answer 15

Aortic S and/or ARegurg

Question 16

CXR shows a “water-bottle” heart shape. Dx?

Answer 16

Pericarditis

Question 17

What labs would you order to Dx Endocarditis if suspected?

Answer 17

Blood cultures, Echo (to find vegetations)

Question 18

What is the Jones criteria?

Answer 18

Criteria for Rheumatic Fever diagnosis (dt Strep A)
(2 major OR 1 major and 2 minor criteria met = Dx)

Major criteria:
polyarthritis, carditis, subcutaneous nodules, erythema marginatum, Syndehans chorea

Minor criteria:
fever, arthralgia, increased ESR/CRP, leukocytosis, Hx of rheumatic fever/heart disease, ECG shows heart block.

Question 19

What is the Duke criteria?

Answer 19

Criteria for endocarditis diagnosis:
(2 Major OR 1 Major and 3 Minor OR 5 Minor criteria met = Dx)

Major criteria:
positive blood culture, Echo shows intracardiac oscillating mass/valvular dysfunction

Minor criteria:
predisposing heart condition/ IV drug use Hx, fever, Vascular phenomena (eg. arterial emboli, pulmonary infarcts, mycotic aneurysms, intracranial bleed, conjunctival hemorrhages, Laneway lesions)
Immunologic phenomena (glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor)
Blood culture positive for alternate organisms
Echo cartography shows abnormalities but is not specific for endocarditis

Question 20

Endocarditis Tx:

Answer 20

Abx, monitoring
Nattokinase, ASA, fish oil, plavix (anticoagulation)
surgical intervention

Question 21

Pericarditis Tx:

Answer 21

NSAIDs, corticosteroids, pericardiocentesis, pericardectomy (if recurrent)

Bromeliad, proteolytic enzymes, high dose fish oil
high dose crataegus (1 tsp solid extract TID or more)
hydrotherapy…etc

Question 22

What is the universal botanical cocktail for valvular diseases?

Answer 22

3 Cs: Crataegus, Cactus, Convallaria

Question 23

What diagnostic testing would indicate Strep infection?

What are some sequelae of Strep infection?

Answer 23

Throat culture (in cases of pharyngitis)
ASO (anti-streptolysin O) titer (Group A strep)

Sequelae:
SBE, Rheumatic fever

Question 24

What are the 4 stages of ECG findings in pericarditis?

Answer 24

1. ST elevation in all leads except V1
   (ddx MI: would only show regional ST changes)
2. ST segment WNL, T-wave flattening
3. T-wave inversion without Q-wave formation
4. ECG normalization

May also note: PR depression, electrical alternans

Question 25

What is the definitive diagnostic test of Aortic regurg?

Answer 25

Cardiac catheterization

Question 26

What is a sequelae of valvular disease? What would be S/Sxs of this?

Answer 26

CHF!
Look for signs of hemodynamic compromise: dizziness, syncope, ischemia, SOB, orthopnea, air hunger, dear BP, incr pulse, diaphoretic…..

Question 27

What are treatment goals and options for MVP?

Answer 27

prevent bacterial endocarditis: prophylactic Abx before dental procedures only if pt has valve replacement.
immune modulation: HEMP,
Treat anxiety, estrogen dominance in women, ….