Real World NP

COPD guidelines have changed—and if you’re managing COPD in primary care, there are a few updates worth knowing.

In this episode, I walk through how to approach a patient with COPD at a routine visit, especially when you’re seeing them for the first time or inheriting their care from another provider.

We’ll cover how to confirm the diagnosis with spirometry, how to think about GOLD 1–4 alongside the ABE assessment, and how the mMRC and CAT scores fit into your assessment. We’ll also talk about alpha-1 antitrypsin deficiency testing, blood eosinophils and inhaled corticosteroids, initial inhaler therapy, and what to monitor at follow-up.

I also walk through the pieces of COPD management beyond medications—including smoking cessation, vaccinations, exercise and nutrition, pulmonary rehabilitation, and management of comorbidities.

In this episode:

00:00 – Introduction + COPD guideline updates

01:03 – Approaching COPD management in primary care

01:53 – Confirming COPD with spirometry and FEV1/FVC

03:01 – Pre-COPD and PRISm

03:53 – GOLD 1–4 and the ABE assessment

05:12 – Using the mMRC and CAT scores

06:23 – What to assess at a COPD follow-up visit

07:50 – Alpha-1 antitrypsin deficiency testing

08:26 – Blood eosinophils and inhaled corticosteroids

09:37 – COPD management beyond inhalers

11:15 – Pulmonary rehabilitation and comorbidities

11:37 – SABA, SAMA, LABA, LAMA, and ICS

12:21 – Initial COPD treatment by GOLD ABE group

13:50 – Initial treatment for Groups A and B

14:35 – COPD follow-up and spirometry

15:04 – Chest imaging and lung cancer screening

15:46 – When to refer to pulmonology

COPD cheat sheet + Digital NP Binder: realworldnp.com/binder

For a full transcript and conversation chapters, visit the blog: https://www.realworldnp.com/blog/copd-management

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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What does a GI specialist wish primary care providers knew before sending a referral?

In this episode, I’m joined by family nurse practitioner Paige Sosebee, who has worked in gastroenterology since 2019 at a large academic medical center. We talk through some of the most common GI concerns we see in primary care—and what happens on the other side of the referral.

Paige shares practical pearls on H. pylori testing and treatment, GERD and PPI trials, evaluating abnormal liver tests, celiac testing, chronic constipation, SIBO and intestinal methanogen overgrowth (IMO), and how primary care can make GI referrals more useful for both the specialist and the patient.

We also talk about something that comes up constantly for newer NPs: How much of this am I actually supposed to manage myself, and when is it time to ask a specialist for help?

In this episode, we cover:

• H. pylori testing, treatment, and common pitfalls
• GERD management and when to consider EGD
• Elevated liver enzymes and what to do before referring
• Celiac testing and the importance of testing before going gluten-free
• Chronic constipation, red flags, and initial management
• SIBO and intestinal methanogen overgrowth (IMO)
• How to make GI referrals more useful—and when they’re truly urgent

Timestamps:

00:00 – Introduction

02:19 – Meet GI specialist Paige Sosebee, FNP

04:31 – H. pylori testing, treatment & referrals

13:20 – GERD, PPIs & when to consider endoscopy

20:06 – Alginate therapy for GERD

22:31 – Elevated liver tests & GI referrals

24:51 – Elevated alkaline phosphatase & imaging

30:00 – Celiac disease testing

41:10 – Chronic constipation

46:00 – SIBO & intestinal methanogen overgrowth (IMO)

52:50 – When to refer to a GI specialist

56:00 – Clinical resources for primary care NPs

For a full transcript and conversation chapters, visit the blog: http://www.realworldnp.com/blog/gi-specialist

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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When should you refer a patient with CKD to nephrology—and what should you do before they get there?

In this episode, I’m joined by nephrologist and medical educator Dr. Rachel Hilburg to talk through the questions that come up all the time in primary care: interpreting proteinuria and hematuria, deciding when a nephrology referral is urgent, what labs and imaging to order before referral, and what we can actually do to slow CKD progression.

We also talk about the Kidney Failure Risk Equation, cystatin C, kidney-protective medications, preparing patients for dialysis and transplant, caring for patients already on dialysis, and a practical approach to hyponatremia.

Want to feel more confident managing CKD in primary care?

The Chronic Kidney Disease Management Course walks you through CKD diagnosis, monitoring, treatment, slowing disease progression, and when to refer to nephrology.

CKD Management Course: https://www.realworldnp.com/ckd 

Or get the CKD course as part of the Chronic Care Bundle, which also includes diabetes, hypertension, and kidney lab interpretation.

Chronic Care Bundle: https://www.realworldnp.com/chronic-care-series-bundle 

For a full transcript and conversation chapters, visit the blog www.realworldnp.com/blog/nephrologist

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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Valvular heart disease often presents gradually— often slowly becoming more fatigued, less active, or more short of breath over time— making it easy for symptoms to be attributed to aging or deconditioning. In this episode, Liz Rohr sits down with structural heart nurse practitioner Christy Cantey, FNP, to discuss how primary care clinicians can recognize subtle symptoms of valve disease, know when an echocardiogram is appropriate, and understand what happens after a patient is referred to a structural heart program.

They also discuss modern transcatheter valve procedures—including TAVR and TEER—and how these minimally invasive treatments have changed outcomes for patients with aortic stenosis and other valvular diseases.

Timestamps

00:00 Meet Christy Cantey, NP

02:02 What Is Structural Heart Disease?

03:22 Understanding Modern Valve Procedures

06:05 Symptoms That Should Raise Concern

07:28 Two Questions That Reveal Functional Decline

08:51 Why Patients Often Don't Realize How Sick They Feel

09:47 The Challenge of Detecting Heart Murmurs

11:09 When to Order an Echocardiogram

12:07 Why Early Referral Matters

15:35 Working With Structural Heart Programs

18:15 What TAVR and Valve Procedures Are Really Like

20:56 Primary Care Follow-Up After Valve Intervention

23:19 Long-Term Monitoring and Annual Echocardiograms

26:17 How to Counsel Patients Who Are Hesitant About Treatment

32:32 Clinical Pearls and Resources for Learning More

For a full transcript and conversation chapters, visit the blog http://www.realworldnp.com/blog/valve-disease-primary-care

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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The PREVENT Risk Calculator is a newer cardiovascular risk assessment tool developed by the American College of Cardiology (ACC) and American Heart Association (AHA). Designed to replace older pooled cohort equations, it provides a more comprehensive estimate of cardiovascular risk, including both atherosclerotic cardiovascular disease (ASCVD) and heart failure risk.

In this episode, Liz Rohr breaks down what the PREVENT calculator is, how to use it in clinical practice, and why it's becoming an increasingly important part of cardiovascular risk assessment in primary care.

Timestamps:

00:00 - Overview of the Prevent Risk Calculator and its significance in cardiovascular risk assessment

00:26 - How the calculator improves risk estimation over previous tools

01:16 - Key inputs needed for the calculator and optional risk-enhancing factors

01:41 - Incorporating additional data like zip code, A1C, and urine albumin

02:07 - Interpreting 10- and 30-year risk results for ASCVD and heart failure

03:02 - Thresholds for hypertension (≥7.5%) and hyperlipidemia risk categories

03:38 - Practical tips for clinicians on using and interpreting the tool

04:06 - Importance of risk-enhancing factors and patient-specific decision-making

04:55 - Limitations of population-based risks and underestimation in young adults

05:52 - Avoiding over-reliance on the calculator and considering the full clinical picture

06:46 - Summary: integrating the Prevent calculator into patient conversations and management pathways 

For a full transcript and conversation chapters, visit the blog https://www.realworldnp.com/blog/prevent-calculator-aha

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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What actually changed in the newest hypertension guidelines—and what should nurse practitioners be doing differently in clinic?

In this episode, Liz Rohr, MSN, FNP-BC, sits down with Dr. Jordy Cohen, nephrologist, hypertension specialist, researcher, and member of the hypertension guideline writing committee, to break down the updates that matter most for primary care.

Rather than reviewing every recommendation, this conversation focuses on the clinical decisions that can make the biggest difference in practice. Dr. Cohen shares practical guidance on medication selection, single-pill combination therapy, resistant hypertension, screening for primary aldosteronism, and evaluating younger patients with elevated blood pressure. The discussion also covers the PREVENT risk calculator, home blood pressure monitoring, white coat hypertension, and common treatment mistakes that can be avoided in everyday clinical practice.

Whether you're learning hypertension management for the first time or updating your approach based on the latest evidence, this episode offers practical strategies you can apply immediately in primary care.

00:00 – Meet Dr. Jordy Cohen and the new hypertension guidelines

02:27 – Biggest changes in the updated guidelines

04:00 – The PREVENT risk calculator explained

07:30 – Managing hypertension in younger adults

11:40 – Secondary hypertension workup and screening pearls

15:20 – Resistant hypertension: What specialists wish primary care would do first

19:20 – When to start one medication vs. combination therapy

22:10 – Choosing first-line antihypertensive medications

25:40 – Hydrochlorothiazide vs. chlorthalidone vs. indapamide

29:45 – Primary aldosteronism: Who should be screened?

36:00 – Why PRN clonidine should be avoided in severe asymptomatic hypertension

41:10 – Home blood pressure monitoring, white coat hypertension, and validated cuffs

49:40 – Microalbuminuria and practical pearls for primary care

If you found this episode helpful, be sure to subscribe to the Real World NP Podcast and share it with a colleague.

Real World NP provides practical, evidence-based continuing education designed specifically for nurse practitioners to bridge the gap between graduate education and real-world practice.

For a full transcript and conversation chapters, visit the blog https://www.realworldnp.com/blog/HTN-updates-2026. 

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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Urine microalbumin is one of the earliest indicators of kidney damage, but the terminology—and the recommendations—have changed over the past several years.

In this episode, Liz reviews the 2026 updates to urine microalbumin interpretation, including the transition to albuminuria and the urine albumin-to-creatinine ratio (UACR), new hypertension screening recommendations, and practical pearls that every primary care nurse practitioner should know.

Whether you're a new graduate or an experienced NP looking for a refresher, this episode will help you better understand what the test measures, when to order it, and how to avoid some of the most common interpretation pitfalls.

Chapters:

00:00 Introduction to Microalbuminuria

01:38 Understanding Urine Microalbumin Testing

06:44 Clinical Significance of Microalbumin Levels

10:38 Conclusion and Course Invitation

11:40 Introduction to Real WorldNP Podcast

11:40 Exploring Resources for New NPs

The Renal Lab Interpretation course takes a deeper, case-based approach to urine albumin, creatinine, eGFR, electrolyte abnormalities, and common kidney disorders seen in primary care.

We’re doing a LIVE round of the Lab Interpretation Series (which includes the Renal Lab Interpretation Course) starting in August with Live Q&As, learn more https://www.realworldnp.com/live

For a full transcript and conversation chapters, visit the blog https://www.realworldnp.com/blog/microalbuminuria-2026-updates 

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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Irritable bowel syndrome (IBS) is one of the most common—and often frustrating—conditions seen in primary care. Patients may come in with chronic abdominal pain, diarrhea, constipation, bloating, or a mix of symptoms, and many have already been told that their testing is “normal.” So how do you confidently evaluate IBS, rule out more serious conditions, and help patients move forward?

In this episode, Liz talks with neurogastroenterologist Dr. Zach Spiritos about the real-world approach to IBS, including the underlying pathophysiology, common diagnostic pitfalls, practical workup strategies, and treatment options that go far beyond medication alone.

Whether you're a new NP or an experienced clinician, this episode offers practical strategies to help you approach IBS with greater confidence and compassion.

Timestamps:

00:00 - Introduction to Dr. Zach Spiritos and episode overview

02:16 - Pathway into neuro gastroenterology and training background

05:06 - What is IBS? Symptoms, diagnosis, and underlying mechanisms

07:36 - Factors contributing to IBS: trauma, antibiotics, triggers

09:21 - Differential diagnosis: celiac, SIBO, bile acid malabsorption

11:54 - When to consider endoscopy and testing strategies

14:35 - History-taking tips for primary care clinicians

17:54 - Managing expectations in chronic GI conditions

20:12 - Overuse of endoscopy and its limited findings

22:08 - Understanding what endoscopy can actually reveal

24:23 - Communicating with patients who have “all tests normal”

27:40 - The multitude of IBS treatment approaches: diet, psychological, medication

32:12 - Role of diet and FODMAP in symptom management

35:10 - Pharmacological options for IBSC and IBSD

39:06 - Medications overview: Linzess, Amitiza, Viberzi, and others

44:04 - The role and limitations of probiotics and fiber

45:08 - Tips on managing patient expectations and chronicity

46:54 - Setting goals and tracking progress with patients

48:16 - Final advice: empower patients with knowledge, manage expectations, and tailor treatments

For a full transcript and conversation chapters, visit the blog www.realworldnp.com/blog/ibs

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© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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Hey! We’re taking a hiatus from the podcast while the team focuses on becoming an accredited organization for continuing education. We’re developing new courses to bridge the gap between graduate education and real-world practice.

In the meantime, we’re inviting clinicians to contribute to paid blog posts and articles— we want to build a community dedicated to quality education and patient care.

Stay informed of upcoming content by subscribing to our email list at www.realworldnp.com/guide.

Apply to become a blog post writer here!

For a full transcript and conversation chapters, visit the blog http://www.realworldnp.com/blog/podcast-break

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This episode focuses on leadership and role transition questions, specifically addressing a scenario where a new nurse practitioner is struggling with confrontational conversations with nursing staff. The host provides advice on how to navigate these situations using a framework called nonviolent communication. The framework involves expressing observations, feelings, needs, and requests in a clear and non-confrontational manner. The host also emphasizes the importance of building rapport and facilitating open communication within the team. Additional resources and episodes on leadership are recommended.

Key Takeaways:

-Leadership is a challenging skill to navigate, especially in the healthcare field where there is often a lack of training.

-Using the nonviolent communication framework can help facilitate difficult conversations by expressing observations, feelings, needs, and requests.

-Building rapport and open communication within the team is crucial for effective collaboration and patient care.

-Seeking support and additional resources on leadership can further enhance leadership skills and strategies.

For a full transcript and conversation chapters, visit the blog www.realworldnp.com/blog/confrontation

© 2024 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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