MRCP2-4361

MRCP2-4361

A 67-year-old retired farmer presents with a 3-week history of increasing shortness of breath, non-specific non-pleuritic chest pain and weight loss. His medical history includes previous angina and hypertension. He is known to keep racing pigeons in a barn on his property and is an active smoker with a 35 pack year history. On examination, bilateral clubbing and tar staining are noted. Respiratory examination revealed a respiratory rate of 20 breaths per minute, sats 93% on air, reduced bilateral chest expansion and reduced air entry in both bases associated with dullness to percussion.

A chest radiograph demonstrates moderate right >left bilateral pleural effusions and patchy opacities across both lung fields in a non-lobar distribution. CT thorax with high-resolution slices demonstrates bilateral pleural effusion, thickened pleura with no lung parenchyma abnormalities.

Lung function testing demonstrates FEV1 1.8ls, FVC 60% of predicted.

What is the most appropriate next investigation?