AFP: American Family Physician Podcast

Episode 244 – December 2025 – Part 2
Date: December 30, 2025
Contributors: Dr. Steve Brown (B), Dr. Justin Chediak (C), Dr. Rachel Dunn (D)

Main Theme & Purpose

This episode presents clinical pearls reviewed by the University of Arizona College of Medicine-Phoenix Family Medicine Residency team. The panel reviews essential updates and evidence-based practices from the December 2025 issue of American Family Physician (AFP). Clinical topics include ankle sprain management, topical therapy for axillary hyperhidrosis, dementia evaluation, frailty scoring for hip fracture outcomes, heart failure with preserved ejection fraction (HFpEF) risk, and a rapid-fire round of clinical answers.

Key Discussion Points & Insights

1. Management of Ankle Sprains (01:29–05:11)

• Delaying the Initial Exam

  • "Don't examine too early. Those first few days are one big, puffy mystery ankle. Like a water balloon with toes." (B, 01:59)
  • The clinical exam is most reliable at 4–7 days post-injury.
  • Key findings: lateral swelling, hematoma, ATFL tenderness, positive anterior drawer/talar tilt (Sensitivity: ↑ to 96%).

• Ordering X-rays

  • Apply Ottawa Ankle Rules: history of inability to bear weight or bony tenderness at critical sites (malleoli, navicular, base of the 5th metatarsal). Sensitivity ~91%.
  • "Order standard AP, lateral, and mortise views with weight bearing if possible." (B, 02:58)

• Acute Management

  • Pain control, joint protection (limited mobility 5–10 days), early movement/PT.
  • "Don't go wild on oral NSAIDs... Topical NSAIDs or acetaminophen work great." (B, 03:22)
  • Semi-rigid braces are superior to elastic wraps. PT should include proprioception, balance, and strength.

• Prevention & Return to Play

  • Bracing during sports and 8–12 weeks of PT; bracing for up to 12 months post-injury.
  • Physical impairments (proprioception, strength) raise reinjury risk.
  • PAASS framework for return to play: Pain, Ankle impairments, Athlete perception, Sensory motor control, Sports performance.

• Persistent Pain

  • Consider syndesmotic or osteochondral injuries; use squeeze test for syndesmotic sprains.
  • "Dynamic ultrasound can catch peroneal tendon subluxation." (B, 04:59)

Memorable moment:
"Sometimes I think the human ankle was designed specifically to be sprained. It's like evolution just said, lol, good luck."
(C, 01:39)

2. Axillary Hyperhidrosis: Soft Pyronium Topical Gel (05:16–07:24)

• Two large RCTs included individuals ≥9 years old with primary axillary hyperhidrosis (>6 months).
• Sofpironium gel (12.45%) vs. vehicle, used nightly.
• Primary outcomes: ≥2-point improvement on disease scale or ≥70% reduction in sweat.
  • "By week six, about 38%... met both targets, compared with 18% in the control group. This gives a number needed to treat of about 5." (D, 06:14)
• Side effects: mild anticholinergic effects (dry mouth, blurred vision), local dermatitis.
• 4% withdrew due to side effects; counseling is important.
• Not yet widely available; cost may be prohibitive, but manufacturer coupons exist.

Quote:
"This local option with once daily bedtime use is appealing and the evidence level is high. Level 1B."
(C, 06:56)

3. Evaluation of Suspected Dementia (07:44–10:43)

• Diagnosis must distinguish between aging and neurocognitive disorder.

  • Red flags: repeating questions, getting lost, difficulties in conversation/tasks, personality changes.
  • "Families usually notice these long before patients do. So a really good history from caregivers is essential." (B, 08:10)

• Initial screening tools:

  • Mini-Cog: three-word recall + clock drawing.
  • MIS (Memory Impairment Screen)
  • AD8: caregiver questionnaire.

• Further assessment if the screen is abnormal/gut feeling signals concern:

  • MOCA for mild cognitive impairment.
  • RUDAS for cultural/education barriers.

• Evaluation: review medications, physical/psychiatric exam, B12/folate, TSH, CBC, CMP.

• Imaging: non-contrast MRI preferred (CT if MRI unavailable).

• Consider mimics: depression, delirium, sleep apnea, B12 deficiency, alcohol use, infections (HIV, neurosyphilis).

Quote:
"Dementia evaluation is a marathon, not a sprint. It often takes multiple visits, careful discussions with families, and coordinated planning."
(D, 10:34)

4. Frailty Scoring for Hip Fracture Outcomes (11:25–13:52)

• Frailty scoring recommended for ≥70yo admitted with hip fracture.

  • "Frail patients have higher risks of mortality and complications... They also stayed in the hospital about 2.6 days longer." (B, 12:08)
  • Poorer discharge function and higher risk of discharge to facilities.

• Instruments:

  • 26-item Frailty Index: comorbidities, cognition, nutrition, polypharmacy, mobility, incontinence, social vulnerability.
  • Cumulated Ambulation Score (CAS): out-of-bed, sitting, walking.

• Recommendation: Comprehensive risk assessment including frailty score and delirium screening.

Bottom line:
"Frailty scoring matters. It gives us better data, better conversations and hopefully better outcomes."
(C, 13:44)

5. HFpEF Risk Prediction in Exertional Dyspnea (13:52–15:45)

• Heart Failure with preserved EF (≥50%), presents as exertional dyspnea.

• Three main risk-prediction tools:

  • H₂FPEF: Needs echo (filling pressure); AUC 0.886.
  • HFAPEf (from HFA/ESC): BNP thresholds, echo, exercise; AUC 0.90.
  • HFpEF-ABA: Only age, BMI, and a-fib history; AUC 0.81; usable without advanced tests.

• Tools aid diagnostic approach and streamline management.

Memorable moment:
"Rachel and Justin, I have an actual haiku. Oh, boy.
Short of breath. Struggle
Unknown. Fill Pressures Unsure.
Use tool. Breathe easy."
(B, 15:45)

6. AFP Clinical Answers Speed Round (16:02–17:41)

• Ambulatory ECG vs. Echo for Palpitations:

  • Two weeks of EKG monitoring has highest yield-to-cost ratio.

• Initial Labs for Bleeding Disorders:

  • CBC, PT, PTT, peripheral smear, fibrinogen, ±vWD studies.

• Intermittent SSRIs for PMDD:

  • Acceptable alternative to continuous dosing.

• Acute Bacterial Arthritis in Kids:

  • Blood cultures before antibiotics, plain films, CRP for tracking. Don't delay antibiotics if ill-appearing. ESR/procalcitonin less useful.

• Anaphylaxis after Epi:

  • Not all require EMS; if resolution is quick and sustained, patients can be monitored at least an hour.

Quote:
"No. Conservative care can be considered after complete or near complete symptom resolution... patients should be monitored for at least an hour."
(D, 17:26)

Notable Quotes & Memorable Moments

• On the frequency of ankle sprains:
  "Sometimes I think the human ankle was designed specifically to be sprained." – (C, 01:39)

• On the unpredictability of a newly injured ankle:
  "Those first few days are one big, puffy mystery ankle. Like a water balloon with toes." – (B, 01:59)

• On dementia evaluation:
  "Dementia evaluation is a marathon, not a sprint." – (D, 10:34)

• Poetry and humor (on HFpEF tool):
  "Short of breath. Struggle
  Unknown. Fill Pressures Unsure.
  Use tool. Breathe easy." – (B, 15:45)

Segment Timestamps

• 00:31 – Intro/Hosts and episode structure
• 01:29 – Ankle sprain management
• 05:16 – Axillary hyperhidrosis topical gel evidence
• 07:44 – Dementia evaluation
• 11:25 – Frailty scoring for hip fracture outcomes
• 13:52 – HFpEF risk prediction rules
• 16:02 – Clinical Answers speed round

This summary highlights clinical best practices and practical humor. For the full conversation and more nuanced discussion, listen to the episode.