This slide contains in brief explanation about the auscultating areas and sequence of the Cardiovascular, Respiratory and Gastrointestinal system including the abnormal heart, breath and abdominal sounds along with the landmarks of auscultation. Please read the references for more information.

1. Areas of Auscultation
Presented by Akhilesh Chandanshive
B.P.T. III Year
Navodaya College of Physiotherapy, Raichur

2. Introduction
• Auscultation is a term for listening to the internal sounds of the
body, usually using a stethoscope.
• It is performed for the purposes of examiningthe circulatory
systemandrespiratory system,as well asthe gastrointestinal
systemand is used to provide strong evidencein including or
excludingpathological conditions.

3. Optimal Environment
• Quiet – the ambiencenoise might interfere the heart and lung
sounds
• Warm– so that the patient feels comfortable while the upper part
of the body is exposed and to avoid shiveringthat may add noise.
• Appropriate lighting– to allow good coordination between visual
and auscultatory findings.

4. Examination of CVS (Heart)
1. Traditional Auscultatory Areas
• The base of the heart normally lies beneath the sternum at the 3rd
ICS.
• Its Apex is usually located between the 4th and 6th ICS, near or
medial to the left mid-clavicularline.
• The Apex is where apical impulses are taken and is usually the
point of maximum impulse (PMI).

5. • An infant’s heart is positioned more horizontally in the chest
cavity than an adult’s heart, i.e.,apex is at the 4th ICS and until age
4 the apical impulse is to the left of the mid-clavicularline. By age
7, the heart is in the same position as the adult’s heart.

6. 2. Locatingthe Auscultating areas.
• The Auscultating areas for Heart sounds are as follows:
i. Aortic Area
ii. Pulmonary Area
iii. Erb’s Point
iv. TricuspidArea
v. Mitral Area

7. • TheAorticArea is located at the 2nd right ICS, close to the
sternalborder. This is the wheretheascendingaorta is
closest to the thoracic cage and therefore the soundsof the
aortic valve and theaorta are bestheard.
• ThePulmonicAreais located at the2nd leftICS, close tothe
sternalborder. This is the area wherethesoundsof the
pulmonicvalve andthe pulmonaryartery are bestheard.
• TheTricuspidArea islocated at the5th ICS, close to the
sternalborder. This is the area wherethesoundsof the
tricuspidvalve and right ventricleare bestheard.

8. • The MitralAreais located at or near the 5th ICS, just medialto the
left mid-clavicularline. This area, directlyover the left ventricle,
is sometimes referredto as the apical area, or apex. The sounds of
mitral and left ventricleare heard best in this area.
• Erb’spoint differs from the four other areasin that it isn’t named
after a heart valve, but it’s a good location to hear the sounds of
aortic andpulmonic origin. It is located at the 3rd left ICS close to
the sternal border.

10. Normal Heart Sounds
 Normal S1
 M1 (closure of the mitral valve) and T1 (closure of Tricuspid Valve) are
usually perceived as a single sound called S1, which is hear best near
the apexof the heart over the Mitralarea.
 As you inch the stethoscope from the mitral area toward the tricuspid
area, without losing track of S1, the M1 and T1 components may become
evident. Expiration makes them easier to hear.
 Normal S2
 S2 has two basic components, Aortic (A2) and Pulmonic (P2)
components and are associated with the closure of Aortic and
Pulmonary Valves respectively.
 S2 is usually heard best near the heart’s base, over the PulmonicArea
or over the Erb’spoint.

11.  The splitting of S2 into the A2 and P2 components is heard best during
the inspiration over the Erb’s point.
 Normal S3
 S3 is, a typically low pitch, dull, thud-like sound, heard with the bellof
the stethoscope near the apex ofthe heart, over the mitralarea.
 S3 is caused by vibrations occurring during rapid ventricular filling
(normally seen in children and athletic young adults) and is heard best
during expiration when blood flow into the left ventricle is increased
and is heard after S2.
 Normal S4
 Similarly to S3, S4 (usually abnormal) can be heard best with the bell
of the stethoscope during expirationnear the heart’s apex over the
Mitralarea and is associated with Atrial Contraction (filling of
Ventricles)
 S4 precedes S1, timing is pre systolic.

12. Abnormal Heart Sounds
AbnormalSounds AuscultatingAreas Patient’sPosition
1. Opening Snaps NearApex, Mitral area Left lateralDecubitus
2. Pulmonic Ejection Sounds
(PES)
NearBase, Pulmonic Area Sitting/Supine
3. Aortic Ejection Sound
(AES)
Base, Apex, Mitral area, Aortic areaandErb’s
point
Sitting, Leaning
forward
4.. Mid-Systolic Clicks (MSC) Apex, Mitral area and Tricuspid area Standing/ Valsalva
maneuver
5. Systolic Ejection
Murmurs (SEM)
Left Sternalborder, Aortic andMitral areas Supine with legs
raised/Brief
Exercises, etc.
6. Tricuspid Regurgitation
Murmurs
Tricuspid Area during deepinspiration, may
radiate to the right sternalborder
Deep breathing while
Sitting/Standing
7. Mitral Regurgitation
Murmurs
Apex, Mitral Area, may radiateto axillaor
posteriorly over lungbases
Sitting /Supine
8. Mitral Valve Prolapse
Murmurs
Apex, Mitral Area Standing/ Squatting

13. Abnormal Sounds AuscultatingAreas Patient’sPosition
9. Ventricular Septal Defect
Murmur
Lower SternalBorder, andif loud, over the entire
precordium
Irrelevant
10. Tricuspid & Mitral
stenosis murmur
Tricuspid Area, Apex andMitral Area with the bell
of stethoscope
Left lateralrecumbent
11. Patent Ductus Arteriosus
Murmurs
Entire left 1st and2nd ICS, if loud, can be heard
over the left sternal border or Mitral Area
Irrelevant
12. Pulmonary Regurgitation
(Graham Steell)Murmurs
Along the left sternal borderover the 3rd and 4th
ICS, intensified during inspiration
Irrelevant
13. Mid-Diastolic Aortic
Regurgitation (Austin Flint)
murmurs
Apex, Over the Mitral Area using the Bellof
stethoscope.
Irrelevant

14. Examination of Respiratory System
 General Principles
• As most normal lung sounds are low pitched, the bell is normally
preferred over the diaphragm.
• The patient should be askedto breathe with his mouth open. This
is to prevent sound beingproduced from a partially closed nose.
• Avoid auscultation within 2-3 cmfrom the mid-linein the upper
part of the chest since breath sounds in these areas may normally
have a bronchial character.

15. • If the chest is hairy, moisten the chest wall with water and apply
the chest piece tightly to avoidsounds produced by the friction
with hair.
• Press the diaphragmof the stethoscope against the patient’s
chest wall over the ICS. Try not to listen directly over the bone.
Never listen through clothing, which impedesor alters sound
transmission.

16. Auscultatory Areas and Sequence
• Breath sounds are heard over the anteriorchestwallsurface,
the lateralchest wallsurfaces,and the posteriorchestwall
surface.
 Anterior chest wall surfaces
• The lung apicesextend ¼ inches to 1 ½ inches(2-4cm) above the
clavicles.
• The trachea bifurcates at the levelof the sternalangle, the
junction between the manubrium and the body of the sternum.

17. • The ribs and ICS provide precisehorizontal landmarks to describe
the location of breath sounds; the 2nd rib and the 2nd ICS serve as
reference points.
• The vertical landmark lines on the anterior chest wall surface
include the mid-clavicularlines and the mid-sternal line.
• The right and left mid-clavicularlines extend downward from the
center of each clavicle.
• The mid-sternal line bisects the sternum. The right lung base
crosses the 6th rib at the right mid-clavicularline, andthe left lung
base crosses the 7th rib at the left mid-clavicularline.

19. Lateral Chest Wall Surfaces
• The lateral chest wall surfaces are
also dividedusing landmark lines.
• The anterior axillaryline extends
downward from the anterior axillary
fold, the mid-axillaryline extends
downward from the apex of the
axilla, and the posterior axillaryline
extends downward from the
posterior axillaryfold.

20. Posterior Chest Wall Surface
• Bony structures underlying the posterior chest wall surface also
provide landmarks to locate breath sounds.
• The scapulae’sinferior borders, located at the same level as the
7th rib, serve asreference points.
• The numbered thoracic vertebrae provide horizontal landmarks.
[When auscultating the posterior chest wall, keep in mind that you’ll
be mostly hearingthe lower lobes because of the anatomical
position of the lobes.]

21. • Landmark lines on the posterior chest wall surface provide
vertical reference points.
• The mid-scapularline extends downward from the inferior angle
of each scapula, and the vertebral line extends downward over
the vertebrae.

23. Normal Breath Sounds
 Trachealand Bronchial Breath sounds
Normal breath sounds heard over the trachea (Trachealbreath
sounds) andMainstream bronchi (BronchialBreath sounds) are
produced by turbulent airflow patterns.
TrachealBreath sounds are harsh and high pitched and can be
heard over the Trachea.
Bronchial Breath sounds are loud and high pitched and can be
heard next to the trachea.

24. Trachealand MainstreamBronchial breath sounds are heard over
the chest wall on the either side of the sternum from the 2nd ICS to
the 4th ICS anteriorly and along the Vertebral column from 3rd ICS
to the 6th ICS posteriorly.
 Vesicular Breath sounds
Vesicular breath sounds are produced by changesin airflow
patterns.
Thesesounds are transmittedthrough the lung tissues andthe
chest wall.
Thesenormal sounds are quieter than the tracheal and bronchial
sounds.

28. Auscultatory Sequence
• The auscultatory sequence for the posterior chest wall surface
includes 10 different sites.
• The first site is above the left scapula over the lung apex. From
there, the auscultatory sequence follows a pattern that
progressesdownward from the lung apices to the bases.
• The upper lobes of both right and left lungs can be heard in the C7
- T3 vertebrallevels and the lower lobes can be heard in the T3 –
T10 vertebral levels.

29. • Sites 5, 7, & 10 are located over the lateral chest wall surfaces.
• The anterior chest wall auscultatory sequence includes 9 sites and
follows the same pattern as the posterior chest wall sequence.
• Right lung Upper lobe can be heard between the supra clavicular region
and the 3rd ICS, middle lobe can be heard between the 4th ICS and the 6th
ICS and the lower lobe can be heard in the 7th ICS.
• Left lung Upper lobe can be heard between the supra clavicular region
and the 5th ICS, and the lower lobe in the 6th and 7th ICS.
• The pattern also includes sites over the lateral chest wall surfaces.

32. Examination of Gastrointestinal
System
Introduction
• Auscultation of the abdomen is for detecting bowel sounds,
succusion splash, venous hum, friction rub and vascular bruits.
• Unlike other physicalexaminations,auscultation of bowel sounds
is performed prior to percussion or palpation, as both of these
could alter the regularity of bowel sounds.

33. Regionsof Abdomen
• Abdomen can be divided into 9 regions by drawing two imaginary
vertical lines (mid-clavicular lines at either sides) and two horizontal
lines (one at L1 vertebral - sub costal level and other at the level of
tubercles of iliac crest). The nine regions are as follows:
I. Right Hypochondrium
II. Left Hypochondrium
III. Epigastrium
IV. Right Lumbar Region
V. Left Lumbar Region
VI. Umbilical Region
VII. Right Iliac Fossa
VIII. Left Iliac Fossa
IX. Hypogastrium

35. Auscultation Sequence
I. Withthe patientsupine, place your stethoscope bell to the rightof the
umbilicus anddo not move it.
II. Listenfor up to 3 mins before concludingthatthe bowel soundsareabsent.
III. Listenabovethe umbilicus over the aortafor arterialbruits.
IV. Listen2-3cm lateralto the umbilicus for bruitsfrom renal arterystenosis.
V. Listenover the Liverfor bruits.
VI. Listenfor Venous hum betweenthe Xiphisternum andumbilicus.
VII. Test for a succussion splash; thissounds likea half filled waterbottle being
shaken,normally heardwithin2 hrs aftera meal.

36. Definitions
• Normal bowel sounds are gurgling noises occurring every 5-10
seconds.
• A friction rub, which sounds like rubbing your dry fingers together,
maybe heard over the liver(Perihepatitis)and spleen
(Perisplenitis)
• Venous hum is heard between Xiphisternumand umbilicus due to
turbulence of blood flow in well developedcollaterals asa result
of portal hypertension.
• A bruit is an abnormal swishingor blowing sound from blood
flowing through a narrowed or partially occluded artery.

37. • Bruits can be auscultated over 5
structures :
I. Aorta - Just above umbilicus
II. Bilateral renal arteries – Right and
Left Lumbar regions on the mid
clavicular lines.
III. Bilateral iliac arteries – Right and left
iliac regions
IV. Hepatic Artery – Right Hypochondriac
region on the right mid clavicular line
V. Splenic Artery – Left Hypochondriac
region on the left mid clavicular line

38. References
o Auscultation Skills– Breath& HeartSounds by Jessica ShankCoviello, 5th
Edition– For Examinationof CVS(Heart)andRespiratorySystem.
o R Alagappan– Manual of PracticalMedicine,6th Edition– For Examinationof
Gastrointestinalsystem (Introduction,regionsof abdomen,definitions)
o Macleod’sClinicalExamination,14th Edition– For Examinationof
GastrointestinalSystem (AuscultationSequence)
o https://www.medmastery.com/guides/abdominal-examination-clinical-
guide/how-auscultate-abdomen- For Auscultation of Bruits

39. THANK YOU