Differentiation Of The S4 From The S3

1. How does the quality or pitch of the S4 differ from that of the S3?

ANS: They do not differ. They may both be described as a low-pitched thud or boom.

Note: Because of their very low frequency of vibrations, they often feel more like a physical "pop" or movement felt by the eardrum than like a sound.

2. How can you tell without a phonocardiogram or pulse tracing whether an S3 or an S4 is present when a tachycardia causes confusion?

ANS: a. If you can slow the rate with carotid sinus pressure, you may be able to discern that the extra sound keeps a constant relationship to the Sj, in which case it is an S4. If it maintains a constant relationship to the S2 and moves away from the Sj, it is an S3. b. Wait for a pause following a premature beat. An S4 precedes the Sj that ends the pause. 3. If both an S3 and an S4 are present, what is the rhythm called? ANS: Quadruple rhythm, train-wheel rhythm, or double gallop.

Apex impulse tracing (apex cardiogram) from a 55-year-old man with two previous infarctions. Surprisingly, despite his double gallop, he was almost asymptomatic without treatment.

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