Tetralogy of fallot physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, M.B.B.S. [2], Keri Shafer, M.D. [3]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [4]

Overview

Tetralogy of Fallot is associated with cyanosis, clubbing, a thrill and a harsh systolic ejection murmur over the left sternal border.

Physical Examination

Appearance of the Patient

• The patient may be small due to a failure to thrive. Patients may be found in squatting position (compensatory mechanism).

Skin

• Central cyanosis may be present.
• Cyanosis is most prominent at lips and nail beds.

Eyes

• Retinal engorgement may be present.

Heart

Palpation

• A thrill may be present at left sternal border.
• A right ventricular impulse may be prominent.

Auscultation

Heart Sounds

• First heart sound (S1) is normal
• Second heart sound (S2) is single as P2 is absent.

Murmurs

• A harsh systolic ejection murmur best heard at the left sternal border is usually present. The loudness and length of systolic murmur is inversely proportional to the severity of right ventricular outflow tract obstruction (RVOTO). In other words as the RVOTO worsens, the murmur softens. The more cyanotic the patient, the softer the murmur.
• As the RVOTO progresses towards occlusion the right ventricular blood is diverted to left ventricle through ventricular septal defect. This causes the pulmonic murmur to become shorter and softer. P2 is faint and delayed in mild cyanosis and inaudible in severe cyanosis.
• A diastolic murmur may be heard due to aortic regurgitation.

Extremities

• Clubbing
• Cyanosis