Diagnosis of Hyperhidrosis

• Assess urine osmolality
  –Hyperosmolar urine (i.e., when the kidney reaction to hypernatremia is the excretion of a minimal volume of urine that is maximally concentrated) suggests an extrarenal etiology of the hypernatremia
  –Urine osmolarity is decreased in renal losses (e.g., diuretics and DI) and increased in GI, respiratory, and skin losses or poor intake
• Urine Na⁺is elevated in renal losses (>20 meq/L); decreased in GI, respiratory, and skin losses or poor intake (<10 meq/L); and normal in hyperaldosteronism

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Source: In a Page: Signs and Symptoms, 2004

Night Sweats: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Infections
  –HIV
  –Tuberculosis
  –Infectious mononucleosis
  –Fungal (e.g., histoplasmosis, coccidioidomycosis)
  –Lung or other abscess
  –Endocarditis
  –Osteomyelitis
• Neoplasms
  –Leukemia
  –Hodgkin's disease and other forms of lymphoma
  –Solid tumors (e.g. prostate, adrenal, renal, testicular)
• Menopause/premature ovarian failure
• Hyperthyroidism
• Diabetes mellitus (nocturnal hypoglycemia)
• GERD
• Obstructive sleep apnea
• Chronic fatigue syndrome
• Anxiety
• Pregnancy
• Drugs [e.g., antipyretics (most common), antihypertensives, phenothiazines, antiretroviral agents]
• Substance abuse (including alcohol)
• Orchiectomy
• Endocrine tumors
  –Pheochromocytoma
  –Carcinoid
• Chronic eosinophilic pneumonia
• Prinzmetal's angina
• Temporal arteritis
• Takayasu's arteritis

Workup and Diagnosis

• Complete history and physical examination
  –Note associated symptoms, such as flushing, pain, and tachycardia
  –Review full past medical and social history; review of systems
  –Complete physical with focus on endocrine, lymphatic, and dermatologic systems
• Laboratory testing depends on the presumed etiology; a reasonable initial workup includes CBC with differential, eosinophil count, electrolytes, BUN/creatinine, calcium, magnesium, TSH, urinalysis and culture, and ESR
• Consider the following testing if indicated: FSH (perimenopause), PPD, chest X-ray, HIV viral load/antibody, blood cultures, monospot, 3 AM glucose level to assess for nocturnal hypoglycemia, sleep study, free T4, 24-hour urinary catecholamines, 5-hydroxyindoleacetic acid, echocardiogram, and/or CT of chest/abdomen/pelvis

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Source: In a Page: Signs and Symptoms, 2004

Hypernatremia: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Dehydration
  –GI losses, especially watery diarrhea or profuse vomiting (very common)
  –Impaired oral intake and inability to respond to normal thirst mechanisms (e.g., young infants, altered mental status, or iatrogenic administration of IV fluids)
• Central diabetes insipidus (DI)
  –Decreased or absent production of ADH
  –Idiopathic
  –Head trauma
  –Suprasellar or infrasellar tumors
  –Langerhans cell histiocytosis
  –Granulomatous disease (including tuberculosis, Wegener granulomatosis and sarcoidosis)
  –Infection
  –Cerebral hemorrhage
  • Nephrogenic DI (NDI)
    –Inability to respond to ADH
    –Primary (congenital abnormality)
    –Secondary (acquired renal tubular dysfunction, e.g., progressive renal insufficiency; medications, e.g., lithium)
  • Severe skin or other insensible losses
    –Excessive sweating
    –Persistent rapid breathing
    –Burns
  • Increased total body sodium (rare in children)
    –Salt intoxication from
          –Sodium chloride tablets
          –IV NaCl or NaHCO₃
          –Breast milk after significant maternal sodium load
          –Concentrated formula
    –Primary hyperaldosteronism

  Workup and Diagnosis

  • History
    –Vomiting, diarrhea
    –Poor oral intake, recurrent dehydration
    –Medications or salt supplementation
    –Bicarbonate administration
    –Burns
    –Renal disease
  • Symptoms
    –Lethargy, seizures, coma
    –Polyuria, polydipsia
    –Headache, vision changes
  • Family history
    –Recurrent dehydration or early infant death (NDI)
  • Physical exam
    –Blood pressure
    –Assessment of hydration status (pulse, perfusion)
    –Midline defects (suggests presence of pituitary/hypothalamic defects/central DI)
    –Funduscopic exam
  • Labs
    –Chemistry panel
    –Serum osmolarity
    –Urinalysis
    –Urine osmolarity
  • Additional evaluation based on the clinical situation
    –Water deprivation test (to evaluate for central vs nephrogenic DI)
    –CT or MRI of the head

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Night Sweats: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Environmental
  –High room temperature, excessive wrapping or too many bed covers may be the most common cause (young children cannot control their environment)
• Tuberculosis
  –The disease most commonly associated with night sweats in the medical literature
  • Malignancy
    –Hodgkin lymphoma is the malignancy most commonly associated with night sweats; night sweats are among the “B” symptoms in staging, but their presence does not adversely affect prognosis
    –Leukemia and solid tumors may also cause night sweats
  • Alcohol or spicy food ingestion
  • Drugs
    –Antidepressants, cholinergics, antitussives, antipyretics, decongestants, insulin, sulfonylurea agents
    • Other infections
      –Indolent chronic infections: Subacute endocarditis, osteomyelitis, abscesses often present with fever, night sweats
      –HIV
      –Histoplasmosis
    • Endocrinologic disorders
      –Nocturnal hypoglycemia
      –Hyperthyroidism
      –Diabetes insipidus
      –Pheochromocytoma
    • Anxiety disorder/panic attacks
    • Sleep disorders
      –Obstructive sleep apnea
      –Nightmares
    • Drug abuse
    • GERD
    • Neurologic disease
      –Hypothalamic lesions
      –Head injury
      –Cerebral palsy
      –Familial dysautonomia
    • Pregnancy
    • Obesity
    • Autoimmune diseases
    • Mercury poisoning

    Workup and Diagnosis

    • History
      –Bedroom temperature, sleep habits
      –Fever, weight loss
      –Fatigue, sleepiness at school
      –Other symptoms: Heartburn, cough, flushing, polydipsia, polyuria
      –Nightmares, palpitations, panic attacks
      –Past medical history and medications
    • Physical exam
      –Vital signs, growth parameters
      –Lymphadenopathy, pallor, petechiae
      –Skin exam (heat rash, erythema nodosum)
      –Hypertrophic tonsils
      –New-onset murmur
    • Labs
      –CBC, ESR if hematologic malignancy or chronic
    • infection is suspected
      –Fasting blood sugar
      –Electrolyte abnormalities for DI
      –Urine VMA for pheochromocytoma
    • Radiology
      –Chest X-ray may show lesions consistent with TB or mediastinal widening due to lymphoma
    • Studies
      –PPD to test exposure to tuberculosis
      –Sleep study if sleep apnea is suspected
      –pH probe if confirmation of GERD is necessary

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Hyperhidrosis (Excessive Sweating): Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Fever
• Emotional stimuli
  –Sweaty palms and soles is referred to as volar hyperhidrosis
• Exercise
• Increased ambient temperature (heat)
• Spicy foods
• Obesity
• Atopy

• Congestive heart failure
  –May also be accompanied by poor feeding, pallor, cyanosis, tachypnea, lethargy, exercise intolerance
  –Causes include congenital heart disease, cardiomyopathies and viral myocarditis

• Shock, respiratory failure
• Hypoglycemia
• Syncope
  –Vasovagal syncope is commonly preceded by sweating
• Medications/drugs
  –Withdrawal (e.g., alcohol, opioids)
  –Overdose of salicylates, organophosphates
  –Insulin, emetics
• Cluster headaches
• Hyperthyroidism
• Pheochromocytoma
  –An adrenal tumor associated with hypertension and symptoms of excessive catecholamines
• Familial dysautonomia (Riley-Day syndrome)
  –An autosomal-dominant sensory neuropathy
  –Characterized by hypotonia, feeding problems, and poor autonomic control
• Spinal cord injury
• Juvenile rheumatoid arthritis
• Lymphoma
• Raynaud phenomenon
  –Sweating often accompanies the extremity color changes
• Night sweats
  –Most commonly associated with TB and malignancy (see also “Night Sweats” entry)

Workup and Diagnosis

• History
  –Precipitating factors, including emotional stimuli, exercise, heat, spicy foods
  –Fever, associated symptoms
  –Current medications
  –Possibility of ingestions
  –Any problems with feeding or exercise
  –Past medical history including chronic illnesses
  –Family history of any cardiac or sweating problems
• Physical exam
  –Vital signs, including temperature, pulse, respiratory rate, and blood pressure
  –Assessment of airway, breathing, and circulation
  –Cardiac and lung exam, paying special attention to any murmurs, abnormal heart sounds, pulses, irregular rhythms
  –Skin for capillary refill, rashes, pallor, or cyanosis
  –Signs of systemic illness
  • Labs
    –Since most causes of excessive sweating are benign, laboratory evaluation is not usually needed
    –Consider obtaining glucose, drug screen, thyroid function tests
    –Based on history and physical exam, consider an electrocardiogram or echocardiogram

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Source: In A Page: Pediatric Signs and Symptoms, 2007

HYPERNATREMIA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Dehydration can be diagnosed clinically by the tenting of the skin, mushy eyeballs, and concentrated urine. Laboratory work up includes serial electrolytes, chemistry panel, serum and urine osmolality, serum ADH, plasma renin, 24-hour urine aldosterone level, and consultation with an endocrinologist or a nephrologist. It is wise to withhold all noncritical drugs until a diagnosis is certain.

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Source: Differential Diagnosis in Primary Care, 2007

EXCESSIVE SWEATING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Pinpointing the diagnosis involves a search for other symptoms and signs of the above conditions. A chest x-ray film to rule out pulmonary tuberculosis is especially important in a patient presenting with night sweats. Accurate charting of the temperature will indicate those cases due to fever. Urine vanillylmandelic acid (VMA) levels and a thyroid workup will spot pheochromocytomas and hyperthyroidism. A 36- to 48-hour fast with frequent glucose determinations will help diagnose insulinomas and other hypoglycemic states. Because this is not usually the major presenting symptom, the workup will usually center on another symptom. Asking about caffeine ingestion will often spot the cause without expensive laboratory testing.

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Source: Differential Diagnosis in Primary Care, 2007

Diaphoresis: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient is diaphoretic, quickly rule out the possibility of a life-threatening cause. Begin the history by having the patient describe his chief complaint. Then explore associated signs and symptoms. Note general fatigue and weakness. Does the patient have insomnia, headache, and changes in vision or hearing? Is he often dizzy? Does he have palpitations? Ask about pleuritic pain, a cough, sputum, difficulty breathing, nausea, vomiting, abdominal pain, and altered bowel or bladder habits. Ask the female patient about amenorrhea and any changes in her menstrual cycle. Is she menopausal? Ask about paresthesia, muscle cramps or stiffness, and joint pain. Has she noticed any changes in elimination habits? Note weight loss or gain. Has the patient had to change her glove or shoe size lately? patient for diagnostic tests, such as blood tests, cultures, chest X-rays, immunologic studies, biopsy, a computed tomography scan, and audiometry. Monitor the patient's vital signs, including temperature.

Pediatric pointers

Diaphoresis in children commonly results from environmental heat or overdressing; it's usually most apparent around the head. Other causes include drug withdrawal associated with maternal addiction, heart failure, thyrotoxicosis, and the effects of such drugs as antihistamines, ephedrine, haloperidol, and thyroid hormone.

Assess the child's fluid status carefully. Some fluid loss through diaphoresis may precipitate hypovolemia more rapidly in a child than in an adult. Monitor input and output, weigh the child daily, and note the duration of each episode of diaphoresis.

Geriatric pointers

Fever and night sweats, the hallmark of TB, may not occur in elderly patients, who instead may exhibit a change in activity or weight. Also, keep in mind that older patients may not exhibit diaphoresis because of a decreased sweating mechanism. For this reason, they're at increased risk for developing heatstroke in high temperatures.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Skin, clammy: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If you detect clammy skin, remember that rapid evaluation and intervention are paramount. (See Clammy skin: A key finding, page 564.) Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is he taking medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

Next, examine the pupils for dilation. Also, check for abdominal distention and increased muscle tension.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Hyperhidrosis: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

CONFIRMING DIAGNOSIS Clinical observations and patient history confirm hyperhidrosis.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Diaphoresis: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient is diaphoretic, quickly rule out the possibility of a life-threatening cause. (See When diaphoresis spells crisis, page 238.) Begin the history by having the patient describe his chief complaint. Then explore associated signs and symptoms. Note general fatigue and weakness. Does the patient have insomnia, headache, and changes in vision or hearing? Is he often dizzy? Does he have palpitations? Ask about pleuritic pain, cough, sputum, difficulty breathing, nausea, vomiting, abdominal pain, and altered elimination habits. Ask the female patient about amenorrhea and any changes in her menstrual cycle. Is she menopausal? Ask about paresthesia, muscle cramps or stiffness, and joint pain. Has she noticed any changes in elimination habits? Note weight loss or gain. Has she had to change her glove or shoe size lately?

Complete the history by asking about travel to tropical countries. Note recent exposure to high environmental temperatures or to pesticides. Did the patient recently experience an insect bite? Check for a history of partial gastrectomy or of drug or alcohol abuse. Finally, obtain a thorough drug history.

Next, perform a physical examination. First, determine the extent of diaphoresis by inspecting the trunk and extremities as well as the palms, soles, and forehead. Also, check the patient’s clothing and bedding for dampness. Note whether diaphoresis occurs during the day or at night. Observe the patient for flushing, abnormal skin texture or lesions, and an increased amount of coarse body hair. Note poor skin turgor and dry mucous membranes. Check for splinter hemorrhages and Plummer’s nails (separation of the fingernail ends from the nail beds).

Then evaluate the patient’s mental status and take his vital signs. Observe the patient for fasciculations and flaccid paralysis. Be alert for seizures. Note the patient’s facial expression, and examine the eyes for pupillary dilation or constriction, exophthalmos, and excessive tearing. Test visual fields. Also, check for hearing loss and for tooth or gum disease. Percuss the lungs for dullness, and auscultate for crackles, diminished or bronchial breath sounds, and increased vocal fremitus. Look for decreased respiratory excursion. Palpate for lymphadenopathy and hepatosplenomegaly.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Skin, clammy: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If you detect clammy skin, remember that rapid evaluation and intervention are paramount. (See Clammy skin: A key finding.) Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is the patient taking any medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

Next, examine the pupils for dilation. Check for abdominal distention and increased muscle tension.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Night Sweats: History.
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 Night sweats can be characterized by determining onset, frequency, exacerbations, and remissions of symptoms. Question patients about the current state of known disorders. Excessive sweating is associated with poor nocturnal glycemic control (Chapter 14.1). Flares of rheumatologic disorders (rheumatoid arthritis, lupus, juvenile rheumatoid arthritis, and temporal arteritis) cause sweating too. Pregnancy temporarily changes the intrinsic thermostat in many women who perspire excessively (2). Patients who are immunocompromised are at increased risk for infections, especially with atypical agents. Patients with a history of substance abuse need to be asked about needle use and contaminants.

A. Review of systems. Other symptoms that can accompany night sweats include flushing (carcinoid syndrome, pheochromocytoma), joint pain, sleep apnea, menstrual irregularities, reflux, cough, headache, dysuria, dyspnea, rashes, fatigue, palpitations, and weight and bowel habit changes.

B. Exposure factors. Inquire about recent immunizations or new medicines such as antidepressants (3), cholinergics, meperidine, estrogen inhibitors, gonadotropin inhibitors, niacin, steroids, stimulants, over-the-counter preparations, antipyretics, and naturopathic therapies. Question patients about exposure to sexually transmitted diseases (STDs), human immunodeficiency virus (HIV), hepatitis, tuberculosis, or occupational and travel-related exposures. Also ask about increases in general changes in the ambient night temperature.

C. Psychological factors. Anxiety, nightmares, and psychoactive preparations can precipitate night sweats in healthy individuals.

 D. Family history. Patients who report a family history of hereditary disorders and possible malignancies should have appropriate screening.

Physical examination.

 The physical examination should address the pertinent positives noted in the patient’s medical history. Note the patient’s weight and temperature. Examination of the head, eyes, ears, nose, and throat (HEENT) should focus on common types of infection: sinusitis, pharyngitis, and otitis. A thorough examination of lymph nodes is helpful to identify infection or lymphatic abnormalities (Chapter 15.1). The cardiopulmonary examination can also signal infection, valvular disease, and stimulant use. Patients should be examined for abscesses, skin ulcers, septic joints, phlebitis, and osteomyelitis.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Diaphoresis/Night Sweats: Differential Overview
(Field Guide to Bedside Diagnosis)

Diaphoresis

❑ Fever

❑ Hot flashes

❑ Anxiety

❑ Drugs

❑ Gustatory

❑ Thyrotoxicosis

❑ Parkinson disease

❑ Autonomic neuropathy

❑ Central neurologic injury

❑ Pheochromocytoma

❑ Carcinoid

❑ Acromegaly

Night Sweats

❑ Malignancy

❑ Lymphoma

❑ Tuberculosis

❑ HIV

❑ Bacterial endocarditis

❑ Osteomyelitis

❑ Pyogenic abscess

❑ Drugs

❑ Nocturnal hypoglycemia

Diagnostic Approach

Eccrine glands are concentrated on the palms, soles, face, and axilla. They function to cool the body through evaporation. They are under cholinergic control and may be stimulated by epinephrine. Apocrine glands are associated with hair follicles in the axilla and groin. Their secretions are viscid and produce an odor after acted on by bacteria.

Measuring the temperature during diaphoresis helps to determine whether a fever is present, which suggests infection.

Night sweats are distinguished as drenching sweats that require changing the bedclothes. “Night sweats of unknown origin” have a differential similar to “fever of unknown origin.”

Excessive sweating with vasoconstriction (cold and clammy skin) may be caused by insulin hypoglycemia, dumping syndrome, drug withdrawal, shock, vasovagal states, or intense pain.

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Source: Field Guide to Bedside Diagnosis, 2007

Hyperhidrosis: Diagnosis
(Handbook of Diseases)

Clinical observations and the patient history confirm hyperhidrosis.

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Source: Handbook of Diseases, 2003

Skin, clammy: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient’s condition permits, obtain his medical history. Does he have type 1 diabetes mellitus or a cardiac disorder? Is he taking medication? If so, determine whether he takes an antiarrhythmic. Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination? 

Physical examination

Check the patient’s vital signs. Perform a complete cardiovascular assessment, followed by a physical assessment. Check the patient’s blood glucose level. Next, examine the pupils for dilation. Also, check for abdominal distention and increased muscle tension.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Diaphoresis: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient is diaphoretic, quickly rule out the possibility of a life-threatening cause. (See When diaphoresis spells crisis, page 204.) Begin the history by having the patient describe his chief complaint. Then explore associated signs and symptoms. Note general fatigue and weakness. Does the patient have insomnia, headache, and changes in vision or hearing? Is he often dizzy? Does he have palpitations? Ask about pleuritic pain, cough, sputum, difficulty breathing, nausea, vomiting, abdominal pain, and altered bowel or bladder habits. Ask the female patient about amenorrhea and any changes in her menstrual cycle. Is she menopausal? Ask about paresthesia, muscle cramps or stiffness, and joint pain. Has she noticed any changes in elimination habits? Note weight loss or gain. Has the patient had to change her glove or shoe size lately?

Complete the history by asking about travel to tropical countries. Note recent exposure to high environmental temperatures or to pesticides. Did the patient recently experience an insect bite? Check for a history of partial gastrectomy or of drug or alcohol abuse. Finally, obtain a thorough drug history.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Skin, clammy: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is the patient taking any medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Sweating: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Physiologic Causes

Pathologic Causes

Cardiac Failure

Infection

Hypoglycemia

Thyrotoxicosis