Apical pleural capping and a continuous heart murmur.

A 20-year-old asymptomatic woman was admitted to the hospital for workup of a continuous heart murmur. Five years previously, she had had a normal chest roentgenogram (Fig 1 ) before needle drainage of bilateral axillary abscess. On physical examination she had a continuous, machinery-like murmur heard predominantly on the second right intercostal space accompanied by a suprasternal systolic thrill. The distribution of the murmur was wide over both supraclavicular areas, as well as both pectoral regions, louder in the right side. The blood pressure was equal on both upper extremities. Her current chest x-ray film is shown on Figure 2.