What is the next recommended test for a 62-year-old patient with shortness of breath, clubbing of fingers, dry inspiratory crackles at bases, and parasternal lift?

High-Resolution CT (HRCT) of the Chest is the Next Recommended Test

For a 62-year-old patient with shortness of breath, finger clubbing, dry inspiratory crackles at the bases, and parasternal lift, high-resolution CT (HRCT) of the chest is the most appropriate next diagnostic test. 1

Clinical Presentation Analysis

The patient presents with a constellation of findings highly suggestive of interstitial lung disease (ILD) with possible pulmonary hypertension:

• Shortness of breath: Cardinal symptom in both ILD and pulmonary hypertension
• Finger clubbing: Strongly associated with ILD, particularly idiopathic pulmonary fibrosis (IPF) 2, 3
• Dry inspiratory crackles at bases: Classic finding in IPF and other fibrotic lung diseases 1
• Parasternal lift: Suggests right ventricular hypertrophy, commonly seen in pulmonary hypertension 1

Diagnostic Algorithm

Step 1: HRCT Chest

HRCT is the cornerstone diagnostic test because:

• It can identify specific patterns of ILD, particularly the UIP (usual interstitial pneumonia) pattern seen in IPF 1
• The 2018 ATS/ERS/JRS/ALAT guidelines emphasize HRCT as essential for diagnosing IPF 1
• It can detect subtle parenchymal abnormalities not visible on standard chest radiographs 1
• It can help distinguish between different types of ILD (IPF, NSIP, hypersensitivity pneumonitis) 1

Step 2: Pulmonary Function Tests (PFTs)

After HRCT, PFTs should be performed to:

• Assess restrictive pattern (reduced FVC with preserved FEV1/FVC ratio)
• Evaluate diffusion capacity (DLCO), which is typically reduced in ILD and pulmonary hypertension 1, 4
• Establish baseline lung function for monitoring disease progression 1

Step 3: Echocardiography

To evaluate for pulmonary hypertension suggested by the parasternal lift 1

Evidence Supporting HRCT as Next Test

The 2018 ATS/ERS/JRS/ALAT guidelines for diagnosis of IPF strongly emphasize HRCT as the primary diagnostic tool 1. The guidelines state that HRCT has superior sensitivity (95.7%) compared to PFTs alone for detecting ILD. An FVC <80% has only 47.5% sensitivity for detecting ILD, whereas HRCT has 100% sensitivity 1.

The 2015 ESC/ERS guidelines for pulmonary hypertension include HRCT in their diagnostic algorithm for evaluating suspected PH, particularly when associated with lung disease 1.

Clinical Implications

The combination of finger clubbing and bibasilar inspiratory crackles in a 62-year-old strongly suggests IPF, which has significant mortality implications (median survival <3 years without treatment) 5. The parasternal lift suggests possible pulmonary hypertension, which is a common complication of IPF (prevalence 32-85%) and significantly worsens prognosis 6, 5.

Interestingly, HRCT findings will guide further management:

• If UIP pattern is present, antifibrotic therapy may be indicated
• If pulmonary hypertension is confirmed, right heart catheterization would be needed for definitive diagnosis 4

Common Pitfalls to Avoid

1. Starting with chest X-ray only: While often done first, a normal chest X-ray does not exclude ILD or pulmonary hypertension 1

2. Relying solely on PFTs: PFTs alone have insufficient sensitivity for early ILD detection and may be normal despite significant disease 1, 4

3. Delaying HRCT: Given the high mortality of IPF and the prognostic impact of pulmonary hypertension, prompt HRCT is essential 5

4. Missing pulmonary hypertension: The parasternal lift suggests possible PH, which occurs in up to 85% of IPF patients and significantly worsens outcomes 6, 5

HRCT will provide the most comprehensive initial assessment of both the lung parenchyma and potential pulmonary vascular disease in this patient with findings highly suggestive of IPF with possible pulmonary hypertension.