Thursday, March 3, 2011

Cardiology: Murmurs!

The stethoscope has practically become the icon of healthcare.  To wear a stethoscope suggests that a person has some sort of clinical knowledge.  After all, why else would a person have a stethoscope on their person if they did not actually know how to use it?  A stethoscope amplifies sound to make very subtle noises audible to the human ear.  Thus the sounds of the hearts valves closing, the movement of air into and out of the lungs, the bowels doing their thing, and so on get recognized clinically with the use of a stethoscope.  Without an understanding of what the sounds actually mean such information proves useless, allowing the stethoscope to serve as nothing more than a mere piece of jewelry.

When putting the stethoscope to the chest one can look at the chest as having four separate areas in which to listen for heart sounds:
  • Aortic: the right second intercostal space adjacent the sternum
  • Pulmonic: the left second intercostal space adjacent the sternum
  • Tricuspid: the left third and fourth intercostal spaces adjacent the sternum
  • Mitral: the left fifth intercostal space in the mid-clavicular line, often the point of maximal intensity
The location of a heart sound allows for the listener to determine the significance of a murmur based on the clinical picture.  Some of the sickest patients may have a murmur which needn't be addressed while some of the healthiest patients can have murmurs which signify the presence of a silent killer.   This means that the clinician wields a heavy tool in his or her stethoscope.  

Just as a jugular venous pressure wave shows the cardiac cycle of systole and diastole, the stethoscope auscultation, or listening to the heart provides an audible representation of heart function.  Normally two sounds, or beats get heard: S1 and S2.  When someone describes the heart as making a lub dub noise, they are referring to S1 and S2.
  • S1 is the sound of the bicuspid and tricuspid valves closing during systole, the aortic and pulmonic valves should be open
  • S2 is the sound of the aortic and pulmonic valves closing during diastole, the mitral and tricuspid valves should be open
To learn mumurs, which usually sound like a whoosh instead of or after a beat, it's easiest to think of them in terms of whether they occur in systole or diastole.  Knowing their location helps to limit the differential.

Systolic murmurs are those which occur during systole, and can be further classified upon when the murmur actually occurs.

  • Early to mid systolic murmurs
    • Pulmonic Stenosis (PS)
    • Tricuspid Regurgitation (TR)
    • Atrial Septal Defect (ASD)
    • Idiopathic Hypertrophic Subaortic Stenosis (IHSS)
    • Mitral Regurgitation (MR)
  • Mid to late systolic murmurs
    • Mitral Valve Prolapse (MVP)
    • Aortic Stenosis (AS)
  • Holocystolic--occurring throughout all of systole
    • Tricuspid Regurgitation (TR)
    • Mitral Regurgitation (MR)
    • Ventricular Septal Defect (VSD)
Notice that TR and MR can occur as either early/mid systolic as well as pan-systolic.  The difference being that something acute occurs early, where as a chronic condition happens throughout.  

Diastolic murmurs also occur, albeit considerably less to know than the list of 10 systolic murmurs.  Often one auscultates these best in the neck, and can quantify them based on the sound they make: a rumble vs. a blow.
  • Diastolic Rumbles
    • Tricuspid Stenosis (TS)
    • Mitral Stenosis (MS)
    • Austin Flint 
  • Diastolic Blows
    • Aortic Regurgitation (AR)
    • Pulmonic Regurgitation (MR)
Once the clinician has auscultated a murmur he or she must somehow differentiate the type.  An echocardiogram can effectively diagnose problems with valves and septa (the plural for septum, not the transit authority).  However, since not always practical or available, the practitioner should remember a few fundamentals to accurately diagnose a murmur by physical exam.  Since the heart handles systemic circulation, look at the heart as a dual circuit: the right side of the heart receives blood from the venous circulation, anything which increases venous return will increase a murmur on the right; the left side of the heart pumps blood into arterial circulation, anything which increases the arterial blood pressure will increase a left sided murmur.  
  • Inspiration & leg raising: increase the amount of blood from venous circulation returning to the heart, this increase in preload leads to an increase in the duration of right sided murmurs
  • Squatting: increases the amount of blood returning to the heart as well as the systemic arterial blood pressure, this increase in both preload and afterload results in increased duration of right and left sided murmurs
  • Hand grip: constriction of the radial and ulnar arteries leads to a backup of arterial blood which increases the arterial blood pressure, this increase in afterload causes an increase in left sided murmurs
  • Valsalva & standing: leads to a decrease in both preload and afterload, ultimately reducing the duration of both right sided and left sided murmurs
One very important exception exists to these rules: IHSS
  • Duration increases with valsalva
  • Duration decreases with squatting
In considering the pathophysiology of IHSS, it makes sense.  Because of the hypertrophy of the subaortic area of the left ventricle blood will have a difficult time getting from the left ventricle into the aorta.  However, if the pressure in the arterial circulation increases it will lead to an increase in left ventricular pressure in order to compensate.  Where as this will increase the effect of most left-sided pathologies and thus increase their associated murmurs, in IHSS the pressure increase will push against the hypertrohpied tissue and essentially push it out of the way such that blood will move by easier and result in a diminished murmur.  Following the same logic the opposite is also true.  

Some people could not help themselves and insisted on putting their namesake to a diastolic murmur.  Nonetheless three particularly important ones exist:
  • Carey Coombs Murmur: the diastolic murmur of mitral stenosis heard as a result of rheumatic heart disease
  • Graham Steell Murmur: the diastolic murmur of pulmonic valve regurgitation
  • Austin Flint Murmur: the diastolic murmur heard best in the mitral area associated with severe aortic regurgitation compressing against a normal mitral valve

Although not very recent, a 1990 study showed that in diagnosing pediatric murmurs the clinical skills of an experienced cardiologist have a sensitivity of 96% and specificity of 95%.  While it may seem great, just ask yourself this: how many doctors today rely on their physical exam skills as much as those who practiced decades ago?  Just how many doctors today actually qualify as experienced as determined by that article?  Since the article left out such criteria I cannot know, but I suspect the number would be considerably less. 


ResearchBlogging.org

John F. Smythe MD, Otto H. P. Teixeira MD, Peter Vlad MD, Pierre Paul Demers MD, & William Feldman MD (1991). Initial evaluation of heart murmurs: Are laboratory tests necessary? The Indian Journal of Pediatrics, 58 (2), 231-231 DOI: 10.1007/BF02751126

31 comments:

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  14. Hello everyone. I was heartbroken because i had very small penis, not nice to satisfy a woman, i had so
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    but none could offer me the help i searched for. i saw some few comments about this specialist called Dr osemuhau and decided to email him on
    so I decided to give his herbal product a try. i emailed him and he got back to me, he gave me some
    comforting words with his herbal pills for Penis t, Enlargement Within 1 week of it, i began to feel the
    enlargement of my penis, " and now it just 2 weeks of using his products my penis is about 9 inches
    longer and am so happy..feel free to contact Dr osemuhau on(drosemuhau@gmail.com) him this number +2348168714427

    ReplyDelete
  15. I am Miss alisha,From USA. I will start by saying to all that have experience heart break and also cant do with out there lover should please stop here and read up my story, So as you will know how to go solving or getting your ex back from this spell caster..AND AGAIN I WILL WANT TO ALSO TELL ALL THAT THIS SPELL CASTER I WILL WANT TO TELL THE WHOLE WORLD ABOUT IS HARMLESS AND DO NOT HAVE ANY SIDE EFFECT, BUT TO RESTORE AND GIVE YOU BACK WHAT YOU DESERVE, COS WHEN I MEET WITH THIS SPELL CASTER THAT WAS INTRODUCED TO ME BY THE WIFE OF MY BOSS IN MY WORKING PLACE, HE MADE IT CLEAR THAT HE CAN CAST SPELL ON SO MANY OTHER PROBLEMS EXCEPT IN GETTING YOUR EX OR MAKING YOUR LOVER TO LOVE YOU MORE THAT WILL SUITE YOU. Last year December, My lover was cheating on me and was not also give me the attention that a man should give to a woman,And really that was troubling my mind and tearing my heart apart to the extent that i was not concentrating in the office the way i use to before the break up by my lover.And before that incident,I always see how my boss use to love his wife so much. I was bringing to think that i was not doing the right thing to him that will make him love me forever,So i really gathered my courage and went to my boss wife office to ask her the secret that made her husband love her so dearly,In the first place she refused in telling me,She asked me why i am asking her such a question,That if is it not normal for every man to love his wife.I told her the reason that made me ask her about this question,That my lover started cheating on me lately,When i knelt down before her for her to see my seriousness in this issue that i went to ask her,She opened up to me by telling me that i should not tell anybody about what she want to tell me,The wife to my boss started to say to me that she used a very powerful spell on his husband to love her,And the spell that she used is harmless, But the spell is just to make him love her and never to look for any other woman except her. I QUICKLY ASK HER HOW DID SHE GET TO KNOW THIS GREAT,POWER,DURABLE AND PERFECT WORK SPELL CASTER,she said that a friend of hers also introduce her to him. Then i also ask her how i can meet with this spell caster.SHE SAID EVERYTHING TO ME,THAT THE NAME OF THIS SPELL CASTER IS Dr.AZEN .My next question to her was how can i get this wonderful spell caster,She said she is going to give me the email of the spell caster for me to contact him for my problem,Really she gave to me this spell caster email:[azentemple@gmail.com]or what'sapp +2349038299828. and i contacted him and explained all to him,And after every thing that needed to be done by the spell caster, In the next two days, My lover that hated me so much came to house begging for forgiveness and i was so glad that i have finally gotten my heart desire..I was so grateful to this spell caster for what he has done for my life.. So i made a promise to him that i will always come

    ReplyDelete
  16. I am Miss alisha,From USA. I will start by saying to all that have experience heart break and also cant do with out there lover should please stop here and read up my story, So as you will know how to go solving or getting your ex back from this spell caster..AND AGAIN I WILL WANT TO ALSO TELL ALL THAT THIS SPELL CASTER I WILL WANT TO TELL THE WHOLE WORLD ABOUT IS HARMLESS AND DO NOT HAVE ANY SIDE EFFECT, BUT TO RESTORE AND GIVE YOU BACK WHAT YOU DESERVE, COS WHEN I MEET WITH THIS SPELL CASTER THAT WAS INTRODUCED TO ME BY THE WIFE OF MY BOSS IN MY WORKING PLACE, HE MADE IT CLEAR THAT HE CAN CAST SPELL ON SO MANY OTHER PROBLEMS EXCEPT IN GETTING YOUR EX OR MAKING YOUR LOVER TO LOVE YOU MORE THAT WILL SUITE YOU. Last year December, My lover was cheating on me and was not also give me the attention that a man should give to a woman,And really that was troubling my mind and tearing my heart apart to the extent that i was not concentrating in the office the way i use to before the break up by my lover.And before that incident,I always see how my boss use to love his wife so much. I was bringing to think that i was not doing the right thing to him that will make him love me forever,So i really gathered my courage and went to my boss wife office to ask her the secret that made her husband love her so dearly,In the first place she refused in telling me,She asked me why i am asking her such a question,That if is it not normal for every man to love his wife.I told her the reason that made me ask her about this question,That my lover started cheating on me lately,When i knelt down before her for her to see my seriousness in this issue that i went to ask her,She opened up to me by telling me that i should not tell anybody about what she want to tell me,The wife to my boss started to say to me that she used a very powerful spell on his husband to love her,And the spell that she used is harmless, But the spell is just to make him love her and never to look for any other woman except her. I QUICKLY ASK HER HOW DID SHE GET TO KNOW THIS GREAT,POWER,DURABLE AND PERFECT WORK SPELL CASTER,she said that a friend of hers also introduce her to him. Then i also ask her how i can meet with this spell caster.SHE SAID EVERYTHING TO ME,THAT THE NAME OF THIS SPELL CASTER IS Dr.AZEN .My next question to her was how can i get this wonderful spell caster,She said she is going to give me the email of the spell caster for me to contact him for my problem,Really she gave to me this spell caster email:[azentemple@gmail.com]or what'sapp +2349038299828. and i contacted him and explained all to him,And after every thing that needed to be done by the spell caster, In the next two days, My lover that hated me so much came to house begging for forgiveness and i was so glad that i have finally gotten my heart desire..I was so grateful to this spell caster for what he has done for my life.. So i made a promise to him that i will always come

    ReplyDelete
  17. Hello all online viewer ,,,, HERPES AND HIV to heal
    Does anyone still doubt natural herbal medicine? I have seen the great importance of natural herbs and the wonderful work they have done in people's lives. I wonder why people are still spending their money on surgery, injections and medications that can not cure you completely. Natural herbs can cure all kinds of diseases, including herpes, diabetics, asthma, HIV, hepatitis, ALS, etc. I saw it with my own eyes. I was cured of HIV and my aunt and her husband were cured of the herpes virus and tested negative after using herbal medicine. I ' have also been healed from HIV and tested negative to HIV after using herbal medicine by Dr. HAZIM who uses natural herbs to heal different types of diseases. Even Dr. Sebi proves to the world that natural herbs can cure all diseases and has cured countless people using natural herbs. I know is hard to believe but am a living testimony. There is no harm in trying herbal medicine. Contact or write Dr.Hazim on: usmandrhazim@gmail.com (phone / whatsap no): +2349058026857,

    ReplyDelete
  18. I am Miss alisha,From USA. I will start by saying to all that have experience heart break and also cant do with out there lover should please stop here and read up my story, So as you will know how to go solving or getting your ex back from this spell caster..AND AGAIN I WILL WANT TO ALSO TELL ALL THAT THIS SPELL CASTER I WILL WANT TO TELL THE WHOLE WORLD ABOUT IS HARMLESS AND DO NOT HAVE ANY SIDE EFFECT, BUT TO RESTORE AND GIVE YOU BACK WHAT YOU DESERVE, COS WHEN I MEET WITH THIS SPELL CASTER THAT WAS INTRODUCED TO ME BY THE WIFE OF MY BOSS IN MY WORKING PLACE, HE MADE IT CLEAR THAT HE CAN CAST SPELL ON SO MANY OTHER PROBLEMS EXCEPT IN GETTING YOUR EX OR MAKING YOUR LOVER TO LOVE YOU MORE THAT WILL SUITE YOU. Last year December, My lover was cheating on me and was not also give me the attention that a man should give to a woman,And really that was troubling my mind and tearing my heart apart to the extent that i was not concentrating in the office the way i use to before the break up by my lover.And before that incident,I always see how my boss use to love his wife so much. I was bringing to think that i was not doing the right thing to him that will make him love me forever,So i really gathered my courage and went to my boss wife office to ask her the secret that made her husband love her so dearly,In the first place she refused in telling me,She asked me why i am asking her such a question,That if is it not normal for every man to love his wife.I told her the reason that made me ask her about this question,That my lover started cheating on me lately,When i knelt down before her for her to see my seriousness in this issue that i went to ask her,She opened up to me by telling me that i should not tell anybody about what she want to tell me,The wife to my boss started to say to me that she used a very powerful spell on his husband to love her,And the spell that she used is harmless, But the spell is just to make him love her and never to look for any other woman except her. I QUICKLY ASK HER HOW DID SHE GET TO KNOW THIS GREAT,POWER,DURABLE AND PERFECT WORK SPELL CASTER,she said that a friend of hers also introduce her to him. Then i also ask her how i can meet with this spell caster.SHE SAID EVERYTHING TO ME,THAT THE NAME OF THIS SPELL CASTER IS Dr.AZEN .My next question to her was how can i get this wonderful spell caster,She said she is going to give me the email of the spell caster for me to contact him for my problem,Really she gave to me this spell caster email:[azentemple@gmail.com]or what'sapp +2349038299828. and i contacted him and explained all to him,And after every thing that needed to be done by the spell caster, In the next two days, My lover that hated me so much came to house begging for forgiveness and i was so glad that i have finally gotten my heart desire..I was so grateful to this spell caster for what he has done for my life.. So i made a promise to him that i will always come

    ReplyDelete
  19. I am Miss alisha,From USA. I will start by saying to all that have experience heart break and also cant do with out there lover should please stop here and read up my story, So as you will know how to go solving or getting your ex back from this spell caster..AND AGAIN I WILL WANT TO ALSO TELL ALL THAT THIS SPELL CASTER I WILL WANT TO TELL THE WHOLE WORLD ABOUT IS HARMLESS AND DO NOT HAVE ANY SIDE EFFECT, BUT TO RESTORE AND GIVE YOU BACK WHAT YOU DESERVE, COS WHEN I MEET WITH THIS SPELL CASTER THAT WAS INTRODUCED TO ME BY THE WIFE OF MY BOSS IN MY WORKING PLACE, HE MADE IT CLEAR THAT HE CAN CAST SPELL ON SO MANY OTHER PROBLEMS EXCEPT IN GETTING YOUR EX OR MAKING YOUR LOVER TO LOVE YOU MORE THAT WILL SUITE YOU. Last year December, My lover was cheating on me and was not also give me the attention that a man should give to a woman,And really that was troubling my mind and tearing my heart apart to the extent that i was not concentrating in the office the way i use to before the break up by my lover.And before that incident,I always see how my boss use to love his wife so much. I was bringing to think that i was not doing the right thing to him that will make him love me forever,So i really gathered my courage and went to my boss wife office to ask her the secret that made her husband love her so dearly,In the first place she refused in telling me,She asked me why i am asking her such a question,That if is it not normal for every man to love his wife.I told her the reason that made me ask her about this question,That my lover started cheating on me lately,When i knelt down before her for her to see my seriousness in this issue that i went to ask her,She opened up to me by telling me that i should not tell anybody about what she want to tell me,The wife to my boss started to say to me that she used a very powerful spell on his husband to love her,And the spell that she used is harmless, But the spell is just to make him love her and never to look for any other woman except her. I QUICKLY ASK HER HOW DID SHE GET TO KNOW THIS GREAT,POWER,DURABLE AND PERFECT WORK SPELL CASTER,she said that a friend of hers also introduce her to him. Then i also ask her how i can meet with this spell caster.SHE SAID EVERYTHING TO ME,THAT THE NAME OF THIS SPELL CASTER IS Dr.AZEN .My next question to her was how can i get this wonderful spell caster,She said she is going to give me the email of the spell caster for me to contact him for my problem,Really she gave to me this spell caster email:[azentemple@gmail.com]or what'sapp +2349038299828. and i contacted him and explained all to him,And after every thing that needed to be done by the spell caster, In the next two days, My lover that hated me so much came to house begging for forgiveness and i was so glad that i have finally gotten my heart desire..I was so grateful to this spell caster for what he has done for my life.. So i made a promise to him that i will always come

    ReplyDelete
  20. I'm 15 years old. I was born with HIV my mother passed away because of the HIV infection And I regret why i never met Dr Itua he could have cured my mum for me because as a single mother it was very hard for my mother I came across Dr itua healing words online about how he cure different disease in different races diseases like HIV/Aids Herpes,Parkison,Asthma,Copd,Epilepsy,Shingles,Cold Sore,Infertility, Chronic Fatigues Syndrome,Fibromyalgia, Diabetes Hepatitis even Cancer I was so excited but frighten at same time because I haven't come across such thing article online then I contacted Dr Itua on Mail drituaherbalcenter@gmail.com I also chat with him on what's app +2348149277967 he tells me how it works then I tell him I want to proceed I paid him so swiftly Colorado post office I receive my herbal medicine within 4/5 working days he gave me guild lines to follow and here am I living healthy again can imagine how god use men to manifest his works am I writing in all articles online to spread the god work of Dr Itua Herbal Medicine,He's a Great Man.

    ReplyDelete
  21. Spell to fix your broken marriage or relationship problem or after a divorce or Breakup,I was recently scam by two of them, until one faithful day i meet a man called Dr Oselumen who help me to get back to the father of my kid after we have been separated for two years,I only pay for the items required for the spell and he cast the spell for me within 24hours my ex husband called me and beg me to forgive him for everything until the end of the world he will never leave me again we are back together.if you need a real and quick love spell or you are passing through pregnancy problem Dr Oselumen is the answer, Please if any body needs. LOVE SPELL,LOTTERY,PREGNANCY SPELL, DIVORCE SPELL,STOP COURT CASE AND WIN ANY COURT PROBLEM,DEATH SPELL,BUSINESS SPELL AND MANY MORE YOU MAY NEED. Email him now for your own help. via email droselumen@gmail.com add him on whatsapp line or call +2348054265852.

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  22. MY TESTIMONY ABOUT HOW DR IMOLOA HERBAL CREAM ENLARGE MY PENIS FROM 4 INCHES TO 8 INCHES

    Hello everyone here i want to share a marvelous testimony oh how Dr Imoloa HERBAL MIXTURE CREAM saved me from shame and disgrace .So Many Women Today Cheat On Their Husband All Because Of The Poor Performance Of Their Husband In Bed,I Have Come To Know That Women Love Men Who Last Long In Bed And Also Has That Big Dick That Can Make Them Scream And Also Make Them Rich Their Climax,Women Truly Love Good Sex. I Have Been Passing True Sexual Problems For The Past Six Years Now All Because Of The Size Of My Penis And My Poor Performance In Bed I Caught My Wife With A Man On Our Matrimonial Bed I Was Heart Broken And Confused When I Asked Her Why She Did All What She Did She Told Me I Was Not Good In Bed That I Can Not Satisfy Her That She Needs A Man Who Can Satisfy Her That Was How She Broke Up With Me At That Moment. I Told My Self I Was Never Going To Have Any Thing To Do With Any Woman Again I Started Going To The Club Sleeping Around With Different Girls at a Point I Got Tired Of Living That Kind Of Life Because That Was Never Part Of Me I Was On Line Last Month When I Came Across so many testimonies On   Dr imoloa, How He Made their Sex Life Come Back To Life And That He Had Giving Them The Real Size Of Penis A Man  Suppose To Have I Got Interested And I Contacted Him At Once Luckily For Me He Was Online After About 30 Minutes He Replied Me And Then He Told Me Every Thing I Needed To Do After Every Thing He Sent Me A herbal cream Package True The DHL courier  Service Which I Received The Next three Days And Then I Started Using Them As Instructed By Him After About 2 Weeks I Started Seeing My Penis Got to 8 inches And i Felt So Many Changes Inside Of Me And Today I Am Happily Married With 2 kids And Last Up more than 1 Hour On Bed and can go up to 10 rounds with my wife All Thanks To Dr imoloa For Making Me Feel Like A Man Once Again.note he also have cure for..PENIS ENLARGEMENT, BREAST ENLARGEMENT, DIABETES 1/2,HIV/AIDS,HERPES,CANCER,PREMATURE EJACULATION,WEAK ERECTION,ERECTILE DYSFUNCTION ,LOW SPERM COUNT PREGNANCY HERBAL MEDICINE HIGH BLOOD PRESSURE LOW SPERM COUNT LYME DISEASE many more..  Contact Via drimolaherbalmademedicine@gmail.com or  whatssapp--+2347081986098

    ReplyDelete
  23. Hi!

    Who knows more about chokeberry aronia nutrition?

    Thank you!
    Anthony

    ReplyDelete
  24. I'm so excited to share my testimonies about the Good Work of Dr. Anuge who got me cured from herpes simplex virus (HSV1&2) with his herbs, I never thought that I would live on earth before the year runs out. I have been suffering from herpes, I had spent a lot of money going from one Hospital to another looking for a way to get rid of this disease, the hospital has been my home everyday residence. Constant checks up have been my hobby not until this fateful day, I was searching through the internet, I saw a testimony on how @Dr_anuge7 helped someone in curing his herpes disease using his healing Herbs, quickly I copied his email just to give him a test I spoke to him, he told me that he is going to provide the herbal cure to me, which he did, after I received his herbs and I took it as instructed. I was cured permanently from herpes. My herpes disease was gone. so I decided to share my testimony, that nothing is impossible with God, God used a man to heal me. No matter what you are passing through, no matter how deadly the sickness is and no matter what the situation is God that did mine is still going to do yours, people suffering from herpes, brain tumor, kidney disease, pcos, AIDS, ALS,copd, asthma, arthritis,herpes, Cancer,Hpv, any kind of disease, you can reach him now via Gmail address: dranuge@gmail.com or whatsapp +2348164866838

    ReplyDelete
  25. READ CAREFULLY VERY IMPORTANT MESSAGE
    I want to share a testimony of how Dr_Ogodo1 herbal mixture cream saves me from shame and disgrace, my penis was a big problem to me as the size was really so embarrassing,and i was also having weak erection problem. I can't make love to my wife and my penis was just too small a full grown man like me having 4 inches penis and to worsen it i don't last long in bed,i can't even last two minutes it was really a thing of shame to me. My wife was really tired of me because my sex life was very poor,she never enjoyed sex,i was always thinking and searching for solutions everywhere until when i saw a testimony of how Dr_Ogodo1 herbal mixture cream have been helping people regarding their sex life, so i decided to give him a try and to my greatest surprise in less than one week of taking the herbs my penis grow to 8 inches i couldn't believe my eyes and as i speak now my penis is now 8 inches and i do not have week erection again. I can make love to my wife longer in bed. And my marriage is now stable,my wife now enjoy me very well in bed.
    * He can also bring back your Ex
    *Love spell
    * Herpes virus diseases
    *Diabetes
    *Aid virus
    *STD/HSV
    *Cancer/typhoid E.t.c you contact him through the mail. Ogodoherbalhomesolution@gmail.com
    You can also WhatsApp him on +2349044680467

    ReplyDelete
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