Cardiac Exam II: Auscultation

1. Position the patient at 30-45 degrees.

2. Make sure the area being examined is exposed, and never auscultate through the gown.

3. Place the stethoscope in the defined anatomical landmarks (Figure 1). A good rule of thumb to find the second intercostal space is to locate the angle of Louis (manubriosternal joint), which is at this level. Palpate across and down with your fingers to locate the other intercostal spaces described.

Figure 1. Auscultation surface landmarks.

1. Aortic area
   1. Place the diaphragm of the stethoscope at the 2^nd intercostal space, right sternal edge. This is the anatomical landmark for the aortic valve.
   2. Listen for at least 5 sec for the second heart sound, which represents the aortic valve closing.
2. Pulmonic area
   1. Place the diaphragm of the stethoscope at the 2^nd intercostal space, left sternal edge. This is the anatomical landmark for the pulmonary valve.
   2. Listen for at least 5 sec for the second heart sound, which represents the pulmonary valve closing.
3. Tricuspid area
   1. Place the diaphragm of the stethoscope at the 4^th - 5^th intercostal space, left sternal edge. This is the anatomical landmark for the tricuspid valve.
   2. Listen for at least 5 sec for the first heart sound, which represents the tricuspid valve closing.
4. Mitral area
   1. Place the diaphragm of the stethoscope at the 5^th intercostal space, mid-clavicular line (same area as the apex beat). This is the anatomical landmark for the mitral valve.
   2. Listen for at least 5 sec for the first heart sound, which represents the mitral valve closing.

4. Other auscultation areas:

Auscultation of the lungs and major arteries also provides essential information of the function of the cardiovascular system.

1. Auscultate with the diaphragm of the stethoscope at the bases of the lungs. Listen for any crepitations or crackles, which indicate fluid in the lungs (pulmonary edema), a sign of heart failure.
2. Auscultate with the bell of the stethoscope at the carotid arteries. Frequently, a murmur that is present from the aortic valve may be heard. Also, auscultate here for a bruit (a swishing sound produced by turbulent blood flow), which is a sign of carotid artery stenosis.
3. Auscultate for abdominal bruits at the renal arteries and femoral arteries to assess for peripheral vascular disease.