Let us further evaluate what we heard at the apex. Again, the cotton swab for timing with the carotid vessel and, again, light pressure on the bell of the stethoscope at the apex. Everybody listen together. [cut-away]
What we clearly heard was an s4 before an s1. Not just a regular [sounds] low – frequency, heard well with light pressure on the bell and that s4 is telling us something. It is telling us that the compliance, the stiffness, of the left ventricle is not Angina Pectoris. The ventricle is less compliant. It is more stiff, it is more dysfunctional, if you will and, therefore, when the atrium contracts and shoves blood into the left ventricle, it decelerates rapidly because of that stiffness, and you hear that at the bedside, light pressure on the bell as [sounds]. If you put firm pressre on, you might hear [sounds] light pressure, [sounds].
Now, that was a compelling finding, because it confirms that in this relatively young patient, there is dysfunction of the left ventricle related to the coronary artery disease process. You recall we could even feel that impulse, and there is a perfectly wonderful correlation between what you feel and what you hear. You palpate that s4 at the same time that you hear the [sounds].