To distinguish a physiologic split S2 heart sound, it is best to listen with the stethoscope at:
A. Left fifth intercostal space midclavicular line
B. Fourth intercostal space left sternal border with patient holding his or her breath
C. Second intercostal space left sternal border with inspiration
D. Fourth intercostal space right sternal border with expiration
ANS: C
Normally, the S1 and S2 occur as single sounds. In some conditions, these sounds may be split and occur as two sounds. In healthy young adults, a physiologic split of S2 may be detected in the second and third left interspaces during inspiration as a result of changes in the amount of blood returned to the right and left sides of the heart. During inspiration, there is an increased filling time and therefore increased stroke volume of the right ventricle, which can delay closure of the pulmonic valve, causing the second heart sound to be split. This physiologic split differs from other splits that are pathologic in origin in that it occurs with inspiration and disappears with expiration.
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