Breathlessness. Left sided crackles to mid zone.
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Marked enlargement of the cardiac silhouette, even for an AP projection. Small right pleural effusion and small-to-moderate left pleural effusion.
There is a very long list for an enlarged cardiac silhouette, but when one is as big as this, and with a slightly globular shape then pericardial effusion should be near the top. Comparison with prior chest x-rays is always very useful, and will often show a marked change in size in a short timeframe, confirming the diagnosis.