Normal heart sounds

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Normal heart sounds


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USMLE® Step 1 questions

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Normal heart sounds

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USMLE® Step 1 style questions USMLE

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A 70-year-old man comes to the emergency department for the evaluation of syncope. Physical examination shows weak and slow rising arterial pulse. Cardiac auscultation reveals a harsh midsystolic murmur best heard at the right second intercostal space. Splitting of the second heart sound (S2) is also appreciated. Which of the following maneuvers will most likely eliminate the splitting of the second heart sound?

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Aortic stenosis

S4 heart sound and p. 728

Cardiomyopathy p. 317

S4 heart sound and p. 728


heart sounds of p. 294, 297

Heart sounds p. 294

associations p. 728

auscultation of p. 297

cardiac cycle p. 294

cardiac tamponade p. 481, 717

splitting in p. 296

Mitral regurgitation

S3 heart sound p. 728

Restrictive cardiomyopathy p. 317

S4 heart sound and p. 728

Splitting of heart sounds p. 296


heart sounds of p. 297


If you put a stethoscope over the chest, you’ll usually hear something that sounds like lub dub, lub dub, lub dub, which repeats over and over again, with each cardiac cycle, or heartbeat.

Now, the question is, where does this sound come from? Normally, blood is constantly moving through the four chambers of the heart- coming through the veins into the right atrium, going to the right ventricle, then shooting off via the pulmonary arteries to the lungs and coming back from the pulmonary veins into the left atrium and the left ventricle, to be pumped into the aorta. So, in every step, some valves have to open and others have to close. Valves are just “communicating doors” that, when open, allow blood to pass through, and when closed, hold blood within a chamber. So, in total, our heart has four valves- two atrioventricular valves, which separate the atria from the ventricles and are the mitral valve, on the left side, and the tricuspid valve, on the right side, and two semilunar valves, which separate the ventricles from the large arteries coming off of them and are the pulmonary valve, on the right side, and the aortic valve, on the left side. And when these valves are closing, just like a door slamming shut, they are going to make a sound that is transmitted in the direction of the blood flow.

Now the heart is positioned in such a way that the sound of the closing of each of these valves is projected onto a small area on the chest wall. If you place a stethoscope between the second and third rib, known as the right second intercostal space, just next to the upper border of the sternum, you’ll hear the aortic valve closing. Then, if you place a stethoscope in the left second intercostal space, at the left upper sternal border, you can hear the pulmonary valve closing. Making our way down, between the fourth and fifth rib, next to the left lower border of the sternum, is where you can best hear the tricuspid valve closing. Finally, let’s move down to between the fifth and sixth rib, so in the left fifth intercostal space, near the midclavicular line. The midclavicular line is the imaginary line that gets drawn from the midpoint of the left clavicle, or the collarbone, straight down, so you can find where it intersects with the fifth intercostal space. That’s where the mitral valve closing is best heard.


Heart sounds are the noises generated by the beating heart and the resultant flow of blood through it. Specifically, the sounds reflect the turbulence created when the heart valves snap shut. In cardiac auscultation, an examiner may use a stethoscope to listen for these unique and distinct sounds that provide important auditory data regarding the condition of the heart. There are two normal heart sounds: S1 and S2. S1 is caused by the closing of atrioventricular valves at the beginning of systole; whereas S2 is caused by the closing of aortic and pulmonary valves closing at the beginning of diastole.


  1. "Medical Physiology" Elsevier (2016)
  2. "Physiology" Elsevier (2017)
  3. "Human Anatomy & Physiology" Pearson (2018)
  4. "Principles of Anatomy and Physiology" Wiley (2014)
  5. "Auscultation of the heart" Clinical Anatomy (2016)

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