Physical Examination
General Examination:
The patient may have a cyanotic appearance, clubbing of the fingers, or abnormal facies (part of a syndrome).
Radial and brachial pulses will be weak on the Blalock Tussig shunt side (consider if there is a lateral thoracotomy scar on the same side)
Blood pressure should be checked on both arms to detect a wide pulse pressure to look for aortic regurgitation, and the side contralateral to any shunt should be used.
Precordial Inspection:
The patient may have a visible midline sternotomy scar on the chest from total correction surgery or lateral thoracotomy scar due to a Blalock-Taussig shunt.
The patient may have a Corrigan's pulse suggesting aortic regurgitation (a complication following repair surgery or due to associated aortic root disease).
The patient may have a pacemaker or implantable cardioverter-defibrillator (ICD) for sustained complete heart block postoperatively or for treatment of malignant ventricular arrhythmias.
Palpation:
The patient may have a thrill palpable along the left sternal edge from a residual ventricular septal defect (VSD) or residual right ventricular outflow tract (RVOT) obstruction.
There may be a left parasternal heave suggestive of RV pressure overload.
Auscultation:
A pansystolic murmur may be heard at the apex with radiation to the axilla due to mitral regurgitation.
A pansystolic murmur may be heard at the left sternal edge that increases in intensity with inspiration due to tricuspid regurgitation.
A loud pansystolic murmur may be heard at the left sternal border due to residual VSD.
An early diastolic murmur may be heard at the third left intercostal space accentuated with expiration and leaning forward due to aortic regurgitation.
An ejection systolic murmur may be heard in the pulmonary area due to RVOT obstruction or pulmonary stenosis or a flow murmur (if the valve is replaced)
An early diastolic murmur may be heard in the pulmonary area due to pulmonary regurgitation.
An early diastolic murmur may be heard in the aortic area due to aortic regurgitation.
The second heart sound may be soft due to pulmonary regurgitation and aortic regurgitation, and if present, it is usually single due to absence of the pulmonary component.
What constitutes Tetralogy of Fallot?
Complications of TOF