List the classic clinical  findings  on praecordial  examination  in a patient with 
Tetralogy of Fallot.

[Click here to toggle visibility of the answers]

College Answer

List the classic clinical  findings  on praecordial  examination  in a patient with 
Tetralogy of Fallot.

•     ESM or PSM
•     Right ventricular heave
•     A loud single second sound


Tetralogy of Fallot has a constellation of physical examination findings which the savvy candidate will have to memorise, unless they are constantly dealing with ToF patients.

Basically, the pathology is a sort of pulmonic stenosis, a VSD and RV hypertrophy.

The right ventricular heave is to be expected with RVH.

The ejection systolic murmur in the parasternal region may be either aortic or pulmonic in origin, but most typically is due to RVOT obstruction by the hypertrophied walls. It has a harsh crescendo-decrescendo quality, and tends to diminish as the contractility increases (because as the RV works harder, more blood is shunted to the left venticle across the VSD, and less blood travels via the RVOT thus generating less noise).

The loud second heart sound will be single because the stenosed pulmonic valve does not produce enough noise as it closes.


A little history about the Blalock-Taussig shunt...

UpToDate has a good summary: Pathophysiology, clinical features, and diagnosis of tetralogy of Fallot; of course you have to pay for it.

There is an old article which details the diagnostic features in ToF. As it pre-dates TTE, the focus is on physical examination.
MCCORD, MALCOM C., J. A. C. K. VAN ELK, and S. GILBERT BLOUNT. "Tetralogy of Fallot Clinical and Hemodynamic Spectrum of Combined Pulmonary Stenosis and Ventricular Septal Defect." Circulation 16.5 (1957): 736-749.

It would be rude not to reference Arthur Fallot himself. 
Fallot, Dr Arthur. Contribution à l'anatomie pathologique de la maladie bleue (cyanose cardiaque), par le Dr. A. Fallot,... Barlatier-Feissat, 1888.