Patients with an uncomplicated small-to-moderate size ventricular septal defect usually are asymptomatic, demonstrating neither cyanosis nor exercise intolerance. Typical physical findings of such a ventricular septal defect include a harsh systolic murmur that begins simultaneously with the first heart sound, heard best at the lower left sternal edge, normal splitting, respiratory variation and intensity of the second heart sound and a mid diastolic flow rumble at the apex, if the shunt is at least moderately large. There may be increased precordial impulses of both ventricles, but one would not expect only a right ventricular impulse. The murmur of right ventricular infundibular stenosis heard in tetralogy of Fallot can be misinterpreted as due to a small ventricular septal defect.