Auscultation Practice: Where to Place the Stethoscope, Normal vs Adventitious Lung Sounds and How to Train Your Ear

Published · By VMS, Alehundred Studios

Auscultation practice works when you listen at the same sites, in the same order, every time: five areas over the heart, matched points on both sides of the chest for the lungs, and a short list of normal and adventitious sounds to name. A fixed route plus repeated, scored listening is what turns the stethoscope into a skill.

The bar is high. In a randomized trial of new graduate nurses published in the Nagoya Journal of Medical Science, 87.0% of the pre-test answers for fine crackles were incorrect, and the authors note that "clinical experience does not necessarily lead to the acquisition of lung auscultation skills." Below are the sites, the sounds and a practice plan for medical, PA, nursing and EMS students. For murmurs in depth, see our guide to heart sounds practice.

What are the auscultation sites of the heart?

The heart is auscultated over five classic areas, four along the sternum and one at the apex. A study in Scientific Reports that recorded heart sounds at each of them lists the landmarks:

  1. Aortic area: "the second intercostal space on the right sternal border"
  2. Pulmonic area: "the second intercostal space on the left sternal border"
  3. Erb's point (secondary aortic area): "the third intercostal space on the left sternal border"
  4. Tricuspid area: "the fourth intercostal space on the left sternal border"
  5. Mitral area: the apex, at the fifth intercostal space near the left midclavicular line

Treat these as starting points, not exact targets. The UC San Diego guide to the cardiovascular exam warns that "Valves are not strictly located in these areas," so listen in more places whenever you hear something abnormal.

At each site, start with the diaphragm (higher-pitched sounds) and "listen specifically for S1 and then S2." Then lay the bell (low-pitched sounds) lightly over the apex to look for an S3 or S4, ideally with the patient turned onto the left side. If you lose track of which sound is which, "You may find it helpful to tap out S1 and S2 with your fingers as you listen."

What are the auscultation sites of the lungs?

The lungs are auscultated at matched points on both sides of the chest, back, sides and front, comparing each spot with the same spot on the other side. MedlinePlus notes that normal lung sounds "occur in all parts of the chest area, including above the collarbones and at the bottom of the rib cage," so cover the whole chest.

The UC San Diego guide to the lung exam lays out a practical route:

  1. Start at the top of the back. "Listen over one spot and then move the stethoscope to the same position on the opposite side and repeat."
  2. Work down the back. "The entire posterior chest can be covered by listening in roughly 4 places on each side."
  3. Add the sides. The right middle lobe is heard in the right axilla and the lingula in the left axilla.
  4. Finish at the front. Listen to the anterior fields the same way, with the patient sitting upright.

Knowing the lobes helps you localize a finding: the lower lobes "occupy the bottom 3/4 of the posterior fields," while the upper lobes are heard "in the anterior chest and at the top 1/4 of the posterior fields."

Ask for slow, deep breaths through the mouth, a few coughs first to clear secretions, and a forced exhalation if you suspect wheezing. Always listen on bare skin, never through a gown. As the UCSD guide puts it, "You'll lose points on scored exams (OSCE, CPX, USMLE)!"

What are normal heart and lung sounds?

Normal heart sounds are S1 and S2, and normal lung sounds are soft vesicular breath sounds over most of the chest, with louder bronchial sounds over the trachea. The National Heart, Lung, and Blood Institute describes the heartbeat as a "lub-DUB" sound. "The 'lub' is the sound of these valves closing," meaning the valves between the atria and ventricles, and after the ventricles contract, "the aortic and pulmonary valves close and make the 'dub' sound."

In younger patients, S2 normally splits on inspiration: "pulmonic valve closure is delayed, allowing you to hear first A2 and then P2," per the UCSD guide.

For the lungs, a healthy person breathing through the mouth produces a soft sound on inspiration with little noise on expiration: vesicular breath sounds. Bronchial (tubular) breath sounds are the louder sounds normally heard over the trachea. Heard out at the edges of the chest, they point to consolidation, because "the consolidated lung acts as a terrific conducting medium."

Looking for normal heart sounds audio? Start with your own chest and your classmates'. Normal S1, S2 and vesicular sounds are what you will hear on almost everyone, so learn them live until they are automatic.

What are the adventitious lung sounds?

Adventitious lung sounds are abnormal sounds heard on top of the normal breath sounds, and they fall into two families. A systematic review in PLOS ONE explains that "Adventitious sounds can be classified into two categories, continuous and discontinuous, based on their duration." Wheezes, rhonchi and stridor are continuous; crackles and pleural rubs are discontinuous.

Do not forget decreased or absent breath sounds. MedlinePlus lists causes such as air or fluid in or around the lungs, a thicker chest wall, over-inflation (as in emphysema) and reduced airflow to part of the lungs.

How do you practice heart and lung sounds auscultation?

You practice heart and lung sounds auscultation by fixing the route, learning normal first, adding one abnormal sound at a time and testing yourself in random order. A plan that follows the evidence above:

  1. Fix the route. Five heart areas in the same order, then the lungs top to bottom and side to side. A fixed route keeps you from skipping a site under OSCE pressure.
  2. Learn normal cold. S1, S2, the S2 split, vesicular and bronchial sounds, on yourself and on classmates.
  3. Add one adventitious sound at a time. Move on only when you recognize the current one every time.
  4. Use the formal name, the side and the timing. Fine crackles at the right base, late in inspiration, is a finding; something crackly is not.
  5. Quiz yourself in random order. Shuffled sounds are closer to an exam than a playlist.
  6. Combine formats. In the Nagoya trial, paper-based material improved recognition of wheeze (p=0.004) and coarse crackles (p=0.035), web-based material improved fine crackles (p=0.026), and the control group showed no significant change. The authors suggest that combining the two "may be more effective."
  7. Finish with a timed station. Run the whole exam, from introduction to closing, against the clock.

For heart murmur practice questions, use the UCSD guide's list: systole or diastole? Crescendo-decrescendo or constant? How loud, from 1/6 to 6/6? Where is it loudest, and where does it radiate?

What should a lung sounds quiz for nursing include?

A good lung sounds quiz for nursing includes normal sounds, the main adventitious sounds and diminished or absent sounds, played in random order, with answers given by formal name and side. That is the format the Nagoya trial used: seven sounds, "normal," "wheeze," "rhonchi," "coarse crackles," "fine crackles," "left lung diminish," and "right lung absent," played randomly on a physical assessment simulator.

Its pre-test shows where new nurses struggle. The share of incorrect answers was 98.6% for a diminished left lung, 91.3% for an absent right lung, 87.0% for fine crackles, 69.6% for coarse crackles, 53.6% for rhonchi, 26.1% for wheeze and 10.1% for normal sounds. Quiet findings are the hardest, so always compare sides, and give fine crackles extra repetitions.

Does the USMLE test heart sounds with audio?

Yes: the official USMLE practice software includes audio items. The Step 1 question formats page states that "The Step 1 interactive testing experience includes items with associated audio findings" and tells candidates to "Become familiar with how these types of test items function before your test day." For Step 2 CK, the question formats page lists "items with audio or video findings" in its interactive testing experience.

So USMLE heart sounds practice should play the sounds and make you place each one in the cardiac cycle before naming the diagnosis. Our heart sounds practice guide covers S1 to S4 and murmur grading.

Where does VMS fit in auscultation practice?

VMS, the Virtual Medical Simulator, is not a sound library. It trains the encounter around the stethoscope, which an OSCE station scores along with your ears. On a PC (mouse and keyboard) or in VR (laser pointer), you pick your program (Medicine, Physician Assistant, Nursing or EMS) and run a case as an OSCE station: one virtual patient, a step-by-step checklist and a score from 0 to 100%. You introduce yourself, gain consent, wash your hands or put on gloves, examine the patient with your hands (palpate, auscultate, take a pulse) and with tools such as the stethoscope and reflex hammer, and close the encounter.

Practice in Teach or Train mode, then press the OSCE exam button for a random patient in Test mode, with no hints and a time limit. Attempts are saved to your account, and educators see results per student. VMS comes with 3 free cases, so you can try the whole workflow without paying. A subscription unlocks every case, and a subscriber can share their cases with friends or classmates in multiplayer, as long as the subscriber hosts the session and stays connected. For the full exam sequence, see our head-to-toe assessment for nursing guide.

FAQ

What are the auscultation sites of the heart?

Aortic (2nd intercostal space, right sternal border), pulmonic (2nd intercostal space, left sternal border), Erb's point (3rd intercostal space, left sternal border), tricuspid (4th intercostal space, left sternal border) and mitral (the apex, 5th intercostal space near the left midclavicular line).

What are the auscultation sites of the lungs?

Matched points on both sides: roughly four on each side of the back, both axillae for the right middle lobe and lingula, and the anterior chest for the upper lobes, comparing each point with its twin.

What is the difference between crackles, wheezes and rhonchi?

Crackles are brief, non-musical pops, fine late in inspiration or coarse early in inspiration. Wheezes are high-pitched continuous sounds from narrowed airways, mostly on expiration. Rhonchi are low-pitched, snoring sounds from secretions or rough flow in the large airways.

What is a list of abnormal heart sounds?

S3 and S4 (normal up to the ages of 20 to 30, pathologic in older patients), systolic murmurs such as aortic stenosis and mitral regurgitation, and diastolic murmurs such as aortic regurgitation and mitral stenosis. Our heart sounds practice guide covers each one.

How do you practice for a lung sounds quiz in nursing school?

Learn normal sounds first, add one adventitious sound at a time, then quiz yourself in random order, answering with the formal name and the side. Give extra time to fine crackles and diminished or absent sounds.

Does the USMLE include heart sounds audio?

Yes. The official USMLE interactive testing experience includes items with audio findings for Step 1 and items with audio or video findings for Step 2 CK, so practice with audio.

Sources

  1. MedlinePlus, National Library of Medicine. Breath sounds. 2025.
  2. MedlinePlus, National Library of Medicine. Stridor. 2026.
  3. MedlinePlus, National Library of Medicine. Wheezing. 2026.
  4. National Heart, Lung, and Blood Institute. How the Heart Works: How the Heart Beats. NIH.
  5. Goldberg C. The Lung Exam. Practical Guide to Clinical Medicine, UC San Diego School of Medicine.
  6. Goldberg C. Cardiovascular Exam. Practical Guide to Clinical Medicine, UC San Diego School of Medicine.
  7. Wang JK, Chang YF, Tsai KH, et al. Automatic recognition of murmurs of ventricular septal defect using convolutional recurrent neural networks with temporal attentive pooling. Scientific Reports, 2020.
  8. Pramono RXA, Bowyer S, Rodriguez-Villegas E. Automatic adventitious respiratory sound analysis: A systematic review. PLOS ONE, 2017.
  9. Higashiyama S, Tamakoshi K, Yamauchi T. Effectiveness of a new interactive web teaching material for improving lung auscultation skills: randomized controlled trial for clinical nurses. Nagoya Journal of Medical Science, 2022.
  10. United States Medical Licensing Examination. Step 1 Test Question Formats. USMLE.
  11. United States Medical Licensing Examination. Step 2 CK Test Question Formats. USMLE.