Gabriel Habib, Sr., M.S., M.D., F.A.C.C., F.C.C.P., F.A.H.A.
Her blood pressure was on the low side. I felt her pulse in the carotid artery in her neck; it was weak, difficult to detect. Unlike the usual thumping carotid artery, her pulse rose only reluctantly to the examining finger. At the base of her neck, on the chest wall, there was an easily felt shudder, a rough vibration with each pulse, like a cat’s purr. When I listened to her heart, . . . I heard a gruff,
harsh sound like the clearing of a throat. . . . It was no great Oslerian feat of diagnosis on my part to suspect that she had severe aortic stenosis.
harsh sound like the clearing of a throat. . . . It was no great Oslerian feat of diagnosis on my part to suspect that she had severe aortic stenosis.
John Stone (1936–2008)
“The Long House Calls” from
In the Country of Hearts: Journeys in the Art of Medicine, 1990
PHYSICAL EXAMINATION
1. Explain normal splitting of the second heart sound (S2).
S2 is normally split into aortic (A2) and pulmonic (P2) components caused by the closing of the two respective valves. The degree of splitting varies with the respiratory cycle or physiologic splitting. With inspiration, the negative intrathoracic pressure leads to increased venous return to the right side of the heart and a decrease to the left side. The increased venous return to the right atrium (RA) causes P2 to occur slightly later and A2 to occur slightly earlier, leading to a widening of the S2 split. With expiration, the negative intrathoracic pressure is eliminated and A2 and P2 occur almost simultaneously. The largest contributor
to the physiologic third heart sound (S3) split is the respiratory variation in the timing of
the pulmonic closure sound.
to the physiologic third heart sound (S3) split is the respiratory variation in the timing of
the pulmonic closure sound.
