Aortic is usually first as pressures are higher

-physiological split in children

-during inspiration pulm open longer. Split is normal

-fixed split is caused by septal defect

-widened split with pulmonary stenosis, pulmHT

-reverse split with Ao stenosis, hypertrophic cardiomyopathy and LBBB (worse with expiration)

-low pitched mid-diastolic sound

-blood swishing in ventricles

-associated with increased cardiac output (pregnancy, fluid overload, thyrotoxicosis)

-associated with elevated filling pressure: stiff ventricle wall, dilated ventricle unable to pump (HF) and increased volume in ventricle (AR, MR)

-occurs at end of diastole when atria is contracting

-caused by blood swiching in atrium as try and contract against stiff ventricle (HF hypertrophy)

-MR

-tricuspid regurgitation

-VSD

-AS

-pulmonary stenosis

-hypertrophic cardiomyopathy

-MS, TS

-acute rheumatic fever

pericarditis

-louder when patient sits forward and exhales

-pneumomediastinum

(post open heart surgery, pneumothorax, pericardial effusion)