a u s c u l t a t i o n    t u t o r
S4 Gallop

S4 is a low intensity, low pitch sound that is best heart with the bell of the stethoscope pressed lightly on the apex area of
the heart.  The sound of S4 occurs only in presystole and can easily be confused with a split S1.  S4 is created during
atrial contraction by the vibration of the valves, papillae, and ventricular wall. Therefore, only patients with atrial
contraction can have an S4.  An S4 is always suspect and can indicate Hypertension, AMI, or coronary artery disease.   
One trick you can use to identify S4 from other tones is the rhythm should mimic the rhythm of Ken-tuc-ky.  
t h e     h e a r t
Normal Cardiac Cycle
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