MRCP2-3685

MRCP2-3685

A 70-year-old man presents to the emergency department with progressive shortness of breath over the last two weeks, which worsens when leaning forward. His wife has noticed changes in his appearance, with facial swelling and discoloration. He has a medical history of right-sided heart failure, myocardial infarction, type two diabetes, COPD, and small cell lung cancer diagnosed three months ago. He used to smoke 20 packs of cigarettes a year and drinks moderate amounts of alcohol.

During the examination, he appears calm at rest, but his face is swollen and slightly purple. His neck veins are distended, and his JVP is significantly elevated to 4cm. Bibasal crepitations are heard during auscultation, and there is pitting edema at the ankles. A chest X-ray shows a widened mediastinum. What is the most appropriate investigation to establish the diagnosis?