Tracheal
Harsh · I ≈ E
Directly over the trachea. Very loud and high pitched. Rarely assessed deliberately, but it is the reference for what raw airway sound is like.
Paramedic assessment · Field reference
Auscultation is not random placement. Every site sits over a specific lobe or downstream
of a specific valve, and the sequence exists so you compare left against right at the same
level before moving down. Select any marker to see what sits underneath it.
The prehospital minimum is six points — apices, bases, and the lateral chest — marked here
with a dashed halo — the four-point anterior pattern in your textbook figure, plus the
lateral pair. The six posterior points replace them when the patient can be sat forward.
Everything unmarked belongs to the comprehensive exam.
Start here
Each marker carries its surface landmark, the structure beneath it, and what an abnormal finding there means.
The numbering follows the order you actually work in — side to side at each level, then down. That ladder pattern is the whole point: a crackle only means something if you know the other side sounded different.
Harsh · I ≈ E
Directly over the trachea. Very loud and high pitched. Rarely assessed deliberately, but it is the reference for what raw airway sound is like.
Loud, high · I < E
Over the manubrium. Expiration is longer than inspiration with a distinct pause between. Heard out in the periphery, it signals consolidation — solid lung transmits sound better than air.
Medium · I = E
First and second intercostal spaces beside the sternum, and between the scapulae posteriorly. Sits over the major bronchi, so it is a blend of the two extremes.
Soft, low · I > E
Over most of the peripheral lung fields. Inspiration is roughly three times expiration with no pause. This is what the majority of your sites should sound like.
Start of systole · Loudest at apex
Closure of the mitral and tricuspid valves as the ventricles begin to contract. Higher pitched and slightly longer than S2. Use the diaphragm. S1 coincides with the carotid upstroke, which is how you confirm which sound you are hearing.
End of systole · Loudest at base
Closure of the aortic and pulmonic valves as the ventricles relax. Shorter and higher pitched than S1. Splitting into two audible components on inspiration is normal at the pulmonic area — inspiration delays pulmonic closure by increasing right-sided venous return.
Early diastole · Bell at apex
Low-pitched thud as blood rushes into a ventricle that is already full or poorly compliant. Normal in children, athletes and pregnancy. In an adult over about 40 with dyspnea, it is one of the strongest bedside indicators of heart failure and volume overload.
Late diastole · Bell at apex
The atrium contracting against a stiff ventricle, just before S1. Associated with long-standing hypertension, ventricular hypertrophy, aortic stenosis and acute ischemia. It cannot exist in atrial fibrillation, because there is no organized atrial contraction to produce it.
Turbulent flow · Graded I–VI
Blood moving through a narrowed or leaking valve. Describe four things: timing (systolic sits between lub and dub, diastolic after dub), location, radiation, and pitch. Right-sided murmurs get louder on inspiration; left-sided ones do not.
Scratchy, leathery · Erb’s point
Inflamed pericardial surfaces grinding together, often with a to-and-fro quality across the cycle. Suggests pericarditis. Unlike a pleural rub, it persists when the patient holds their breath — a distinction you can make in the back of the truck.
Time-critical · Any site
Fluid in the pericardial sac damping the sound. With jugular venous distension and hypotension, that is Beck’s triad and points at cardiac tamponade. Obstructive shock — the pump is intact but cannot fill. Consider it in penetrating chest trauma and after CPR.
Honest expectations
A moving ambulance, road noise and a clothed patient defeat most of the subtle findings above. Get S1 and S2 and their rate and regularity, listen for muffling, and note anything obviously abnormal. Do not document a murmur grade you could not actually hear.
These apply to both systems. Most missed findings are not subtle pathology — they are a diaphragm on a shirt, half a breath, or a side never compared against the other.