Describe S3 in the following terms:

- Timing

- Pitch

- Location

- Cause

- Associated Problems

- Alleviating/Aggravating Circumstances

Timing

- early diastole, .12-.20 sec after S2

Pitch

- low-pitched, heard with bell

Location

LV-->@apex

RV-->4th LICS

Cause

- ventricle reaches elastic limit

Associated Problems

- Systolic Heart Failure

- (w/ overfilled ventricle) decreased ventricular ejection fraction

- Valvular regurgitation and high output states

Alleviating/Aggravating Circumstances

- RV --> increases in intensity during inspiration & with maneuvers that increase venous return (leg elevation)

- LV --> decreases in intensity during inspiration

Describe S4 in the following terms:

- Timing

- Pitch

- Location

- Cause

- Associated Problems

- Alleviating/Aggravating Circumstances

-Identifying/Distinguishing Factors

Timing

- late diastole, .04-.12 seconds prior to S1

- presystolic gallop

Pitch

- low-pitched atrial sound heard w/ bell

Location

- Left @ apex

Right @ 4th LICS

Cause

- atrial contraction against a stiff, non-compliant ventricle w/ elevated diastolic pressure

Associated Problems

- ventricular hypertrophy

- pulmonary HTN (or) pulmonary stenosis -->

RV hypertrophy

- systemic HTN (or) aortic stenosis --> LV hypertrophy

- Leads to MI

Alleviating/Aggravating Circumstances

- Right S4 increases in intensity with inspiration

- Left S4 decreases in intensity with inspiration

- Left S4 is inaudible while standing

- Cannot occur with A-Fib

Identifying/Distinguishing Factors

S1 split vs S4

- Left S4 is louder @ apex, S1 split louder @ LSB

- Left S4 should disappear with firm pressure to bell

Describe an Opening Snap (OS) in regards to:

- Timing

- Pitch

- Location

- Cause

- Associated Problems

- Alleviating/Aggravating Circumstances

-Identifying/Distinguishing Factors

Timing

early diastolic, follows A2 by .03-0.15 seconds

Pitch

- high-pitched sound

Location

- (mitral stenosis) half way between LSB and Apex

- (tricuspid stenosis) 4th ICS @ LSB

Cause

- opening of mitral/tricuspid valve under high pressure

Associated Problems

- Mitral Stenosis

- Tricuspid Stenosis

Alleviating/Aggravating Circumstances

- if split second sound widens on standing, OS is present

Identifying/Distinguishing Factors

- 2nd component of split S2 is louder @ apex than at 2nd LICS (OS not split S2)

- S2-OS interval if shorter -->more severe stenosis

Describe a Valvular Ejection Sound in regards to:

- Timing

- Pitch

- Location

- Cause

- Associated Problems

- Alleviating/Aggravating Circumstances

-Identifying/Distinguishing Factors

Timing

- follows S1 by .04-.06 seconds

Pitch

- high-pitched

Location

- (right heart) @ 2nd/3rd LICS

- (left heart) @ apex & 2nd RICS

Cause

- occurring when a deformed and rapidly ascending aortic or pulmonary valve reaches its elastic limit

Associated Problems

- Pulmonic Stenosis

- Aortic Stenosis

- Bicuspid Aortic Valve

Alleviating/Aggravating Circumstances

- (pulmonic stenosis) decreases in intensity during inspiration

- (aortic stenosis) constant intensity throughout respiratory cycle

Identifying/Distinguishing Factors

- Closer the pulmonic ejection sound occurs to S1 --> more severe the pulmonic stenosis

Describe a Vascular Ejection Sound in regards to:

- Timing

- Pitch

- Location

- Cause

- Associated Problems

- Alleviating/Aggravating Circumstances

-Identifying/Distinguishing Factors

Timing

- follows S1 by .04-.06 seconds

Pitch

- high-pitched

Location

- (right heart) @ 2nd/3rd LICS

- (left heart) @ apex & 2nd RICS

Cause

- originating from forceful ejection of blood into the great vessels

Associated Problems

- Systemic HTN

- Pulmonary HTN (Idiopathic)

- Ascending aortic aneurysm

Alleviating/Aggravating Circumstances

- (Idiopathic Pulmonary HTN) may remain constant or decrease in intensity during inspiration

Identifying/Distinguishing Factors

- (Idiopathic Pulmonary HTN) can be absent while inhaling

Describe a Midsystolic Click (MSC) in regards to:

- Timing

- Pitch

- Location

- Cause

- Associated Problems

- Alleviating/Aggravating Circumstances

-Identifying/Distinguishing Factors

Timing

- mid-systole

Pitch

- high-pitched

Location

- @ apex and 4th LICS

Cause

- sudden tensin of chordae tendineae as the AV valve leaflets balloon into the atra during mitral/tricuspid valve prolapse

Assocatied Problems

- mitral/tricuspid valve prolapse

Alleviating Aggravating Circumstances

- moves closer to S1 with maneuvers that decrease size of LV (valsalva or standing)

- moves closer to S2 with maneuvers that increase venous return --> increase size of LV (elevation of the legs or squatting)

Identifying/Distinguishing Factors

- presence of MSC diagnoses mitral valve prolapse (w/o echo)

- variable in intensity from exam to exam