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<span id="v98250935" class="anchor" ></span><div class="para" > <p >Sound is that of S1–S2–S3.</p></div>

Third Heart Sound

<span id="v98250937" class="anchor" ></span><div class="para" > <p >Sound is that of S4–S1–S2.</p></div>

Fourth Heart Sound

<span id="v98256569" class="anchor" ></span><div class="para" > <p >Pertussis in a child, with whooping. Pertussis causes paroxysmal coughing; only about half of patients develop classic whooping. </p></div><span id="v98256570" class="anchor" ></span><div class="para" > <p >In this recording, the child coughs without inspiration until she has emptied her lungs of air, then breathes in with a whoop. The whoop is caused by vocal cord adduction during inspiration.</p></div>

Whooping Cough (Classic Whoop)

<span id="v98263478" class="anchor" ></span><div class="para" > <p >Prolonged expiratory phase with wheezing.</p></div>

Wheezing

<span id="v98251728" class="anchor" ></span><div class="para" > <p >This holosystolic mitral regurgitation murmur maintains the same intensity throughout systole and extends from S1 to S2.</p></div>

Mitral Regurgitation Murmur

<span id="v98261427" class="anchor" ></span><div class="para" > <p >The murmur of a ventricular septal defect is similar to that of mitral regurgitation but is louder at the left lower sternal border than at the apex.</p></div>

Ventricular Septal Defect Murmur

<span id="v98263464" class="anchor" ></span><div class="para" > <p >Inspiratory stridor in croup.</p></div>

Stridor

<span id="v98251748" class="anchor" ></span><div class="para" > <p >Sound is that of S1 followed by a late-systolic click and S2.</p></div>

Mitral Valve Prolapse (With Late-Systolic Click)

<span id="v98250923" class="anchor" ></span><div class="para" > <p >S1 splitting is normal in many patients and is thought to be caused by mitral valve closure followed by an aortic ejection sound.</p></div>

Split First Heart Sound

<span id="v98251709" class="anchor" ></span><div class="para" > <p >S1 is soft; S2 is obscured by a soft regurgitant murmur and a louder, low-pitched, late-diastolic murmur. The diastolic murmur mimics mitral stenosis and is attributed to mitral valve leaflet vibration or mild obstruction caused by rapid regurgitant flow.</p></div>

Austin Flint Murmur

<span id="v98250931" class="anchor" ></span><div class="para" > <p >Sound is that of wide splitting, ie, S1–A2–P2 at rest (“out”) with an even wider A2–P2 interval with inspiration (“in”). Right bundle branch block delays pulmonic valve closure so that S2 splitting becomes audible at rest. Inspiration decreases intrathoracic pressure, drawing more blood into the right ventricle and postponing pulmonic valve closure even more, so that the normal split becomes wider.</p></div>

Split Second Heart Sound in Right Bundle Branch Block

<span id="v98251726" class="anchor" ></span><div class="para" > <p >An S3 that accompanies mitral regurgitation suggests a dilated left ventricle and progression to heart failure.</p></div>

Mitral Regurgitation Murmur With 3rd Heart Sound

<span id="v98256566" class="anchor" ></span><div class="para" > <p >Pertussis in a child, without whooping. Pertussis causes paroxysmal coughing; only about half of patients develop classic whooping. </p></div><span id="v98256567" class="anchor" ></span><div class="para" > <p >In this recording, the child coughs without inspiration until she has emptied her lungs of air, then breathes in. There is a slight pause between the paroxysm and inspiration. In severe cases of pertussis, this pause may be long enough to qualify as apnea; children may become cyanotic, and the apnea may be life threatening.</p></div>

Whooping Cough (Paroxysm)

<span id="v98250927" class="anchor" ></span><div class="para" > <p >Sound is that of S1–S2 at rest (“out”) and S1–A2–P2 with inspiration (“in”). S2 splits with inspiration because intrathoracic pressure decreases, drawing more blood into the right ventricle and postponing pulmonic valve closure.</p></div>

Split Second Heart Sound

<span id="v98251707" class="anchor" ></span><div class="para" > <p >Sound is that of a normal S1 followed by a sharp or slapping S2 and a blowing, high-pitched, decrescendo diastolic murmur.</p></div>

Aortic Regurgitation

<span id="v98250929" class="anchor" ></span><div class="para" > <p >Sound is that of paradoxical splitting, ie, S1–P2–A2 at rest (“out”) and S1–S2 with inspiration (“in”). Left bundle branch block delays aortic valve closure, so that split is audible at rest; inspiration decreases intrathoracic pressure, drawing more blood into the right ventricle and postponing pulmonic valve closure until it is superimposed on A2 and splitting becomes inaudible.</p></div>

Split Second Heart Sound in Left Bundle Branch Block

<span id="v98256572" class="anchor" ></span><div class="para" > <p >Pertussis in an adult, with whooping. </p></div><span id="v98256573" class="anchor" ></span><div class="para" > <p >In this recording, the patient coughs without inspiration until he has emptied his lungs of air, then breathes in with a whoop. The whoop is caused by vocal cord adduction during inspiration.</p></div>

Whooping Cough (Adult Patient)

<span id="v98251594" class="anchor" ></span><div class="para" > <p >A diastolic knock is a loud third heart sound (S3) caused by constrictive pericarditis.</p></div>

Diastolic Knock

<span id="v98251737" class="anchor" ></span><div class="para" > <p >Prominent mitral stenosis murmur with presystolic accentuation, described as resembling a growl and bark. Mitral stenosis murmurs are typically rumbling and low-pitched and crescendo through diastole.</p></div>

Mitral Stenosis Murmur

<span id="v98261377" class="anchor" ></span><div class="para" > <p >Sound is that of fixed second heart sound (S2) splitting, ie, S1–A2–P2 at rest (“out”) and with inspiration (“in”). Splitting is fixed because the volume of flow through the right ventricle is increased throughout the respiratory cycle, eliminating the normal delay in closure of the pulmonic valve associated with inspiration.</p></div>

Split Second Heart Sound With Atrial Septal Defect

<span id="v98250953" class="anchor" ></span><div class="para" > <p >The murmur becomes audible only with inspiration (“in”) because inspiration decreases intrathoracic pressure, drawing more blood into the right ventricle and increasing right ventricular outflow.</p></div>

Pulmonic Stenosis Murmur

<span id="v98251741" class="anchor" ></span><div class="para" > <p >Sample illustrates typical features of mitral stenosis: The murmur is rumbling or low-pitched and begins early in diastole with crescendo to S2.</p></div>

Mitral Stenosis

<span id="v98249902" class="anchor" ></span><div class="para" > <p >A leathery sound that fluctuates with the respiratory cycle.</p></div>

Friction Rub

<span id="v98261391" class="anchor" ></span><div class="para" > <p >The murmur of patent ductus arteriosus is classically continuous and machine-like in character. It may be accompanied by an S3 and a mitral diastolic flow murmur when left-sided volumes are large.</p></div>

Patent Ductus Arteriosus Murmurs

<span id="v98250925" class="anchor" ></span><div class="para" > <p >High pulmonary artery pressures may dilate the pulmonary artery, stretching the valve ring and causing a click when taut cusps open rapidly.</p></div>

Pulmonary Ejection Click

<span id="v98251739" class="anchor" ></span><div class="para" > <p >Intensity of the murmur of mitral stenosis varies with changes in length of the cardiac cycles. In this sample of atrial fibrillation, the murmur increases in intensity with longer cycles and decreases in intensity with shorter cycles, because the volume of blood flowing across the mitral valve changes. Overall intensity is decreased because atrial contraction is lost.</p></div>

Mitral Stenosis in Atrial Fibrillation

<span id="v98249313" class="anchor" ></span><div class="para" > <p >Typical breath sounds heard over the trachea and areas of lung consolidation.</p></div>

Normal Bronchial Breath Sounds

<span id="v98258994" class="anchor" ></span><div class="para" > <p >Friction rubs are frequently described as creaking or scratching but may sound like more common murmurs. This rub is most often triphasic, with a soft systolic component and 2 louder components in quick succession during early diastole.</p></div>

Pericardial Friction Rub

<span id="v98250951" class="anchor" ></span><div class="para" > <p >The 6th beat is a ventricular premature beat (VPB). The 7th beat illustrates post-VPB potentiation of the murmur due to increased left ventricular filling during the post-VPB compensatory pause.</p></div>

Aortic Stenosis Murmur

<span id="v98250943" class="anchor" ></span><div class="para" > <p >Sound is that of S1–A2–OS with a relatively long A2–OS interval. The opening snap (OS), most commonly caused by mitral stenosis, is thought to be caused by abrupt downward bulging (snapping) of the anterior leaflet as left ventricular pressure drops below left atrial pressure during diastole. A2–OS can be distinguished from a split S2 by dynamic maneuvers (OS intensity increases with inspiration, A2–OS interval widens with standing), a triple S2 (ie, A2–P2–OS), and a louder volume at the apex.</p></div>

Mitral Valve Opening Snap

<span id="v98249322" class="anchor" ></span><div class="para" > <p >Areas of consolidation cause a patient's vocalized "E" to sound like "A."</p></div>

E to A Change

Crackles

<span id="v98249311" class="anchor" ></span><div class="para" > <p >Typical breath sounds heard over most lung fields.</p></div>

Normal Breath Sounds

<span id="v98251750" class="anchor" ></span><div class="para" > <p >The systolic murmur in this sample has a honking or whooping character, which is attributed to valvular leaflet vibration.</p></div>

Mitral Valve Prolapse

<span id="v98250939" class="anchor" ></span><div class="para" > <p >Sound is that of S4–S1–S2–S3 in rapid succession.</p></div>

Summation Gallop

<ul ><span id="v91646281" class="anchor" ></span><div class="para" > <p >Sound is that of a crescendo-decrescendo ejection murmur. The 6th beat in the sample is a ventricular premature beat (VPB). The 7th beat illustrates post-VPB potentiation of the murmur due to increased left ventricular filling during the post-VPB compensatory pause, which causes increased turbulent flow past the stenotic valve during the next ventricular contraction.</p></div></ul>

Aortic Stenosis Murmur (Crescendo-Decrescendo Ejection Murmur)

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