lynn236

I would NOT order a full autoimmune panel on that patient. These tests are not cheap and are each actually quite complex for the labs to do. I think it would be clinically inefficient and frankly unfair to bill the patient for all of them especially if nothing conclusive results from them (which is the most likely scenario). It is crucial to understand the indications, sensitivity, specificity, cost and clinical utility of these tests. Several studies have suggested that overuse of common serum rheumatologic tests leads to unnecessary referrals and further laboratory work-ups. Failure to use these tests in a knowledgeable and thoughtful manner can result in diagnostic confusion and increased costs all around. As someone who has been a practicing NP for longer than most new grads have been alive, I would personally refer a patient like that to a physician.

I wouldn't immediately suspect SLE due to the negative dsDNA and negative RNP. You can go ahead and run anti-smith antibodies to verify; however, at her age I would also imagine that she has either had clinical manifestations of lupus by now or not. I leaned towards diffuse as most labs automatically run an ACA (which would be indicative of limited if positive) when seeing a positive Scl 70. Im not sure what was or not done in this case so you can go ahead and order the following: ACA (indicates limited if positive), anti-RNA pol I/III (indicates diffuse if positive...Other tests which would be especially helpful to send over to the rheumatologist if she has not already been seen by them are: anti-U3RNP, anti-PM-Scl, and anti-U1RNP. One way or another they will most likely put her on an immunosuppresive regimen. If you are going to be the patients primary care provider you will have to be cognizant as she will have compromised immune functioning. Also, look out for management of drug interactions and regularly monitoring blood pressure, renal function, lung function, and heart function.

The primary differential from that series is diffuse scleroderma with a possible sjogren overlap. What is the patient's age? You should refer management to a rheumatologist who can manage the patient and likely also collaborate with other specialists as well (nephrology, pulmonology, cardio, gi). Im assuming the patient is female, so once that diagnosis is confirmed you should also refer to genetics or immunology to have her HLA genes sequenced as their can be other overlap susceptibilities beyond sjogrens. This can be done at any local academic hospital.

Heard this from a colleague today and wanted to get the opinion of everyone on this forum. Apparently there have been suggestions that NP's should take and pass the ABIM (American Board of Internal Medicine) exam in order to become licensed/independently practicing NPs. Can anyone confirm or deny this and if so exactly what will be entailed in preparing for the ABIM exam? Will currently practicing NPs be grandfathered in or still have to take it? Thanks..