Cardiology: Graham Steell murmur: practice question

A General Medicine question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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General Medicine · Cardiology: Graham Steell murmur

Sample item

A woman with long-standing rheumatic mitral stenosis develops severe pulmonary hypertension. A new high-pitched early diastolic decrescendo murmur is heard at the left second and third intercostal spaces and gets louder on inspiration. What is the murmur due to?

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

C. Pulmonary regurgitation from dilatation of the valve ring

In pulmonary hypertension the pulmonary artery and valve ring dilate, producing functional pulmonary regurgitation, the Graham Steell murmur. Right-sided murmurs become louder on inspiration, which separates it from aortic regurgitation. It is classically described with mitral stenosis.

Option by option

  • A. Tricuspid regurgitation from right ventricular dilatation

    Tricuspid regurgitation gives a pansystolic murmur at the lower left sternal edge, not an early diastolic one.

  • B. Increased flow across the stenosed mitral valve

    Increased flow across a stenosed mitral valve gives a low-pitched diastolic rumble at the apex.

  • C. Pulmonary regurgitation from dilatation of the valve ring (correct)

    Correct. A high-pressure, dilated pulmonary root leaks in diastole, and right-sided murmurs increase on inspiration.

  • D. Aortic regurgitation from rheumatic valve involvement

    Aortic regurgitation is best heard at the left sternal edge in held expiration with the patient leaning forward, and it does not increase on inspiration.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

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Questions about this General Medicine question

What is the answer to this General Medicine question?

The best answer is C, Pulmonary regurgitation from dilatation of the valve ring. In pulmonary hypertension the pulmonary artery and valve ring dilate, producing functional pulmonary regurgitation, the Graham Steell murmur.

Why is "Tricuspid regurgitation from right ventricular dilatation" not the answer?

Tricuspid regurgitation gives a pansystolic murmur at the lower left sternal edge, not an early diastolic one.

Why is "Increased flow across the stenosed mitral valve" not the answer?

Increased flow across a stenosed mitral valve gives a low-pitched diastolic rumble at the apex.

Why is "Aortic regurgitation from rheumatic valve involvement" not the answer?

Aortic regurgitation is best heard at the left sternal edge in held expiration with the patient leaning forward, and it does not increase on inspiration.

What concept does this question test?

It tests Cardiology: Graham Steell murmur in General Medicine. Right-sided murmurs become louder on inspiration, which separates it from aortic regurgitation. It is classically described with mitral stenosis.

How hard is this question?

We tag it as a multi-step question: it asks you to combine more than one idea. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Cardiology: Graham Steell murmur?

For each disease know the classic presentation, the best test, and the first-line treatment. Then use the flashcards and the other General Medicine questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.