Non-bacterial thrombotic endocarditis physical examination: Difference between revisions

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{{Non-bacterial thrombotic endocarditis}}
{{Non-bacterial thrombotic endocarditis}}
{{CMG}}; {{AE}}{{Aisha}}
{{CMG}}; {{AE}}{{Aisha}}[[User:Sara Mohsin|Sara Mohsin, M.D.]]
==Overview==
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
Line 18: Line 18:


==Physical Examination==
==Physical Examination==
Physical examination of patients with [disease name] is usually normal.
There are no specific findings for non-bacterial thrombotic endocarditis. Patients with NBTE may show signs of systemic thromboembolism, cardiac dysfunction, and underlying diseases.


OR
===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.  
Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
 
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
 
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  


===Vital Signs===
===Vital Signs===


*High-grade / low-grade fever
*Fever (if due to malignancy or complicated by secondary infectious endocarditis
*[[Hypothermia]] / hyperthermia may be present
*Hypotension (if severe left ventricular dysfunction is present)
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Tachycardia]]  
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea
*Tachypnea / bradypnea
*Orthopnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
===Skin===
* Skin examination of patients with [disease name] is usually normal.
*Raynaud's phenomenon (incase of peripheral embolism)
OR
*Malar rash (in patients with SLE)
*[[Cyanosis]]
*[[Jaundice]]
* [[Pallor]]
* Bruises
 
<gallery widths="150px">
 
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
* HEENT examination of patients with NBTE is usually normal.
OR
* Abnormalities of the head/hair may include ___
* Evidence of trauma
* Icteric sclera
* [[Nystagmus]]
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
===Neck===
* Neck examination of patients with [disease name] is usually normal.
*[[Jugular venous distension]] may be noted secondary to heart failure due to valvular dysfunction
OR
*[[Lymphadenopathy]] (in the case of malignancy)
*[[Jugular venous distension]]
 
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]


===Lungs===
===Lungs===
* Pulmonary examination of patients with [disease name] is usually normal.
*lung fields may be dull on percussion in the presence of secondary infection, or pleural effusion due to malignancy
OR
* Asymmetric chest expansion OR decreased chest expansion
*Lungs are hyporesonant OR hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds OR distant breath sounds
*Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]


===Heart===
===Heart===
* Cardiovascular examination of patients with [disease name] is usually normal.
Left ventricular hypertrophy due to aortic or mitral valve disease can present as any of the following:
OR
**Displacement of apex beat
*Chest tenderness upon palpation
**Enlarged and sustained apical impulse
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
**S4
*[[Heave]] / [[thrill]]
**S2 (due to aortic root dilatation)
*[[Friction rub]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the stethoscope


===Abdomen===
===Abdomen===
* Abdominal examination of patients with [disease name] is usually normal.
OR
*[[Abdominal distension]]  
*[[Abdominal distension]]  
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant  
*Abdominal pain/tenderness in the left upper quadrant due to splenic embolism
*[[Rebound tenderness]] (positive Blumberg sign)
*Flank pain
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Ascites may be observed in cases of heart failure and fluid overload
*Guarding may be present
 
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
===Genitourinary===
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
* 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
 
{| class="wikitable"
|+Some physical examination findings in patients with Nonbacterial thrombotic endocarditis
!style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Pathology}}
!style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Physical examination finding}}
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Left ventricular hypertrophy]]<ref>https://www.medscape.com/answers/241381-7641/what-are-signs-of-left-ventricular-hypertrophy-lvh-in-cardiac-exam-of-hypertension-high-blood-pressure</ref><ref name="pmid11499746">{{cite journal| author=Okin PM, Devereux RB, Nieminen MS, Jern S, Oikarinen L, Viitasalo M | display-authors=etal| title=Relationship of the electrocardiographic strain pattern to left ventricular structure and function in hypertensive patients: the LIFE study. Losartan Intervention For End point. | journal=J Am Coll Cardiol | year= 2001 | volume= 38 | issue= 2 | pages= 514-20 | pmid=11499746 | doi=10.1016/s0735-1097(01)01378-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11499746  }} </ref><ref name="pmid4227953">{{cite journal| author=Pinto IJ, Nanda NC, Biswas AK, Parulkar VG| title=Tall upright T waves in the precordial leads. | journal=Circulation | year= 1967 | volume= 36 | issue= 5 | pages= 708-16 | pmid=4227953 | doi=10.1161/01.cir.36.5.708 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4227953  }} </ref><ref name="pmid12392827">{{cite journal| author=Okin PM, Devereux RB, Fabsitz RR, Lee ET, Galloway JM, Howard BV | display-authors=etal| title=Quantitative assessment of electrocardiographic strain predicts increased left ventricular mass: the Strong Heart Study. | journal=J Am Coll Cardiol | year= 2002 | volume= 40 | issue= 8 | pages= 1395-400 | pmid=12392827 | doi=10.1016/s0735-1097(02)02171-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12392827  }} </ref><ref name="pmid25170097">{{cite journal| author=Shah AS, Chin CW, Vassiliou V, Cowell SJ, Doris M, Kwok TC | display-authors=etal| title=Left ventricular hypertrophy with strain and aortic stenosis. | journal=Circulation | year= 2014 | volume= 130 | issue= 18 | pages= 1607-16 | pmid=25170097 | doi=10.1161/CIRCULATIONAHA.114.011085 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25170097  }} </ref><ref name="pmid11078306">{{cite journal| author=Mehta A, Jain AC, Mehta MC, Billie M| title=Usefulness of left atrial abnormality for predicting left ventricular hypertrophy in the presence of left bundle branch block. | journal=Am J Cardiol | year= 2000 | volume= 85 | issue= 3 | pages= 354-9 | pmid=11078306 | doi=10.1016/s0002-9149(99)00746-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11078306  }} </ref>
|[[Left ventricular hypertrophy|LVH]] can [[Presenting symptom|present]] as any of the following:


===Back===
*[[Displacement]] of [[apex beat]]
* Back examination of patients with [disease name] is usually normal.
*[[Enlarged left ventricle|Enlarged]] and [[Sustained release|sustained]] [[apical impulse]]
OR
*[[S4|S<sub>4</sub>]]
*Point tenderness over __ vertebrae (e.g. L3-L4)
*[[S2|S<sub>2</sub>]] (due to [[aortic root]] [[dilatation]])
*Sacral edema
*[[ECG]] findings of [[Left ventricular hypertrophy|LVH]] include:
*Costovertebral angle tenderness bilaterally/unilaterally
**Increased [[QRS axis and voltage|QRS voltage]]
*Buffalo hump
**Increased [[QRS duration]] ([[Wide QRS complex tachycardias|widened QRS]] [[Association (statistics)|associated]] with complete or incomplete [[Left bundle branch block|LBBB]])
**[[Left axis deviation]] ([[Horizontal correlation|horizontal]]/frankly leftward (≥-30º) [[QRS axis]] in the [[frontal plane]] [[Lead|leads]] or [[normal]]/[[Vertical direction|vertical]] [[axis]])
**[[Right axis deviation]]
**[[Repolarization]] [[abnormalities]] such as [[ST depression|ST depressions]] and [[T wave inversions]] in [[Lead|leads]] with [[Relatively compact|relatively]] [[Taller than average|tall]] [[R waves]] (referred to as '''[[Left ventricle|LV]] "[[Strain (biology)|strain]]" [[pattern]]''' or '''"[[Left ventricular hypertrophy|LVH]] with [[Association (statistics)|associated]] [[ST]]-[[T wave]] [[abnormalities]]"''')
**Prominent '''[[positive]]''' [[T waves]] in the [[lateral]] [[chest]] [[Lead|leads]]
**[[Left atrial]] [[Abnormality (behavior)|abnormality]] has the following two important major [[Presenting symptom|presentations]]:
***Increased duration of [[P waves]] (≥120 [[Millisecond|milliseconds]]) in the [[limb leads]]
***[[Biphasic]] [[P waves]] with a prominent negative (terminal) component (≥40 [[Millisecond|milliseconds]] in duration and/or ≥1 mV in depth) in [[V1-morph|V1]]
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Congestive heart failure]]
|[[Physical examination]] findings of [[CHF]] include:


===Genitourinary===
*[[Dyspnea]]
* Genitourinary examination of patients with [disease name] is usually normal.
*[[Orthopnea]]
OR
*[[Paroxysmal nocturnal dyspnea]]
*A pelvic/adnexal mass may be palpated
*[[Peripheral edema]]
*Inflamed mucosa
*[[Lethargy]]
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
*[[Rales]] on [[lung examination]]
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Secondary infective endocarditis]] ([[IE]])<ref>https://emedicine.medscape.com/article/216650-clinical</ref><ref name="pmid29238103">{{cite journal| author=Jingushi N, Iwata M, Terasawa T| title=Clinical features of patients with infective endocarditis presenting to the emergency department: a retrospective case series. | journal=Nagoya J Med Sci | year= 2017 | volume= 79 | issue= 4 | pages= 467-476 | pmid=29238103 | doi=10.18999/nagjms.79.4.467 | pmc=5719206 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29238103  }} </ref><ref name="pmid23574121">{{cite journal| author=Hoen B, Duval X| title=Clinical practice. Infective endocarditis. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 15 | pages= 1425-33 | pmid=23574121 | doi=10.1056/NEJMcp1206782 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23574121  }} </ref><ref name="pmid26341945">{{cite journal| author=Cahill TJ, Prendergast BD| title=Infective endocarditis. | journal=Lancet | year= 2016 | volume= 387 | issue= 10021 | pages= 882-93 | pmid=26341945 | doi=10.1016/S0140-6736(15)00067-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26341945  }} </ref>
|[[Infective endocarditis|IE]] can [[Presenting symptom|present]] as:


===Neuromuscular===
*[[Fever]]
* Neuromuscular examination of patients with [disease name] is usually normal.
*[[Rigors]]
OR
*[[Night sweats]]
*Patient is usually oriented to persons, place, and time
*[[Headache]]
* Altered mental status
*[[Myalgias]]
* Glasgow coma scale is ___ / 15
*[[Anorexia]]
* Clonus may be present
*[[Malaise]]
* Hyperreflexia / hyporeflexia / areflexia
*[[Shortness of breath]]
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
*[[Cough]]
* Muscle rigidity
*[[Joint pains]]
* Proximal/distal muscle weakness unilaterally/bilaterally
*[[Presenting symptom|Presence]] of a [[new]] or [[Change detection|changing]] [[heart murmur]] in 80% to 85% of [[patients]] (due to  [[aortic insufficiency]], [[tricuspid regurgitation]] or [[mitral regurgitation]])
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*[[Widened pulse pressure]] (due to [[aortic insufficiency]])
*Unilateral/bilateral upper/lower extremity weakness
*[[Petechiae]] (10% to 40% of [[patients]])
*Unilateral/bilateral sensory loss in the upper/lower extremity
*[[Osler's nodes]] (7% to 10% of [[patients]])
*Positive straight leg raise test
*[[Janeway lesions]] (6% to 10% of [[patients]])
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*[[Splinter hemorrhages]] (5% to 15% of [[patients]])
*Positive/negative Trendelenburg sign
*[[Evidence]] of [[embolization]]
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*[[Conjunctival hemorrhage]]
*Normal finger-to-nose test / Dysmetria
*[[Roth's spot|Roth's spots]] in [[retina]]
*Absent/present dysdiadochokinesia (palm tapping test)
*Poor [[oral hygiene]]
*[[Teeth]] might have [[periodontitis]], [[plaque]] or [[calculus]]
*[[Gingivitis]]
*[[Splenomegaly]] (15% to 30% [[patients]])
*[[Left upper quadrant abdominal pain|Left upper quadrant pain]] (due to [[splenic infarct]] from [[embolization]])
*[[Flank pain]] (due to [[embolus to the kidney]])
*[[Stroke]] and [[Focal neurologic signs|focal neurologic findings]] (due to [[septic emboli]])
*[[Seizures]]
*[[Intracranial hemorrhage]]
*[[Signs]] of a [[brain abscess]]
*[[Gangrene]] of [[fingers]]
*[[Back pain]] (due to [[vertebral osteomyelitis]])
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Mitral valve disease]]<ref name="HojnikGeorge1996">{{cite journal|last1=Hojnik|first1=Maja|last2=George|first2=Jacob|last3=Ziporen|first3=Lea|last4=Shoenfeld|first4=Yehuda|title=Heart Valve Involvement (Libman-Sacks Endocarditis) in the Antiphospholipid Syndrome|journal=Circulation|volume=93|issue=8|year=1996|pages=1579–1587|issn=0009-7322|doi=10.1161/01.CIR.93.8.1579}}</ref>
|
* High-[[Pitch|pitched]] “blowing” [[holosystolic murmur]] of '''[[mitral regurgitation]]''' (more common) which is best [[Hearing|heard]] at the [[apex of the heart]] with the [[patient]] in left [[lateral]] [[decubitus]] [[Position effect|position]].


===Extremities===
* Mid-[[diastolic]], rumbling [[Heart murmur|murmur]] of '''[[mitral stenosis]] ('''with or without an [[Austin Flint murmur]]).
* Extremities examination of patients with [disease name] is usually normal.
|-
OR
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Aortic valve disease]]
*[[Clubbing]]  
|
*[[Cyanosis]]  
*[[Early diastolic murmur]] of [[Aortic regurgitation|'''aortic''' '''regurgitation''']]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*[[Widened pulse pressure]] due to [[aortic insufficiency]]
*Muscle atrophy
* Bobbing of the [[uvula]] ([[new]]-onset [[aortic regurgitation]])
*Fasciculations in the upper/lower extremity
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Tricuspid valve disease]]
|
*[[Holosystolic murmur]] of [[Tricuspid regurgitation|'''tricuspid''' '''regurgitation''']]
|}


==References==
==References==

Revision as of 17:13, 16 August 2020

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]Sara Mohsin, M.D.

Overview

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

OR

Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

OR

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

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


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[1][2][3][4][5][6] LVH can present as any of the following:
Congestive heart failure Physical examination findings of CHF include:
Secondary infective endocarditis (IE)[7][8][9][10] IE can present as:
Mitral valve disease[11]
Aortic valve disease
Tricuspid valve disease

References

  1. ↑ https://www.medscape.com/answers/241381-7641/what-are-signs-of-left-ventricular-hypertrophy-lvh-in-cardiac-exam-of-hypertension-high-blood-pressure
  2. ↑ Okin PM, Devereux RB, Nieminen MS, Jern S, Oikarinen L, Viitasalo M; et al. (2001). "Relationship of the electrocardiographic strain pattern to left ventricular structure and function in hypertensive patients: the LIFE study. Losartan Intervention For End point". J Am Coll Cardiol. 38 (2): 514–20. doi:10.1016/s0735-1097(01)01378-x. PMID 11499746.
  3. ↑ Pinto IJ, Nanda NC, Biswas AK, Parulkar VG (1967). "Tall upright T waves in the precordial leads". Circulation. 36 (5): 708–16. doi:10.1161/01.cir.36.5.708. PMID 4227953.
  4. ↑ Okin PM, Devereux RB, Fabsitz RR, Lee ET, Galloway JM, Howard BV; et al. (2002). "Quantitative assessment of electrocardiographic strain predicts increased left ventricular mass: the Strong Heart Study". J Am Coll Cardiol. 40 (8): 1395–400. doi:10.1016/s0735-1097(02)02171-x. PMID 12392827.
  5. ↑ Shah AS, Chin CW, Vassiliou V, Cowell SJ, Doris M, Kwok TC; et al. (2014). "Left ventricular hypertrophy with strain and aortic stenosis". Circulation. 130 (18): 1607–16. doi:10.1161/CIRCULATIONAHA.114.011085. PMID 25170097.
  6. ↑ Mehta A, Jain AC, Mehta MC, Billie M (2000). "Usefulness of left atrial abnormality for predicting left ventricular hypertrophy in the presence of left bundle branch block". Am J Cardiol. 85 (3): 354–9. doi:10.1016/s0002-9149(99)00746-8. PMID 11078306.
  7. ↑ https://emedicine.medscape.com/article/216650-clinical
  8. ↑ Jingushi N, Iwata M, Terasawa T (2017). "Clinical features of patients with infective endocarditis presenting to the emergency department: a retrospective case series". Nagoya J Med Sci. 79 (4): 467–476. doi:10.18999/nagjms.79.4.467. PMC 5719206. PMID 29238103.
  9. ↑ Hoen B, Duval X (2013). "Clinical practice. Infective endocarditis". N Engl J Med. 368 (15): 1425–33. doi:10.1056/NEJMcp1206782. PMID 23574121.
  10. ↑ Cahill TJ, Prendergast BD (2016). "Infective endocarditis". Lancet. 387 (10021): 882–93. doi:10.1016/S0140-6736(15)00067-7. PMID 26341945.
  11. ↑ Hojnik, Maja; George, Jacob; Ziporen, Lea; Shoenfeld, Yehuda (1996). "Heart Valve Involvement (Libman-Sacks Endocarditis) in the Antiphospholipid Syndrome". Circulation. 93 (8): 1579–1587. doi:10.1161/01.CIR.93.8.1579. ISSN 0009-7322.

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