ERIC!! You are KILLING it on the 'Tube man. Congratulations of edutaining the world!

This is a GREAT video. I never knew I wanted S1, split S2 and S3 in the same clip until I listened to it here. Thank you Doctor Strong.

If you initially struggle with the more obscure findings such as MVP click, opening snap, abnormalities of S2 splitting, don't worry - these relatively minor details will not hold you back from becoming an outstanding doctor. But if you work hard at the improving your cardiac exam over years, I think you'll find this skill to be helpful in diagnosis, as well as personally rewarding.

I have never commented on a video on youtube i signed in just to thank you,,, you just saved my life :) i really can't thank you enogh !

Thanks so so much Dr Eric for this informative video and for your time!

The general point you are making is very valid - we don't fully understand the physics of what generates S1 and S2 (or S3, S4 either). Whether S1 and S2 are caused by sudden approximation of the cusps, vibration of the cusps, or vibrations within the blood is debated and not known for certain. However, the distinction is prob. of minimal clinical relevance, and in the interest of clarifty for beginners, I usually simplify it and describe the sounds as just being caused by valve closure....

Dr. Strong, That makes much sense for you to use really clear examples, especially for us beginners! Once we understand and can differentiate the classic sounds, then we have a basis to which we can compare the variations. Thank you!

My preferred video on this particular topic. Thank you, Dr. Strong.

Brazil's medical students says thank you for your lectures! Saving our souls in exam seasons!

extremely comprehensive. thank you from a doctor in australia. Keep up the outstanding work.

Great job, very helpful explaining the sounds and conditions associated.

Im a postmaster nurse practitioner student! This was an excellent presentation! I have stored in my library for frequent use! Thanks Dr. Strong :)

The internet is amazing. Wish we had it in the 80's

I agree. Thanks Dr. Strong. I'm also an R.N. (applying for FNP school). This video is one of the most helpful I've seen (and I've seen a lot).

LBBB causes a soft S1 through two closely related mechanisms. First, it leads to a longer delay from atrial contraction to LV contraction, mimicking the same effect as a long PR interval. Second, the force of LV contraction in early systole is diminished in LBBB as the ventricle is depolarized in a relatively uncoordinated and inefficient fashion. The consequence of both these mechanisms is a less vigorous closure of the mitral valve, and thus softer S1.

udaypmishra: The conventional wisdom is that severe MR decreases LV afterload by providing a second route by which blood can exit the LV. This shortens the time it takes for LV pressure to drop below aortic pressure, which then causes A2 to occur earlier. There are several reasons why this explanation may not hold up, and in reality, we aren't really sure why this happens. Bottom line however, a wide S2 from MR is an obscure finding whose specific clinical relevance is probably minimal.

Thank you for your prompt answer! Your lecture is very useful!

Thank you so much for sharing this, it's very good for reviewing this topic!

Excellent video. I auscultated my heart after experiencing heart palpitations (which I attributed to stress) and identified an S2 split with inspiration and expiration. I had a friend of mine (ED physician) take a listen and he agreed. Made an appointment with my cardiologist (I was diagnosed with postural orthostatic tachycardia syndrome a while back...it's not a big deal) and told him I wanted an echo to rule out an ASD. Well, the echo confirmed my suspicion!

just found this channel, thank u very much. These videos have been soo useful for my cardiology exam!!

Awesome work doc!! highly informative,useful and best compiled. Thanks doc for making students like us learn

Hello Dr. Strong. Thank you for a wonderful presentation. I think this video is a must for all medical doctors.

Well done! More power to you Doc!

WOW. Dr. Strong thank you for your lectures.

Thank you Mr. Strong. This helped me a lot.

Dr. Strong, I'm in nursing school right now and your video about heart sounds has been the clearest presentation of the material that I have seen so far. Thank you for that. I'm wondering if you have a similar video about auscultation of adventitious lung sounds.

Im a student of medicine from india just beginning to get an idea of abnormal heart sounds..and I should say the content you have presented is the best iv seen so far compared to any book or video iv seen yet! Thanks a lot doctor :)

Thank you so much Dr. Eric. You save my life

16:29 haha sounds like Iron Maiden to me. The best educational KZfaq channel, no question, thank you for these great videos.

Thank you so much! Excellent lecture!

great help as always, thank you .

Super :) Very interesting video. It helps a lot to well hear the different heart sounds . Thank to you .

Besides this details, thanks for the nice, well done presentation.

Thank you ! I like your lectures! Ella

Cool. Great job, Doctor!

sooo helpful... thank u doctor. i was referencing harrisons while watching this..and ur video is more comprehensive and easy to understand. thank u for the the audio aid. i will recommend it to everyone.

Med Student at University of Witwatersraand SA. Really useful! Thanks for the lecture!

Very good video, great content !

very nicely made video, very informative.

thx for your lectures, thy r very good and helpful!!!!

yonatan703, I'm not sure I understand what you mean by "cap"...

Oh Doctor you nailed it!!! Awesome 💓

Thank you very much for a very informative lecture.

thank you for the excellent lecture

helpd a LOT IN CLINICAL POSTING.

It WAS very helpful, thank you for sharing your video, highly appreciated.

Preeti, the best way to differentiate them is by their duration. S3 and S4 are brief - simulated by tapping your finger on a wooden surface. Murmurs last longer - simulated by modestly forceful exhalation through pursed lips. If you compare the audio examples from this lecture to those in my accompanying lecture on heart murmurs, I think it will be more clear. Thanks for watching!

Sure, no problem!

very helpful lecture, thank you very much.

This is amazing.I have been hearing all sorts of sounds and calling them different names.Sometimes I call it "added sounds" Please Dr Eric,how do one download the videos? Some of us that are living in low income countries where internet connection is a privilege may want to go through these videos severally.May I plead that you that you give us access to download it?

Excellent presentation

cspvlncspvln, I'm glad you found it helpful. I don't have a lung sounds video yet, but I'm planning to post one in the next couple of months. (I'm still waiting for really clear examples of some abnormal sounds in my patients...)

Was very helpful, thank you for sharing you video

Thank you Dr Strong. I never master then, not sure i am now either. But with you said in modern, it might be less important. You are a great instructor. I wish to have internet then too. I cant thank you enough.

Thank you sooo much! This made me burst into applaud as the heart sound audios are phenomenal!

Thank you for for the excellent lecture. Only thing I want to point out is in cases of isolated Pulmonary hypertension, due to decrease in hangout interval, there will be shortened inspiratory spilt of s2. The video mentioned it in wide split. That can happen in case when there is associated RV failure with PAH, in which case it can have a fixed split s2.

Great vid.thx man

excellent video.

Dear Eric! This video saved me from congenital cardiac anomalies! Thank you so much (especially for the pathophysiology of S2 split part - that explanation was crucial for me)!

helped me a lot. thanks Dr. :)

Unfortunately, I can't really offer more specific or directed advice since I don't have access to this other info. I would probably start by making sure your doctor checked a standard EKG, and asking about whether an "ambulatory EKG" such as an event monitor was appropriate.

which has 2 subtypes - atrial and ventricular. Although "abnormal", it is not necessarily dangerous, though would require explanation if you were young and otherwise healthy. The only way to diagnose this is to get an EKG at the exact moment you are having the problem. Depending on where you live, an event monitor or something called a Ziopatch could help diagnose this, but depending on the other components of your medical history and exam, your doctor may not feel it's necessary.

soooo helpful!!! thank you!!!!

I'm sorry, but I'm not familiar with the abbreviation, CVS. Is that the cardiovascular system? If so, I won't be able to make a video outlining the remainder of the CV exam (venous waveforms, arterial pulsations, precordial movements, etc...) for some time as a high quality video would require actors for demonstration, and better AV equipment than I have available. I suggest taking a look at my colleagues' website for "The Stanford 25" for more info on this. (Choose the 2nd google result.)

Having said that, the sensation you are describing sounds like what doctors technically refer to as "palpatations" - a subjective sensation that your heart is beating either irregularly or more quickly than normal (yours is more the irregular type). The cause of palpatations vary depending upon your age and medical history. For example, if you told me that you are 60 years old and had a heart attack last year,

WOW... excellent video, the way yuo present the theory and de audio clips is very helpful. I've just finisihed med school, and I'm currently in a 1 year program of basic and clinical research, ( my area is neurodegenearative diseases and biomarkers in the skin), in the next months I'm goint to present the "ENARM test",in order to qualify for a medical residency, and I'm happy to get back to the basics I spend to much time in the lab, and I've got a little bit rusty in some clinical skills.

thank you .it is very helpful

Dear Eric, thank you very much, for all the work you've done, so far, in spreading the knowledge in cardiology in the best possible I was able to find n the internet. As a geophysicist, who spent more than 30 years in understanding the complex interference of the reflected seismic waves, bounced from thin layers, I am witnessing, that today's reflection seismic imaging, suffers from paradigms, inherited form old acquisition technology and "way of thinking", which still exist in the 21st century . Stethoscope, as a dominant diagnostic tool, today, should and must be abandoned, due to plenty of reasons. The main one is the subjective audio perception capabilities of an practitioner, that should lead to "quantitative" estimation of the audio signal. By analogy of 12 lead ECG acquisition equipment, in the same time, proper audio equipment should be designed, where each of the channels should be properly and precisely corrected for the frequency and phase spectrum in order to eliminate plethora of parameters in regard to specific patient (i.e. obesity, subtle difference in acoustic parameters of the patient's tissue, etc). Further more, in order to perform separation of superimposed signals should be analysed by frequency decomposition *in order to detected close events, both in qualitative and quantitative manner. In other words, new, audio acquisition equipment should be designed in audio consistent way, prior to mentioned objective manner of sound event separation, as well as it's quantitative analysis. Once again, thank you for fantastic work you've done. Kind Regards, Aleksandar Dzunic

Congratulations. Thank you.

Thank you for all your effort. Priceless education to the world.... Please do continue to hold the forte and teaching :)

Great effort

Thank you so much! - making medical school just a little more manageable!!

I too am in nursing school and this lecture was the most clear explanation I have heard on heart sounds, and gave me some great tips when I perform my assessments(TAKE MY TIME). I will definitely recommend this video to my classmates. Thanks Doctor Strong!!!

Very interesting and useful

Thank u sir for this wonderful lecture:))))

THIS IS SO GOOD 😭

excellent!

Khakalukia, it takes a long time and years of intentional practice to get really good at cardiac auscultation. But you don't necessarily need to strive to become an expert. Most physicians will never get there. What you should focus on first is being sure to not miss the critical findings: S3 in a patient with dyspnea of unknown etiology, new AR murmur in a patient with bacteremia, etc...

What an explanation 👍

...If one was going to make a career out of cardac physiology research, then definitely, one would want to be more specific than this. (For example, it's prob. true that the tricuspid valve contributes very little to the audible S1 in normal individuals - though can in patients with significant right sided pathology). The most clear review of these issues that I'm aware of is in Bedside Cardiology by Jules Constant - an all-around favorite book of mine.

Thank you sir its really great

Excellent video! Thanks! Do you have a video describing "rubs"?

Thank you soooo much

Thank you Doctor , This is my second time listening to this lecture. Actually i nearly skip this topic, I did not get it at all, can you imagine at that time, professor would lecture you about heart sound ,writing in blackboard and no sound demonstrable like you have now. I was evasive about cardiology, despite there were many abnormal heart sound around at that time. Many rheumatic hear disease in pediatrics , MR , even infective endocarditis, Now as you spent about of time discuss about evidence that weather this is helpful in modern medicine about this skill. one would go directly to the EKG and echocardiogram.

I like this presentation

Thank you!

Your are best sir... No match for u🙏

Thank you doctor

nice work

Literature evidence on this phenomenon exists but is scant (see PubMed#5945151). The wide split with pulm HTN is seen only in cases where the RV is starting to fail from pressure overload. As a result of RV failure, the rise in RV pressure during systole is delayed, and RV relaxation is delayed, which then delays the closing of the pulmonic valve. The fact that the PA pressure is high more affects the speed with which the valve closes (i.e. loud P2), and less affects the timing of closure.

أنت أفضل وأحد شكرا لك

mdafzalhussain, I'd love to be able to dub my lectures into a number of other languages, but unfortunately, I only know English and a bit of New Guinea pidgin (not kidding!). I would place a public request for help to translate these, but it would seem to be quite challenging to synch the audio with the slides without speaking the language. Maybe after Khan Academy realizes they should hire me I'll have the technical support needed...

Thank you sir 😭

@drericstrong: Hello, I don't understand why increasing RV afterload (like in the pulmonary hypertension) delays P2 sound! Could you explain me please? Because I thought that if the pressure was rising faster after the valve, it would close it faster...

it is confusing to distinguish between wide splitting S2 from S3 and S4. could you throw more light on that?

Does he have patreon whr I can support his work?

Holding my damn heart watching this

Thank you for this lecture and many others. Very educational. Just wondered if you have any lectures on chest sounds? Many thanks

At time of S1 the mitral and tricuspid valves are closing, but normally that's not that what we hear at auscultation! The healthy valves doesn't make enough sound to be heard be human ear. S2 is rather the sound of vibrations on the blood-column caused by the heart muscles. What do you think?

Thank you