[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular) › Cardiac auscultation: the areas and the order [Clinical exam](https://durgical.com/en/clinical-exam/) · [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular) # 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)](https://durgical.com/en/anatomy/fibrous-rings-of-the-heart-valves/) · [Mitral anterior leaflet](https://durgical.com/en/anatomy/anterior-leaflet-of-left-atrioventricular-valve/) · [Tricuspid anterior leaflet](https://durgical.com/en/anatomy/superior-leaflet-of-right-atrioventricular-valve/) · [Aortic right coronary cusp](https://durgical.com/en/anatomy/right-coronary-leaflet/) · [Pulmonary anterior cusp](https://durgical.com/en/anatomy/anterior-semilunar-leaflet-of-pulmonary-valve/) · [Sternum](https://durgical.com/en/anatomy/sternum/) ## Key points - Aortic: right second interspace. Pulmonic: left second interspace. Tricuspid: left fourth interspace, sternal border. Mitral: left fifth interspace, midclavicular line. - Diaphragm for high pitch; light bell for low pitch (S3, S4, mitral stenosis rumble). - Left lateral decubitus: mitral and gallops. Sitting forward in expiration: aortic regurgitation and rub. - S1 coincides with the carotid pulse. ## 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. ## Memory aid Walk the stethoscope downhill: start where the two great arteries leave (right, then left, second space), pause at Erb on the way down, and finish at the two inflow valves at the bottom: tricuspid beside the sternum, mitral out at the apex. ## 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. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/cardiac-auscultation-the-areas-and-the-order/) ## See it in 3D The structures of Durgical's 3D anatomy where it is found. - [Valve rings (fibrous skeleton)](https://durgical.com/en/anatomy/fibrous-rings-of-the-heart-valves/) - [Mitral anterior leaflet](https://durgical.com/en/anatomy/anterior-leaflet-of-left-atrioventricular-valve/) - [Tricuspid anterior leaflet](https://durgical.com/en/anatomy/superior-leaflet-of-right-atrioventricular-valve/) - [Aortic right coronary cusp](https://durgical.com/en/anatomy/right-coronary-leaflet/) - [Pulmonary anterior cusp](https://durgical.com/en/anatomy/anterior-semilunar-leaflet-of-pulmonary-valve/) - [Sternum](https://durgical.com/en/anatomy/sternum/) ## Related - [Heart sounds: S1, S2 and its splitting, S3 and S4](https://durgical.com/en/clinical-exam/heart-sounds-s1-s2-and-its-splitting-s3-and-s4/) - [Murmurs: timing, grade, location and radiation](https://durgical.com/en/clinical-exam/murmurs-timing-grade-location-and-radiation/) - [Valve murmurs: the table to know](https://durgical.com/en/clinical-exam/valve-murmurs-the-table-to-know/) - [Dynamic auscultation: Valsalva, squatting, standing and handgrip](https://durgical.com/en/clinical-exam/dynamic-auscultation-valsalva-squatting-standing-and-handgrip/) - [Precordial inspection and palpation: apex beat, heaves and thrills](https://durgical.com/en/clinical-exam/precordial-inspection-and-palpation-apex-beat-heaves-and-thrills/) ## Related conditions - [Aortic Valve Stenosis](https://durgical.com/en/conditions/aortic-valve-stenosis/) - [Mitral regurgitation](https://durgical.com/en/conditions/mitral-regurgitation/) - [Mitral stenosis](https://durgical.com/en/conditions/mitral-stenosis/) - [Aortic regurgitation](https://durgical.com/en/conditions/aortic-regurgitation/) - [Acute pericarditis](https://durgical.com/en/conditions/acute-pericarditis/) [← All of the clinical exam](https://durgical.com/en/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](https://openstax.org/books/clinical-nursing-skills/pages/24-3-nursing-assessment) (OpenStax (Rice University), 2024); [19.3 Cardiac Cycle - Anatomy and Physiology 2e | OpenStax](https://openstax.org/books/anatomy-and-physiology-2e/pages/19-3-cardiac-cycle) (OpenStax (Rice University), 2022); [18.2 Cardiovascular System - Clinical Nursing Skills | OpenStax](https://openstax.org/books/clinical-nursing-skills/pages/18-2-cardiovascular-system) (OpenStax (Rice University), 2024). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/cardiac-auscultation-the-areas-and-the-order/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/cardiac-auscultation-the-areas-and-the-order/