Clinical Diagnostics- Thoracic, Respiratory & Cardiology

Veterinary

What are the 7 GENERAL parameters of an animal’s body that need to be evaluated when assessing the respiratory system in a clinical exam?

1. Lymph nodes of the head, neck, and thorax; 2. Nares and nasal mucous membranes; 3. Paranasal sinuses; 4. Oral cavity & pharynx; 5. Neck including the larynx and trachea; 6. Thoracic cavity- physical attributes, physical capabilities and lungs; 7. Breathing parameters

What is the examination scheme with normal findings for Lymph Nodes?

Size- Varies by species; Cow 3-5 cm in length, horse ≤4 cm in length

Shape- Varies by species; bean-shaped/elongated shape with a smooth contour

Consistency- Tightly elastic

Symmetry- Symmetrical

Surface of Lymph node- Smooth, except for horse mandibular lymph node (grainy)

Fluctuation- No fluctuation or discharge or on palpation

Movability- Easily movable, overlying skin and lymph node

Temperature of overlying skin- ordinary and evenly distributed

Pain reaction- painless on palpation

Which lymph nodes should be evaluated throughout the head, neck and thorax?

Head: Mandibular or submandibular, parotid, retropharyngeal; Neck: Superficial cervical; Thorax: Axillary

What is the examination scheme with normal findings for evaluating Nares & Nasal Mucous Membranes during a clinical exam?

Surrounding area- Clean

Breathing sounds- Silent

Exhaled air- Warm, humid, and exhaled symmetrically from both nostrils

Discharge- Without discharge

Nasal mucous membranes

Surrounding area- Clean

Colour- Pink-pale (cats & ruminants) / pale-pink (dogs & horses)

Smoothness- Smooth

Discharge- Without discharge

Capillary refill time- ≤2 sec

What is the examination scheme with normal findings for Paranasal Sinuses when conducting a clinical exam?

Bone structure, consistency & symmetry- Solid & symmetrical

Temperature of overlying skin- Ordinary

Pain reaction- No pain reaction

Percussion sound- Tympanic

What are the names of the paranasal sinuses that need to be evaluated?

Sinus frontalis (Frontal sinus) and Sinus maxillaris (Maxillary sinus)

What is the examination scheme with normal findings for an oral cavity + pharynx (cranial neck) assessment during a clinical exam?

Surrounding area- Clean

Content in the oral cavity- Average amount of saliva

Smell of oral cavity- Species specific

Mucous membranes- Smooth, dewy, shiny

Capillary refill time- ≤ 2 sec

Tongue- Ordinary, mobile

Teeth, occlusion- Ordinary occlusion (bite), teeth are undamaged and without pathological sharp edges

Cranial neck (pharynx)

Position & movement of head and neck- Ordinary

Symmetry- Symmetrical without swelling

Pain reaction- No pain reaction

Temperature of overlying skin- Ordinary, evenly distributed

What are the examination schemes for both Larynx & Trachea with their normal findings during a clinical examination?

Larynx

Surrounding area- Clean

Laryngeal cartilage- Smooth, elastic

Pain reaction- No pain reaction

Breathing sounds- Laryngeal

Palpation-induced cough- Cough not induced

Trachea

Surrounding area- Clean, without volume changes

Breathing sound- Tracheal

Pain reaction- No pain reaction

Tracheal cartilage- Smooth, elastic

Tracheal Endoscopy

• Mucous colour- pale

• Form & movement of tracheal lumen- Species specific, during breathing phase trachea is not significantly flattened

• Content (mucus, phlegm, foreign body etc)- Small amounts of transparent mucus

What are the examination scheme parameters and their normal findings that need to be evaluated in the thoracic region during a clinical exam to assess respiratory conditions?

Thorax

Shape & Volume- Slightly round & elongated

Pain reaction- No pan reaction on palpation or percussion

Palpable sounds (fremitus pectoralis)- Not present

Breathing

• Frequency (Breaths/min)- Dogs, Cows & Camelids 10-30; Cat 20-40; Horse 8-16; Sheep & Goat 12-20; Pigs 10-20; Rabbit 35-100; Ferret 30-40; Rat & hamster 40-120

• Type- Costoabdominal in most species; dogs more costal; horses biphasic; ruminants slightly more abdominal

• Quality & rhythm- Consecutive inhalation-exhalation-pause

• Depth- Adequate

• Symmetrical movement of the thoracic walls- Symmetrical

• Presence of Dyspnea- Not observed

Lung Auscultation

• Normal breathing sounds- Normal breathing sounds

• Abnormal breathing sounds- Not observed

Lung Percussion

• Percussion sound-

  • clear, loud & atympanic for large animals

  • clear, loud & tympanic for small animals

• Percussion/lung borders-

  • Dorsal border- 4-6 cm from the processus transversus

  • Caudoventral borders

    • Tuber coxae: Horse 16th intercostal space; Cow 12th rib; Dog/cat 11th rib; Pig 11/12th rib

    • Tuber Ischii: Horse 14th intercostal space; Dog/cat 11th rib; Pig 10th rib

    • Articulatio humeri: Horse 10th intercostal space; Cow 8th rib

What are the respiration ratios for Horses, Cattle, Dogs & Pigs?

Horse 1:1.8; Cow 1:1.2; Dog 1:1.64; Pig 1:1

What are the two types of tachypnea?

1. Polypnea

2. Hyperpnea

Define Polyp- & Hyper-pnea

Polypnea- A type of tachypnea that is characterised by fast and shallow respiration.

Hyperpnea- A type of tachypnea that is characterised by fast and deep (increased amplitude) respiration

How will polypnea physically present in a patient?

Polypnea is can be caused by anxiety, painful or restrictive conditions in the thorax resulting in more respiration stemming from the abdominal part of the body than the thoracic.

How will hyperpnea present physically in a patient?

Hyperpnea is caused by physiological states resulting in hypoxemia, hypercapnia, acidosis and/or pain. This will usually present as greater costal breathing in an attempt to to balance gases, electrolytes and temperatures

What are two ways a decreased respiratory rate (bradypnea) can present? And what is a potential cause of each

1. Slow & shallow- CNS depression or metabolic alkalosis

2. Slow & deep- Occasionally from severe airway obstruction

What are the 9 respiratory rhythm disorders and what is a condition or example of each?

1. Increase of inspiratory phase- Upper respiratory tract pathologies (stenosis) in brachycephalic breeds

2. Increase in expiratory phase- Lower respiratory tract pathologies in the bronchi and alveoli

3. Jerky respiration- One or both phases (inspiration or expiration) are divided and jerky. Caused when there is pain during respiration in cases of peritonitis and pleuritis

4. Two-phased inspiration- First part of inspiration is short, and second is long. Also caused by pain; pleuritis, traumatic reticuloperitonitis, pericarditis

5. Two-phased expiration- First part of expiration is passive followed by a second part that is active. Seen in cases of lower respiratory tract pathologies in the small bronchi, alveoli, asthma, RAO. Passive expiration isn’t sufficient for emptying the lungs

6. Cheyne-stokes Respiration- Intermittent apneic periods with gradually increasing and decreasing respiration. Associated with CNS diseases

7. Biot’s respiration- Periodic apnea where breathing amplitude remains deep and uniform. CNS disorders

8. Kussmaul Respiration- Deep, laboured breathing pattern associated with severe metabolic acidosis or diabetic ketoacidosis

9. Grocco’s Dissociated Respiration- Uncoordinated action between respiratory muscles in acidosis, CNS disorders or uremias

What is the definition of asphyxia?

A fast progressing form of dyspnea that causes severe hypoxemia and pulmonary edema

What are the three types of dyspnea and what areas of the respiratory tract typically have pathologies for each type?

1. Inspiratory- Upper respiratory obstruction, restrictive lung disease, space-occupying lesions. Accompanied by stridor

2. Expiratory- Lower respiratory tract, Heaves/RAO

3. Mixed- Lungs, General laboured breathing caused by lung pathologies, cardiac disease or anemia

Define Pectus excavatum

Dorsal deviation of the caudal sternum and the associated costal cartilages OR a ventral to dorsal narrowing of the thorax

Define Pectus carinatum

‘Pigeon chest’ a ventral protrusion of the sternum

What causes palpable sounds when referring to respiration?

Vibrations of the thoracic wall in cases of severe fibrinous pleuritis, endocarditis and pericarditis

What is acoustic percussion?

A non-invasive technique for detecting pleural and superficial parenchymal lesions by detecting changes in resonance or dullness.

What are the lung percussion borders for horses?

Dorsal: 4-6 cm from the processus transversus

Caudoventral: Tuber coxae 16th intercostal space, Tuber ischia 14th intercostal space, Articulatio humeri: 10th intercostal space

What are the lung percussion borders for cows?

Dorsal: 4-6 cm from processus transversus

Caudoventral: Tuber coxae 12th rib, Articulatio humeri 8th rib

True or False: Small animal lung percussion will sound Clear, loud and atympanic

False- Clear, loud and tympanic. Large animals will have an atympanic sound

Which type of percussion technique is more useful in detecting larger lung lesions; Finger-Finger or Hammer-Pleximeter?

Hammer-pleximeter

In the cranioventral part of the lung percussion area, there is a spot that has a dull sound in comparison to other lung areas. What is this called?

Cardiac Notch or Cardiac dullness

What pattern should lung percussion be performed in?

Begin from the craniodorsal aspect of the thorax and move dorsal to ventral inside each intercostal space. Perform on both sides of the thorax

What are five pathological changes to lung percussion borders?

1. Increased percussion area

2. Extension of the area to the costodiaphragmatic juction

3. Local protrusion of the caudoventral border

4. Cranial recession of caudoventral border (reduction in lung volume)

5. Changes of the area around the region of the heart

What are 3 reasons why the sound of lung percussion would be dull and empty?

1. Consolidation

2. Tissue formation that does not contain air

3. Fluid accumulation

What are 3 other sounds that can be detected during lung percussion?

1. Tympanic

2. Cracked-pot sound (Olla rupta)

3. Metallic

What the instances where a tympanic sound could be heard during lung auscultation?

1. Pulmonary tissue has become more dense but still contains air (pneumonia, congestion)

2. Severe Pneumothorax in large animal

3. Diaphragmatic hernias- gas-containing abdominal organs get trapped in the thoracic cavity

4. Small animal auscultation

What could be a cause of an increased bilateral lung percussion area? What could be a cause of a unilateral increase?

Bilateral- asthma syndromes, alveolar emphysema. Pronounced around Tuber coxae level

Unilateral- Compensatory emphysema when the contralateral lung function is reduced or absent due to pneumonia, exudative pleuritis etc)

What could be the cause of local caudoventral lung percussion border protrusion?

Compensatory emphysema on the caudoventral lung regions

What are two reasons for a cranial recession of the caudoventral lung percussion border (reduced lung volumes)?

1. Abdominal organ sizes have increased (splenomegaly, neoplasias, luminal distention etc)

2. Consequence of lung or pleural disease (atelectasis, after correcting pneumothorax/hydrothorax/exudative pleuritis)

What could cause the extension of the lung percussion field until the costabdominal junction?

Gives the impression that lungs fill the entire thorax. Might be seen in cases of uni- or bi-lateral pneumothorax

Why might there be changes of the lung percussion area at the level of the heart?

Likely caused by changes of the heart percussion area due to heart disease, diseases of the cardiac muscles, pericardium, presence of neoplasias etc.

True or False: Lung percussion is extremely useful in small animal diagnostics

False- use of visual diagnostics is superior in small animal

What general reasons could cause changes to lung percussion sound characteristics?

• Species

• size

• body condition

• age

What are the two types of categories to describe deformities of the thorax?

• Acquired

• Congenital

What are some causes of acquired thoracic deformities?

• Nutritional deficiencies due to alimentary dystrophies

• Traumas to the thoracic region

• Respiratory diseases

What are the congenital deformities of the thorax?

• Pectus excavatum

• Pectus carinatum (pigeon chest)

Definition dyspnea

Difficult or laboured breathing characterised by excessive and obvious movements or expansion of the thoracic and abdominal walls with each breath

What occurs during dyspnea?

Impaired gas exchange and may cause cyanosis

What signs are animals likely to exhibit when experiencing dyspnea?

• Anxious facial expressions

• Preference of standing or sternal recumbency

• Elbows may be abducted from the chest and thorax

• Head and neck extended and held horizontal to the ground to reduce airflow resistance

• Potential sweating

Asymmetrical breathing can be observed in cases of…

• Unilateral pneumothorax

• Unilateral atelectasis

• Extensive lesions reducing function of one lung

• Unilateral painful conditions (rib fractures, pleuritis etc.)

If an animal is using primarily costal breathing, pathologically, what could this potentially indicate?

Lesions or pathologies often found on the diaphragm, or in the abdominal cavity. May indicate fluid accumulation or enlarged abdominal organs, or a painful diaphragm

If an animal is primarily using abdominal breathing, pathologically, what could this potentially indicate?

Lesions or pathologies are often located in the thorax. It may indicate fluid accumulation, painful thorax or reduced elasticity

What are the four types of agonal respiration rhythm disorders?

1. Cheyne-stokes

2. Biots

3. Kussmauls

4. Grocco’s

True or False: Most reptiles and amphibians have primitive, bag-shaped structures that do not contain mammalian-like alveolar structures

True. Turtles and some snakes do have lungs but they are different from mammalian structures

What does reptile breathing rate positively correlate with?

Positive ambient temperature

What produces normal breath sounds?

Large airways- Turbulent airflow in the trachea and bronchi. ‘H’ sound

Peripheral airways- No significant breathing sounds, laminar airflow. ‘F’ sound louder during inspiration but barely audible

What are the 3 types of airflow in the respiratory tract?

1. Laminar

2. Turbulent

3. Vortices

Explain the systematic pattern of lung auscultation during a clinical exam

1. Using a stethoscope, start at the larynx, move to the trachea and then the thorax at the level of the tracheal bifurcation.

2. Start the thoracic portion of the auscultation over the middle third of the thorax at the level of the heart

3. Monitor movements of the thoracic and abdominal walls simultaneously

4. Systematically move the stethoscope horizontally and vertically in the intercostal spaces in a checkerboard pattern

5. Listen to at least 2 breathing cycles

6. Re-auscultation of anomalies should be done and compared to normal areas

7. Repeat on other side of thorax

What state should be stimulated to auscultate a horse’s lung fields?

Hyperventilation by occluding the nostrils or using a re-breathing bag

What sound is likely to be heard when auscultating the cervical trachea of a horse?

Coarse crackles

To auscultate the cranial aspects of the lungs in horses and cattle, where should you place your stethoscope?

High up into the axilla

True or False: It is easiest to auscultate breathing sounds of South American Camelids over the larynx and trachea rather than thoracic cavity

True- dense fibre coats can making auscultation over the thorax difficult

Increasing sound transmission during auscultation can be caused by what two things?

1. Increase of tissue density (disease)

2. Non-air filled lung tissue

Diminished breath sound intensity can be caused by what two things?

1. Decreased lung inflation

2. Space-occupying lesions

What are two reasons why normal breath sounds would increase? And what are some examples

1. Hyperventilation

   • Exercise

   • Respiratory tract disease

   • Anxiety

   • Acidosis

   • High temperature

   • Cardiac failure

2. Localized lung sound changes if conducting airways to the affected lobes are occluded or if there is pleural effusion

   • Consolidation,

   • pulmonary edema,

   • atelectasis

What are three reasons why there would be decreased or absent breath sounds and provide examples

• Species with normally quiet or inaudible (horses esp)

• Obesity

• Regional loss of breath sounds

  • Space-occupying lesions in pleural cavity (air, fluid)

Decreased normal breath sounds can be categorized into ..

1. Diminished

2. Barely audible

3. Absent (respiratio nulla)

What are two types of adventitious breath sounds and their subcategories?

1. Crackles

   • Coarse

   • Fine

2. Wheezes

   • Expiratory

   • Inspiratory

How can wheezes be characterised?

• High pitched

• Low pitched (ronchi)

• Monophonic

  • Fixed - single note, constant pitch and timings = partial obstruction of a single airway

• Polyphonic- compromised by severe different notes of different pitches, timings and stopping/starting simultaneously = multiple airway obstructions

When can you expect to auscultate pleural friction?

When there are irregularities of the visceral and parietal pleura where they layers have become inflamed and start rubbing together

What type of sound can be expected on auscultation when there is an accumulation of gas and fluid in the thorax? What conditions can it be associated with?

Splashing

• Anaerobic infections in the pleural and pericardial cavities

• Pulmonary gangrene

• Traumatic lesions

List examples of extraneous audible sounds while auscultating

• Skin & hair

• Adventitious breath sounds can be mistaken for heart murmurs

• Muscular contractions

• GI sounds

• Purring

What is the cardiac examination scheme with normal findings?

Heart area

• Heart apex beat (ictus cordis) inspection- not visible

• Heart apex beat (ictus cordis) palpation- Palpable, moderately strong

  • Dogs, cats & horses- in the 5th intercostal space, at the apex of the heart

  • Cows- in the 4th intercostal space, at the base of the heart

• Palpable heart sounds (fremitus)- Not palpable

Heart percussion

• Percussion sounds

  • Dogs & horses- Absolutely muffled,

  • Cows & pigs- Relatively muffled

• Dorsal & Caudal percussion borders:

  • Cow: 1-2 cm under the shoulder joint at the 5th rib

  • Horse: 3-5 cm under the shoulder joint at the 6th rib

  • Dog: 1-2 cm under the shoulder joint at the 7th rib

Heart Auscultation

• Heart tones

  • Frequency

    • Dog 60-160

    • Cat 120-240

    • Horse 28-40

    • Cow 60-70

  • Loudness- Medium loud

  • Rhythm- Rhythmic

  • Punctum maximum/optimum- According to species

    • Dogs, cats & horses

      • Mitral valve in the 5th intercostal space, apex of the heart (S1), Pulmonary artery valve- 3rd intercostal space (S2), Aortic valve- 4th intercostal space (S2)

    • Cows

      • Mitral valve in the 4th intercostal space, based of the heart (S1), Pulmonary artery valve- 3rd intercostal space (S2), Aortic valve- 4th intercostal space above mitral valve (S2)

• Murmurs- Without murmurs

  • Phase

    • Present/absent

    • Systole/Diastole/Biphasic

  • Loudness (levels I-VI)

  • Characteristics (rising/falling)

What makes the S1 sounds and S2?

S1- Closures of AV (mitral & tricuspid) and beginning of contraction

S2- Close of semilunar valves due to isovolumic contractions

What are 4 symptoms that can be helping in diagnosing cardiac problems?

1. Colour of the mucous membranes

2. Venous pulse & jugular filling

3. Arterial pulse of the femoral artery, quality and rhythm

4. Pulse deficit

How could you recognize a drop in blood pressure without using a diagnostic instruments?

Looking at the colour of the mucous membranes- they will be pale or cyanotic

What are two potential causes of a positive jugular pulse?

Tricuspid insufficiency & pericardial effusion

What could a weak arterial pulse? What could cause a strong, jumping arterial pulse?

Weak- conditions with small stroke volumes & ejection fractions like DCM, Pericardial effusion, aortic stenosis

Strong, Jumping- Conditions with increased ejection fraction usually associate with Patent Ductus arteriosis, anaemia and hyperthyreosis

List and explain the types of heart rhythms

1. Irregular

   • Irregularities of the beat in a regular pattern = respiratory sinus arrhythmia

   • Irregular beats occurs without a pattern, chaotic = Extra-beats, atrial fibrillation

2. Equality

   • Unequal- extra-beats, atrial fibrillation

Where is the Ictus cordis located in horses, cows, dogs and dogs?

Dogs, cats & horses: in the 5th intercostal space at the apex of the heart

Cows: in the 4th intercostal space, at the base of the heart

What kind of pathological changes can occur at the Ictus cordis?

1. Reduced or disappeared

2. Increased or ‘knocking’

3. Abnormal location

4. Fremitus cardialis

What would some of the reasons for an increased/knocking ictus cordis?

• Fever, excitation, cachexia

• Heart failure

• Anemia

• Myocarditis

What could cause a reduced or disappearing ictus cordis?

• Pericardial or pleural effusions

• Neoplasias in the pericardium or thorax

• Emphysema increasing the lung volume

• Pneumothorax

• Obesity, thick body walls

How could the location of ictus cordis be altered?

• Increased abdominal pressure

• Neoplasias or abscesses in the thoracic cavity

• Effusions

• Dextrocardia

What are percussion borders for the heart in Horses, Cows and Dogs?

Horses: 3-5 cm below the shoulder and caudal to the 6th rib

Cows: 1-2 cm below the shoulder joint and caudal to the 5th rib

Dogs: 1-2 cm below the shoulder joint and caudal to the 7th rib

What type of cardiac percussion pathologies can be detected on examination?

1. Increased percussion area

2. Reduced percussion area

3. Percussion sounds

Define the Punctum maximum

Point of maximal impulse intensity felt against the chest wall and is the point of auscultation

What pattern is used to auscultate the heart?

Start by locating the punctum maximum (location specific to the species) on the left side of thorax; Mitral valve will offer the strongest and clearest audible heart sound. This will be located at caudal to the 4th rib in cows, and caudal to the 5th rib in horses, dogs and cats.

Move the stethoscope from the mitral valve to the pulmonary valve in the 3rd intercostal space, and the aortic valve will be in the 4th intercostal space and slightly dorsal to the locations of the other valves.

Then move to the right side of the thorax and locate the tricuspid valve which will be either in the 5th intercostal space (horses, cats and dogs) or 4th (cattle).

What are the 5 general heart sound pathologies?

1. Increased frequency (tachycardia)

2. Reduced frequency (bradycardia)

3. Muffled, quiet heart sounds

4. Increased volume of heart sounds

5. Gallop rhythms

What are some examples of why a patient would be experiencing tachycardia?

• Heart failure (compensatory)

• Tachyarrhythmias (atrial fibrillation, supra ventricular and ventricular tachycardia)

• Fever, pain, anaemia, dehydration

• Stress, excitement, fear

What are some examples of that could cause bradycardia?

• AV blocks, idioventricular rhythm

• Sinus bradycardia- hypothyroidism, hyperkalemia, hypothermia, medication

• Increased intracranial pressure

• Athletic and working animals

List reasons that would result in a muffled or quiet heart sound on examination

• Pericardial and pleural effusions

• Adiposity

• Diaphragmatic hernia

• Hypovolemia

• DCM

What could cause increased heart sound volume? What type of sounds change?

S1 sound- Chest wall thickness, sympathicotonia, tachycardia, arterial hypertension

S2 sound- Pulmonary hypertension (Cor pulmonale), systemic hypertension (louder towards the aorta)

What type of heart sound pathology is associated with changes in S3 and S4 phases?

Gallop rhythms

What kind of arterial pulse quality is associated with; Sinus rhythms, Sinus Tachy & Brady, Ventricular tachycardia, and supraventricular tachycardia and AV block?

Sinus rhythms- Normal

Sinus tachy- Normal/weak

Sinus Brady- Norma/strong

Ventricular tachy- very weak

Supraventricular tachy- weak

AV block- Normal

Name two heart rhythm irregularities that result in a chaotic pulse & pulse deficit

• Atrial fibrillation

• Frequent extrasystoles

How are heart murmurs characterised?

Extracardiac and intracardiac

List the three types of extracardiac murmurs

1. Pericardial

2. Pleuro-pericardial

3. Cardiopulmonary

Which extracardiac murmurs are associated with ‘friction’ and ‘squash’ sounds? And what causes these sounds

Pericardial & Pleuropericardial.

Friction is associated with fibrin or tumor in the pericardial sac or pleural cavity

Squashing sounds are associated with fluid and gas collecting in the the pericardial sac or pleural cavity

List the characteristics for each extracardiac murmur

Pericardial- not related to the heart cycle but is synchronous with the heartbeat. Associated with sounds of friction and squashing

Pleuropericardial- not related to the heart cycle and disappears or reduced when respiration stops. Associated with sounds of friction and squashing

Cardiopulmonary- Not related to the heart cycle. Synchronous with heart sounds, during systole this can be heard due to air circulating in the lungs. Produces ‘ffff’ sound at the end of inspiration. Not clinically significant

What are the types of intracardiac murmurs and what are their characteristics?

• Functional- always occurs in systole, silent, soft and at a higher frequency and can disappear

• Endocardial- structural changes causing a louder, scraping sound

  • Systolic

  • Diastolic

How are murmurs graded?

Murmurs are graded on a scale of I-VI and divided into two categories, holosystolic and pansystolic. Levels I-III are in the holosystolic category and mean normal heart sounds can still be heard in the presence of a murmur while intensity of the murmur increases. The pansystolic category includes levels IV-VI and means the murmur has intensified and normal heart sounds are no longer audible.

Which heart murmurs are best auscultated on the left side of the heart at the base? And at the apex?

Base

• Pulmonary & aortic stenosis

• Patent ductus arteriosus

Apex

• Mitral valve insufficiency

Which heart murmurs are best auscultated on the right side of the heart at the base? And at the apex?

Base

• Ventricular septal defect

Apex

• Tricuspid valve insufficiency (endocardiosis)

• Ventricular septal defect