Case 6 Cardiology

Transient Heart Sound

Work it one clue at a time. The diagnosis stays hidden until you reveal it.

Clue 1

You hear an extra transient heart sound near S1. Now what?

Clue 2

Not sure you hear three sounds? Here is normal S1 and S2 to serve as a control.

Clue 3

There are two sounds. Listen to this clip and then re-listen to the above clip. When you do, you will hear three sounds. Two near where S1 should be, followed by S2.

So what’s the differential for extra transient sounds near S1?

DDx: Split S1, S4 gallop, Ejection click

Split S1 and S4 gallop can be challenging to distinguish because both are best heard over the APEX area. However, the split S1 sounds are closer together than the S1-S4 interval. And the S4 is best heard with the BELL of the scope. Listen to this split S1:

Now take a listen to this S4 gallop:

Clue 4

Notice that the S1-S4 interval is longer compared to the split S1 above. And while we are listening over the same area of the chest (apex), the bell is being used rather than the diaphragm.

What about the ejection click? It is perhaps the easiest to distinguish because it is often heard over the BASE of the heart – very atypical for the split S1 and S4. The click is best appreciated with the diaphragm of the scope as it is higher pitched.

So back to our patient. What is the extra sound?

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