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EMG 2
Introduction
While on the EMG 1 or 2 rotation, the resident responsibilities will include attending PCMH Rehab EMG outpatient clinic, PCMH Rehab EMG inpatient clinic, BSOM- Family Practice EMG clinic, Chowan EMG outpatient clinic, Bertie EMG outpatient clinic, Heritage EMG outpatient clinic, Podiatry Office EMG outpatient clinic. The resident will assess & examine the patient, then formulate a tactical plan for the electrodiagnostic procedure. Cases will be discussed with the attending physician. The resident then will perform the appropriate electrodiagnostic procedures and develop a clear, accurate and comprehensive report for the referring physician. The residents will also assist with the education of junior residents, medical students, residents from outside PM&R Departments and Allied Health students when they are present in the clinic. The resident is expected to satisfactorily complete a total of approximately 200 electrodiagnostic studies (observed, participated or performed) during residency training EMG 1 & 2). The resident is expected to use available web based, computer and paper resources & publications (e.g. minimonographs and case reports) to assist him/her in accomplishing the goals and objectives noted below. On the EMG 2 rotation, the PGY-4 resident has the added responsibility of mentoring and leading the EMG 1 (PGY-3) resident through various difficult diagnostic processes.
Medical Knowledge
The resident will:
1. Identify the appropriate instrument settings for needle EMG and nerve conduction studies.
2. Describe the electrophysiologic basis of generation and conduction of a potential in a nerve.
3. Be able to describe the peripheral neurologic, muscular, vascular and osseous anatomy of the upper limbs, lower limbs, head and thorax.
4.Define types of insertion activity, endplate activity, positive fibrillations, negative fibrillations, fasciculation potentials, myokymic discharges, and complex repetitive discharges, and recognize myotonic discharges.
5. Describe the configuration of motor unit action potentials (MUAPs) in normal muscles, as well as identify neurogenic and myogenic patterns.
6. Identify appropriate instrument settings and indications for single fiber EMG.
7. Identify the settings and parameters used for stimulation of peripheral nerves.
8. Demonstrate the techniques for nerve conduction studies (median, ulnar, radial, tibial, peroneal, etc).
9. Measure duration, amplitude and area of the evoked potentials and their neurophysiologic basis.
10. Characterize the electrical alterations resulting from axonal loss and demyelination.
11. Identify the pathway and instrument settings for recording of H reflex and F wave; describe the technique of unusual conduction; i.e. blink reflex, pudendal reflex, spinal nerve stimulation.
12. Describe the 10-20 International System as applied to evoked potential studies.
13. Explain instrumentation requirements and parameters for evoked potential settings.
14. Evaluate the contribution of SEP’s in diagnosis in radiculopathy, brachial plexopathy, and ulnar neuropathy.
15. Summarize the effects of temperature, age, gender & height on nerve conduction studies.
16. Explain instrumentation requirements, parameters and technique to perform sympathetic skin response.
17. Explain instrumentation requirements, parameters and technique to performrepetitive nerve stimulation studies.
Patient Care
1. Interpret the responses to repetitive stimulation in normal subjects and the electrophysiologic expression of abnormalities of neuromuscular transmission.
2. Diagnose the presentation of the following syndromes:
a. Entrapment Sydromes
i. median nerve: carpal tunnel, anterior interosseus syndrome, pronator teres syndrome
ii. ulnar nerve: Guyon’s canal entrapment, ulnar nerve compression at the elbow
iii. radial nerve: posterior interosseus syndrome, Saturday night palsy, radial nerve entrapment at the spiral groove
iv. femoral nerve: femoral cutaneous ulnar nerve
v. tibial nerve: including tarsal tunnel syndrome
vi. peroneal nerve: including peroneal nerve palsy
b. Systemic Disorders
i. peripheral neuropathy and differentiate axonal vs. demyelating
ii. mononeuritis multiplex
iii. Guillain-Barre syndrome
iv. plexopathy, including lumbosacral plexopathy, brachial plexopathy syndrome
v. myopathies: including myotonia dystrophica, polymyositis, and secondary myopathies
vi. Myasthenia gravis, LEMS, and botulism
3. Identify the clinical significance of upper and lower extremity evoked potentials as well as dermatomal sensory evoked potentials.
4. Analyze the data from an electrodiagnostic study on a patient with:
a. Polyneuropathy
b. Mononeuropathy
c. Radiculopathy
d. Generalized weakness and fatigue
5. Demonstrate proficiency in performing upper & lower extremity conduction studies & electromyography.
6. Demonstrate the ability to tailor studies to efficiently diagnose pathology, taking into account the patient’s history and physical examination findings.
7. Demonstrate the ability to alter a study in progress according to evolving findings.
8. Demonstrate the ability to minimize discomfort (both physical & emotional) to patients while undergoing electrodiagnostic evaluation.
9. Justify the use of electrodiagnostic evaluation for a managed care executive presenting with new onset of right handed weakness & numbness.
10. Contrast typical electrophysiologic findings in Bell’s Palsy with those in other causes of facial weakness; formulate a treatment plan for a patient with Bell’s Palsy.
11. Summarize the issues pertaining to reporting of results of electrodiagnostic studies to the patient and the referring physician.
Interpersonal and Communication Skills
1. Present information to patients & other care team members in an effective manner.
2. Establish trust and maintain positive rapport with patients, caregivers & family members.
3. Demonstrate effective listening skills.
4. Promote teamwork in the clinical setting.
5. Complete dictations and chart notes in a legible & timely manner.
Professionalism
1. Demonstrate sensitivity and responsiveness to age, culture, disability and gender of patients and colleagues.
2. Consider effects of personal, social and cultural factors in the disease process and patient management.
3. Demonstrate reliability, punctuality, integrity and honesty in all interactions with patients and colleagues.
4. Accept personal responsibility for own actions & decisions.
5. Apply sound ethical principles in practice (e.g., informed consent, confidentiality, veracity, provision or withholding of care).
Practice-Based Learning and Improvement
1. Demonstrate skill in supervising junior residents and medical students in information gathering, decision-making, and patient management.
2. Evaluate and/or modify own practice, incorporating feedback from others.
3. Use information technology to appraise & assimilate evidence from scientific studies to enhance patient care outcomes.
Systems-Based Practice
1. Summarize the physician’s role in advocating for patient care needs
2. Summarize the physician’s role in disease management across various levels of the health care system in a cost effective manner.
3. Demonstrate how to access various community resources on behalf of the patient.
4. Demonstrate integrity and responsibility in interactions with insurance and/or disability-oriented agencies.
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