AuscultifyCardiac Auscultation Areas: APETM and the 5 Sites of the Heart
There are five cardiac auscultation areas: Aortic (2nd right intercostal space at the sternal border), Pulmonic (2nd left intercostal space at the sternal border), Erb's point (3rd left intercostal space), Tricuspid (4th to 5th left intercostal space at the lower left sternal border) and Mitral or apex (5th left intercostal space at the midclavicular line). The mnemonic is APETM, remembered as "All Physicians Take Money" or "APE To Man". Listen in that order, top right to bottom left.
The heart and lung sites hub gives the overview; this page covers the cardiac sites in detail, including the four-area version, how to find each landmark and which positions bring each sound out.
The five areas at a glance
| Area | Landmark | Best heard | Common murmurs | Chest piece |
|---|---|---|---|---|
| Aortic | 2nd right ICS, right sternal border | A2, S2 | Aortic stenosis (radiates to carotids), aortic root AR | Diaphragm |
| Pulmonic | 2nd left ICS, left sternal border | P2, S2 splitting | Pulmonic stenosis, ASD flow murmur, Graham Steell PR | Diaphragm |
| Erb's point | 3rd left ICS, left sternal border | Both S1 and S2 roughly equal | Aortic regurgitation, HCM, innocent flow murmurs | Diaphragm |
| Tricuspid | 4th to 5th left ICS, lower left sternal border | S1, right-sided S3 and S4 | Tricuspid regurgitation, VSD, tricuspid stenosis | Diaphragm, then bell |
| Mitral (apex) | 5th left ICS, midclavicular line | S1, left-sided S3 and S4 | Mitral regurgitation (radiates to axilla), mitral stenosis, MVP | Diaphragm, then bell |
APETM, All Physicians Take Money and APE To Man
All three versions encode the same top-right to bottom-left sweep. "All Physicians Take Money" is the older four-area form (Aortic, Pulmonic, Tricuspid, Mitral). "APE To Man" adds the E for Erb's point between pulmonic and tricuspid.
The 4 auscultatory areas: where Erb's point went
Many nursing texts and older physical diagnosis books teach four auscultatory areas, one per valve, and skip Erb's point. Nothing is lost anatomically: Erb's point is not a valve area. It earns its place in the five-site version because the diastolic murmur of aortic regurgitation is often loudest there, because S2 splitting is easy to assess there, and because it sits where the aortic and pulmonic outflow tracts overlap so both semilunar valves project sound to it. If your school teaches four, add Erb's point anyway when you are looking for AR.
The second pulmonic area
"Second pulmonic area" is an older name for the 3rd left intercostal space, the same spot as Erb's point. You will also see it called the second aortic area. The two names reflect the same fact: the sound of both semilunar valves reaches this space. When someone documents a murmur at the "second pulmonic area", read it as 3rd left ICS at the sternal border.
How to find the landmarks
- Find the sternal notch at the top of the sternum, then run your finger down about 5 cm to the horizontal ridge where the manubrium meets the body of the sternum. This is the angle of Louis (sternal angle).
- Slide laterally from the angle of Louis onto the rib that attaches there. That is the 2nd rib. The space immediately below it is the 2nd intercostal space: aortic area on the right, pulmonic on the left.
- Walk your fingers down one space at a time along the left sternal border: 3rd ICS (Erb's point), 4th and 5th ICS (tricuspid area).
- For the apex, count to the 5th left ICS and move laterally to the midclavicular line, the vertical line through the midpoint of the clavicle. Palpate for the apex beat; if you can feel it, listen there, since it moves lateral and inferior in a dilated heart.
In women, ask permission and gently displace breast tissue upward or laterally to reach the apex. Listening through the breast muffles everything.
Sequence and positions
Begin supine at 30 to 45 degrees with the diaphragm, sweeping A, P, E, T, M. At each site identify S1 and S2 first, then listen to systole and diastole separately. S1 is loudest at the apex and tricuspid area, S2 at the base; palpating the carotid confirms which is which. Then repeat the apex and lower left sternal border with the bell for low-pitched sounds. Two additional positions complete the exam:
- Left lateral decubitus: roll the patient onto the left side and listen at the apex with the bell. This brings the apex against the chest wall and is the best position for S3, S4 and mitral stenosis.
- Sitting forward, breath held in end-expiration: listen with the diaphragm at Erb's point and the aortic area. This is the position for aortic regurgitation and pericardial rubs.
Chest piece selection is covered in the bell vs diaphragm guide.
Radiation sites
Some murmurs are heard beyond the five areas, and checking these spots is part of the exam. Aortic stenosis radiates to the carotids, so listen over both carotid arteries with the patient briefly holding their breath. Mitral regurgitation radiates to the left axilla; a posteriorly directed jet can even reach the back. Aortic regurgitation from the valve tends to radiate down the left sternal border, whereas AR from a dilated root radiates down the right. The systolic murmur of coarctation is heard over the left interscapular area.
Sites are where sounds are loudest, not where valves sit
All four valves lie close together behind the sternum, roughly along a line from the 3rd left costal cartilage to the 6th right costal cartilage. The auscultation areas are spread across the precordium because sound travels downstream with the blood: aortic valve sounds follow the ascending aorta up and to the right, pulmonic sounds follow the pulmonary trunk up and to the left, and mitral sounds are heard where the left ventricle touches the chest wall at the apex.
Learn where and what together in Auscultify
Every recording in Auscultify's library is tagged with the real site where it was captured, so an aortic stenosis clip sounds the way it does at the 2nd right ICS and a mitral stenosis rumble the way it does at the apex. The Landmarks quiz mode puts a chest-wall map in front of you and asks you to place each sound at the correct site, and missed placements come back sooner through spaced-repetition weighting.
Drill the sites free →FAQ
What are the 5 areas of the heart for auscultation?
Aortic (2nd right ICS at the sternal border), pulmonic (2nd left ICS at the sternal border), Erb's point (3rd left ICS), tricuspid (4th to 5th left ICS at the lower left sternal border) and mitral or apex (5th left ICS at the midclavicular line). The mnemonic is APETM: All Physicians Take Money, or APE To Man.
What are the 4 auscultatory areas?
The four-area version drops Erb's point and keeps aortic, pulmonic, tricuspid and mitral, remembered as All Physicians Take Money. Erb's point is added in the five-area version because aortic regurgitation and S2 splitting are often best heard there.
Where do you place the stethoscope for heart sounds?
Start at the 2nd right ICS beside the sternum, move to the 2nd and then 3rd left ICS, slide down the left sternal border to the 4th to 5th space, and finish at the apex in the 5th left ICS at the midclavicular line. Use the diaphragm at every site, then repeat the apex and lower sternal border with the bell.
Where is the pulmonic area?
The pulmonic area is the 2nd left intercostal space immediately beside the sternum. Find the angle of Louis, slide left onto the 2nd rib and drop into the space below it. It is the best place to hear P2, S2 splitting and pulmonic stenosis.
What is the second pulmonic area?
The second pulmonic area is another name for Erb's point, the 3rd left ICS at the sternal border. It is also called the second aortic area, because both semilunar valves project sound here and the murmur of aortic regurgitation is often loudest at this spot.
Where are S1 and S2 heard best?
S1 is loudest at the apex and tricuspid area, because it comes from mitral and tricuspid closure. S2 is loudest at the base, at the aortic and pulmonic areas, because it comes from aortic and pulmonic closure.