1. S1
   1. Influenced by
      1. Position of MV
      2. Structure of MV
      3. Rate of Rise of LV systolic pressure
      4. Conduction between heart and stethoscope
   2. Loud
      1. Increased cardiac output
      2. MS
         1. accentuated and delayed S2
   3. Soft
      1. Poor conduction
      2. Slow rise of LV systolic pressure
      3. Prolong PR interval
      4. Imperfect closure: MR
      5. MS with calcification of Anterior leaflet of MV
2. S2
   1. Normal Splitting
      1. A2-P2
      2. Incraesed in Inspiration
      3. Normally A2 louder than P2
      4. P2 > A2
         1. Pulmonary hypertension
   2. Narrow splitting
      1. increased pulmonary resistence
         1. Pulmomary hypertension
   3. Persistent splitting
      1. RBBB
      2. Left VPC
      3. Left pacemaker
      4. prolong Right ventricle contraction
         1. Pulmonary embolism
         2. Pulmonary stenosis
      5. Increased right side volume
         1. Right side heart failure
         2. ASD
   4. Fixed splitting
      1. ASD
         1. no difference of blood flow between inspiration and expiration
   5. Paradoxical (reverse) splitting
      1. LBBB
      2. Right VPC
         1. or Right side pacemaker
      3. severe aortic ouflow obstruction
      4. large Aortic-PA shunt
      5. systolic hypertension
      6. left ventricle failure
         1. IHD
         2. Cardiomyopathy
3. Systolic sound: Ejection sound
4. Diastolic sound
   1. Opening snap
      1. high pitch, early diastolic
      2. MS
   2. 3rd heart sound
      1. low pitch afer A2
      2. Terminal of LV Rapid filling
      3. Increased volume of ventricle filling
         1. normal children and High C.O pt
         2. CHF
         3. AR
   3. 4th heart sound
      1. Low pitch, pre-systolic
      2. Effective atrial contraction
5. Systolic murmur
   1. Pansystolic murmur
   2. Midsystolic mumrur
6. Diastolic murmur
   1. open snap
   2. 3rd heart sound