What we heard at the apex was so very prominent, that the high and low frequency sounds could be heard well with either head of the stethoscope. In this case, we'll use the diaphragm to listen and we will hear a fourth sound in presystole a prominent systolic murmur and a third sound in early diastole. Let's all listen together, timing these events with the carotid vessel. Everyone listen. [Cut-away]
Let us address the acoustic events one at a time. There was a prominent systolic murmur. It could be described as holosystolic, high in frequency. The unusual thing is that it was decrescendo in configuration. Could that be a clue to some special kind of pathophysiology that is occurring?
Now, in addition to that systolic murmur were the fourth sound, just prior to systole, and a third sound in early diastole. Both of these are filling sounds and both could logically reflect a reduction of compliance of the left ventricle, so that as blood is pumped into the ventricle in presystole by the atrial kick, it decelerates rapidly, setting up vibrations. Similarly, in early diastole, during rapid filling, the same type of pathophysiology could occur. Alternatively, that third sound is occasionally due to flow. We heard three events at the apex of significance, we heard the systolic murmur of an unusual decrescendo configuration and two filling sounds. It is telling us much about the pathophysiology in this case.
Oscilloscope
By viewing an oscilloscopic imaging and simultaneously listening, we can further appreciate this auscultatory events.