Sensation

This part of the examination is difficult, and findings are not always reproducible. The tests are crude, and the results are dependent on the cooperation of and interpretation by the patient.

Sensory findings are always subjective. A painless ulcer on the sole of an anesthetic foot or a cigarette burn on the edge of the middle finger are objective signs, but their significance rests on what the patient says about them.

Sensory symptoms depend on the vocabulary and intelligence of the patient. Descriptions such as "numb," "tingling," "prickling," "asleep," and "like dental anesthetic coming out" are the most common. The rare patient says "The part is dead; there is no feeling in it at all." Others say that the part (eg, the side of the face) is normal or unremarkable if it is not touched but feels different when he shaves, for example.

More subtle sensory symptoms are descriptions such as "My fingers [or toes] feel swollen like sausages," "The skin is too tight," or "I feel as though I have tight gloves on all the time."

Symptoms in the lower limbs may be described in this way: "I feel as though I'm walking on cotton wool" (possibly a posterior column lesion) or "My shoes are full of small stones; my feet are on fire" (a possible peripheral nerve lesion) as well as the more usual descriptions of numbness, tingling, and prickling. The proximal pain and peripheral paresthesia clue—"I have pain in my shoulder and down the back beside my shoulder blade and my little finger is asleep"—clearly tells you where the sensory signs should be.

When you hear these symptoms, examine the part in more detail and, if necessary, examine only the symptomatic area the next day.

The patient with no sensory complaints (including pain) and nothing in his history to suggest a disturbance of sensation should have a sensory examination lasting 5 min, consisting of the following:

• Touch and pain sensation over the face (always the corneas), hands, feet, and trunk

• Vibration sense and joint passive movement sense in the fingers and toes

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