In our second session today, Ms. Debra O'Reilly and I will present the neuromuscular exam, cranial nerve examination. Ms. O'Reilly is a board-certified physician assistant with a decade of experience in the field of neuromuscular medicine. She's a senior instructor in the neuromuscular section in the Department of Neurology at the University of Colorado School of Medicine. And again, my name is Diana Kwan, and I also work with Ms. O'Reilly in the neuromuscular section at the University of Colorado. Hello, and welcome to our lecture demonstration on the examination of the cranial nerves for neuromuscular patients. My name is Diana Kwan, and I am a professor of neurology at the University of Colorado, Denver. Here with me today is our physician assistant, Debra O'Reilly, who will be co-hosting the session with me. As many of you may remember from your clinical training or your neuroanatomy classes, there are 12 cranial nerves which innervate the head and neck region. I normally will break them into groups, which allows me to more efficiently evaluate everything in the clinics. Typically, the olfactory nerve, which supplies smell, is not one that is very important in neuromuscular diseases, but we will show you how to test it. Cranial nerve 2 is the mediator of vision, and this is very important for our conditions. Cranial nerves 3, 4, and 6, ocular, motor, trochlear, and abducens nerves, are important for extraocular movement. Cranial nerve 5, which is the trigeminal nerve, I will typically examine by itself, and that handles sensation in the face. Cranial nerve 7 is mainly the muscles of facial expression. Cranial nerve 8 handles hearing and vestibular function. Cranial nerves 9 and 10 are important in pharyngeal function and speech, swallowing. Cranial nerve 11 is important in the neck musculature and trapezius function. And then the hypoglossal nerve, cranial nerve 12, is important in tongue function. As I mentioned, cranial nerve 1 is not a nerve that is especially helpful for distinguishing among different neuromuscular disorders, but we will show you how to test it. It's pretty simple. Cranial nerve 2, on the other hand, is very important and is often somewhat neglected in the neuromuscular examination. Blurry vision is a very common neurologic complaint and a very common complaint among patients with neuromuscular disease. There are several aspects of cranial nerve 2 that are important to look at. The first is visual acuity, and here we're mainly concerned not so much with refractive errors or errors that can be corrected with glasses or contact lenses. Those are usually due to underlying eye disease and not something that worries us too much, so we always want to test this the patient's best corrected vision. So if they have glasses or contact lenses, they should be wearing them for testing. And this is important because in people who have neuromuscular disease, if they're weak or if they have proprioceptive or other sensory deficits, maybe their balance isn't great. And vision is very important as a compensatory mechanism, and so we want to get a good sense of how well the patient can see, whether there's blindness or cataracts that may amplify some of their underlying neuromuscular deficits. With the visual fields, this is very important for functional tasks like driving or just generally walking around and avoiding obstacles in your path. So we want to take a good look at the visual fields. For the pupils, most patients will not notice problems in pupillary function. It may just manifest as blurry vision or difficulties accommodating to light and dark, but for patients with certain types of neuropathy where there may be autonomic dysfunction, it's important to look at how well the pupils react to light and accommodation. Very occasionally, there can be situations in which neuromuscular diseases have associated retinal problems. For example, in FSH dystrophy, there may be retinal disease or in mitochondrial conditions, you can sometimes see retinal problems. So if you can get a good look in there at the retina, that is occasionally helpful. But I would say that for most neuromuscular doctors, our exam is not typically a dilated exam and we would never exclude the possibility of retinal disease just on the basis of our exam. We'd probably refer those patients to ophthalmology for a more detailed test. Okay, now we're going to go ahead and demonstrate cranial nerve one testing. So Deb, would you mind pulling your mask down slightly? Just uncovering your nose. Okay, so I'm going to have you cover up your left nostril. All right, and if I had something that was pungent, I would put it right under this nostril like this and ask the patient if she could smell it, and then I'd do the same and then I'd do the same exact thing on the other side, holding it right up and having them give a good sniff. So that's cranial nerve one. With cranial nerve two, we always start with acuity. So there's a few different ways of doing this, but I might have you start with just covering up your left eye. So let's test one eye at a time and we can use a near card if you don't have this handy. A magazine or any printed material in your clinic would probably suffice. We're mainly interested in seeing if she can read at whatever distance is comfortable for her and having the patient keep her glasses or contact lenses on. So what's the smallest line you can read there? Four, two, six, seven, three, nine. Perfect, and that's 20-20. And then we'll have you just switch to the other eye. And sometimes patients memorize the numbers so I'll have her read that same line but backwards. Nine, three, seven, eight, two, four. Perfect, or you could use the E's or the X's and O's if you have those on your near card. All right, so that's the visual acuity, and then we'll go ahead and test visual fields. We want to do all this before we start shining the lights into her eyes, which can cause little bright spots and impair your vision. So normally I'll stand in front of the patient and have her look directly at my nose, but in this case I don't want to block the camera. So I'll just have you look, Debra, straight at the camera. And again, I would test one eye at a time. Go ahead and cover the left eye first. Standing right in front of the patient, I would hold my fingers kind of in front of her and just test one field at a time. So here, how many fingers do you see? How about there? Two, four, one, two, one. Good, and sometimes if we just want to see if there's any neglect, we can kind of do both sides at once. So how many fingers there? Three. Perfect. All right, and then go ahead and switch sides, and we do the same exact thing on this side. One, two, one, four. And it's good to mix it up a little bit. How about there? Two, four total. Right, okay. So that's typically how we would do visual fields. If the patient can't see well, then you could just use finger movement. So if you cover up your left eye, you can just tell me which finger is moving. Left. Right. And you could do that in all four quadrants if we think that the acuity is not that great. Okay, so that's visual fields. And then the next thing we're going to do is pupillary exam. So I'm going to turn the lights out. We want to make sure it's dim enough. To do the pupillary exam, you want to start with the room reasonably dark, and you want to make sure your light is bright enough. So I'm going to just shine it on Deb's forehead so you can kind of see how bright it is. All right, and then if we're just checking light reflex, we're going to come in from the side and shine the light right in the pupil. So start from the side and shine it in, and she's got a nice pupillary reflex. We're going to do the other side, and you can see a nice reaction there. Okay, and then to do the accommodative reflex, we'll have her look straight out into the distance, and you can see the size of the pupils when she does that. And then I'm going to have her look just kind of right down towards the nose, and we can see the pupils constrict when she does that. So if you look out again and then look at my finger, that brings the pupils down, and that's the accommodative reflex. Cranial nerves three, four, and six are usually examined together. These are the nerves that innervate the extraocular muscles. Cranial nerve three carries the heaviest load. It innervates several of the extraocular muscles, including the superior and inferior rectus muscles, the medial rectus, the inferior rectus, and the inferior oblique. Those muscles are named by where they attach on the eyeballs. In addition, cranial nerve three also innervates the eyelid muscle or the levator. So an individual who has a complete cranial nerve three palsy, their eye will be tautic, so the lid will be down, and they will have their eye deviated down and out. So that's the classic third nerve palsy, down, out, and the lid is lowered. Cranial nerve three also has some extra functions. We had talked a little bit about the pupillary light reflex on the last slide. So with the pupillary light reflex, that's a two-nerve reflex. The afferent arm is mediated by cranial nerve two. Light enters the eye, and cranial nerve two carries that afferent signal back into the brainstem. And then the efferent arm is via the parasympathetic fibers on the outside of cranial nerve three. So when light enters the eye, cranial nerve three parasympathetic fibers cause the pupil to constrict. With the accommodative reflex, again, it's the same parasympathetic fibers, but this time the afferent arm is through the medial rectus. So when we look inward and slightly downward, that activates the afferent arm of the accommodative reflex, and the efferent fibers, those parasympathetic fibers on cranial nerve three, will cause the pupils to constrict. And so that's accommodation, and we'll show you how to do that. Cranial nerve four has a much simpler job. There's really only one muscle that is innervated by this nerve. It's called the superior oblique, and its main function is to intort the eyeball and press it down. So patients who have a cranial nerve four palsy, let's say it's this eye, the eyeball will be extorted, so it'll be weak in intortion, so it'll be rotated outwards due to unopposed action from the other muscles, and the eye will be slightly lifted up. So what this does is it causes the axis of vision to go from straight up and down to deviated externally. And when people have this, they see double, and the way they correct that is to try to rotate the head in such a way that the axis of vision is then aligned with the intact eye. So the head tilt that occurs in a cranial nerve four palsy will be away from the affected eye. So that's cranial nerve four. And with cranial nerve six, that's the lateral rectus muscle, and in patients who have weakness there, the eye deviates medially. And so patients will try to accommodate or compensate for this by turning their head towards the good eye or away from the side with the deficit. Since the side with the deficit can't pull the eye outward, people will just turn inwards to try to get their alignment better so that they're not seeing double. And basically with the cranial nerves, the key things that happen are diplopia and ptosis. So these are very common complaints in neuromuscular conditions. And with diplopia, we always want to make sure that we're dealing with binocular diplopia because the reason that people see double due to these cranial nerve palsies is because the eyes are not aligned due to weakness. And usually if you close one eye, then the double vision should go away if it's due to a cranial nerve palsy. If the double vision is monocular, that is usually an indication of intrinsic eye pathology. So that's not in the realm of neuromuscular disease. Depending on when or in what head position the diplopia occurs, sometimes you can tease out which nerve is involved. We talked about cranial nerve 3, the eye is down and out. Cranial nerve 4, the eye is extorted and lifted up slightly, causing compensatory head tilt. And then with cranial nerve 6, we talked about how there's weakness with lateral gaze on the side that's weak and patients will typically look away from the side of the lesion. So depending on what they tell you about when their double vision is worst, you can sometimes tease out which nerve it is. Now, where we run into trouble is if the problem is variable, which can be very common in neuromuscular conditions like myasthenia gravis, for example. And if you come and you look at a patient one day and their eyes are very misaligned, but you come back on another clinic visit and they look a lot better or the misalignment is different from the first exam, that may be a good clue that we're dealing with a neuromuscular junction disorder rather than an actual cranial nerve palsy, which should remain relatively fixed in terms of directionality. With ptosis, we are always interested in variability and whether the problem is unilateral or bilateral. Sometimes patients can have ptosis simply because of dehiscence of the levator muscle, or if it's bilateral, it can be weakness due to the levator from an underlying muscular condition as well. Certain types of muscular dystrophies, such as oculopharyngeal or mitonic dystrophy, most commonly can cause ptosis as well as a whole host of other primary muscle diseases. Okay, now we're going to demonstrate cranial nerves three, four, and six. So the first thing is to start with observation and we see Deb has no evidence of ptosis and her eyes are nice and symmetrically open. So to look at ocular motility, I'll start by having the patient just look straight ahead and I would say about an arm's distance from the patient's nose is a good place to go. And we'll start by having you look way up and then track down and track over to the left and to the right. And occasionally in extreme gaze, we may see a few beats of nystagmus, but usually not a concern that can sometimes be a common finding. And then you can also have them look diagonally and just watching the movement of the eyes. And are you seeing double at all? No. Perfect. All right, good. So that's cranial nerves three through six. With ptosis, you can sometimes see a phenomenon called curtaining and we'll show you an example of that in a patient. But basically the anatomy behind it relates to something called Herring's law of reciprocal innervation. So both eyelids receive the same input to lift up. And in some neuromuscular conditions like myasthenia gravis, where there's ptosis, we can see a phenomenon called curtaining. And basically what that involves is if you manually lift the tautic lid up, the other lid will, because both eyelids receive the same amount of innervation, you're allowing this eye to rest by holding it up manually. And what happens is the input driving the eyelids upward actually decreases due to Herring's law of reciprocal innervation. So the other eye that you're not holding up will kind of drop down. So you'll see that phenomenon called curtaining where this other eye will curtain down. And I'll show you an example of that. Yeah. Okay. And then I'm going to just lift your eyelid here. So I want you to just look straight ahead. Good. All right. And relax. Again. And then we're going to just check the other eye here. So again, just look straight ahead. So like since you've been pulling on them, they're not as droopy. Yeah. Okay. Good. All right. Cranial nerve five basically has two major functions. There's a sensory component, which basically supplies most of the face. And then there's a motor component, which supplies the muscles of mastication, jaw opening, and closing. So primarily the masseters, the temporalis, the lateral pterygoids, and the digastric. With sensation, we can think of the face as being three different regions. The upper, which is the ophthalmic, the maxillary, which is kind of the middle of the face and the cheek, and the lower, which is the mandibular. Sometimes it's kind of hard when patients complain about focal areas of sensation disturbance in the face to know if it's really a cranial nerve 5 problem or if there may be a functional component. And there are a couple of reflexes that we'll show you, including the corneal reflex, that can be helpful for this. And those involve stimulating the afferent or the sensory branches of 5 and looking for motor response with cranial nerve 7. Okay, so we're going to test cranial nerve 5 now. So 5 has both sensory and motor components, but we'll start with the sensory. So we want to check the three main divisions. So we're going to check up here in the forehead, in the cheeks, and in the jaw area. And would you say that feels pretty symmetrical? Yes. Okay. If you're concerned that maybe there's a functional component, the patient's complaining about asymmetry of sensation, you can also look at the reflexes. I'm not going to do the corneal reflex in depth because it's a little unpleasant, but you can take a tissue if you have that in your clinic. Or if you have a Q-tip, you want to just make sure that the cotton is brought to kind of a fine point. Let's see that. And basically, you want to come from the side and gently stroke the cornea kind of right at the edge of where the cornea and the iris are, or the sclera and the iris. So you want to do that on this side and this side. And the patient should blink because it's pretty annoying, and they should blink both eyes symmetrically. You can also do that with your Q-tip. And then the other thing that you can look at is the middle division of cranial nerve 5. And so this I will do. It's not too terrible. So you can take your tissue or your Q-tip and just gently stroke right around the nostril. It's pretty noxious, right Deb? And just gently kind of tickle the nostril, and the patient will grimace slightly. So that's cranial nerve 5 for the sensation. And then with the motor component, I have people bite down, and you can feel the masseters contract back here, and nice and symmetrical there. So then I'll also check jaw strength. I'll have you open your mouth, and we'll try to press you up, and then open again. And I'm going to try to push you over and over this way. Okay, and that's cranial nerve 5. So cranial nerve number 7 is the facial nerve, and it is a predominantly motor nerve, though it does have some parasympathetic and sensory components as well. The motor division of the facial nerve innervates the muscles of facial expression, and so initial observation for any asymmetry of expression can provide a lot of clues into facial nerve involvement, including some hemifacial weakness and other patterns of weakness that we often see in neuromuscular conditions. So various tests can further evaluate for the patterns of weakness. So having patients raise their eyebrows to wrinkle their forehead, closing their eyes tightly, and attempting to forcefully open their eyelids really helps examine the upper portion of the facial nerve. And then for the lower portion of the facial nerve, we ask patients to puff out their cheeks. We palpate their cheeks, and we can tell the differences between the two sides. We also have them show us their teeth and also whistle. So weakness of facial expression can be seen in several neuromuscular conditions, including myasthenia gravis, ALS, various myopathies, Guillain-Barre syndrome, and others. So when the stapedis muscle of the inner ear becomes weak, we can also get a hyperacusis. So that's important to to know that that muscle is also involved. Cranial nerve number seven also contains taste fibers from the anterior two-thirds of the tongue, though as you know, we don't tend to test this in the clinical setting. Okay, so we're going to do cranial nerve number seven, the facial nerve, looking at the muscles of facial expression. First, we start by having the patient raise their eyebrows, and we look for the symmetry of the wrinkles in the forehead, and that looks great, and she can go and relax. I'll have her take off her glasses for me, and then close her eyes and squeeze them very tight, and try to open the eyes, and we don't do that. So we can see it's very symmetrical and very strong. The other thing we'll have her do is we'll have her puff out her cheeks, and then push on the cheeks, and we see that that's strong. There's no air loss from that test, and then I like to have her smile. We look at the symmetry of the smile, and then another thing you can do is have the patient whistle. Very good. All right, and so that is cranial nerve number seven, the facial nerve, and sometimes if people have like a little bit of asymmetry, and you're not sure whether they're just, their smile is lopsided, you could have them pull out their driver's license or an old photo, and you can look at that too, just to see if there's anything new. Absolutely. Very good. Keep them very tight. Good. Open them all the way up like you're surprised. Yeah. All right. Can you smile? Show me your teeth. All right. Open your mouth. Say ah. Ah. Stick your tongue straight out. Good. Yeah. Now puff those cheeks again like you did. All right. Yeah. Wait there. Okay. Good. Can you raise your shoulder? Cranial nerve number eight, the vestibulocochlear nerve, is a solely sensory nerve, and it specializes in sound reception and balance. Simply observing and inquiring as to the presence of a hearing aid is your first clue that there may be hearing loss. To test patients for gross hearing, we will often have them block one of their ears, rub our fingers, or whisper in the opposite ear, and asking the patient if they are able to hear the sound that is performed on both ears. If there is any abnormality, then we can use the Rene and Weber test to further understand the etiology of the hearing loss. So, both the Rene and Weber tests are performed using the 256 hertz tuning fork. For the Rene test, the examiner will strike the tuning fork on their hand, place it at the patient's mastoid, and ask them to indicate when the sound is extinguished. Once that occurs, the tuning fork is then placed in front of the external auditory canal, and the patient is asked to indicate if they are able to hear the sound. So, a normal response is to indeed hear the sound in front of the ear after it's been extinguished at the mastoid. In patients with conductive hearing loss, they lose their ability to hear the tuning fork in front of their ear. Sensory neural deafness is a finding in which they are equally unable to hear at both the mastoid and in front of the ear. And we do see sensorineural hearing loss in some of our neuromuscular conditions. So, the Weber test is performed then by placing the tuning fork in the middle of the forehead. Patients who have normal hearing should hear the sound equally in both ears. In patients with conductive deafness will hear the sound louder in the abnormal or affected ear, whereas patients who have sensorineural hearing loss, the sound is heard better in the normal ear. So, that can really be helpful to differentiate which ear is affected. So, vestibular function is not common in neuromuscular disease, but it can help us determine an alternative explanation for patient symptoms. It can be assessed, you know, in other aspects of your exam, such as when you're assessing patient gait, looking for nystagmus when you're performing cranial nerves 3, 4, and 6. And that can clue us into maybe their gait disturbance, you know, is it cerebellar, is it postural instability, impaired consciousness, or something else. Okay, this is cranial nerve number 8. Looking at the acoustic and vestibular systems. And so, we would start by testing hearing. So, I'd ask the patient to cover their left ear. Okay, and tell me, do you hear this? I do. Okay, I'd cover the right ear. Do you hear this? I do. Okay, and another thing you could do, if you didn't want to rub your fingers, you could also whisper numbers in their ear. So, I'll have you cover your left. 68. Okay. 100. Very good, she got those correct. And then, we would also, we can also do the Weber and Rene test, if there was an abnormality there, we would, we would move on to these other tests. So, the Weber test, you tap your tuning fork, and you hold it in the center of their forehead, and you ask if they can hear and feel it the same in both ears. I do. She does. So, which is good. And then, you look for lateralization with that test. Then, the other thing you could do is the Rene test. So, you tap your tuning fork, you hold it right against the mastoid, and ask the patient to tell me when it stops. So, I hear that, and it's fading, and now it's gone. Okay, and do you hear it now? I do still hear a little bit. Okay, and do it on the right. And it's buzzing pretty loud. And now, it's gone. And do you hear it now? I hear a little bit still. Okay, very good. And then, the, for the vestibular component, you, that tends to be tested a little bit more in other parts of your exam, you know, with your gait testing, and for nystagmus, and that sort of thing. And that's cranial nerve number eight. Cranial nerves nine and ten are tested together. Cranial nerve number nine is the glossopharyngeal nerve, which has sensory component of the upper pharynx and the posterior one-third of the tongue. We test the sensory piece of the nerve clinically by performing a gag reflex. This is done having a tongue depressor and gently touching the back of the patient's throat. A normal response is to elicit a gag. The vagus nerve is cranial nerve number ten, and this nerve provides motor function to the pharynx, larynx, and the soft palate. We assess cranial nerve number ten by observing the soft palate and the elevation of the soft palate, which can be done during the gag reflex. However, the gag reflex is not always performed clinically because it can be uncomfortable to the patient. So, if it is not performed, simply having the patient say, ah, and observing the soft palate that way will suffice. We assess the patient's voice during our conversations with them, and we can simply have them cough during the clinic, which will tell us a lot about the integrity of the vagus nerve. We can also perform a simple bedside swallow test by having them sip on water, though this is not commonly done at the bedside. Patients with myosinogravis, ALS, and other neuromuscular conditions may have deficits in cranial nerve number ten that specifically present with dysarthria or dysphagia. All right, so we're going to test cranial nerves nine and ten together, and these can be assessed using the gag reflex. So, you use your tongue depressor, you reach back into the back of their throat, and they should be able to feel it and then create a motor response to that, the reflex. And Dr. Kwon and I discussed that we don't always test that because it can be unpleasant. If there's swallowing problems, then that can certainly be tested. And then the other thing you can do while you're assessing the gag reflex is look at the palate in the back of the mouth and the uvula. And so I'll have Dr. Kwon open her mouth, and I like to get my light and look in the back of her throat and have her say, ah, allows you to see the soft palate and the uvula and the symmetry of their movements. And then I also like to have her cough. And then we will, you know, throughout our history taking, we've listened to articulation, but I will ask her formally to say the days of the week for me. Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday. Very good. And that is cranial nerves number nine and number 10. Cranial nerve number 11 is the spinal accessory nerve. This nerve is primarily involved in motor innervation of the sternocleidomastoid and the upper trapezius muscles. So, the sternocleidomastoid allows for head rotation to the opposite side when unilaterally contracted. When bilateral sternocleidomastoid contraction occurs, it results in neck flexion. Trapezius muscle is important in shoulder and arm movement. So, examination of this nerve begins by inspection for any muscle wasting or fasciculations. Sternocleidomastoid is then tested by asking the patient to turn their head either left or right against resistance applied by the examiner. An inability of the patient to counter this resistance on either side suggests a deficit of the spinal accessory nerve on the contralateral side. The trapezius muscle is assessed by having the patient shrug their shoulders against resistance applied by the examiner. So, trapezius weakness can also result in shoulder drooping, scapular waning, and weakness with forward shoulder elevation. Okay, so this is cranial nerve number 11, which is motor function. And so, what I start by doing is looking at the symmetry of the neck muscles. So, mostly looking at that sternocleidomastoid as well as the trapezius muscle. And so, this is where having your patient in a gown can be quite useful. You want to look at the the bulk and the tone of those muscles. And so, to test the sternocleidomastoid, I ask the patient to turn their head to the left against my hand as hard as they can. Okay, very good. And then to the right. And that's really assessing that sternocleidomastoid. And then to test the trapezius, I'll have her shrug her shoulders up against my resistance. And that's nice and strong and symmetrical. And that's cranial nerve number 11. Cranial nerve number 12 is the hypoglossal nerve, which provides motor innervation to the tongue. We evaluate this nerve by first inspecting the tongue, looking for any asymmetry or atrophy or fasciculations, which we can see in motor neuron disease. Tongue atrophy will initially present with decreased bulk at the tip of the tongue. But as the condition progresses, we may see wrinkling or scalloping at the sides of the tongue. We want to test the strength of the tongue by having the patient press the tongue to the inside of their cheek as the examiner provides resistance on the outside of the cheek. And we do that on both sides. We also want to assess for any deviation of the tongue. So deviation to either side suggests a lesion in the nerve on the contralateral side. Deficits of cranial nerve number 12 can present with impairments in chewing, swallowing, and speaking, which we can see in numerous neuromuscular conditions. So cranial nerve number 12 is the hypoglossal nerve, and it's looking at the motor function to the tongue. So for again, I like to inspect. So I have the patient open their mouth, stick their tongue out at me, and then we want to look at its function, so back and forth. And then we're looking for any fasciculations or atrophy. Then what I'll do is I'll have her is I'll have her put her tongue to her cheek and have her resist me. And that's symmetrical and strong. And then that is cranial nerve number 12. Hello. So if anyone has any questions about the cranial nerve exam, we're happy to take those at this time. Thank you very much for joining us and taking time out of your busy clinic days. It's exciting that the AANEM has invited us to be as APPs to be a part of their educational curriculum. And so we all can embrace it and we get to do more of this in the future. So it's always a little bit difficult to do a demonstration of the physical exam on video. We'd ideally like to have small group sessions where people can kind of practice on each other with the instructors or faculty kind of circulating around the room to offer advice or demonstrate particular techniques. And we're hoping to do that at the fall meeting, which will be here in Aurora, Colorado, our hometown. And perhaps we'll be able to get some in-person teaching here for a first time in a long time. So we'll just give folks another minute or so. And if there aren't any other questions, we'll say thank you to everybody. All right. Sounds like everyone's got this. And hope to see you all at the national meeting in the fall. Thank you so much, Dr. Kwon and Ms. O'Reilly. Thank you very much for your time. We really appreciate it. And we'll see everybody else next week at the same time for week number four of this APP series. Thank you and have a wonderful afternoon. Enjoy the rest of your lunch. Take care.

neurology

cranial nerves

neuromuscular patients

examination

clinical settings

vision

sensation

muscles