right subclavian picc line has its tip at in the proximal svc. a single lead left-sided pacer is incompletely visualized but the lead appears intact and unchanged in overall position. the heart remains markedly enlarged which may reflect cardiomegaly, although pericardial effusion could also have this appearance. the left costophrenic angle is not entirely included on the current study but there do appear to be layering bilateral effusions with associated patchy airspace disease likely reflecting compressive atelectasis. there has been interval appearance of mild perihilar and interstitial edema. no pneumothorax is seen.