Real World NP

You're seeing a patient for a preoperative evaluation before an upcoming surgery. The surgeon has requested some testing and documentation—but how do you determine what your patient actually needs before their procedure?Which patients need additional cardiovascular evaluation? When should you use RCRI or DASI? Do you need to order an ECG, chest X-ray, or routine labs? And how do you document your assessment without saying the patient is "cleared" for surgery?In this updated episode of Real World NP, we're walking through a practical approach to the preoperative evaluation for noncardiac surgery in primary care, including updated cardiovascular risk assessment recommendations and how to apply them during an actual patient visit.What You'll Learn:What your role is during a preoperative evaluationHow to assess surgical risk and identify reasons to pause before surgeryUsing RCRI, ACS NSQIP, and DASI to assess cardiovascular risk and functional capacityWhat to include in the preoperative history and physical examAssessing chronic conditions and pulmonary risk before surgeryWhen preoperative labs, ECGs, and imaging are indicatedMedication considerations before surgery, including anticoagulants, diabetes medications, and SGLT2 inhibitorsWhat to document and communicate to the surgical and anesthesia teamsTimestamps00:00 – Introduction01:32 – Your role in the preoperative evaluation02:13 – Assessing surgical risk03:04 – Reasons to pause before surgery03:58 – Cardiovascular risk assessment: RCRI and ACS NSQIP04:45 – Functional capacity and DASI05:24 – Preoperative history and chronic conditions06:56 – Pulmonary risk assessment07:25 – Physical exam and selective testing08:25 – Perioperative medication considerations09:37 – Documenting the preoperative evaluationResources Mentioned:Preoperative Evaluation Cheat Sheet: A quick-reference guide to surgical risk, cardiovascular assessment, functional capacity, testing, and documentation. Get your copy at www.realworldnp.com/binder For a full transcript and conversation chapters, visit the blog: https://www.realworldnp.com/blog/preop-exam-nurse-practitioner ______________________________© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

Starting insulin in type 2 diabetes can feel intimidating—especially when you're a new NP seeing a patient with an A1C of 13% or 14% and wondering: Does this patient need insulin? Can I safely manage them outpatient? And how much insulin should I actually start?In this episode, I walk through a practical approach to starting basal insulin in adults with type 2 diabetes, including updates from the 2026 ADA and AACE guidelines.We'll cover when insulin is appropriate, how to calculate a starting dose, how to titrate using fasting blood glucose, and what to do when fasting glucose is at goal but A1C remains elevated.We'll also talk about CGM, preventing hypoglycemia, and making insulin initiation manageable for patients—because you don't have to solve everything in one visit, but you do need to make sure your patient can safely manage their treatment at home.For a full transcript and conversation chapters, visit the blog: www.realworldnp.com/blog/starting-insulin-type-2-diabetesNeed a Quick Insulin Reference?The Digital NP Binder includes an updated Starting Insulin in Type 2 Diabetes cheat sheet with dosing, titration, monitoring, and treatment considerations for primary care. https://www.realworldnp.com/binderWant More Support with Diabetes Management?The Diabetes Management in Primary Care course covers medication selection, treatment adjustments, insulin therapy, diabetes monitoring, and more. https://www.realworldnp.com/diabetes______________________________© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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 updates01:03 – Approaching COPD management in primary care01:53 – Confirming COPD with spirometry and FEV1/FVC03:01 – Pre-COPD and PRISm03:53 – GOLD 1–4 and the ABE assessment05:12 – Using the mMRC and CAT scores06:23 – What to assess at a COPD follow-up visit07:50 – Alpha-1 antitrypsin deficiency testing08:26 – Blood eosinophils and inhaled corticosteroids09:37 – COPD management beyond inhalers11:15 – Pulmonary rehabilitation and comorbidities11:37 – SABA, SAMA, LABA, LAMA, and ICS12:21 – Initial COPD treatment by GOLD ABE group13:50 – Initial treatment for Groups A and B14:35 – COPD follow-up and spirometry15:04 – Chest imaging and lung cancer screening15:46 – When to refer to pulmonologyCOPD cheat sheet + Digital NP Binder: realworldnp.com/binderFor a full transcript and conversation chapters, visit the blog: https://www.realworldnp.com/blog/copd-management ______________________________© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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 pitfallsGERD management and when to consider EGDElevated liver enzymes and what to do before referringCeliac testing and the importance of testing before going gluten-freeChronic constipation, red flags, and initial managementSIBO and intestinal methanogen overgrowth (IMO)How to make GI referrals more useful—and when they’re truly urgentTimestamps:00:00 – Introduction02:19 – Meet GI specialist Paige Sosebee, FNP04:31 – H. pylori testing, treatment & referrals13:20 – GERD, PPIs & when to consider endoscopy20:06 – Alginate therapy for GERD22:31 – Elevated liver tests & GI referrals24:51 – Elevated alkaline phosphatase & imaging30:00 – Celiac disease testing41:10 – Chronic constipation46:00 – SIBO & intestinal methanogen overgrowth (IMO)52:50 – When to refer to a GI specialist56:00 – Clinical resources for primary care NPsFor a full transcript and conversation chapters, visit the blog: http://www.realworldnp.com/blog/gi-specialist ______________________________© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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

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.Timestamps00:00 Meet Christy Cantey, NP02:02 What Is Structural Heart Disease?03:22 Understanding Modern Valve Procedures06:05 Symptoms That Should Raise Concern07:28 Two Questions That Reveal Functional Decline08:51 Why Patients Often Don't Realize How Sick They Feel09:47 The Challenge of Detecting Heart Murmurs11:09 When to Order an Echocardiogram12:07 Why Early Referral Matters15:35 Working With Structural Heart Programs18:15 What TAVR and Valve Procedures Are Really Like20:56 Primary Care Follow-Up After Valve Intervention23:19 Long-Term Monitoring and Annual Echocardiograms26:17 How to Counsel Patients Who Are Hesitant About Treatment32:32 Clinical Pearls and Resources for Learning MoreFor a full transcript and conversation chapters, visit the blog http://www.realworldnp.com/blog/valve-disease-primary-care______________________________© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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 assessment00:26 - How the calculator improves risk estimation over previous tools01:16 - Key inputs needed for the calculator and optional risk-enhancing factors01:41 - Incorporating additional data like zip code, A1C, and urine albumin02:07 - Interpreting 10- and 30-year risk results for ASCVD and heart failure03:02 - Thresholds for hypertension (≥7.5%) and hyperlipidemia risk categories03:38 - Practical tips for clinicians on using and interpreting the tool04:06 - Importance of risk-enhancing factors and patient-specific decision-making04:55 - Limitations of population-based risks and underestimation in young adults05:52 - Avoiding over-reliance on the calculator and considering the full clinical picture06:46 - 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______________________________© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

Hypertension Guidelines Updates: Practical Pearls for Primary Care with Dr. Jordy CohenWhat 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.Timestamps00:00 – Meet Dr. Jordy Cohen and the new hypertension guidelines02:27 – Biggest changes in the updated guidelines04:00 – The PREVENT risk calculator explained07:30 – Managing hypertension in younger adults11:40 – Secondary hypertension workup and screening pearls15:20 – Resistant hypertension: What specialists wish primary care would do first19:20 – When to start one medication vs. combination therapy22:10 – Choosing first-line antihypertensive medications25:40 – Hydrochlorothiazide vs. chlorthalidone vs. indapamide29:45 – Primary aldosteronism: Who should be screened?36:00 – Why PRN clonidine should be avoided in severe asymptomatic hypertension41:10 – Home blood pressure monitoring, white coat hypertension, and validated cuffs49:40 – Microalbuminuria and practical pearls for primary careIf 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. ______________________________© 2026 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.