Non-bacterial thrombotic endocarditis physical examination

non-bacterial thrombotic endocarditis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aisha Adigun, B.Sc., M.D.[2]

Overview

There are no specific physical exam findings for non-bacterial thrombotic endocarditis. Patients with NBTE may show signs of systemic thromboembolism, cardiac dysfunction, and underlying diseases.

Physical Examination

There are no specific findings for non-bacterial thrombotic endocarditis. Patients with NBTE may show signs of systemic thromboembolism, cardiac dysfunction, and underlying diseases.

General appearance

• Patients with NBTE usually appear non-toxic. Patients may present with acute signs of cerebral or systemic embolisms of signs or cardiac dysfunction.

Vital Signs

• Fever (if due to malignancy or complicated by secondary infectious endocarditis
• Hypotension (if severe left ventricular dysfunction is present)
• Tachycardia
• Tachypnea
• Orthopnea

Skin

• Raynaud's phenomenon (incase of peripheral embolism)
• Malar rash (in patients with SLE)

HEENT

• HEENT examination of patients with NBTE is usually normal.

Neck

• Jugular venous distension may be noted secondary to heart failure due to valvular dysfunction
• Lymphadenopathy (in the case of malignancy)

Lungs

• lung fields may be dull on percussion in the presence of secondary infection, or pleural effusion due to malignancy

Heart

Left ventricular hypertrophy due to aortic or mitral valve disease can present as any of the following:

• • Displacement of apex beat
  • Enlarged and sustained apical impulse
  • S4
  • S2 (due to aortic root dilatation)

Abdomen

• Abdominal distension
• Abdominal pain/tenderness in the left upper quadrant due to splenic embolism
• Flank pain
• Ascites may be observed in cases of heart failure and fluid overload

Genitourinary

• Genitourinary examination of patients with NBTE is usually normal

Extremities

• Clubbing may be seen in patients with malignancies
• Cyanosis due to peripheral embolism
• Pedal edema may be observed if heart failure is present
• Polyarthralgia and arthritis may be observed

Some physical examination findings in patients with Nonbacterial thrombotic endocarditis

Pathology	Physical examination finding
Left ventricular hypertrophy	LVH can present as any of the following: Displacement of apex beat Enlarged and sustained apical impulse S4 S2 (due to aortic root dilatation) ECG findings of LVH include: Increased QRS voltage Increased QRS duration (widened QRS associated with complete or incomplete LBBB) Left axis deviation (horizontal/frankly leftward (≥-30º) QRS axis in the frontal plane leads or normal/vertical axis) Right axis deviation Repolarization abnormalities such as ST depressions and T wave inversions in leads with relatively tall R waves (referred to as LV "strain" pattern or "LVH with associated ST-T wave abnormalities") Prominent positive T waves in the lateral chest leads Left atrial abnormality has the following two important major presentations: Increased duration of P waves (≥120 milliseconds) in the limb leads Biphasic P waves with a prominent negative (terminal) component (≥40 milliseconds in duration and/or ≥1 mV in depth) in V1
Congestive heart failure	Physical examination findings of CHF include: Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Peripheral edema Lethargy Rales on lung examination
Secondary infective endocarditis (IE)	IE can present as: Fever Rigors Night sweats Headache Myalgias Anorexia Malaise Shortness of breath Cough Joint pains Presence of a new or changing heart murmur in 80% to 85% of patients (due to aortic insufficiency, tricuspid regurgitation or mitral regurgitation) Widened pulse pressure (due to aortic insufficiency) Petechiae (10% to 40% of patients) Osler's nodes (7% to 10% of patients) Janeway lesions (6% to 10% of patients) Splinter hemorrhages (5% to 15% of patients) Evidence of embolization Conjunctival hemorrhage Roth's spots in retina Poor oral hygiene Teeth might have periodontitis, plaque or calculus Gingivitis Splenomegaly (15% to 30% patients) Left upper quadrant pain (due to splenic infarct from embolization) Flank pain (due to embolus to the kidney) Stroke and focal neurologic findings (due to septic emboli) Seizures Intracranial hemorrhage Signs of a brain abscess Gangrene of fingers Back pain (due to vertebral osteomyelitis)
Mitral valve disease	High-pitched “blowing” holosystolic murmur of mitral regurgitation (more common) which is best heard at the apex of the heart with the patient in left lateral decubitus position. Mid-diastolic, rumbling murmur of mitral stenosis (with or without an Austin Flint murmur).
Aortic valve disease	Early diastolic murmur of aortic regurgitation Widened pulse pressure due to aortic insufficiency Bobbing of the uvula (new-onset aortic regurgitation)
Tricuspid valve disease	Holosystolic murmur of tricuspid regurgitation