Nerve Conduction Studies & Evoked Potentials 1 —
Training activity: 2

Details

Obtain a history and perform appropriate clinical examination for patients attending for upper limb nerve conduction studies

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like? 

• Identify what is expected of you in relation to performing appropriate clinical examinations and obtaining a relevant clinical history. 

• Consider how the learning outcomes apply, specifically in relation to performing clinical examinations, obtaining a clinical history, and demonstrating effective and compassionate communication skills. 

• Discuss with your training officer to gain clarity of what is expected of you in relation to the required depth of history and the scope of the clinical examination. 

What is your prior experience of this activity? 

• Think about what you already know about taking patient histories or performing clinical examinations, especially for neurological conditions. 

• Consider possible challenges you might face during the activity, such as communication barriers, obtaining sensitive information, or performing an accurate examination for potential upper limb neuropathies (e.g., Carpal tunnel syndrome). 

• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if the patient presents with symptoms beyond routine upper limb entrapment or if complex neurological issues are identified. 

• Acknowledge how you feel about interacting closely with patients to gather information and perform examinations. 

What do you anticipate you will learn from the experience? 

• Consider the specific skills you want to develop, such as eliciting a focused history for upper limb neuropathies and performing relevant physical assessments. 

• Identify the specific insights you hope to gain into connecting patient symptoms and clinical signs with potential neurophysiological findings. 

What additional considerations do you need to make? 

• Consult actions identified following previous experiences of patient interactions, history taking, or examination. 

• Identify important information you need to consider before embarking on the activity, such as reviewing academic content on clinical examination of patients attending for upper limb entrapments and the pathophysiology of relevant conditions. 

In action

Is anything unexpected occurring? 

• Are you noticing anything surprising or different from what you anticipate whilst obtaining the patient history or performing the clinical examination? 

• Are you encountering situations such as:  

• • The patient presents with complex symptoms or a clinical history that significantly deviates from the expected upper limb entrapment pathology e.g., Carpal tunnel syndrome, complicating the focus of the examination? 

• • Communication barriers arise unexpectedly, challenging your ability to demonstrate effective communication 

• • You detect clinical signs e.g., unexpected motor weakness that require an immediate deviation from the planned upper limb examination approach 

How are you reacting to the unexpected development? 

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to asking questions or performing examination techniques? 

• Consider the steps you are taking in the moment, such as:  

• • Immediately adjusting your questioning to focus on the unexpected clinical history detail, while simultaneously documenting the information clearly 

• • Pausing the examination to consult a guide or discreetly seek advice from a senior colleague about the unexpected clinical finding 
• How are you feeling in that moment? For instance, are you finding it difficult to adapt your history-taking strategy to manage the complex symptoms? Is it affecting your confidence in performing an accurate clinical examination? 

What is the conclusion or outcome? 

• Identify how you are working within your scope of practice. For example, are you successfully completing a focused neurological examination appropriate to the unexpected finding? Or are you needing support because the patient’s complex symptoms are beyond your current experience for accurate clinical assessment? 

• What are you learning as a result of the unexpected development? For example, are you mastering a more effective technique for adapting communication style to address patient anxiety? Or gaining insight into the wide range of symptoms that may mimic upper limb entrapment? 

On action

What happened? 

• Begin by summarising the key steps you took when obtaining the patient history and performing the appropriate clinical examination. 

• Consider specific events, actions, or interactions which felt important, such as how you communicated the purpose of the examination or how you assessed specific neurological signs related to suspected upper limb entrapments. 

• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately adapting your questioning technique when the patient presented with complex, atypical symptoms, complicating the history review.  

• How did you feel during this experience, e.g., did you feel focused on differentiating between relevant and irrelevant symptoms or stressed by the diagnostic uncertainty? 

How has this experience contributed to your developing practice? 

• Identify what learning you can take from this experience regarding history taking and examination. What strengths did you demonstrate, e.g., clear and compassionate communication? What skills and/or knowledge gaps were evident, e.g., unfamiliarity with a specific physical manoeuvre used to detect subtle ulnar nerve neuropathy? 

• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in correlating specific historical details with required examination steps? 

• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding the need to expand the neurological examination beyond the upper limbs due to unexpected findings, and how you reacted to this. 

What will you take from the experience moving forward? 

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving the structure and focus of your history taking and clinical examination. 

• What will you do differently next time you approach obtaining history and performing clinical examination, for instance, by proactively structuring history questions to efficiently rule out non-entrapment pathologies? 

• Do you need to practise any aspect of the activity further, such as specific neurological examination techniques or key learning outcomes related to performing clinical examinations? 

Beyond action

Have you revisited the experiences? 

• How have your subsequent experiences of obtaining histories and performing clinical examinations since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent patient presented with complex co-morbidities requiring differential diagnosis (e.g., cervical radiculopathy mimicking Carpal Tunnel Syndrome, CTS), forced you to re-evaluate the depth of neurological history taking you applied during your first attempt at this training activity. 

• Considering what you understand about upper limb anatomy, differential diagnoses (e.g., radiculopathy vs. entrapment), and the structure of a neurological examination now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your clinical history and examination technique based on further learning and experiences? For example, how you proactively integrated specific sensory testing methods for the radial nerve territory (often overlooked in routine CTS screening), demonstrating you have adapted improvements based on further learning. 

• Has discussing ambiguous patient symptoms found during history taking or the impact of an incomplete physical examination with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a case where key occupational history was missed, leading to an initial misclassification, refined your understanding of the critical nature of holistic patient history capture during the initial assessment. 

How have these experiences impacted upon current practice? 

• How has the learning from this initial training activity, in combination with subsequent history taking and examination experiences, contributed to your overall confidence and competence in obtaining a clinical history and performing an appropriate upper limb clinical examination, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated ability in systematic history taking and examination now enables you to summarise a patient’s complex clinical context efficiently during an OCE assessment focusing on obtaining a patient history. 

• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to obtaining patient histories and performing clinical examinations for NCS? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Neurologist or Senior Neurophysiologist immediately when a patient presents with unexpected motor symptoms suggesting proximal pathology that falls outside routine upper limb entrapment assessment scope. 

• Looking holistically at your training journey, how has this initial history taking and clinical examination experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to performing clinical examinations, obtaining clinical history, and demonstrating effective communication skills? For example, how this foundational experience has supported your development in practicing safely by providing the necessary knowledge base for the subsequent learning outcomes focused on performing diagnostic tests and preparing factual reports. 

Relevant learning outcomes

#	Outcome
# 2	Outcome Perform clinical examinations of patients attending for upper limb nerve conduction studies.
# 3	Outcome Obtain a clinical history from patients attending an upper limb nerve conduction study and a multi-modality evoked potential studies.
# 4	Outcome Explain procedures to patients in order to obtain informed consent for upper limb nerve conduction studies and multi-modality evoked potential studies.
# 7	Outcome Apply legislation and guidelines and manage risk in the performance of upper limb nerve conduction studies and multi-modality evoked potential studies.
# 9	Outcome Demonstrate effective and compassionate communication skills with all stakeholder including patients and the multidisciplinary team.