Patients with tetralogy of Fallot usually appear small due to a failure to thrive. Physical examination of patients with tetralogy of Fallot is usually remarkable for cyanosis, systolic thrill, systolic ejection murmur, and Clubbing.

• Patients with tetralogy of Fallot usually appear small due to a failure to thrive
• Patients may be found in squatting position (compensatory mechanism)

• Tachycardia with regular pulse
• Tachypnea

• Cyanosis may be present

• Retinal vessels engorgement may be present

• Neck examination of patients with tetralogy of Fallot is usually normal.

• Pulmonary examination of patients with tetralogy of Fallot is usually normal.

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

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

• 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.

• Abdominal examination of patients with tetralogy of Fallot is usually normal.

• Clubbing
• Cyanosis is most prominent at lips and nail beds

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