S1 Apical mid systolic click of mitral valve prolapse

At upper left sternal border, a click may be heard from pulmonic

valve stenosis

Tricuspid valve abnormalities (e.g., Ebstein anomaly) may cause

billowing of the leaflets and
result in multiple clicks

in VSD, PDA, mitral or tricuspid regurgitation and severe right

ventricular
outflow tract obstruction.

if the first heart sound is not heard at the lower left sternal
border, there is most likely a congenital heart defect, and there
will be other clinical and
auscultatory findings.

Wider splitting of S2 on inspiration is related not only to increased

venous return but also to
pressures in the aorta and pulmonary artery (PA) (it is significantly
higher in the Ao than in
the PA, so Ao valve closes first)

Loud single S2: heard with PA hypertension (increased pressure

closing the PV causes early closure
of the anterior semilunar valve resulting in a loud single S2)

in truncus arteriosus, there is only 1 valve so there is a single

S2

S3 Hear early in diastole; creates a gallop rhythm with S1 + S2; very

low frequency and is best heard
with bell of the stethoscope at cardiac apex; asking patient to lie on
left side may increase intensity of
S3
On occasion may be heard normally in children with no pathology:
in older people, it represents the
presence of CHF and is caused by sudden deceleration of blood flow
into LV from the LA

S4 Occurs in late diastole, just prior to S1 (presystolic) and is

produced by a decrease in compliance
(increased stiffness) of the LV
Low frequency (lower than S3) and best heard with bell of the
stethoscope pressed lightly against the
skin; never hear with atrial fibrillation because the contraction of the
atria is ineffective
Summation gallop rhythm (S3 + S4) may be found with improving
CHF, myocarditis, or a
Cardiomyopathy

Still’s murmur Murmur is loudest while supine (greater blood

flow) and decreases sitting or standing—opposite
to the finding of HOCM. Also increases with fever or exercise
(hyperdynamic states).
Venous hum Only diastolic murmur that is not pathological;
represents blood flow returning from the head and
flowing from SVC into the RA, is a continuous
murmur

Levonorgestrel is a hormonal medication which is used in

a number of birth control methods. As an emergency birth
control, sold under the brand name Plan B among others,
it is useful within 120 hours of
The ESR is a non-specific marker of inflammation and depends on both the size, shape and
number of red
blood cells and the concentration of plasma proteins such as fibrinogen, alpha2-globulins and
gamma
globulins
Causes of a high ESR
temporal arteritis
myeloma
other connective tissue disorders e.g. systemic lupus erythematosus
other malignancies
infection
other factors which raise ESR: increasing age, female sex, anaemia
Causes of a low ESR
polycythaemia
afibrinogenaemia/hypofibrinogenaemia

Plasma potassium levels are regulated by a number of factors including aldosterone, acid-base
balance and
insulin levels. Metabolic acidosis is associated with hyperkalaemia as hydrogen and potassium
ions compete
with each other for exchange with sodium ions across cell membranes and in the distal tubule.
ECG changes
seen in hyperkalaemia include tall-tented T waves, small P waves, widened QRS leading to a
sinusoidal
pattern and asystole
Causes of hyperkalaemia:
acute kidney injury
drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers,
spironolactone,
ciclosporin, heparin**
metabolic acidosis
Addison's
rhabdomyolysis
massive blood transfusion.