IMPRESSION:
Severe enlargement of the cardiac silhouette is recently unchanged, consistent
 with cardiomegaly and/or pericardial effusion.  Left lower lobe is air less,
 due to severe atelectasis and/or pneumonia.  Moderate bilateral pleural
 effusion has increased and mild pulmonary edema may have developed. 
 Persistent mediastinal widening could be explained by vascular engorgement
 alone,adenopathy could be present as well.  CT scanning would be required for
 that evaluation, and to detect pneumonia that might be obscured on the
 conventional radiograph.
 
 ET tube in standard placement, esophageal drainage tube passes into stomach
 and out of view.  Right jugular line ends in the region of the superior
 cavoatrial junction.  No pneumothorax.