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Normal Second heart sound (Identify the abnormalities of S2)

The most difficult thing in auscultation is to identify the abnormalities of S2.

Physiology of Second heartsound
Two components for 2nd heart sound are- aortic and pulmonary

Aortic component it is the 1st component and loud one heard in all areas.

Pulmonary component - 2nd component and soft, heard only over pulmonary area.

Normal second heart sound
It is a high pitched sound with normal split - 2 components are separately heard during inspiration and as single component during expiration over the pulmonary area.
Distance between the 2 components during inspiration is 0.04 sec, during expiration is 0.02 sec. Human ear can appreciate, when the distance between the 2 components is 0.03 or more. Normal second heart sound is expressed as - normal in intensity and normal split with respiration.

Things to look for in S2:
Intensity
Splitting
A2 heard over aortic area and pulmonary area and the apex.
P2 heard over pulmonary area and 2-4 LICS only and not at the apex.
P2 heard over the apex only in pulmonary artery hypertension and in young.
Best site for S2 in COPD - epigastrium.

NINDS (National Institute of Neurological Disorders and Stroke ) criteria for possible PSP

NINDS criteria for possible PSP

  • Gradually progressive disorder with onset aged 40 years or older.
  • Either vertical supra nuclear palsy or both slowing of vertical saccades and prominent postural instability with falls in the first year of onset.
  • No evidence of other diseases that can explain the clinical features.

Criteria for probable PSP

Vertical supranuclear palsy with prominent postural instability, falls in the first year of onset, and other features of possible PSP, as follows:

  • Symmetric proximal greater than distal akinesia or rigidity.
  • Abnormal neck posture, especially retrocollis.
  • Poor or absent response of parkinsonism to levodopa therapy.
  • Early dysphagia and dysarthria.
  • Early cognitive impairment with at least 2 of the following: apathy, abstract thought impairment, decreased verbal fluency, imitation behavior, or frontal release signs.

Criteria for definite PSP are as follows:

  • History of probable or possible PSP.
  • Histopathologic evidence that is typical of the disease.

Measurements of abdomen


  1. Abdominal girth should be measured at the level of umbilicus
  2. Periodic measurement is done to assess prognosis in ascites, paralytic ileus.
  3. Measure the distance between lower end of xiphisternum to umbilicus and from umbilicus to symphysis pubis. Normally umbilicus is in mid position, it is displaced down in ascites, upper abdominal mass, displaced upwards  in ovarian or pelvic tumors
  4. Spinoumbilical measurement - It is the  distance between umbilicus and anterior superior iliac spines. Normally they are equidistant. Shift of umbilicus to one side will occur in case of tumors that originating from the other side of the abdomen.


What is Gallop rhythm

3 sounds heard during each cardiac cycle produce triple rhythm

Triple rhythm with sinus tachycardia produce Gallop rhythm imitating the sounds of galloping horse.
LV S3 gallop - is an important auscultatory sign of Left ventricular failure.
LVS3 is a sign of systolic dysfunction of ventricle.
Early S3 is heard in RVEMF -this is due to sudden limitation of ventricular filling.
Pericardial knock - An early S3 in constrictive pericarditis as in RV EMF.

S3 gallop is common in:
  1. Dilated cardiomyopathy.
  2. Decompensated aortic valve disease.
  3. Decompensated hypertensive heart disease.
RV S3 is always pathological
It is heard at LLSB.
Inspiratory augmentation is  present.
This is  associated with tricuspid regurgitation.
Atrial gallop S1,S2, S4
Ventricular gallop S1, S2, S3

Quadruple Rhythm
Quadruple rhythm is the presence of 4 heart sounds
(S1, S2, S3 and S4).

Summation Gallop
Summation is the presence of S1,S2 with merged S3 and S4

Causes of Striae over the abdomen

Striae is due to stretching of the abdominal wall that is severe enough to cause rupture of the elastic fibres in the skin and produces pink linear marks with a wrinkled appearance indicates recent change in the size of abdomen.

Striae types:
White striae or striae albicans  is seen in 

  • Obese persons who lost weight suddenly
  • Following pregnancy 
  • Relieving ascites
Purple striae usually represent the rupture of subepidermal connective tissue seen in
  • Recent or past abdominal distension
  • Cushing's syndrome
  • Prolonged steroid therapy
Broad silvery lines (striae gravidarum) are seen after repeated pregnancies.

Types of continuous murmur

 Continuous murmur with cyanosis

  • TOF with PDA
  • Pulmonary atresia with bronchopulmonary anastomoses
  • Pulmonary AVF
Continuous murmur with systolic > diastolic component
  • PDA
  • Peripheral Pulmonaryartery stenosis
  • Broncho pulmonary anastomoses
Continuous Murmurs with Diastolic Accentuation
  • Rupture of sinus of Vakalva (RSOV)
  • Coronary arteriovenous fistula
  • Anomalous origin of left coronary artery from pulmonary artery (ALCAPA)
  • Pulmonary arteriovenous fistula

Inspection for shape and movement of the chest

Looking from above (standing behind the patient), over the shoulders or the upper part of the chest.If standing or sitting is not possible for the patient, inspect the chest in Iying down position, patient lies absolutely straight in the bed in supine position) inspect from the

  • Top.
  • Foot end of the bed.
  • The sides in profile.
  • Head end.
  • Back (try to turn the patient to any one side).
The following are the points to note :
  1. Any deformity, fullness or depression (i.e. shape of the chest), apical impulse etc.
  2. Back (winging of the scapula, drooping of the shoulder, kyphoscoliosis, gibbus. skin changes).
  3. Whether both the sides of the chest arc moving simultaneously and symmetrically.
  4. Classically  winged scapula is found in paralysis of nerve to serratus anterior (C 6 ,7) and sometimes in facio-scapulo-humeral muscular dystrophy.
  5. Assessment of the expansion of the upper lobes is better achieved by inspection
  6. From behind the patient, looking down at the clavicles during moderate respiration.
  7. Equal on both sides - normal
  8. Reduced movement on one side -  pleural disease ,pulmonary disease
  9. Bilaterally reduced movement - in emphysema.