S4 Gallop

The S4 occurs in late diastole, just before S1, coinciding with atrial contraction (the a wave in the jugular venous waveform). It is generally present when the heart is so stiff that it is reliant upon a significant amount of filling via atrial contraction. Like the split S1, the S4 gallop is best heard over the apex of the heart. However, unlike the split S1, it is best heard with the bell of the stethoscope because of its low pitch.

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Patient 6

This is a middle aged man with poorly controlled diabetes mellitus who was admitted to hospital for a soft tissue infection. Cardiac exam revealed an S4 gallop of unknown clinical significance. Echocardiography was completely normal.