bipolardoc

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My girl friend is an RN. We has a discussion about different heart sounds. We somewhat of a difference in opinion, she says not everyone has S3, and S4, it is only for those who are ill. I said it is normal and everyone has an S1, S2, S3, and S4.

My question does everyone have an S1, S2, S3, and S4

Can someone just have an S1, and S2 and not the latter two.

I know that sometimes S3, and S4 are heard at earlier ages, etc.. Are S3, and S4 indication of abnormality and if so in what way.

Thank you guys!
 
OP
bipolardoc

bipolardoc

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My girl friend is an RN. We has a discussion about different heart sounds. We somewhat of a difference in opinion, she says not everyone has S3, and S4, it is only for those who are ill. I said it is normal and everyone has an S1, S2, S3, and S4.

My question does everyone have an S1, S2, S3, and S4

Can someone just have an S1, and S2 and not the latter two.

I know that sometimes S3, and S4 are heard at earlier ages, etc.. Are S3, and S4 indication of abnormality and if so in what way.

Thank you guys!
 

soonereng

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My girl friend is an RN. We has a discussion about different heart sounds. We somewhat of a difference in opinion, she says not everyone has S3, and S4, it is only for those who are ill. I said it is normal and everyone has an S1, S2, S3, and S4.

My question does everyone have an S1, S2, S3, and S4

Can someone just have an S1, and S2 and not the latter two.

I know that sometimes S3, and S4 are heard at earlier ages, etc.. Are S3, and S4 indication of abnormality and if so in what way.

Thank you guys!
R U Serious?

Ever Heard Of the Internets?
 

alwaysaangel

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Your girlfriend is a nurse - she's been trained in this and yes she knows better than you. S3 and S4 are signs of pathology in adults.
 

masterofmonkeys

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the nurses win.

S4 is a classic sign in CHF. USUALLY you will hear this in anyone with compromised heart function, regardless of whether they're stable or not. USUALLY.

S3 is often heard in CHF patients who are decompensated or in an acute episode.
 

PeepshowJohnny

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Your girlfriend is correct. Most "normal" people will typically only have S1 and S2.

S3 (following S2 and thus, early diastole) can be thought of as the blood entering a ventricle that is already full and thus producing a noise. Thus, it's often heard in people with heart failure where a low ejection fraction means there is a lot of retained volume in the ventricle. Thus, in adults it can be pathological. However, kids have such hyperdynamic circulations (accept a lot of blood, pump a lot of blood) they can produce this noise too and it can be completely benign.

S4 (preceding S1 and thus, late diastole) is thought to be due to the atrial kick expelling blood against a stiff venticular wall. Thus, it is almost always pathologic (even in children, although I've read a few sources only that say kids have have a physiologic S4) from things like aortic stenosis or certain cardiomyopathies that decrease venticular compliance.
 
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bipolardoc

bipolardoc

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Your girlfriend is correct. Most "normal" people will typically only have S1 and S2.

S3 (following S2 and thus, early diastole) can be thought of as the blood entering a ventricle that is already full and thus producing a noise. Thus, it's often heard in people with heart failure where a low ejection fraction means there is a lot of retained volume in the ventricle. Thus, in adults it can be pathological. However, kids have such hyperdynamic circulations (accept a lot of blood, pump a lot of blood) they can produce this noise too and it can be completely benign.

S4 (preceding S1 and thus, late diastole) is thought to be due to the atrial kick expelling blood against a stiff venticular wall. Thus, it is almost always pathologic (even in children, although I've read a few sources only that say kids have have a physiologic S4) from things like aortic stenosis or certain cardiomyopathies that decrease venticular compliance.
I guess she did win, thanks guys!
 

lostforever

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You can have an S3 in highly active adults without any pathologic concerns. Bradycardia with large stroke volume to maintain CO.
 

howelljolly

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an S3 can be normal in atheletes, as stated above.

I believe that this observation is accredited to Donald Knowlan, MD the team physician for the Washington Redskins.

 

J-Rad

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S4 (Have listened to a kid at our place with a great S4, always sounds like "Jippa Boom" to me [the whole "Kentucky" and "Tennessee" were never that helpfulto me])-always pathological.
S3 ("Lub BaDub Dub [with S2 split])-Can be pathological or normal (in addition to above, in anyone up to about age 30). Differentiation? Clinical status. If they're healthy, it's probably just physiologic. If signs of CHF are present, it's not physiologic.

OP, technically just about everyone has four heart sound within S1 and S2. S1 made up of M1 & T1 (mitral and tricuspid closure in that order) and S2 made up of A2 & P2. M1 & T1 are milliseconds apart usually, so I think most mortal humans aren't going to readily appreciate that. And as you probably know, A2 & P2 physiologically split with inspiration, especially notable in the pediatric population (in fact, truly single S2 is pathological). S1 can be split more audibly: if it's M1 and T1 splitting it could be RBBB or Ebstein's anomaly (which occasionally can present late). An opening click of either semilunar valve can make for a split S1 as well. At higher heart rates (esp. seen in the pediatric ages) a split S1 can be hard to differentiate from a gallop. Likewise, prominent splitting of S2 (physiologically or not) can be confused with a gallop at higher heart rates.
 

howelljolly

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S4 (Have listened to a kid at our place with a great S4, always sounds like "Jippa Boom" to me [the whole "Kentucky" and "Tennessee" were never that helpfulto me])-always pathological.
S3 ("Lub BaDub Dub [with S2 split])-Can be pathological or normal (in addition to above, in anyone up to about age 30). Differentiation? Clinical status. If they're healthy, it's probably just physiologic. If signs of CHF are present, it's not physiologic.

OP, technically just about everyone has four heart sound within S1 and S2. S1 made up of M1 & T1 (mitral and tricuspid closure in that order) and S2 made up of A2 & P2. M1 & T1 are milliseconds apart usually, so I think most mortal humans aren't going to readily appreciate that. And as you probably know, A2 & P2 physiologically split with inspiration, especially notable in the pediatric population (in fact, truly single S2 is pathological). S1 can be split more audibly: if it's M1 and T1 splitting it could be RBBB or Ebstein's anomaly (which occasionally can present late). An opening click of either semilunar valve can make for a split S1 as well. At higher heart rates (esp. seen in the pediatric ages) a split S1 can be hard to differentiate from a gallop. Likewise, prominent splitting of S2 (physiologically or not) can be confused with a gallop at higher heart rates.
Drat! As I was reading I was thinking that I could show up my favorite SDN pediatric cardiologist.
S1 can split when something causes the RV to contract later, or the LV to contract earlier.... a Right BBB, an ASD; or Left PVCs/VT.

Something that can really help you differentiate an S3 or S4 from other sounds, such as splitting, knocks, clicks, snaps, and boinks... S3 and S4 are low frequency sounds because they are caused by lower velocity events. So, as with low frequency sounds, you will be able to hear them better with the bell of the stethoscope than with the diaphragm. If you hear it better the other way around, its probably not an S3 or S4 - its a boink or something.
 

J-Rad

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Drat! As I was reading I was thinking that I could show up my favorite SDN pediatric cardiologist.
S1 can split when something causes the RV to contract later, or the LV to contract earlier.... a Right BBB, an ASD; or Left PVCs/VT.

Something that can really help you differentiate an S3 or S4 from other sounds, such as splitting, knocks, clicks, snaps, and boinks... S3 and S4 are low frequency sounds because they are caused by lower velocity events. So, as with low frequency sounds, you will be able to hear them better with the bell of the stethoscope than with the diaphragm. If you hear it better the other way around, its probably not an S3 or S4 - its a boink or something.
Dude, seriously I wish I knew this kind of esoteric stuff when I was a medical student. Props to you. :thumbup:
You're right about ASD. Just remember that classically for the boards, ASD causes a fixed and/or widely split S2.
 

howelljolly

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:oops: I love the heart.

I realized that in my sillyness, I overly complicated the 'take-home' clinical pearl to the point of uselessness. But, its very useful since everyone has S2 splitting.

If you can't decide if something (lub-dadub) is S2 splitting, or S3, listen with the bell. If the "dub" gets louder, its an S3.