document_title: Letter (paper size)

question_text: how big is a sheet of printer paper

question_tokens: how big is a sheet of printer paper

text: Letter (paper size)

text: Letter or ANSI Letter is a paper size commonly used as home or office stationery in the United States, Canada, Chile, Mexico, the Dominican Republic and the Philippines. It measures 8.5 by 11.0 inches (215.9 by 279.4 mm). US Letter size paper is a standard defined by the American National Standards Institute (ANSI, paper size A) in contrast to the A4 paper used by many other nations, adopted at varying dates, which is defined by the International Organization for Standardization (specifically, in ISO 216).

text: Details[edit]

text: Ronald Reagan made this the paper size for U.S. federal forms in the early 1980s; previously, the smaller "official" Government letter size, 8.0 by 10.5 inches (203 mm × 267 mm), was used in government, while standard 8.5 × 11 inch paper was used by most other offices.[1]

text: In the U.S., paper density is usually measured in "pounds per ream" (of 500 sheets). Typical Letter paper has a basis weight of paper of 20 or 24 pounds (9.1 or 10.9 kg) – the weight of 500 sheets (a ream) of 17-by-22-inch (432 mm × 559 mm) paper at 70 °F (21.11 °C) and at 50% humidity.[2] One ream of 20-pound Letter-sized paper weighs 5 pounds (2.3 kg), and a single Letter-sized sheet of 20-pound paper weighs 0.16 ounces (4.536 g), which is equivalent to 75.19 g/m2. Some metric information is typically included on American ream packaging, 20-pound paper is also labeled as 75 g/m2. The most common density of A4 paper is 80 g/m2.

text: The precise origins of the dimensions of US letter size paper (8.5 × 11 in) are not known. The American Forest & Paper Association says that the standard US dimensions have their origin in the days of manual paper making, the 11" length of the standard paper being about a quarter of "the average maximum stretch of an experienced vatman's arms".[1] The letter size falls within the range of the historical quarto size, which since pre-modern times refers to page sizes of 8 to 9 inches (200 to 230 mm) wide and 10 to 11 inches (250 to 280 mm) high, and it is indeed almost exactly one quarter of the old Imperial (British) paper size known as Demy 4to (17½"×22½"), allowing ½" for trimming.[3]

text: The related paper size known as half letter, statement, or organizer L is exactly one half of the US letter size (8.5 × 5.5 in).


document_title: God bless you

question_text: where did god bless you come from when someone sneezes

root

text: God bless you

text: This is the current revision of this page, as edited by ClueBot NG (talk | contribs) at 01:48, 10 August 2017 (Reverting possible vandalism by 2602:306:3236:53B0:FD0D:6115:8D86:A2AC to version by 71.251.24.77. Report False Positive? Thanks, ClueBot NG. (3099641) (Bot)). The present address (URL) is a permanent link to this version.

tag: table

text: Look up God bless you in Wiktionary, the free dictionary.

text: God bless you (variants include God bless or bless you[1]) is a common English expression, used to wish a person blessings in various situations,[1][2] especially as a response to a sneeze, and also, when parting or writing a valediction.[1][3]

tag: p

text: The phrase has been used in the Hebrew Bible by Jews (cf. Numbers 6:24), and by Christians, since the time of the early Church as a benediction, as well as a means of bidding a person Godspeed.[4][5] Many clergy, when blessing their congregants individually or as a group, use the phrase "God bless you".[6]

text: A typical polite response after being told "bless you" in response to sneezing is to thank the person who has said it.

text: Origins and legends[edit]

text: National Geographic reports that during the plague of AD 590, "Pope Gregory I ordered unceasing prayer for divine intercession. Part of his command was that anyone sneezing be blessed immediately ("God bless you"), since sneezing was often the first sign that someone was falling ill with the plague."[7] By AD 750, it became customary to say "God bless you" as a response to one sneezing.[8]

text: The practice of blessing someone who sneezes dates as far back as at least AD 77, although it is far older than most specific explanations can account for.[9] Some have offered an explanation suggesting that people once held the folk belief that a person's soul could be thrown from their body when they sneezed,[9] that sneezing otherwise opened the body to invasion by the Devil or evil spirits,[10][11] or that sneezing was the body's effort to force out an invading evil presence.[9] In these cases, "God bless you" or "bless you" is used as a sort of shield against evil.[12] The Irish Folk story "Master and Man" by Thomas Crofton Croker, collected by William Butler Yeats, describes this variation.[13] Moreover, in the past some people may have thought that the heart stops beating during a sneeze, and that the phrase "God bless you" encourages the heart to continue beating.[9][10][11]

text: In some cultures, sneezing is seen as a sign of good fortune or God's beneficence.[9][14] As such, alternative responses to sneezing are the German word Gesundheit (meaning "health") sometimes adopted by English speakers, the Irish word sláinte (meaning "good health"), the Spanish salud (also meaning "health") and the Hebrew laBri'ut (colloquial) or liVriut (classic) (both spelled: "לבריאות") (meaning "to health").

text: In Persian culture, sneezing sometimes is called "sabr =صبر," meaning "to wait or be patient." And when trying to do something or go somewhere and suddenly sneezing, one should stop or sit for a few minutes and then re-start. By this act the "bad thing" passes and one will be saved. This is observed in Indian culture as well.

text: In Greek culture, sneezing was widely recognized as a divine omen. In Book 17 of Homer’s Odyssey, Penelope speaks to Eumaeus in private about the suitors feasting in the halls of the king's palace, and how surely Odysseus will return and kill them. Suddenly her son Telemachus sneezes and Penelope laughed. A sneeze meant the intercession of the gods to make her statement come true. It was a blessing from the gods, connecting the sneeze to the "God Bless You."


document_title: Live Fast Die Young

question_text: who said live fast die young and leave a good looking corpse

text: Live Fast Die Young

text: "Live Fast, Die Young" may refer to:

text:
Live Fast, Die Young, a biography of James Dean
Live Fast, Die Young (film), a 1958 film starring Mary Murphy and Norma Eberhardt
Live Fast, Die Young (2008 film), a film by Christopher Showerman
Live Fast Die Young (song), a 1981 song by the US punk band The Circle Jerks
Live Fast Die Young (song), a 1982 song by the UK punk band The Violators (UK Band)
"Live Fast, Die Young," a song on Teflon Don (2010) by rapper Rick Ross
"Live fast, die young, and have a good-looking corpse", an oft-repeated quotation from the 1947 book Knock on Any Door by Willard Motley, also found in the movie version of the book

tag: ul


document_title: Point of order

question_text: when can a point of order be raised

question_tokens: when can a point of order be raised

text: Point of order

text: Explanation and uses[edit]

text:
Point of order (RONR)Class
Incidental motionIn order when another has the floor?
YesRequires second?
NoDebatable?
No (but chair can permit explanation), unless it is submitted to the assembly for a voteMay be reconsidered?
No, unless it is submitted to the assembly for a voteAmendable?
NoVote required
Is ruled by the chair, unless it is submitted to the assembly for a vote (then it requires a majority vote)

text: In Robert's Rules of Order Newly Revised (RONR), a point of order may be raised if the rules appear to have been broken. This may interrupt a speaker during debate, or anything else if the breach of the rules warrants it.[1] The point is resolved before business continues.

text: The point of order calls upon the chair to make a ruling. The chair may rule on the point of order or submit it to the judgment of the assembly. If the chair accepts the point of order, it is said to be ruled "well taken". If not, it is said to be ruled "not well taken".[2]

text: Generally, a point of order must be raised at the time the rules are broken or else it would be too late.[3] For example, if a motion was made and discussion began on it, it would be too late to raise a point of order that the motion was not seconded. If such a motion was adopted without a second, it remains valid and not having a second becomes irrelevant.[4]

text: Exceptions to the rule that a point of order must be raised at the time of violation include that a point of order may be raised at any time a motion was adopted in violation of the bylaws or applicable law, in conflict with a previously adopted motion (unless adopted by the vote to rescind it), or in violation of a fundamental principle of parliamentary law.[5]

text: The ruling of the chair may be appealed to the assembly in most cases. A majority vote against the chair's ruling is required to overturn it.[6]

text: A point of order is sometimes erroneously used to ask a question of information or a question of parliamentary procedure. If a member asks such a question, the chair should treat the question as the appropriate request.

text: Legislative use[edit]

text: In the United States Senate, the chair's ruling on a point of order may be appealed by any Senator.[7] Points of order with regard to the Budget Act or annual budget resolution may be waived by 3⁄5 of the Senate's entire membership.[8] Rule XVI, which prohibits normal legislation in appropriations legislation, may be waived by 2⁄3 of the Senate.[8][9]

text: The United States House of Representatives also allows points of order and appeals.[10]

text: In the Irish Oireachtas (parliament), a point of order can be used in relation to order in the assembly. However, the ruling of the chair in this assembly cannot be appealed.[11]

text: Until 1998 in the British House of Commons, it was required that a member raising a point of order while the House is voting be wearing a hat so they could be easily seen. Two opera hats were maintained in the House for this purpose.[12] This practice was abolished in accordance with the findings of the Select Committee on the Modernisation of the House of Commons.[13] Deriving from this practice, in the Australian House of Representatives it continues to be customary for a member raising a point of order while the House is voting to hold a sheet of paper over the top of their head.[14]


document_title: Leslie Odom Jr.

question_text: what role did leslie odom jr play in rent

text: Leslie Odom Jr.

text: Early life[edit]

text: Odom was born in Queens, New York.[3] His family later moved to the East Oak Lane section of Philadelphia, where he grew up. He attended Julia R. Masterman School for middle school and Philadelphia High School for Creative and Performing Arts for high school.[4][5] He and his family attended Canaan Baptist Church in the Germantown section of Philadelphia, where he sang solos in the church choir.[4]

text: He earned a degree with honors at Carnegie Mellon University in Pittsburgh, Pennsylvania, and then moved to Los Angeles in the summer of 2003.

text: Career[edit]

text: Acting career[edit]

text: Theatre[edit]

text: Odom sang as a teenager, and studied musical theatre in college. At the age of 17 he made his Broadway debut as Paul in Rent. In 2000, he appeared in the ensemble of the one-night Broadway concert version of Dreamgirls.

text: He spent much of his time doing theatre in LA, including in 2010 with Leap of Faith,[6] which moved to Broadway in 2012, with him starring as Isaiah Sturdevant. The show closed shortly afterwards, however he made the move to New York and relocated there.

text: After starring off-Broadway in Venice, and in Witness Uganda (later retitled Invisible Thread) at A.R.T. and in workshops, Odom worked with Lin-Manuel Miranda in the Encores! Off-Center production of Tick, Tick... Boom! playing Michael. Odom also played Nat King Cole in the 2015 one-night Actors Fund of America benefit concert of Bombshell.[7]

text: Odom was nominated for a 2015 Drama Desk Award for Outstanding Featured Actor in a Musical[6] for the role of Aaron Burr in the off-Broadway production of Hamilton at The Public Theater. He continued in the same role at the Richard Rodgers Theatre after the show transferred to Broadway later that year. He also won a 2016 Grammy Award for the cast album, and won the Tony Award for Best Actor in a Musical.

text: Odom's final appearance in the role of Aaron Burr in Hamilton occurred on July 9, 2016.[8]

text: Television[edit]

text: Odom had a recurring role on CSI: Miami which began in 2003. He appeared as Joseph Kayle in nine episodes before leaving in 2006.

text: He followed with a recurring role on Vanished, appearing in 10 episodes as Maliko Christo. From 2006 to 2007, he held a recurring role as Freddy on Big Day, appearing on nine episodes prior to its cancellation. He also had a supporting role in the TV movie Poe in 2011.

text: In the musical television series Smash, Odom had a recurring role as Sam Strickland in 2012, and was promoted to a starring role for the show's final season in 2013.

text: In late 2013, Odom was offered the leading role of Lucas Newsome on State of Affairs. He accepted the role, but ended up backing out to take the part of Aaron Burr in the workshops of the musical Hamilton.

text: In 2013 and 2014, he had a recurring role on Person of Interest as Peter Collier, appearing in eight episodes. He also played Reverend Curtis Scott in seven episodes of Law & Order: Special Victims Unit between 2013 and 2015.

text: Beginning on May 19, 2016, Odom hosted the Broadway.com web series Aaron Burr, Sir: Backstage at Hamilton with Leslie Odom Jr., with a new episode being uploaded every Thursday for eight weeks. Odom was also set to play Jimmy Jam in a 2017 miniseries about New Edition, but ended up leaving the project.

text: He has made guest appearances on several shows including Gilmore Girls, Grey's Anatomy, Supernatural, and The Good Wife. In 2016, Odom was also featured in a commercial for Nationwide Insurance.[9][10]

text: On February 4, 2018, Odom sang "America the Beautiful" during the NBC broadcast of Super Bowl LII.[11]

text: Film[edit]

text: Odom has appeared in multiple short films, and had a supporting role as Declan Hall in the 2012 war film Red Tails.

text: He played Dr. Arbuthnot in Kenneth Branagh's 2017 adaptation of Murder on the Orient Express.[12]

text: Recording career[edit]

text: In 2014, Odom self-released his debut album as a jazz singer, Leslie Odom Jr. on CD and SoundCloud, and promoted the album with several concerts at The Public Theater. In February 2016, he released a version of Selena Gomez's "Good For You" featuring his Hamilton castmate Daveed Diggs.[13]

text: Odom was signed to a four-album deal with S-Curve Records in 2016.[14] He and producer Steve Greenberg narrowed down 200 potential tunes to ten tracks, and Odom recorded an updated and improved version of Leslie Odom Jr. during days off and afternoons before Broadway performances, in order to release the album before Odom left Hamilton.[15] Released in June 2016, the album charted at No. 1 on Billboard Jazz and No. 147 on Billboard 200.

text: On November 11, 2016, Odom released his second album, Simply Christmas, which featured jazz interpretations of Christmas standards. A deluxe edition of the album was released in October 2017, with four additional songs.[16]

text: Odom tours to promote his albums, performing concerts backed by a jazz quintet that includes a drummer, percussionist, bassist, guitarist, and a pianist who is also Odom's musical director.[17]

text: Writing[edit]

text: In June 2017, it was announced that Odom had a book deal for Failing Up: How to Take Risks, Aim Higher, and Never Stop Learning, which he was writing with the intention to inspire younger readers.[18] The book, which was published by an imprint of Macmillan in March 2018, "outlines the setbacks and rejections that preceded his success."[2] Odom modeled his writing on the style of a commencement speech, exploring what he had learned throughout his life and the importance of pursuing passions.[18]

text: Personal life[edit]

text: Odom's wife, Nicolette Kloe Robinson, is an actress who starred in the Diane Paulus-directed off-Broadway musical Invisible Thread (2015).[19] She also appeared in a recurring role in the Showtime original series The Affair.[19]

text: Odom met Robinson in 2008, when she auditioned for Once on This Island in Los Angeles.[19] Robinson, then a student at UCLA, was not selected until the show was in rehearsals, replacing a cast member who left unexpectedly.[19] Odom, who was then an assistant director to Billy Porter, became responsible for bringing Robinson quickly up to speed, and a romantic relationship ensued.[19]

text: They were married on December 1, 2012,[19] and their daughter, Lucille Ruby, was born on April 23, 2017.[20]

text: Credits and awards[edit]

text: Theatre[edit]

text:
Year
Title
Role
Dates
Venue
Notes

1998
Rent
Paul / Cop / others

Nederlander Theatre
Broadway

2001
Dreamgirls
Performer
September 24, 2001
Ford Center for the Performing Arts
Actors Fund Benefit Concert

2004
Jersey Boys
Ensemble
October 5, 2004 – January 16, 2005
La Jolla Playhouse
Tryout

2007
Keep Your Pantheon

Geffen Playhouse
Regional

Being Alive
Performer
August 25 – September 9, 2007
Westport Country Playhouse
Regional

October 25 – December 2, 2007
Philadelphia Theatre Company

2008
Once on This Island
Agwe, God of Water
September 12–14, 2008
Freud Playhouse
Regional; also assistant director

2009
Soul of Rodgers
Performer
October 2–3, 2009
Reprise Theatre Company
Revue

2010
Leap of Faith
Isaiah Sturdevant
October 3–24, 2010
Ahmanson Theatre
Tryout

2012
April 26 – May 13, 2012
St. James Theatre
Broadway

2013
Venice
Markos Monroe
May 28 – June 30, 2013
The Public Theater
Off-Broadway

2014
Tick, Tick... Boom!
Michael
June 24–28, 2014
New York City Center
Encores!

2015
Hamilton
Aaron Burr
January 20 – May 3, 2015
The Public Theater
Off-Broadway

August 6, 2015 – July 9, 2016
Richard Rodgers Theatre
Broadway
Tony Award for Best Actor in a Musical

text: Witness Uganda (later retitled Invisible Thread), 2010

text: Film[edit]

text: This section of a biography of a living person needs additional citations for verification. Please help by adding reliable sources. Contentious material about living persons that is unsourced or poorly sourced must be removed immediately, especially if potentially libelous or harmful. (August 2016) (Learn how and when to remove this template message)

text:
Year
Title
Role
Notes

2007
Scarecrow Joe
Joe
Short

2012
Red Tails
Declan 'Winky' Hall

2015
Luna Goes Cruising
Oscar
Short

2017
Murder on the Orient Express
Dr. Arbuthnot

text: Television[edit]

text:
Year
Title
Role
Notes

2003–2006
CSI: Miami
Joseph Kayle
Recurring role; 9 episodes

2004
The Big House
Lamont
Episodes: "A Friend In Need", "Almost Touched By An Angel"

2006
Threshold
Sergeant Adams
Episode: "The Crossing"

2006
Gilmore Girls
Quentin Walsh
Episode: "Bridesmaids Revisited"

2006
Vanished
Agent Malik Christo
Recurring role; 10 episodes

2006
Close To Home
Jordan Carter
Episode: "Prodigal Son"

2006–2007
Big Day
Freddy
Recurring role; 9 episodes

2007
The Bill Engvall Show
Mr. Pratt
Episodes: "Good People", "Feel Free To Say No"

2007
Supreme Courtships
Marcus
TV movie

2008
Grey's Anatomy
P.J. Walling
Episode: "There's No "I" In Team"

2011
NCIS: Los Angeles
FBI Agent Duane Lausten
Episode: "Archangel"

2011
Zeke and Luther
Mr. Arliss Bunnyson
Episode: "Zeke, Luther, and Kojo Strike Gold"

2011
Bandwagon
Urban Glee performer
Episode: "You Can Do Anything"

2011
Supernatural
Guy
Episode: "Season Seven, Time For A Wedding"

2011
Poe
Julian 'Jupiter' Noble
TV movie

2012
House of Lies
James
Episodes: "Ouroboros", "Veritas"

2013
Smash
Sam Strickland
Lead role; 23 episodes

2013
Person of Interest
Peter Collier
Recurring role; 8 episodes

2013–2015
Law & Order: Special Victims Unit
Reverend Curtis Scott
Recurring role; 7 episodes

2014
Gotham
Ian Hargrove
Episode: "Harvey Dent"

2016
The Good Wife
Barry Pert
Episode: "Unmanned"

2016
Aaron Burr, Sir: Backstage at Hamilton with Leslie Odom Jr
Host
Web series; 8 episodes

text: Awards and nominations[edit]

text:
Year
Award
Category
Nominated work
Result

2002
Princess Grace Award
Acting
Won

2012
Fred and Adele Astaire Award
Best Dancer on Broadway
Leap of Faith
Won

Drama League Award
Distinguished Performance
Nominated

2015
Drama Desk Award
Outstanding Featured Actor in a Musical
Hamilton
Nominated

Lucille Lortel Awards
Outstanding Lead Actor in a Musical
Nominated

2016
Tony Award
Best Actor in a Musical
Won

Grammy Award
Best Musical Theater Album
Won

Broadway.com Audience Awards
Favorite Leading Actor in a Musical
Nominated

Favorite Onstage Pair (w/ Lin-Manuel Miranda)
Won

text: Discography[edit]

text:
Leslie Odom Jr. (2014, self-released)
Leslie Odom Jr. (2016, S-Curve Records)
Simply Christmas (2016, S-Curve)
Simply Christmas (2017 deluxe edition, S-Curve)

text: "Good for You" (2016, self-released on Bandcamp)


document_title: Brazilian Highlands

question_text: where is the brazilian highlands located on a map

text: Brazilian Highlands

text: This article does not cite any sources. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (November 2007) (Learn how and when to remove this template message)

text:
Brazilian Highlands

Region

Pedra da Mina, a mountain in the state of São Paulo, in 1997.

Country
Brazil

Borders on
Amazon Basin & Rainforest (W & NW)
Atlantic coastal strip (SE)

Parts
Caatinga, Cerrado

Highest point
Pico da Bandeira

 - elevation
2,891 m (9,485 ft)

 - coordinates
22°28′S 45°00′W / 22.467°S 45.000°W / -22.467; -45.000

Length
3,500 km (2,175 mi), SW x NE

Area
5,000,000 km2 (1,930,511 sq mi)

Topographic map of Brazil (the Brazilian Highlands/Plateau is the large yellowish and brown area in the east, south and central part of the country)

text: The Brazilian Highlands or Brazilian Plateau (Portuguese: Planalto Brasileiro) are an extensive geographical region, covering most of the eastern, southern and central portions of Brazil, in all approximately half of the country's land area, or some 4,500,000 km² (1,930,511 sq mi). In addition, the vast majority of Brazil's population (190,755,799; 2010 census) lives in the highlands or on the narrow coastal region immediately adjacent to it.

text: Ancient basaltic lava flows gave birth to much of the region. However, the time of dramatic geophysical activity is long past, as there is now no seismic or volcanic activity. Erosion has also played a large part in shaping the Highlands, forming extensive sedimentary deposits and wearing down the mountains.

text: The Brazilian Highlands are recognized for the great diversity to be found there: within the region there are several different biomes, vastly different climatic conditions, many types of soil, and thousands of animal and plant species.

text: Major divisions[edit]

text: Due to their size and diversity, the Brazilian Highlands are usually divided into three main areas:

text:
Atlantic Plateau, extending all along the eastern coast of Brazil, and including several mountain ranges. It was once almost completely covered by the Atlantic Rainforest, one of the richest areas of biodiversity in the world, of which only 7.3% remains.
Southern Plateau, advancing inland in the southern and southern-central portions of the country. Sedimentary rocks covered partially by basaltic lava spills that form the fertile ground known as "purple land". Large portions of this region were also covered by the Atlantic Rainforest, while araucaria highland forest and cerrado grasslands took up much of the rest.
Central Plateau, occupying the central portions of Brazil, with sedimentary and crystalline formations. Approximately 85% was once covered by cerrado vegetation, of which only a small portion remains intact.

text: In addition to the plateau regions, several adjoining or enclosed mountain ranges are considered to be part of the Brazilian Highlands. Some of the most important are (from north to south):

text:
Serra da Borborema
Chapada Diamantina
Serra do Espinhaço
Serra do Caparaó
Serra da Mantiqueira
Serra do Mar
Serra Geral

text: The highest point of the Brazilian Highlands is the Pico da Bandeira in the Serra do Caparaó, 2,891 meters (9,485 ft).


document_title: Elena Gilbert

question_text: what episode does elena die in vampire diaries

text: Elena Gilbert

text: Casting and portrayal[edit]

text:
When I look in the mirror, I just feel different when I'm Katherine or when I'm Elena. My voice changes a little bit, I think, and even just mentally, I feel like I can get away with a lot more.[1]
—Dobrev

tag: div

text: On March 9, 2009, it was announced that Bulgarian-born Canadian actress Nina Dobrev, known for her portrayal of Mia Jones on Degrassi: The Next Generation, had joined the cast of The Vampire Diaries as Elena.[2] She was the second cast member to be announced following Steven R. McQueen, who plays Elena's brother Jeremy Gilbert.[3] Steve West Cinema Blend said the vampire brothers' battle over Elena will wreak havoc on the entire town.".[2] Executive producer Kevin Williamson recalled Dobrev auditioning while having the flu, which he described as the "worst audition ever", and they "didn't even look at her a second time". Dobrev went back home to Canada, yet, still wanting the part, she submitted a videotape audition, which saw her cast as Elena Gilbert.[4]

text: Dobrev said that after reading the script, she was drawn to Elena because she was "this average girl who was damaged in many ways".[5] Initially, she believed that she would be playing the "bad girl" Elena from the books, but the show wanted to go in a different direction for the character.[4] After researching, Dobrev discovered she would also play Elena's 534-year-old vampire doppelgänger Katherine Pierce whose characteristics are the "complete opposite".[5] Dobrev described this as "one of the rarest, coolest opportunities in television, to play two people on the same medium". She had confessed that she enjoys playing Katherine more than Elena.[5] Dobrev stated that she changes her appearance to distinguish Elena from her doppelgänger, Katherine; "Changing my hair helps me transform," she told Glamour.[6] Additionally, she said "I think I have one of the coolest characters on the show — I get to play two completely different people on opposite sides of the spectrum and I just have so much fun doing it".[4] Dobrev felt that her biggest challenge on The Vampire Diaries was distinguishing Katherine and Elena, and found it "interesting" to create a whole new character.[1] In the novels, Katherine originated from Germany. However, in the television series, she is Bulgarian, as is Dobrev, who can speak the language fluently . Dobrev said,  "The writers heard me speaking Bulgarian to my mom on the phone while I was on set one day. One thing led to the other and voila".[7]

text: Development[edit]

text: Characterization[edit]

text: In the books, Elena is considered "one of the popular girls" at her high school and always gets "anything she wants".[8] Executive producer of the television show, Julie Plec, said the Elena from the books was "really kind of selfish". In The Vampire Diaries, Elena's "selfishness" in the books as a human was never explored, because it "didn't ever feel like a characteristic" the show wanted for their heroine.[9] Plec said "We kind of abandoned that queen-bee popular complex that in a lot of ways defined early Elena in the books", while feeling that Elena's actual flaw is her "deep, deep connection to other people".[9] In the books, Elena had blonde hair, but has brown hair in the television show.[10] Describing Elena from the books, Dobrev said she is "one of those mean girls that gets what she wants, popular . . . and she's blonde and blue eyed". Williamson told her that "the angle we wanted to go for was the relatable, nice, girl next door, who the audience roots for".[4] Katherine, on the other hand, is penned as a "conniving, narcissistic, bitch".[4] Describing Elena years later, Dobrev said she evolved from a "younger, naive, sad, young girl" to a "strong woman".[1]

text: Romances[edit]

text: Before The Vampire Diaries, Elena dated Matt Donovan (Zach Roerig), who was unable to move past his feelings for her initially after their break-up.[11] Elena began dating Stefan Salvatore (Paul Wesley), and later discovered he was a vampire.[12] As the episodes progressed, she developed a connection with Stefan's adventurous brother Damon Salvatore (Ian Somerhalder), who consumes human blood, unlike Stefan, who has an animal blood diet.[13] Speaking about the different qualities Stefan and Damon bring to Elena, Dobrev said they have "different qualities that are very appealing", which combined make "the perfect man". She said "Stefan is committed and sweet and protective and loving, and Damon is spontaneous and crazy and fun and exciting".[5]

text: After Elena became a vampire, she became sired to Damon and they slept together. According to Plec during an interview with TVLine, Elena "really believes what she feels is 100 percent genuine and real", and the couple "wants to be together and realizes that they shouldn’t, yet really wants to. So what do they do?"[14] Stefan became heartbroken, feeling angry and betrayed, and lashed out at Damon and Elena.[15] In the season 4 finale, an unsired Elena confirms that she is in love with Damon, and the two kiss passionately. At the end of season 6, the two plan to become human, get married, and have children together, but their dream is abruptly compromised by Kai, who puts Elena into a magical coma. Damon remains entirely devoted to Elena throughout the remaining two seasons as Elena sleeps peacefully.  In the season 8 finale, she is revealed to be happily married to Damon.

text: Transition[edit]

text: Executive producers Julie Plec and Kevin Williamson agreed that in the book series, Elena was turned into a vampire too early, which was around page 200 of The Awakening.[16] Elena's transition into a vampire was planned for two years. Plec said: "That felt obviously too soon, and rushed, and we didn’t want to make a show about a teenage girl who instantly becomes a vampire. But we always knew that her journey would take her there eventually".[16] At the second season's conclusion, Elena was nearly turned into a vampire.[1] Dobrev was happy that she wasn't, because she felt "it would have been too soon", and also didn't think it was something Elena or she wanted.[1]

text: In the show's third season, Elena has a brain hemorrhage which was initially thought to be a concussion, and begins to die.[17] In what was described by the International Business Times as "the moment Vampire Diaries fans have been waiting for", Elena had to choose whether to be driven to Damon or Stefan to say goodbye to. At the time, Klaus was killed, meaning all vampires sprouting from his bloodline also die, which includes Damon and Stefan. She picks to say goodbye to Stefan.[17] However, all these vampires end up surviving when Klaus never really dies. To save her, Doctor Merideth Fell (Torrey DeVitto) fed Elena Damon's blood. Rebekah Mikaelson kills Elena on Wickery Bridge, unaware of the vampire blood in her system. She woke up as a vampire at the end of the season.[17] The Hollywood Reporter interviewed Plec, and described her transition as "monumental changes" which would have Elena in for a "wild ride". Plec said Elena becoming a vampire is "an awakening of a person who is about to go through a lot of changes", and "she is going to evolve as a person and her relationships are going to evolve accordingly".[18] While Stefan was afraid she would hurt someone, Damon thought it was inevitable and wanted to "rip the band-aid off".[18] Plec felt that "She’s, unfortunately, not getting the same advice from the two people she values most in the world. It’s going to make it more difficult for her",[18] while describing the situation as "a whole new Elena and it’s a whole new day. It’s a different dynamic between the three of them especially".[18]

text: Television series[edit]

text: Backstory[edit]

text: Elena Gilbert is born on June 22, 1992 in Mystic Falls, Virginia to John Gilbert (David Anders) and Isobel Flemming (Mia Kirshner) while they were still in highschool. With the help of John's brother Grayson, Isobel and John flee town days later, leaving Grayson and his wife Miranda to adopt Elena as their own. A doctor, Grayson fakes a birth certificate so that it appeared Elena was his daughter with Miranda. The next year, Miranda and Grayson had a child of their own, Jeremy Gilbert. Elena dates her childhood friend Matt Donovan, who was her first love. On 23 May 2009, Elena is picked up by her mother and father after getting in a fight with Matt while attending the party. The three of them later end up in a car accident, with their car driving off a bridge. Stefan Salvatore finds them, and saves Elena, but it was too late to save Grayson and Miranda, who died. It remained unknown for months who saved Elena, and it was considered a miracle that she lived. Her relationship with Matt ended when they broke up.

text: Storyline[edit]

text: Season 1[edit]

text: Elena, still empty after losing her parents, begins to fit back into school. She meets a mysterious new student named Stefan Salvatore. They connect instantly, and begin dating. She meets his older and malevolent brother, Damon. After researching, Elena realizes Stefan was alive in 1953. It is later revealed that he is a 162-year-old vampire. Damon also begins falling for Elena. Elena finds a picture of a woman named Katherine Pierce who looks exactly like her. Stefan reveals that it is the woman who made him and Damon feud 145 years ago, and the person who turned them into vampires. He also told her that he is the person that saved her the night of her parents death. At the end of season one, Elena discovers that Grayson and Miranda weren't her biological parents, and that a woman named Isobel and her uncle John, who she grew up hating, were.

text: Season 2[edit]

text: In season two, she learns that she is a Petrova doppelgänger, having an appearance just like Katherine Pierce, which means that she has to be sacrificed to release Klaus' werewolf side. The sacrifice later happens, but Elena is saved, because John sacrificed himself for her after being put under a spell by Bonnie. However, her aunt Jenna is turned into a vampire and, as part of the sacrifice, is killed by Klaus, leaving Elena without a guardian. In the season two finale, while Damon is dying due to a werewolf bite, she forgives him for forcing her to drink his blood and kisses him with the thought that it might be Damon's last day, however Damon gets cured by drinking Klaus' blood.

text: Season 3[edit]

text: In season three, Elena does everything in her power to make Stefan get his humanity back, which was turned off by Klaus as payment for saving Damon from a werewolf bite in the latter part of season two. Meanwhile, she grows closer to Damon while working together on saving Stefan and trying to defeat Klaus, eventually even sharing a kiss. She later admits to Stefan that she has feelings for Damon as well but that she never stopped loving Stefan. While in Denver together, Elena kisses Damon, later telling him that she doesn't know how she feels about him. It is eventually revealed that Elena met Damon the night of her parent's death, though he compelled her to forget. She eventually chooses Stefan in the season finale but before she can tell him, Elena drowns while having vampire blood in her system. During the last moments of season three, she awakens as a vampire in transition.

text: Season 4[edit]

text: In season four, Elena is faced with the tough decision of whether to die or to feed on human blood so she can fully transition into a vampire. Elena, after realizing Stefan's desperation to keep her alive, decides to complete her transition. Her relationship with Stefan ends, allowing her to begin a proper romance with Damon. Although, it is later revealed there is a sire bond between them. Sometime later whilst searching for the cure for vampirism, Jeremy is fed to the immortal Silas by Katherine. As a result, Damon used the sire bond to convince her to turn off her humanity, due to her incredible grief over losing her brother and the last remaining member of her family. Elena became ruthless without her emotions, going on killing sprees and being very hateful towards her friends. Towards the end of season four, Damon kills Matt in front of Elena to trigger her grief. After revealing that Matt had the Gilbert Ring on, Elena's humanity was switched on and her emotions were focused on hate towards Katherine for killing Jeremy. Season four ended with Bonnie as a ghost after bringing Jeremy back to life and Elena fed Katherine the cure for vampirism in a moment of desperation as she was about to be killed. Elena had chosen Damon as the Salvatore that she loved.

text: Season 5[edit]

text:
In season five, Elena starts at Whitmore College and is happy after spending the summer with Damon. There she realises that Silas has taken Stefan's place and that Stefan is in that safe in a river constantly drowning. She and Damon then find the safe, only to find a dead body there meaning that someone opened the safe and Stefan is a Ripper again. However, Qetsiyah had fried Stefan's brain causing him to suffer amnesia. While trying to bring him back, they almost kiss meaning that she still feels something for him. Qetsiyah soon brings back Stefan's memories and says that Elena and Stefan were always meant to be as the Universe had to unite the doppelgängers of Silas and Amara. This leaves Damon and Elena questioning their relationship. Later on she is kidnapped and experimented on by Wes Maxfield, and she learns that her father also used to experiment on vampires.
Later, when Katherine is about to die as a result of all of her years catching up with her as a result of having the cure in her system, Katherine uses a spell and possesses Elena, a fact that her friends were initially unable to deduce. But once they did, they trapped Katherine and left her with no escape. Stefan stabbed her with the traveller dagger, but ghost Katherine reveals to Bonnie, shortly before trying to cross into the Other Side, that she had injected Dr. Maxfield's enhanced ripper/werewolf virus into Elena's body, infecting Elena. The gang is eventually able to find an antidote.
She unfortunately loses trust in Damon, partly because he killed her friend Aaron, so they break up, but realise they cannot survive being apart and get back together.
Once Markos and his traveller army begin to take over Mystic Falls, setting an anti-magic barrier around the town, the gang comes up with a plan to take out the travellers by killing them all at the same time, overpowering the anchor to the Other Side AKA Bonnie and creating a possible way out of the now-collapsing Other Side. Elena and Damon drive into the gas-filled Mystic Grill with most of the travellers in it, blowing it up and killing most of the people in it, including Elena and Damon. She wakes up as a ghost and finds her body, sending her to Bonnie, where she passes to the Other Side, and she and many others are able to pass back to the land of the living afterwards. But the spell that allows this is broken before Damon passes back through, and as Bonnie is the anchor, she is a part of the Other Side and shall therefore disappear along with it. This leaves the gang mourning the loss of Damon and Bonnie in the season finale.

text: Season 6[edit]

text:
In season six, Elena starts back at Whitmore, and is unable to set foot in her hometown. She is also unable to recover from Damon's death and starts lurking the borders of Mystic Falls in order to grab civilians, drink their blood, then compel them to forget, but as spirit magic no longer works in Mystic Falls, any of her victims who cross into the town remember the ordeal, putting her identity as a vampire at risk when one of her victims, Sarah, comes to town.
Elena begs Alaric to compel her to forget that she ever loved Damon, which Alaric is able to do, due to him being an Enhanced Original, with the ability to compel other vampires. She eventually wears him down and asks her friends to never remind her once the compulsion had been done. After a number of failed attempts, Alaric successfully compels her to forget her love for Damon. She however leaves Alaric with some of her reminders of Damon, should she ever need them again. She is told of her former feelings for Damon soon afterwards, but decides to stay the way she is, as she doesn't want to go back to being unhappy again. She starts to date her classmate, Liam.
Once Damon comes back to life, Alaric tries to convince Elena to allow him to undo the compulsion, a decision she is reluctant to make. She eventually decides to have him undo it, but Alaric goes back to being human again after crossing into Mystic Falls, causing him to lose his vampire status (he only stayed alive because his once fatal human injuries were healed), meaning he will not be able to do so. She is then left to finally come face-to-face with Damon and see if she'll still feel the same way about him. They eventually rekindle their relationship, Elena takes the cure that Bonnie gave Damon. At Alaric's wedding Kai ruins their wedding and casts a sleeping spell on Elena, linking her life to Bonnie's. She makes a sacrifice to let Bonnie live out her life until it is her turn. She bids goodbye to her friends and loved ones before parting ways but knows that she will see Damon, Stefan and Caroline again one day.

text: Season 7[edit]

text: Elena doesn't make an appearance but is heard calling Damon's name when he visits the Armory vault. It was a way of Sybil, the Siren, luring him into a trap.

text: Season 8[edit]

text: In the final episode, Elena makes an appearance. When a weakened Bonnie dies from the sounding bell, she meets Elena in a dream-like forest. Elena hugs her and wonders if she really has died. Enzo appears and says it isn't her time and takes Bonnie back to the world of the living. When Bonnie wakes up, it was Stefan who resuscitated her. Elena, asleep, is then taken to the Mystic Falls High School by Katherine and places her in the boiler room. Stefan tries to rescue Elena, but Katherine had Kai spell the boiler room, so that Elena can't be taken out of the room. After Bonnie had deflected the hellfire back into the bell, Bonnie passes out. Elena wakes up and wanders the school. Stefan meets up with her. It looks like Bonnie has died, but in fact Elena is still sleeping and Stefan's ghost came to visit her in her dream. He had taken the place of killing Katherine instead of Damon, since Damon is human after Stefan gave him the cure. He came to say goodbye. After a tearful hug and saying goodbye, Stefan goes into afterlife. Elena finally wakes up because Bonnie has broken the spell over her. Elena reunites with Damon and the rest of the gang. Elena gives Caroline the message Stefan whispered into her ear, saying he did hear her voice message and will love her forever. In the epilogue, Elena continued to study at medical school. After finishing her education, she went back to Mystic Falls and lived together with Damon, happily married for a long time. After living out her life, she crosses over to the afterlife where she finally reunites with her parents, Aunt Jenna and Uncle John.

text: Post-Season 8[edit]

text: The second-last episode of The Originals, 'The Tale of Two Wolves', features Elijah and Hope Mikaelson visiting Mystic Falls, and the window of a doctor's office reads 'Elena Salvatore, M.D.', implying that Elena got her own medical practice.

text: Reception[edit]

text: Elena has received mainly positive reviews. Steve West of the Cinema Blend compared the story of The Vampire Diaries and the character of Elena to the popular vampire franchise, Twilight, and its protagonist Bella Swan. West said "Clearly Elena is way hotter than Bella, she has two immortal vampires fighting over her".[2] After she transitioned into a vampire, Carina Adly MacKenzie of Zap2it hoped that the "fierce" and "ripper" side of Elena would emerge when "someone messes with the people she loves".[19] McKenzie noted that when a person becomes a vampire, "their strongest personality traits are heightened", and hoped that wouldn't see Elena's "compassion and selflessness" double into "helping old ladies with their groceries and nursing injured animals back to health".[19] Robyn Ross of TV Guide also hoped that after Elena "has had a taste for blood", she would lose control. Prior to her becoming a vampire, Ross thought she was less fun and "slightly boring", and wanted Elena to follow her instinct and "stop protecting everyone's feelings".[20]

text: Elena's romances with Stefan and Damon have become a popular craze with viewers, who have nicknamed them "Stelena" and "Delena".[21] Andy Swift of the website HollywoodLife praised Elena's relationship with Damon, which was a combination of real love and a sired bond, hoping they would live "happily ever after".[21] Vlada Gelman of TVLine, however, felt that their romance was "over in a rather mature way for a young love triangle" and questioned whether Elena was "ready to jump into a relationship with Damon right away" while Stefan was still in the picture.[22]

text: Merchandising[edit]

text: Tonner Doll Company, Inc. created dolls for Elena and Katherine along with Stefan and Damon, from 1864.[23][24]


document_title: Heart sounds

question_text: where does s1 occur in the cardiac cycle

text: Heart sounds

text: Primary heart sounds[edit]

text: Normal heart sounds are associated with heart valves closing:

text: The first heart sound, or S1, forms the "lub" of "lub-dub" and is composed of components M1 (mitral valve closure) and T1 (tricuspid valve closure). Normally M1 precedes T1 slightly. It is caused by the closure of the atrioventricular valves, i.e. tricuspid and mitral (bicuspid), at the beginning of ventricular contraction, or systole. When the ventricles begin to contract, so do the papillary muscles in each ventricle. The papillary muscles are attached to the cusps or leaflets of the tricuspid and mitral valves via chordae tendineae (heart strings). When the papillary muscles contract, the chordae tendineae become tense and thereby prevent the backflow of blood into the lower pressure environment of the atria. The chordae tendineae act a bit like the strings on a parachute, and allow the leaflets of the valve to balloon up into the atria slightly, but not so much as to evert the cusp edges and allow back flow of blood. It is the pressure created from ventricular contraction that closes the valve, not the papillary muscles themselves. The contraction of the ventricle begins just prior to AV valves closing and prior to the semilunar valves opening. The sudden tensing of the chordae tendineae and the squeezing of the ventricles against closed semilunar valves, sends blood rushing back toward the atria, and the parachute-like valves catch the rush of blood in their leaflets causing the valve to snap shut. The S1 sound results from reverberation within the blood associated with the sudden block of flow reversal by the valves. The delay of T1 even more than normally causes the split S1 which is heard in a right bundle branch blockage.

text: The second heart sound, or S2, forms the "dub" of "lub-dub" and is composed of components A2 (aortic valve closure) and P2 (pulmonary valve closure). Normally A2 precedes P2 especially during inspiration where a split of S2 can be heard. It is caused by the closure of the semilunar valves (the aortic valve and pulmonary valve) at the end of ventricular systole and the beginning of ventricular diastole. As the left ventricle empties, its pressure falls below the pressure in the aorta. Aortic blood flow quickly reverses back toward the left ventricle, catching the pocket-like cusps of the aortic valve, and is stopped by aortic valve closure. Similarly, as the pressure in the right ventricle falls below the pressure in the pulmonary artery, the pulmonary valve closes. The S2 sound results from reverberation within the blood associated with the sudden block of flow reversal.

text: Splitting of S2, also known as physiological split, normally occurs during inhalation because the decrease in intrathoracic pressure increases the time needed for pulmonary pressure to exceed that of the right ventricular pressure. A widely split S2 can be associated with several different cardiovascular conditions, including left bundle branch block, pulmonary stenosis, and atrial septal defect.

text: Extra heart sounds[edit]

text: The rarer extra heart sounds form gallop rhythms and are heard in both normal and abnormal situations.

text: Rarely, there may be a third heart sound also called a protodiastolic gallop, ventricular gallop, or informally the "Kentucky" gallop as an onomatopoeic reference to the rhythm and stress of S1 followed by S2 and S3 together (S1=Ken; S2=tuck; S3=y).[1]

text: "lub-dub-ta" or "slosh-ing-in" If new, indicates heart failure or volume overload.

text: It occurs at the beginning of diastole after S2 and is lower in pitch than S1 or S2 as it is not of valvular origin. The third heart sound is benign in youth, some trained athletes, and sometimes in pregnancy but if it re-emerges later in life it may signal cardiac problems, such as a failing left ventricle as in dilated congestive heart failure (CHF). S3 is thought to be caused by the oscillation of blood back and forth between the walls of the ventricles initiated by blood rushing in from the atria. The reason the third heart sound does not occur until the middle third of diastole is probably that during the early part of diastole, the ventricles are not filled sufficiently to create enough tension for reverberation.

text: It may also be a result of tensing of the chordae tendineae during rapid filling and expansion of the ventricle. In other words, an S3 heart sound indicates increased volume of blood within the ventricle. An S3 heart sound is best heard with the bell-side of the stethoscope (used for lower frequency sounds). A left-sided S3 is best heard in the left lateral decubitus position and at the apex of the heart, which is normally located in the 5th left intercostal space at the midclavicular line. A right-sided S3 is best heard at the lower-left sternal border. The way to distinguish between a left and right-sided S3 is to observe whether it increases in intensity with inhalation or exhalation. A right-sided S3 will increase on inhalation, while a left-sided S3 will increase on exhalation.

text: 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.

text: 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.

text: "ta-lub-dub" or "a-stiff-wall"

text: 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.[1] 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.

text: Atrial contraction must be present for production of an S4. It is absent in atrial fibrillation and in other rhythms in which atrial contraction does not precede ventricular contraction.

text: Murmurs[edit]

text: Heart murmurs are produced as a result of turbulent flow of blood strong enough to produce audible noise. They are usually heard as a whooshing sound. The term murmur only refers to a sound believed to originate within blood flow through or near the heart; rapid blood velocity is necessary to produce a murmur. Most heart problems do not produce any murmur and most valve problems also do not produce an audible murmur.

text: Murmurs can be heard in many situations in adults without major congenital heart abnormalities:

text:
Regurgitation through the mitral valve is by far the most commonly heard murmur, producing a pansystolic/holosystolic murmur which is sometimes fairly loud to a practiced ear, even though the volume of regurgitant blood flow may be quite small. Yet, though obvious using echocardiography visualization, probably about 20% of cases of mitral regurgitation do not produce an audible murmur.
Stenosis of the aortic valve is typically the next most common heart murmur, a systolic ejection murmur. This is more common in older adults or in those individuals having a two-leaflet, not a three-leaflet, aortic valve.
Regurgitation through the aortic valve, if marked, is sometimes audible to a practiced ear with a high quality, especially electronically amplified, stethoscope. Generally, this is a very rarely heard murmur, even though aortic valve regurgitation is not so rare. Aortic regurgitation, though obvious using echocardiography visualization, usually does not produce an audible murmur.
Stenosis of the mitral valve, if severe, also rarely produces an audible, low frequency soft rumbling murmur, best recognized by a practiced ear using a high quality, especially electronically amplified, stethoscope.
Other audible murmurs are associated with abnormal openings between the left ventricle and right heart or from the aortic or pulmonary arteries back into a lower pressure heart chamber.

text:
Gradations of Murmurs[1]
(Defined based on use of an acoustic, not a high-fidelity amplified electronic stethoscope)

Grade
Description

Grade 1
Very faint, heard only after listener has "tuned in"; may not be heard in all positions. Only heard if the patient "bears down" or performs the Valsalva maneuver.

Grade 2
Quiet, but heard immediately after placing the stethoscope on the chest.

Grade 3
Moderately loud.

Grade 4
Loud, with palpable thrill (a tremor or vibration felt on palpation)[2]

Grade 5
Very loud, with thrill. May be heard when stethoscope is partly off the chest.

Grade 6
Very loud, with thrill. May be heard with stethoscope entirely off the chest.

text: Though several different cardiac conditions can cause heart murmurs, the murmurs can change markedly with the severity of the cardiac disease. An astute physician can sometimes diagnose cardiac conditions with some accuracy based largely on the murmur, related physical examination, and experience with the relative frequency of different heart conditions. However, with the advent of better quality and wider availability of echocardiography and other techniques, heart status can be recognized and quantified much more accurately than formerly possible with only a stethoscope, examination, and experience. Another advantage to the use of the echocardiogram is that the devices can be hand held.[3]

text: Effects of breathing[edit]

text: Inhalation decreases intrathoracic pressure which allows more venous blood to return to the right heart (pulling blood into the right side of the heart via a vacuum-like effect). Therefore, right-sided heart murmurs generally increase in intensity with inhalation. The decreased (more negative) intrathoracic pressure has an opposite effect on the left side of the heart, making it harder for the blood to exit into circulation. Therefore, left-sided murmurs generally decrease in intensity during inhalation. Increasing venous blood return to the right side of the heart by raising a patient's legs to a 45-degree while lying supine produces similar effect which occurs during inhalation. Inhalation can also produce a non-pathological split S2 which will be heard upon auscultation.

text: With exhalation, the opposite haemodynamic changes occur: left-sided murmurs generally increase in intensity with exhalation.

text: Interventions that change murmurs[edit]

text: There are a number of interventions that can be performed that alter the intensity and characteristics of abnormal heart sounds. These interventions can differentiate the different heart sounds to more effectively obtain a diagnosis of the cardiac anomaly that causes the heart sound.

text: Other abnormal sounds[edit]

text: Clicks – Heart clicks are short, high-pitched sounds that can be appreciated with modern non-invasive imaging techniques.

text: Rubs – The pericardial friction rub can be heard in pericarditis, an inflammation of the pericardium, the sac surrounding the heart. This is a characteristic scratching, creaking, high-pitched sound emanating from the rubbing of both layers of inflamed pericardium. It is the loudest in systole, but can often be heard at the beginning and at the end of diastole. It is very dependent on body position and breathing, and changes from hour to hour.

text: Surface anatomy[edit]

text: The aortic area, pulmonic area, tricuspid area and mitral area are areas on the surface of the chest where the heart is auscultated. Heart sounds result from reverberation within the blood associated with the sudden block of flow reversal by the valves closing. Because of this, auscultation to determine function of a valve is usually not performed at the position of the valve, but at the position to where the sound waves reverberate.

text:
Aortic valve (to aorta)
right second intercostal space
upper right sternal border

Pulmonary valve (to pulmonary trunk)
left second intercostal space
upper left sternal border

Erb's point
Left third intercostal space
left sternal border

Tricuspid valve (to right ventricle)
left fourth, fifth intercostal spaces
lower left sternal border

Mitral valve (to left ventricle)
left fifth intercostal space
left midclavicular line

text: Recording heart sounds[edit]

text: Using electronic stethoscopes, it is possible to record heart sounds via direct output to an external recording device, such as a laptop or MP3 recorder. The same connection can be used to listen to the previously recorded auscultation through the stethoscope headphones, allowing for more detailed study of murmurs and other heart sounds, for general research as well as evaluation of a particular patient's condition.