Patients with pulmonary valve stenosis usually remain asymptomatic unless the obstruction is severe, in which case exercise intolerance may occur. Cyanosis at rest does not occur, unless the obstruction is severe and the patient has an atrial septal defect permitting right-to-left shunt. Typical physical findings of pulmonary valve stenosis include a right ventricular sustained impulse, an ejection sound heard at the upper left sternal edge, louder in expiration, a mid-to-late peaking systolic ejection murmur heard best at the upper left sternal edge and persistent splitting of S2 with decreased intensity of the pulmonary component. The combination of severe pulmonary valve stenosis and an atrial septal defect can mimic the findings in tetralogy of Fallot sufficiently to cause a substantial bedside diagnostic challenge, as both the pulmonary ejection sound and the pulmonary component of S2 - key differential findings - may be inaudible.