**6.3.2 Physical findings**

In infants (and children) with pulmonary oligemia, physical examination reveals central cyanosis, clubbing (in older infants and children), tachypnea or hyperpnea, normal pulses, prominent "a" wave in the jugular venous pulse (if there is inter-atrial obstruction), and no hepatic enlargement. Quiet precordium, and absence of thrills are usual. The second heart sound is usually single. A holosystolic murmur suggestive of VSD may be heard at the left lower or mid sternal border. No diastolic murmurs are heard. In patients with associated pulmonary atresia, no murmurs are usually heard, although in an occasional patient a continuous murmur of PDA may be heard. Signs of clinical congestive heart failure are notably absent.

In the group with pulmonary plethora, examination reveals tachypnea, tachycardia, decreased femoral pulses (if associated with CoA), minimal cyanosis and hepatomegaly. Prominent "a" waves in the jugular veins and/or presystolic hepatic pulsations may be observed with associated inter-atrial obstruction. The second heart sound may be single or split. A holosystolic murmur of VSD is usually heard at the left lower sternal border. An apical mid-diastolic flow murmur may be heard. Clear-cut signs of congestive heart failure are usually present.
