<P> S3 can be a normal finding in young patients but is generally pathologic over the age of 40 . The most common cause of pathologic S3 is congestive heart failure . </P> <P> S4 when audible in an adult is called a presystolic gallop or atrial gallop . This gallop is produced by the sound of blood being forced into a stiff or hypertrophic ventricle . </P> <P> "ta - lub - dub" or "a-stiff - wall" </P> <P> It is a sign of a pathologic state, usually a failing or hypertrophic left ventricle, as in systemic hypertension, severe valvular aortic stenosis, and hypertrophic cardiomyopathy . The sound occurs just after atrial contraction at the end of diastole and immediately before S1, producing a rhythm sometimes referred to as the "Tennessee" gallop where S4 represents the "Ten -" syllable . It is best heard at the cardiac apex with the patient in the left lateral decubitus position and holding his breath . The combined presence of S3 and S4 is a quadruple gallop, also known as the "Hello - Goodbye" gallop . At rapid heart rates, S3 and S4 may merge to produce a summation gallop, sometimes referred to as S7 . </P>

When do you hear s3 and s4 sounds