There is much to learn by listening at the upper left sternal edge in this patient. Let’s listen together, pay attention to the acoustic events around the time of the first heart sound as well as to the character and quality of the second sound. Everyone listen together. [Cut-away]
At about the time of the first heart sound, we hear a very loud clicking sound that comes right after the first heart sound. that is a classic ejection sound. in this case, it confirms our previous suspicions. that is found typically in a patient with a dilated pulmonary artery with pulmonary hypertension. loud, clicking, right after the first heart sound.And then the second heart sound. it was really loud. loud with only one component that we appreciated. It was loud because the pressure in the lungs, in this case, yes, pulmonary hypertension, is so great, that it slaps that valve back making it loud, with the big dilated pulmonary artery enhancing that and, in addition, because of that high resistance, high pressure in the pulmonary circulation, that valve comes back more quickly than a normal valve would, and it fuses with the aortic closure and all you hear is one component, very loud. Again, typical hallmarks of pulmonary hypertension: Loud ejection sound, prominent loud pulmonary second sound.
Osciloscopic image
By viewing an oscilloscopic image and simultaneously listening, we can further appreciate these auscultatory events.
Ejection sounds
Ejection sounds are early systolic, high-frequency events that occur at the onset of systolic flow into the great vessels and are best heard at the aortic and pulmonary areas. They result from doming of a stenotic but mobile semilunar valve or from the initial systolic distention of a diastolic great vessel.
Aortic and pulmonary ejection sounds
In general, aortic ejection sounds are best heard at the upper right sternal edge while pulmonary ejection sounds are best heard at the upper left sternal edge. Pulmonary ejection sounds may diminish with inspiration in some cases.
Differentiate ejection sounds
One must differentiate ejection sounds from other sounds that occur near the time of the first heart sound. Split first heart sounds are best heard at the lower left sternal edge, are more closely opposed, and are of similar high frequency. Fourth heart sounds are heard at the apex and lower left sternal edge, precede the first heart sound and are low in frequency. Systolic clicks are best heard at the apex and lower left sternal edge, occur later during systole and are of similar high frequency.
Loud pulmonary second sounds suggest pulmonary hypertension with a dilated pulmonary artery. The pulmonary sound often fuses with and obscures the aortic second, so the second sound is single.