Examination in all patients with suspected autonomic dysfunction
What physical examination must be performed in all patients with suspected autonomic dysfunction?
• Eye —With attention to the symmetry, shape and size of the pupils, and eyelids (ptosis). Examples of abnormal findings are Horner’s syndrome (asymmetry in pupil size due to ipsilateral dysfunction of sympathetic dilatory pathways) or Adie’s tonic pupil (dilated pupil that constricts poorly to light, and reacts better to accommodation, due to parasympathetic denervation)
• Cardiovascular —Measurement of supine blood pressure and heart rate after 5 to 10 minutes of rest followed by measurement after standing for 3 minutes. Orthostatic hypotension is defined as a drop in systolic blood pressure of ≥20 mm Hg or diastolic blood pressure of ≥10 mm Hg with only modest increase in heart rate.
• Skin —A careful examination of the skin provides valuable clues to the presence of autonomic dysfunction. Particular attention should be given to acral vasomotor and trophic changes of the skin, abnormal temperature and sweating patterns (a dry and warm skin may imply impaired sympathetic output, whereas a cold and sweaty skin may imply overactivity of sympathetic output).