Cardiac auscultation: the areas and the order !

Exam technique

Listening to the heart at four set places on the chest, always in the same order, so no sound or murmur is missed.

Updated 2026-11-01

See it in 3D: Valve rings (fibrous skeleton) · Mitral anterior leaflet · Tricuspid anterior leaflet · Aortic right coronary cusp · Pulmonary anterior cusp · Sternum

What it is

Cardiac auscultation uses areas that are not over each valve but where its sound carries best. A fixed order, with diaphragm and bell and in several positions, prevents omissions. It is the basis for recognizing extra sounds, murmurs and rubs.

Landmark anatomy

The base areas (aortic, pulmonic) pick up the semilunar valves; the lower sternal border and apex pick up the atrioventricular valves.
Sound travels with the flow: aortic stenosis radiates to the carotids and mitral regurgitation to the axilla.
The heart is rotated: the right ventricle is anterior and the left ventricle forms the apex, down and to the left.

Technique, step by step

Quiet room, patient supine with the head of the bed at about 30 degrees, stethoscope directly on skin.
Find the sternal angle (second costal cartilage) and count the intercostal spaces.
Aortic area: right second intercostal space at the sternal border.
Pulmonic area: left second intercostal space at the sternal border. Erb point, the left third space, is usually added.
Tricuspid area: left fourth (or fifth) intercostal space at the lower sternal border.
Mitral area: left fifth intercostal space at the midclavicular line (the apex).
At each area listen first with the diaphragm (high pitch: S1, S2, most murmurs), then with the bell held lightly (low pitch: S3, S4, mitral rumble).
Left lateral decubitus, bell at the apex: S3, S4, mitral stenosis. Sitting forward, breath held in expiration: aortic regurgitation and rub.
Feel the carotid or radial pulse while listening to tell which sound is S1 (it coincides with the pulse).

Abnormal findings

Extra sounds (S3, S4, click, opening snap), murmurs and a pericardial rub are findings to describe and report.
A new murmur or rub in an inpatient is reported to the medical team right away.
Distant heart sounds suggest pericardial effusion, obesity or emphysema.

Common errors

Listening through clothing or pressing the bell hard (it then works as a diaphragm).
Skipping the left lateral and sitting-forward positions.
Mixing up S1 and S2 in tachycardia: feel the pulse at the same time.
Listening with background noise or in a hurry.

Test yourself

Think of the answer, then tap the question to see it.

Which intercostal space, and which side of the sternum, is the aortic area?

The right second intercostal space at the sternal border.

Where is the mitral area?

The left fifth intercostal space at the midclavicular line, over the apex.

Which position brings out the murmur of aortic regurgitation?

Sitting up, leaning forward, breath held in full expiration, diaphragm at the left sternal border.

Why is the bell held with light pressure?

It picks up low-pitched sounds (S3, S4, mitral rumble); pressed hard, the stretched skin acts as a diaphragm and filters them out.

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See it in 3D

The structures of Durgical's 3D anatomy where it is found.

← All of the clinical exam

Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.

Sources: 24.3 Nursing Assessment - Clinical Nursing Skills | OpenStax (OpenStax (Rice University), 2024); 19.3 Cardiac Cycle - Anatomy and Physiology 2e | OpenStax (OpenStax (Rice University), 2022); 18.2 Cardiovascular System - Clinical Nursing Skills | OpenStax (OpenStax (Rice University), 2024).

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Representative model, for educational purposes only.