History Taking · Foundation · Dermatology

Excessive Sweating - Palms and Soles

Practise this PLAB 2 history taking station on Primary Focal Hyperhidrosis. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Georgina, a 24-year-old woman, has come to see you about excessive sweating on her hands and feet since childhood. She is embarrassed about the problem and is seeking treatment options. Please take a focused history and discuss your management plan.

Background notes: PMH: Generally healthy, no chronic conditions

What this station tests

  • Distinguishing primary from secondary hyperhidrosis: focal, childhood onset, bilateral, absent during sleep versus systemic symptoms
  • Excluding thyrotoxicosis, phaeochromocytoma, and lymphoma through targeted questions
  • Stepped treatment: aluminium chloride first-line, then iontophoresis, botulinum toxin, and anticholinergics
  • Normalising the condition: not related to hygiene or anxiety, affects 3% of population
  • Functional impact assessment: handshaking anxiety, client-facing work, relationship impact

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Hyperhidrosis stations test whether the candidate can distinguish primary (benign, focal, often childhood onset) from secondary (systemic cause) hyperhidrosis, and provide a management plan for a condition that is embarrassing and often undertreated. Georgina is 24, with lifelong excessive sweating of palms and soles. She has never sought help before. Open with: 'Georgina, this is something many people feel embarrassed about but it is a real medical condition. Tell me about the sweating and how it affects you.'

Core approach

Confirm primary focal hyperhidrosis. Excessive sweating limited to specific areas (palms, soles, axillae) since childhood or adolescence. Bilateral and symmetrical. Not present during sleep (primary hyperhidrosis stops during sleep; secondary does not). No systemic symptoms: no weight loss, no palpitations, no heat intolerance (excludes thyrotoxicosis), no night sweats (excludes lymphoma or TB). No medications causing sweating. Family history may be positive (genetic component).

Exclude secondary causes through targeted questions. Thyrotoxicosis: weight loss, tremor, palpitations? (No.) Phaeochromocytoma: episodic sweating with hypertension, headache, palpitations? (No.) Menopause: age inappropriate. Medications: SSRIs, opioids, anticholinesterases? (No.) Lymphoma: night sweats, weight loss, lymphadenopathy? (No.) The focal, childhood-onset, bilateral pattern without systemic features confirms primary.

Assess functional impact. She avoids shaking hands, is anxious about her new client-facing role, her partner notices, and it affects her confidence. This impact justifies treatment.

Closing and safety netting

Treatment is stepped. First-line: aluminium chloride hexahydrate (Driclor) applied at night to dry skin, washed off in the morning. This works by mechanically blocking sweat ducts. Start every night for 1 to 2 weeks, then reduce to maintenance (1 to 2 times weekly). If insufficient: iontophoresis (electrical current through water to reduce sweat gland activity, available via dermatology). If still insufficient: botulinum toxin injections (effective for 6 to 9 months per session). Systemic: anticholinergics (glycopyrronium) as last resort (side effects: dry mouth, constipation).

Normalise the condition: 'Hyperhidrosis affects about 3% of the population. It is not related to hygiene or anxiety, it is a medical condition where the sweat glands are overactive.' Reassure about the new job: treatment should improve confidence. Dermatology referral if first-line fails.

Safety net: 'If you develop any new symptoms like weight loss, palpitations, or the sweating starts happening at night, come back as we would need to investigate further.' Follow-up in 4 weeks.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for primary focal hyperhidrosis. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Primary pattern confirmed (focal, bilateral, childhood, absent during sleep). Secondary causes excluded. Functional impact assessed. Family history checked.

Costs marks: Not excluding secondary causes. Not confirming primary pattern. Not assessing impact.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Aluminium chloride prescribed with correct application instructions. Stepped pathway known (iontophoresis, botulinum toxin). Dermatology referral for escalation. Safety netting for secondary features.

Costs marks: Not knowing first-line treatment. No escalation pathway. No referral plan.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Normalising the condition. Addressing embarrassment. Reassuring about the new job. Validating her decision to seek help after years of suffering.

Costs marks: Making her feel embarrassed. Not normalising. Being dismissive of functional impact.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not excluding secondary causes. A candidate who diagnoses primary hyperhidrosis without asking about thyroid symptoms, night sweats, and medications may miss a systemic cause. The exclusion is brief but essential.
  2. Not knowing the treatment pathway. Many candidates know aluminium chloride but not iontophoresis or botulinum toxin. The stepped approach demonstrates knowledge of the full management spectrum.
  3. Not normalising the condition. Hyperhidrosis causes significant embarrassment. Candidates who provide treatment without addressing the psychological dimension miss an important interpersonal opportunity.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take a primary focal hyperhidrosis history in PLAB 2?

Hyperhidrosis stations test whether the candidate can distinguish primary (benign, focal, often childhood onset) from secondary (systemic cause) hyperhidrosis, and provide a management plan for a condition that is embarrassing and often undertreated. Georgina is 24, with lifelong excessive sweating of palms and soles. She has never sought help before.

Where are marks won and lost in this primary focal hyperhidrosis station?

Examiners reward: Primary pattern confirmed (focal, bilateral, childhood, absent during sleep). Secondary causes excluded. Functional impact assessed. Family history checked. Candidates are penalised for: Not excluding secondary causes. Not confirming primary pattern. Not assessing impact.

Where do candidates most often go wrong in this station?

Not excluding secondary causes. A candidate who diagnoses primary hyperhidrosis without asking about thyroid symptoms, night sweats, and medications may miss a systemic cause. The exclusion is brief but essential.

Can I do well in this station without real-world experience of primary focal hyperhidrosis?

This station rewards process over personal experience. The skill being assessed: Excluding thyrotoxicosis, phaeochromocytoma, and lymphoma through targeted questions. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

Related cases