Occurs immediately after S2 in diastole
"Ken-tuck-y"

Also called ventricular gallop

Common in children, young adults, pregnancy

best heard at APEX

LEFT LATERAL DECUBITUS

BELL

decreased ventricular compliance

Occurs immediately before S1 in diastole

"Tenn-e-see"

Also called atrial gallop

common in trained athletes

best heard at APEX
LEFT LATERAL DECUBITUS
BELL

decreased ventricular compliance

hypertension, CAD, aortic stenosis

Mid-systolic

best heard at aortic region (R 2nd ICS)
LEANING FORWARD
BELL

may cause pathological split in S2 (P2, A2)

may also heard S4 (decreased compliance)

turbulent flow through A2

increased ventricular afterload

DIAPHRAGM

associated with aortic or pulmonic disease

Diastolic

best heard at 2, 3, 4 L ICS

LEANING FORWARD
BELL/DIAPHRAGM

aortic valve fails to close completely and blood regurgitates from aorta back into LV

LV volume overload

Diastolic

OPENING SNAP

best heard at APEX
LEFT LATERAL DECUBITUS
BELL

mitral valve thickens and cannot open sufficiently in diastole

Pan Systolic

best heard at APEX

DIAPHRAGM OR BELL
mitral valve fails to close in systole, blood regurgitates from LV to LA

LV volume overload and dilatation

Late Systole

CLICK

best heard at LEFT STERNAL BORDER
VALSALVA/squat

DIAPHRAGM

ballooing of mitral valve into LA

Pan Systolic

best heard at 3, 4, 5 L ICS

DIAPHRAGM

often associated with thrill

S2 may be obscured

congenital hole in interventricular septum causes blood to flow from LV to RV

Mid Systolic

EJECTION SOUND

best heard at 2, 3, 4 L ICS
DIAPHRAGM

S2 gets split and P2 gets diminished

increased RV afterload

may mimic atrial septal defect

Pan Systolic

best heard at LEFT STERNAL BORDER

DIAPHRAGM

associated with elevated JVP

tricuspid valve fails to close in systole, blood regurgitates from RV to RA

pulmonary hypertension