History to be explored in suspected autonomic dysfunction
What features of the history must be explored in all patients with suspected autonomic dysfunction?
Some cardinal symptoms of autonomic dysfunction may be drug induced or have a psychogenic etiology.
With this caveat in mind, special attention to symptoms involving the following systems is essential when obtaining a history:
• Cardiovascular —Orthostatic lightheadedness, dizziness, blurred vision, syncope or near-syncope, fatigue, weakness (especially in the legs on standing), headache, and neck ache after prolonged standing (coat hanger phenomenon), postprandial or postexercise lightheadedness or angina pectoris, fainting after alcohol ingestion or insulin injection, palpitations, resting tachycardia, orthostatic cerebral transient ischemic attack symptoms, angina pectoris.
• Sudomotor and vasomotor —Partial or complete loss of sweating, heat intolerance, excessive sweating (partial or total), facial and upper trunk gustatory sweating (especially when food incites salivation or with ingestion of cheese), nocturnal sweating, skin cracks on distal extremities, dry and shiny skin, unusually cold or warm feet, reduced skin wrinkling, peripheral edema.
• Secretomotor —Dry mouth and eyes, increased saliva production.
• Genitourinary —History of urinary tract infections, lengthened interval between micturitions, increased volume of first morning void, need for straining to initiate and maintain voiding, weakness of stream, postvoid dribbling, sensation of incomplete emptying of bladder, overflow incontinence, frequency and urgency with or without dysuria (with superimposed infection), difficulty in initiating and/or maintaining erection, reduced or absent waking erection, diminished libido, decreased volume of ejaculation, inability to ejaculate, retrograde ejaculation, reduced vaginal lubrication.
• Respiratory —Irregular breathing or apnea during sleep.
• Gastrointestinal —Dysphagia, retrosternal discomfort, heartburn, anorexia, epigastric fullness during or after meals, recurrent episodes of nausea and vomiting (fasting and/or postprandial) associated with upper abdominal pain, constipation, diarrhea (especially nocturnal), fecal incontinence (especially at night), weight loss. Note that explosive diarrhea and severe constipation may alternate.
• Ocular —Blurring of vision, trouble focusing, photophobia, difficulty seeing at night, drooping of eyelids.
• Factors aggravating symptoms —Alcohol, continued standing, hot temperature (environmental, hot bath, fever), exercise, bed rest, food ingestion, and hyperventilation.
