Patients with an atrial septal defect and pulmonary valve stenosis typically present with findings that vary according to the severity of the pulmonary stenosis. A pulmonary ejection sound is usually present regardless of the severity of the stenosis. In patients with severe pulmonary stenosis, findings typically include a giant "a" wave in the jugular venous pulse, and a sustained right ventricular impulse. The auscultatory findings at the upper left sternal edge may include wide, splitting of the second heart sound with a soft P2 component and a systolic long, late peaking, crescendo-decrescendo murmur. A fourth heart sound that increases with inspiration may also be heard at the lower left sternal edge.