Let us together listen carefully at the upper left sternal edge using the carotid vessel as a timing mechanism for systole. Oberve the tip of the cotton swab and also we must watch respiration. Everybody listen together. [Cut-away]
And what do we hear at the upper left sternal edge? Well, to begin with, when the patient inspires we hear normal splitting of the second heart sound. When the patient inspired we heard [sounds], when they expired we heard [sounds]. The splitting was approximately five or six hundredths of a second, so it's normal splitting of the second heart sound in the context of the interval of the splitting, but notice the intensity of one of the components. The pulmonary component was enhanced, definitely louder than normal and that is consistent with some element of pulmonary hypertension in our patient. It's a clue to that possibility.
Oscilloscope
By viewing an oscilloscopic image and simultaneously listening, we can further appreciate these auscultatory events.
Our patient
Normally, the aortic component of the second heart sound is slightly louder than the pulmonic component. In our patient, the pulmonic component is clearly louder, consistent with pulmonary hypertension.