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

Details

Obtain a history and perform a clinical examination of a patients attending for lower 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 obtaining a clinical history and performing a clinical examination for patients attending for lower limb nerve conduction studies.
• Consider how the learning outcomes apply, specifically in relation to performing clinical examination, obtaining history, explaining procedures for consent, applying legislation and guidelines, and demonstrating effective communication.
• Discuss with your training officer to gain clarity of what is expected of you in relation to a successful history and examination relevant to lower limb nerve conduction studies for peripheral neuropathy.

What is your prior experience of this activity?

• Think about what you already know about obtaining patient history and performing clinical examinations.
• Consider possible challenges you might face during the activity, such as communicating effectively with patients about sensitive information, managing patient discomfort during examination, or identifying key symptoms of peripheral neuropathy, and think about how you might handle them.
• 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:
  • When a complex history suggests a differential diagnosis (e.g., radiculopathy vs. neuropathy) requiring clarification on targeted examination.
  • If unclear examination findings require senior verification.
  • When navigating consent if the patient expresses hesitancy or capacity issues
• Acknowledge how you feel about obtaining history and performing a clinical examination within this context.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as eliciting specific history points relevant to lower limb peripheral neuropathy, performing a targeted clinical examination, explaining procedures clearly, or demonstrating compassionate communication, drawing upon previous experiences.
• Identify the specific insights you hope to gain into understanding how patient history and examination findings guide nerve conduction study planning or appreciating the importance of effective communication in this context.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of obtaining history or performing examinations.
• Identify important information you need to consider before embarking on the activity, such as specific questions to ask for peripheral neuropathy, key examination techniques for lower limbs, or institutional guidelines on consent and communication.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst obtaining the clinical history or performing the clinical examination?
• Are you encountering situations such as:
  • Symptoms of peripheral neuropathy expressed by the patient contradict the information on the referral form, complicating your focused history taking?
  • The clinical examination elicits unexpectedly severe pain or discomfort in the lower limb (e.g., foot drop assessment), challenging your technique and communication?
  • Unexpected findings e.g., signs of radiculopathy rather than typical entrapment emerge during the examination, suggesting a differential diagnosis outside the initial scope?

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 questioning or examination technique to prioritise patient comfort?
• Consider the steps you are taking in the moment, such as:
  • Immediately pausing the examination and using compassionate communication to understand the source and extent of the patient’s discomfort.
  • Adapting your history taking to focus on differentiating between potential pathologies (e.g., large vs. small fibre neuropathy) based on the unexpected symptoms.
• How are you feeling in that moment? For instance, are you finding it difficult to adapt your professional communication style while maintaining a systematic examination? Is it affecting your confidence in assessing the patient’s clinical status?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully modifying the examination to obtain necessary data without causing undue distress? Or are you needing support because the patient’s severe physical limitation or distress requires immediate senior clinical guidance to ensure safety and ethical conduct?
• What are you learning as a result of the unexpected development? For example, are you mastering a more effective empathetic approach to communication during sensitive procedures? Or gaining insight into how to immediately adjust examination techniques for different pain presentations?

On action

What happened?

• Begin by summarising the key steps you took when obtaining a history and performing a clinical examination for the patient.
• Consider specific events, actions, or interactions which felt important, such as how you elicited specific symptoms related to large vs. small fibre neuropathy during history taking, or how you managed patient positioning during the lower limb neurological examination.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately altering the physical examination steps when the patient reported unexpected sharp pain, requiring adaptation of your communication.
• How did you feel during this experience, e.g., were you confident in your ability to maintain compassionate communication despite the unexpected finding, or stressed by the need to adapt the standard motor assessment?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding history taking and clinical examination. What strengths did you demonstrate, e.g., systematic approach to documenting symptom progression? What skills and/or knowledge gaps were evident, e.g., unfamiliarity with differentiating specific lower limb entrapments from generalised peripheral neuropathy or correlating complex symptoms with potential conditions?
• Compare this experience against previous engagement with similar activities – has your practice improved in demonstrating effective communication during potentially uncomfortable examination procedures?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding how to document and proceed when examination findings suggested a high spinal cord lesion 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 history taking and lower limb clinical examination.
• What will you do differently next time you approach performing a lower limb clinical examination, for instance, by proactively explaining each component of the motor and sensory assessment to manage patient expectations?
• Do you need to practise any aspect of the activity further, such as developing targeted questioning techniques for differentiating specific neuropathy symptoms or key learning outcomes related to performing a comprehensive clinical examination?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences obtaining history and performing clinical examinations, especially those requiring complex communication or involving ambiguous symptoms, 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 highly localised pain that conflicted with initial generalised neuropathy symptoms forced you to re-evaluate the rigidity of the systematic neurological examination you applied during your first attempt at this training activity.
• Considering what you understand about clinical examination, effective communication, and ethical principles 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 history taking and examination technique based on further learning and experiences? For example, how you proactively reviewed and implemented communication techniques to elicit subtle symptoms of small fibre neuropathies, demonstrating you have adapted improvements based on further learning.
• Has discussing challenging patient interactions or the impact of ambiguous examination findings 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 misinterpretation of a patient’s pain response during F-Wave discussion, refined your understanding of the critical nature of compassionate communication during clinical assessment.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent history and examination experiences, contributed to your overall confidence and competence in obtaining history and performing examinations, particularly in preparing for assessments like Observed Communication Events (OCEs)? For example, how your accumulated ability in performing a systematic clinical examination now enables you to confidently structure a patient interaction for an OCE assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to clinical assessment? 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 Training Officer or Neurologist immediately when unexplained signs of upper motor neuron disease emerge during a peripheral neuropathy assessment, recognising this falls outside routine NCS scope.
• Looking holistically at your training journey, how has this initial history and examination experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to communication, clinical examination, and history taking? For example, how this foundational experience has supported your development in performing subsequent learning outcomes focused on interpreting complex findings, which rely on robust clinical context.

Relevant learning outcomes

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