STUDY - Technical - New Dacian's Medicine
Gallop
(atrial or ventricular) (Classical / Allopathic Medicine)
An atrial or
presystolic gallop is an extra heart sound (known as S4)
that's auscultated or palpated immediately before the first
heart sound (S1). This low-pitched sound is heard best with
the bell of the stethoscope pressed lightly against the
cardiac apex. Some clinicians say that an S4 has the cadence
of the “Ten” in Tennessee (Ten = S4; nes = Sl; see = second
heart sound [S2]).
This gallop
typically results from hypertension, conduction defects,
valvular disorders, or other problems such as ischemia. It
results from abnormal forceful atrial contraction caused by
augmented ventricular filling or by decreased left ventricular
compliance. An atrial gallop usually originates from left
atrial contraction, is heard at the apex, and doesn't vary
with inspiration. It may also originate from right atrial
contraction. If so, it's heard best at the lower left sternal
border and intensifies with inspiration.
A ventricular
gallop is a heart sound (known as S3) associated with rapid
ventricular filling in early diastole. Usually palpable, this
low-frequency sound occurs about 0.15 seconds after S2. It may
originate in either the right or left ventricle. A right-sided
gallop usually sounds louder on inspiration and is heard best
along the lower left sternal border or over the xiphoid
region. A left-sided gallop usually sounds louder on
expiration and is heard best at the apex.
Ventricular
gallops are easily overlooked because they're usually faint.
For better detection, auscultate in a quiet environment;
examine the patient in the supine, left lateral, and
semi-Fowler positions; and have the patient cough or raise his
legs to augment the sound.
Although the
physiologic S3 has the same timing as the pathologic S3, its
intensity waxes and wanes with respiration. It's also heard
more faintly if the patient is sitting or standing.
A pathologic
ventricular gallop may result from one of two mechanisms:
rapid deceleration of blood entering a stiff, noncompliant
ventricle, or rapid acceleration of blood associated with the
increased flow into the ventricle. A gallop that persists
despite therapy indicates a poor prognosis.
Patients with
cardiomyopathy or heart failure may develop a ventricular
gallop and an atrial gallop - a condition known as a summation
gallop.
ALERT:
If you auscultate an atrial gallop in a patient with chest pain:
- take his vital signs and quickly look for signs of heart failure, such as dyspnea, crackles, and jugular vein distention
- connect him to a cardiac monitor, and obtain an electrocardiogram (ECG)
- elevate the head of the bed if he also has dyspnea, and then auscultate for abnormal breath sounds
institute emergency measures, if necessary.
If the patient's condition permits, perform a focused assessment.
If you auscultate an atrial gallop in a patient with chest pain:
- take his vital signs and quickly look for signs of heart failure, such as dyspnea, crackles, and jugular vein distention
- connect him to a cardiac monitor, and obtain an electrocardiogram (ECG)
- elevate the head of the bed if he also has dyspnea, and then auscultate for abnormal breath sounds
institute emergency measures, if necessary.
If the patient's condition permits, perform a focused assessment.
HISTORY:
Review the patient's medical history, noting especially hypertension, angina, valvular stenosis, cardiomyopathy, and other cardiac disorders.
Ask the patient if he has had chest pain. If so, have him describe its character, location, frequency, duration, and any alleviating or aggravating factors. Also, ask about palpitations, dizziness, or syncope.
Ask the patient if he has difficulty breathing after exertion while lying down, or at rest.
Obtain a drug history, including prescription and over-the-counter drugs, herbal remedies, and recreational drugs. Also, ask the patient about alcohol intake.
Review the patient's medical history, noting especially hypertension, angina, valvular stenosis, cardiomyopathy, and other cardiac disorders.
Ask the patient if he has had chest pain. If so, have him describe its character, location, frequency, duration, and any alleviating or aggravating factors. Also, ask about palpitations, dizziness, or syncope.
Ask the patient if he has difficulty breathing after exertion while lying down, or at rest.
Obtain a drug history, including prescription and over-the-counter drugs, herbal remedies, and recreational drugs. Also, ask the patient about alcohol intake.
PHYSICAL
ASSESSMENT:
Auscultate for murmurs or abnormalities in S1 and S2.
Assess the patient for jugular vein distention and peripheral edema.
Auscultate the lungs for pulmonary crackles.
Assess peripheral pulses, noting an alternating strong and weak pulse.
Palpate the liver to detect enlargement or tenderness.
Auscultate for murmurs or abnormalities in S1 and S2.
Assess the patient for jugular vein distention and peripheral edema.
Auscultate the lungs for pulmonary crackles.
Assess peripheral pulses, noting an alternating strong and weak pulse.
Palpate the liver to detect enlargement or tenderness.
SPECIAL
CONSIDERATIONS:
Monitor the patient with a gallop. Watch for and report tachycardia, dyspnea, crackles, and jugular vein distention.
Monitor the patient with a gallop. Watch for and report tachycardia, dyspnea, crackles, and jugular vein distention.
PEDIATRIC
POINTERS:
An atrial gallop may result from a congenital heart disease, such as atrial septal defect, ventricular septal defect, patent ductus arteriosus, or severe pulmonary valvular stenosis.
A ventricular gallop may accompany a congenital abnormality associated with heart failures, such as a large ventricular septal defect or patent ductus arteriosus. It may also result from sickle cell anemia.
An atrial gallop may result from a congenital heart disease, such as atrial septal defect, ventricular septal defect, patent ductus arteriosus, or severe pulmonary valvular stenosis.
A ventricular gallop may accompany a congenital abnormality associated with heart failures, such as a large ventricular septal defect or patent ductus arteriosus. It may also result from sickle cell anemia.
AGING ISSUES:
Because the absolute intensity of an atrial gallop doesn't decrease with age, as it does with an S1, the relative intensity of an S4 increases compared with an S1. This explains the increased frequency of an audible S4 in elderly patients and why this sound may be considered a normal finding.
Because the absolute intensity of an atrial gallop doesn't decrease with age, as it does with an S1, the relative intensity of an S4 increases compared with an S1. This explains the increased frequency of an audible S4 in elderly patients and why this sound may be considered a normal finding.
PATIENT
COUNSELING:
Instruct the patient on what to expect from diagnostic testing, which may include an ECG, echocardiography, and cardiac catheterization.
Instruct the patient on what to expect from diagnostic testing, which may include an ECG, echocardiography, and cardiac catheterization.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common
symptoms, Edition V, McGraw - Hill, 2002.
Dorin,
Merticaru (2010)