The vital signs of a 70-year-old patient with a history of hypertension are BP 180/100 mm Hg and HR 90 bpm.The nurse hears an extra heart sound at the apex immediately before S₁.The sound is heard only with the bell while patient is in the left lateral position.With these findings and the patient's history,the nurse knows that this extra heart sound is most likely:

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A pathological S₄ is termed an atrial gallop or an S₄ gallop.It occurs with decreased compliance of the ventricle and with systolic overload (afterload),including outflow obstruction to the ventricle (aortic stenosis)and systemic hypertension.A left-sided S₄ occurs with these conditions.It is heard best at the apex with the patient in the left lateral position.

The Vital Signs of a 70-Year-Old Patient with a History