Cardiac Auscultation: Cardiac Landmarks for Auscultation

The cardiac auscultation of the chest starts with the examiner looking at the chest called (inspection). During the inspection of the chest the examiner will look for any abnormalities in the chest such as lumps, bruises, moles, and old incisions for surgeries. During the inspection it will yield a lot of high quality information and supplement the interview very nicely. While looking at the chest the examiner will look for the shape of the chest which will again yield other signs of chronic (long term) illness. Such as a barrel shaped chest will depict a person with possible COPD (emphysema). This part of the exam will take less than 5 minutes.

Next part of the cardiac examination is the listening or auscultation of the heart itself. When listening to the heart sounds the examiner first must landmark appropriately and understands what they are listening to. Listening to the heart takes years of experience to pick up the nuances of the heart sounds. By the time the doctor and nurse graduate they have sufficient experience. The examiner places the stethoscope over 4 areas of the chest to listen to the valves of the heart to pick up a possibility of heart murmurs. To listen to the pulmonary valve the stethoscope is placed over the second intercostal space (the space between the 2nd and 3rd rib) left side of the patient’s sternum. The aortic valve is heard over the 2nd intercostal space right side of the patient’s sternum. The tricuspid valve is heard over the 5th intercostal space left side of the patient’s chest. The mitral valve is heard over the 5th intercostals space inline with the middle of the collar bone. The examiner will take their time during the examination of the heart sounds.

Normal Heart Sound


Aortic Regurgitation

Aortic Valve Stenosis

Mitral Valve Regurgitation

Mitral Valve Stenosis

Pulmonary Valve Stenosis

Tricuspid valve Regurgitation


The Stethoscope

Choose the right stethoscope and know how to use it right. Choosing the right stethoscope is a personal choice. The stethoscope is only used for cardiac auscultation and it does not amplify the sounds it only blocks extraneous room noises. An electronic stethoscope does amplify the sound only slightly and choosing one is a personal decision. The stethoscope has three main parts earpiece, tubing and end piece.


The slope of the earpieces should point forward toward the nose and down slightly into the ear canal. Everybody’s ears are different so take the time to adjust the new stethoscope to fit your ears comfortably. Using a pair of pliers to bend the earpieces should do the trick. They should fit snugly into your ear, but should not hurt if they hurt then they go too far into the ear canal. Some stethoscopes come with rubber or plastic ear pieces , but try and experiment with different ones and decide for yourself which ones fit you best. A good fit means better cardiac auscultation.


The tubing is made of a thick soft rubber or thick soft plastic and extends from the ear piece to the endpiece. The internal diameter should around 1/8 inch or 4mm. The length of tubing should not be more than 12 to 14 inches any longer and the sound may become distorted.

End piece

Choose a stethoscope with two end pieces, a bell and a diaphragm. The bell is a shallow concave structure used to hear low pitched sounds such as extra heart sounds or murmurs. The diaphragm has a membrane across its structure resembling a drum and is used to hear high pitched sounds such as normal heart sounds.

How to use a stethoscope

Eliminate any extra room noise such as visitors talking or a radio or TV. The room must be relatively quiet. Start by warming up the the diaphragm and bell by gently rubbing it in your hands this prevents the patient from starting to shiver from a cool stethoscope against warm skin. The slight involuntary shivering can produce small vibrations that can drown out other important sounds. Listening over a hairy chest can cause sounds that mimic lung sounds like small crackling sounds. Eliminate this effect by slightly dampening the hair. Hold the stethoscope between the index and middle finger for cardiac auscultation. Holding the stethoscope with three or more fingers may run the risk of creating more extraneous noise and drowning out other important heart sounds. Make sure the tubing doesn’t rub on bedsheets or clothes or even your own breathe can create extra sounds making it impossible to hear the faint extra heart sounds your patient’s lives depend on. First use the diaphragm holding it loosely between the index and middle finger of which ever hand your comfortable place it on the chest with enough pressure that when you life the stethoscope it leaves a slight ring. Next use the bell of the stethoscope to listen on the extra heart sounds using the index and middle finger of the hand your most comfortable with place it on the chest this time with just slightly less pressure just enough to create a seal between the bell and the patients skin any more pressure and the skin becomes a diaphragm and will drown out any extra heart sounds.

Buying an expensive stethoscope does not guarantee perfect results. Using improper technique can turn an expensive stethoscope into useless junk. Take the time to learn these simple techniques and your practice will flourish in cardiac auscultation.

Visit the HDP store for our full selection of cardiology stethoscopes

Auscultation Order

First the examiner begins noting: 1) the rate and rhythm 2) identify S1 and S2 3) assess S1 and S2 separately 4) listen for extra heart sounds S3 and S4 and 5) listen for murmurs.

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