Ep 181: A 64-Year-Old with Fatigue and Low-Grade Fevers

This is Katarina Heidhausen, Executive Editor of Harrison's Principles of Internal Medicine. Harrison's podcast is brought to you by McGraw Hills Access Medicine, the online medical resource that delivers the latest content from the best minds in medicine. And now, onto the episode. Hi everyone. Welcome back to Harrison's Podcast. We're your co-hosts. I'm Dr. Kathy Handy. And I'm Dr. Charlie Wiener, and we're joining you from the Johns Hopkins School of Medicine.

Welcome to today's episode, a 64-year-old with fatigue and low-grade fevers. Kathy, we recently finished a series on physiology, and today we're going deep on the physical examination. All right, let's go. Okay, today your patient is a sixty-four-year-old man who's coming to see you because he's felt unwell for the past few weeks. He reports fatigue, low grade fevers, anorexia, and a five pound weight loss over that time.

His past history is unremarkable, in fact he seldom sees a physician and he takes no medications. He works as a chef, does not smoke, and typically has one to two glasses of wine nightly after work. He's single and has not been sexually active in the last year. His family history is positive for a history of alcoholism and colon cancer in both his father and his uncle.

All right, tell me about his physical exam. Well generally he is thin but does not look unwell. He has a temperature of one hundred point three Fahrenheit, a normal heart rate, blood pressure, respiratory, and oxygen saturation and room air. The exam is normal except for he has a grade three over six systolic holosystolic murmur heard best at the apex, which radiates to the axilla. His JVP is normal, and his S two is split physiologically.

Is any of that new? Well, the low-grade fever is new, and he's never been told that he has a cardiac murmur, and review of his records does not show any history of a cardiac murmur. I'm going to get right to the question that's going to focus on this heart murmur and your subsequent maneuvers. So the question asks, based on these findings, which of the following is most likely true about this murmur?

Option A is that it gets louder with hand grip. Option B is that it gets louder with inspiration, or option C is that it gets louder with a val salva maneuver. Okay, we have a middle-aged man with an apparently new heart murmur and some recent systemic findings. The bedside maneuvers here are helpful because it may help me with my suspected diagnosis.

But let's do a quick review of murmurs and maneuvers. Okay, let's hear. Heart murmurs are caused by audible vibrations that are due to one, increased turbulence from accelerated blood flow through normal or abnormal orifices. Two, flow through a narrowed or irregular orifice into a dilated vessel or chamber, or three, backwards flow through an incompetent valve, ventricular septal defect or patent ductus arteriosis.

They traditionally are defined by their timing within the cardiac cycle, so we talk about systolic, diastolic, or continuous murmurs. And it's important to note the location and radiation of the murmur because that can help with characterization. What about intensity and configuration? The intensity of a heart murmur is graded on a scale of one to six.

A grade one murmur is very soft and is heard only with great effort. A grade two murmur is easily heard but not particularly loud. A grade three murmur is loud but is not accompanied by a palpable thrill over the site of maximal intensity.

A grade four murmur is very loud and accompanied by a thrill. A grade five murmur is loud enough to be heard with only the edge of the stethoscope touching the chest, whereas a grade six murmur is loud enough to be heard with the stethoscope slightly off the chest. Murmurs of grade three or greater intensity usually signify important structural heart disease and indicate high blood flow velocity at the site of murmur production.

The configuration of a heart murmur may be described as crescendo, decrescendo, crescendo decrescendo or plateau. At Johns Hopkins, I will say that a grade one murmur is only heard by doctor Tom Trail. Shout out to doctor Trail. So our patient had a grade three holocystolic murmur at the apex radiating to the axilla. What do you make of that?

Yes, I'm thinking he likely has some mitral regurgitation. And maneuvers can help? Yes, simple maneuvers that alter cardiac chemodynamics can provide important clues to their cause and significance. So our question mentions hand grip, inspiration, and valsalve.

What's the mechanism for them changing heart murmurs? Hand grip will raise systemic vascular resistance and left ventricular afterlode. The systolic murmurs of mitral regurgitation and ventricular septal defects become louder during sustained hand grip. The murmurs associated with aortic stenosis or hypertrophic obstructive cardiomyopathy will become softer or remain unchanged with these maneuvers.

The diastolic murmur of aortic regurgitation becomes louder in response to interventions that raise systemic vascular resistance. What about inspiration? During spontaneous inspiration, the reduction in pleural pressure and therefore right atrial pressure increases venous return to the right heart. S two gets wider in this circumstance, and murmurs of right sided origin, such as tricuspid or pulmonic regurgitation, increase in intensity during inspiration.

the intensity of left sided murmurs either remains constant or decreases with inspiration. And what about the Valsalva maneuver? Remember the valsalva maneuver is bearing down with a closed glottis, like having bowel movement. That will increase pleural pressure and right atrial pressure, so will decrease venous return, ventricular filling, and cardiac output.

The majority of murmurs decrease in intensity during the strain phase of the maneuver. Two notable exceptions are the murmurs associated with mitral valve prolapse. and hypertrophic obstructive cardiomyopathy or hokum. Both of those murmurs become louder during the valsalva maneuver. Okay, so it sounds like we now have enough information to answer the question.

As I mentioned, I think he has mitral regurgitation. So therefore I'd expect the murmur to get louder with hand grips. So the answer is A. Okay. Quickly review the others. So with option B, the murmur gets louder with inspiration would be a right sided murmur such as tricuspid regurgitation.

And option C was about the murmur getting louder with the val salva maneuver, so that would be mitral valve prolapse or hokum. I can see how auscultation of the heart remains valuable even in this era of bedside technology and POCUS. Absolutely. And before we finish, just to close with our patient, with the systemic findings and new mitral regurgitation murmur, we need to be worried about subacute bacterial endocarditis. So I would recommend drawing blood cultures for him.

I'm glad you brought that up. This is a good topic for a future episode. Yeah, his blood cultures grew enterococcus focalis, for which he was started on appropriate antibiotic therapy. A colonoscopy revealed a resceptable adenocarcinoma in his descending colon. So that heart murmur was an important initial finding. Yep. So the teaching points of today's case are that understanding the timing and the physiology of the cardiac cycle aids in understanding cardiac auscultation.

Maneuvers to change the cardiac output or afterload give valuable bedside information for understanding the etiology of abnormal oscultary findings such as murmurs. You can find this question and other questions like it in the Harrison Self-Review book, and you can learn more about this topic in Harrison's chapter on the approach to the patient with a heart murmur.

Visit the show notes for links to helpful resources, including related chapters and review questions from Harrisons, available exclusively on Access Medicine. If you enjoyed this episode, please leave us a review so we can reach more listeners just like you. Thanks so much for listening.