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3) Apical pulse:S1
• S3: Mechanism:
In early diastole filling blood moves from
• 1) Gallop:
Three or four sounds are spaced to audibly
resemble the center of a horse, the extra
sounds occurs after S2.
• Protodiastolic gallop rhythm
• S3 gallop, ventricular gallop rhythm.
• S1 + S2 + pathologic S3
– In early diastole, the blood through into
ventricle from atrium in failing
myocardium, the ventricular wall tension
is poor, produce vibration. Reflex that the
ventricular function↓
• Auscultation character of S3 gallop:
– lower in pitch
– After S2
– Best hear at apex
– Loudest at the end of expiration.
• S3 gallop: differ from normal S3
– Occur in severe organic heart disease
– HR>100 bpm
– The interval time between S1 and S2 are
almost equal, mimicking quality, normal
S3 is nearer from S2
– Normal S3 will disappear in standing or
sitting position
• Late diastolic gallop
– S4 gallop, atrium gallop
• At late diastole, related to atrial contraction.
In LVEDP ↑ compliance↓ Artial contraction↑
occur precede S1, far from S2
low-pitch; best heard at apex
• Tensity: end of expiration↑(from LA)
end of inspiration ↑(from RA)
• Occur in pressure overload,→LVH, in
myocardial damaged , LV compliance ↓,
such as BP↑, IHSS, CHD.
• Summation gallop
– Overlapping of S3G and S4G while HR↑
• 2) Opening snap
– In MS
– In early diastole of LV, the blood from LA→
LV, the opening MV suddenly stopped make
itself vibration
– After S2. Brief in duration.
– High in pitch. Indicate a flexible valve
• 3) Pericardial knock
– In constrictive pericarditis after
inflamation, pericardial constricted, limit
the diastole of ventricle was limited,
produce the vibration of ventrcular wall.
– 0.1 ″ after S2,
– Loudest at apex.
6. Extra sound in systolic period:
• 1) Early systolic ejection sound
– Dilated great vessel, hypertention with in it.
– After S1, high in pitch.
– PV area: PS , PH inspiration↓, expiration ↑
– AV area: BP ↑,AS
• 2) Middle and late systolic clicks
– In MVP
– Valve, tandae chordea redudent, floppy
– Click: after S1, close to S2
best heard at apex
lower in pitch
Heart murmur
• H M is abnormal sound
• Produce by vibration
• Within the heart or large arteries.
• Mechanism
– Blood velocity↑
– Blood vascosity↓
– Valve: narrowed or incompetent; organic
or relative
– Abnormal connection
– Vibration of loose structure
– Diameter of vessel ↑or ↓
• Character of murmur
• Location:
– Murmur of valvular origin are usually
best heard over their respective valve
area
• Timing:
– Murmurs are timed according to the
phase of cardiac cycle during which they
occur.
– SM, DM , CM.
– Early, middle, late
• Quality
– Depend on: frequency and intensity of
sound wave
– Related to: pathology and hemodynamic
changes of the heart
– Soft, harsh, musical.
– SM: blowing, harsh, musical (seagull)
– DM: blowing, sigh-like, rumbling.
– CM: machine-like, hum
• Radiation: transmitted direction
– With the bloodstream by which they are
produced or propagated from their point
of origin in many directions
– AS
– MR
– MS
• Intensity:
– Related to :
• The severity of abnormal
• The velocity of blood flow
• The pressure gradient of valve
• The myocardial contraction
• Six-point scale of for grading the intensity of
heart murmur
– Grade Ⅰ: basely audible