II.

Engagement in Relevant Content and Appropriate

Learning Activity/Activities

NEUROLOGICAL EXAMINATION / CRANIAL NERVES PHYSICAL ASSESSMENT

MATERIALS

 Reflex Hammer
 128 and 512 (or 1024) Hz Tuning Forks
 A Snellen Eye Chart or Pocket Vision Card
 Pen Light or Otoscope
 Wooden Handled Cotton Swabs
 Paper Clips
 Opthalmoscope

GENERAL CONSIDERATIONS

 Always consider left to right asymmetry.

 Consider Central versus Peripheral.
 Organize into seven categories:
 Mental Status
 Cranial Nerves
 Motor
 Coordination and Gait
 Reflexes
 Sensory
 Special Tests

LEVEL OF CONSCIOUSNESS

Level Response
Alert Responds fully and appropriately to stimuli.
Lethargic Drowsy, responds to questions and fall asleep.
Obtunted Open Eyes, Respond slowly, confused
Stuporous Arouses from sleep only after painful stimuli.
Comatose Unarousable with eyes closed.

MINI MENTAL STATUS EXAMINATION

1. Orientation
Name of this hospital or building?
What year it is?
What is the date today?
What country is this?
What day of the week is it?
What city are you in right now?
What month is it?
What states are you in?
What season of the year?
 2. Registration
Name three objects and have the patient repeat them?

3. Attention and Calculation?

Subtract 7 from 100 in serial fashion?

4. Recall
Do you recall three objects name before?

5. Language test
Confrontation Naming: Ben, Watch
Comprehension
Write any sentence
Repetition
Read and perform the command

6. Construction
Copy the design: Flower, Clock.

THE CRANIAL NERVES

CN Name Functions Type

CN 1 Olfactory Special Sensory: Smell Sensory
CN II Optic Special Sensory: Sight Sensory
CN III Oculomotor Somatic Motor: Superior, Motor
Medial, Inferior Rectus,
Inferior oblique, Visceral
Motor, Sphincter Pupilae
CN IV Trochlear Somatic Motor: Superior Motor
Oblique
CN V Trigeminal Somatic Sensory: Face Mixed
Somatic Motor: Mastication,
Tensor Tympani, Tensor
Palati
CN VI Abducens Somatic Motor: Lateral Rectus Motor
CN VII Facial Somatic Sensory: Post Mixed
External Ear Canal
Special Sensory: Taste
(Anterior 2/3 of Tongue)
Somatic Motor: Muscles and
Facial Expressions
Visceral Motor: Salivary and
Lacrimal Glands
CN Vestibulocochlear Special Sensory: Auditory / Sensory
VIII Balance
CN IX Glossopharyngeal Somatic Sensory: Posterior Mixed
1/3 of Tongue
Special Sensory: Carotid
 Body / Sinus
Somatic Motor:
Stylopharyngeus
Visceral Motor: Parotid Gland
CN X Vagus Visceral Sensory: Aortic Mixed
Arch /Body
Special Sensory: Taste on
Epiglottis
Somatic Motor: Soft Palate,
Pharynx and Larynx
( Vocalization and
Swallowing)

CN XI Spinal Accessory Somatic Motor: Trapezius and Motor

SCM (Sternoclaidomastoid)
CN XII Hypoglossal Somatic Motor: Tongue Motor

INDIVIDUAL CRANIAL NERVE TESTING

A. CRANIAL NERVE I – OLFACTORY NERVE

1. Check each nostrils separately. Occlude the side that is not to be tested. Check if
patient is able to inhale and exhale through the open nostrils.
2. Instruct patient to close their eyes.
3. Place a small test tube filled with something that has a distinct, common odour (e.g.
ground coffee) near the open nostril.
Note: If substance filled tubes are not available, use cotton balls soaked in alcohol. Patient
should be able to identify correctly the odour from approximately 10 cm.

Normal Response: To perceive the scent with either nostril.

Abnormal Response: A unilateral lost of smell may imply a structural brain lesion affecting
the olfactory bulb or tract. It can also be due to local causes such as deviated septum or
blocked nasal passage. Bilateral Loss can occur with rhinitis or damage to the cribriform
plate.

B. CRANIAL NERVE II – OPTIC NERVE

Test for Visual Acuity

Test for Visual Acuity before the rest of the exam or inserting medications into eyes:
1. Test each eye separately. Test patient’s best corrected vision by allowing them to
use their glasses or contact lens if available.
2. Position the patient 20 feet in front of the Snellen Eye Chart (or hold the
Rosenbaum pocket card 14 inches away).
 3. Instruct patient to cover with a card the side that is not to be tested. Ask the
patient to read progressively small letters until you identify the last line that can
be read with 100% accuracy.
4. Record the smallest line the patient read. 100% (20/20 vision, 20/400, etc.).
Repeat with the other eye. Record for each separately, right eye – OD, left eye –
OS).
Normal Response:
Normal Vision: 20/20 – i.e. at 20 ft. the patient reads a line that a normal eye seas at 20ft.

Abnormal Response:
20/30-2 The patient missed two letters of the 20/30 line.

20/200 Legally blind. Patient vision at 20 ft. is equivalent to that of a normal person viewing
the same object at 200ft.

Count Fingers (CF) if the patient cannot read the top line but can count fingers at maximal
distance.

Hand Motion (HF) patient cannot count fingers but can determine directions of hand motion.

Light Perception (LP) only perceives light.

No Light Perception (NLP) – No Light Perception.

Screen Visual Fields by Confrontation

1. Position yourself 2 feet directly in front of the patient and have them look into your
eyes (e.g. left eye should be directly in line with the patient right eye). Ask the patient
to cover the eye that is not to be tested. Test each other eyes separately.
2. Hold your index finger just outside the periphery of your visual field. Your finger
should equidistant between your eye and the patient.
3. Wiggle the finger then move it toward the central visual field. Instruct patient to say
yes if the wiggling finger is seen. The patient and the examiner should detect the
finger at more or less the same time. Test all quadrants.
4. If the field appears normal record that the filed is full to confrontation. If there is
abnormally, record it in words (eg VF – difficulty counting fingers (CF) supero
temporal quadrant – OD) or draw simple diagram depicting the abnormality.
5. Test the other eye.

Note: In order for the test to be reliable, it is assumed that the examiner have normal visual
fields as they are using themselves for comparison.

Visual Pathway and Visual Field Defects

A. Visual Pathway
a. Light rays refelcted by an object pass through the lens which focuses
the light rays into the retina. Retina converts the image into nerve
impulses.
b. Signals formed by rod and cone cells in the retina start on their way into
the brain through optic nerve, then through the opitc chiasm, where some
of the axons from the two retinas undergo decussation, then Optic tract,
then to all major relay station – the Lateral Geniculate Nucleus (LGN) in
the Thalamus.
c. The Lateral Geniculate Nucleus (LGN) receives inouts from both eyes and
relay these messages to the primary visual cortex via the optic radiation.
d. The primary visual cortex (V1) receives input from the LGN and start
processing the visual information. The visual association area (Areas 18
and 19) which immediately surrounds the primary visual area helps in
interpreting the project image.
B. Visual Field Defects

Pupillary Light Reflex

Test for Pupillary Light Reflex

1. Dim the room lights to make the pupil become more dilated.
2. Instruct the patient to look straight into the distance.
3. Shine a bright light obliquely into each pupil in turn.
4. Observe the both direct (same eye) and consensual (other eye) reactions.
Normally, both pupils are symmetric in size and direct and consensual response
are equal.
5. Record pupil size in mm and any asymmetry or irregularity.
 Examination of the Optic Fundi
1. Darken the room as much as possible.
2. Adjust the opthalmosccope to avoid too strong beam of light. Set the dioptre dial to
zero unless you have the preferred setting for your eyes.
3. Hold the opthalmoscope, with your let hand and use left eye to examine the patient’s
left eye. Put free hand onto the patient’s forehead or shoulder for control.
4. Ask the patient to stare on a specific object straight ahead.
5. Look through opthalmoscope and shine the light into the patient’s eye from about two
feet away at a 45 degree angle. Look for the “red orange reflex. Follow the red color
to move within a few inches of the patient’s eye. Inspect the cornea for opacities and
for circular ring at the limbus.
6. Adjust the Diopter dial to bring the retina into focus. Locate a blood vessel and follow
it until you find the optic disc.
7. Inspect outward form the optic disc in at least four quadrants and note any
abnormalities.
8. Move nasally from the disc to observe the Macula.
9. Repeat with the other eye.
 C. CRANIAL NERVE
III (OCULOMOTOR), IV (TROCHLEAR) AND VI (ABDUCENS)

The oculomotor nerve exits the cranial cavity via the superior orbital fissure. Within the orbit
it branches into a superior division (Superior Rectus and Levator Muscle) and an Inferior
division (Medial and Inferior rectus muscle, inferior oblique and the cilliary ganglion).

The Trochlear Nerve is the ONLY cranial nerve to exit the dorsal side of the brain stem. Its
fibers cross in the midbrain before the exit, so that Trochlear neurons innervate to
Contralateral Superior Oblique muscle of the eye.

The Abducens Nerve exits the brain stem at the pontomedullary junction and exits the
cranial vault via the superior orbital fissure. In the orbit it innervates the Lateral Rectus
Muscle.

Test for CN III, CN IV and CN VI

1. Instruct the patient to follow your finger with their eyes without moving their
heads. Move your fingers in the six cardinal directions using an “H” pattern. Note
any failure of movement.
2. Check nystagmus by pausing during upward and lateral gaze (lateral
nystagmus).
3. Bring your finger directly towards the bridge of the patient nose to check
convergence.
Results:
CN III Palsy – Ptosis, Large Pupils, eye down and out.
CN IV Palsy – Diplopia on looking down.
CN VI Palsy – Diplopia on Lateral Gaze.

D. CRANIAL NERVE V – Trigeminal Nerve

Test Temporal and Masseter Muscle Strength

1. Palpate both the Temporalis muscles, locate on the lateral aspects of the forehead.
Palpate both the masseter muscles, locate just in front of the Temporo-Mandibular
joints.
2. Ask the patient to clench their teeth. Normally, this will cause the muscle beneath
your fingers to become taut.

Muscles of Mastication Innervated by CN V

Muscle Action
Masseter Raise the jaw and clench the teeth.
Temporalis Elevates the Mandible.
Medial Pterygoid Closes the Jaw and helps in mastication along with lateral
pterygoid in side to side movement of jaw and protrusion.
Lateral Pterygoid The only one that open the jaw, or depresses the mandible.

The motor component of the V3 supplies the muscles of Mastication.

Test for the Three Divisions of CN V for Pain and Temperature
1. Explain the procedure to the client / patient.
2. Use a suitable sharp object and eliminate visual cues by asking patient to close their
eyes.
3. Assess the three divisions of the CN V for sensation by touching Left and Right side
of:
a. Ophthalmic (V1) – Forehead
b. Maxillary (V2) – Cheek Area
c. Mandibular (V3) – Jaw area

E. Cranial Nerve VII – Facial Nerve

Observation:
Look for any asymmetry – widening of the palpebral fissure or flattening pf the nasolabial
fold. Observe for involuntary facial movements (e.g. hemifacial spasm, orofacial dyskinesia,
myokymia or synkinesis).

Test for Muscles of Facial Expression

Ask the patient to do the following, then note any lag, weakness or asymmetry -
a. Raise eyebrows, close both eyes to resistance, smile, and frown, puff out
cheeks.

Normal Response:
Even if there is asymmetry, there should be no weakness.

Test the Corneal Blink Reflex

1. Instruct the patient to look straight ahead or to look up and away.
2. Using wisp of cotton, touch the cornea or the lateral aspect of the sclera lightly.
3. Observe for the normal blink (direct and consensual) reaction of both eyes. Repeat
on the other side.

Test for Taste

Taste is not typically assessed during a routine neurological examination. Taste is often
tested only when specific pathology is suspected. Check taste with sugar, salt and lime juice
on cotton swabs.

F. Cranial Nerve VIII – Vestibulocochlear

Sensory Pathways
1. Travelling sound waves in the ear canal causes the ear drum to vibrate.
2. The three middle bones of the ear amplifies the vibration after which is transmitted to
the oval window of the inner ear.
3. The vibration stimulates the hair cells of the Organ of Conti generating action
potentials in the neurons of the spinal ganglion of the auditory nerve – this nerve
carries the signal into the brainstem and synapses in the cochlear nucleus.
4. Auditory information is split into at least two stems. One goes to the Ventral Cochlear
Nucleus and the other to the Dorsal Cochlear Nucleus.
5. The Ventral Cochlear Nucleus project to the Superior Olive (important for sound
localization).
6. The superior olive and Dorsal Cochlear Nucleus (important for analysing sound
quality) then project into the Inferior Colliculus via Lateral Meniscus.
 7. From the Inferior Colliculus, both streams of information proceed to Medial
Geniculate Body, the principal relay to the auditory cortex.
8. The Medial Geniculate Body projects to the Primary Auditory Complex.

Screen Hearing
1. Instruct patient to close eyes.
2. Rub your fingers together approximately 2 ½ inches from one ear. Normally the
patient will be able to hear the sound generated. Repeat the same test for the other
ear.
3. If abnormal, proceed with Weber and Rinne Test.

Test for Lateralization (Weber)

1. Use a 512 Hz (256 if deaf) tuning fork.
2. Start the fork vibrating by striking it against the bony edge of your arm or snap the
end of the tuning fork using your thumb and index finger.
3. Place the stem of the tuning fork firmly on top of the patient’s skull. Ask the patient
whether the sound was heard equally in both ears (normal) or there was lateralization
to a side.

Interpretation:
If there is a conductive hearing deficit,, the Weber will lateralize to the affected ear. If there is
sensorineural hearing deficit, the Weber will lateralize to the Normal ear.

Compare Air and Bone Conduction

1. Use a 512 Hz (256 if deaf) tuning fork.
2. Start the fork vibrating then place the stem of the tuning fork against the mastoid
bone behind the ear.
3. Instruct the patient to inform you if they can no longer hear the sound. When the
patient stop hearing it, put the tines of the tuning fork near the patient’s ear. Normally
the patient should be able to hear the sound.
Normal Ear: Air Conduction (AC) is greater than Bone Conduction (BC)
Conductive Hearing Loss: BC is greater than AC.
Sensorineural Hearing Loss: AC is greater than BC (bone and air conduction are both
equally depreciated.)
G. Cranial Nerve – IX Glossopharengeal and X Vagus

Testing Elevation of the Soft Palate

1. Ask the patient to open their mouth and
say “AHHHHH”. Normally, this would
cause the soft palate to rise upward.
2. Observe the uvula. If the tongue
obscures your view, use a tongue
depressor. Normally, the uvula will rise
up straight and in the midline.
3. Note: Other processes can cause
deviation of the uvula (e.g. Peritonsillar
abscess).

Testing for GAG Reflex

1. Ask the patient to widely open their
mouth and gently push tongue using a
depressor to visualize the posterior
pharynx.
2. Brush gently cotton tipped applicator
against the posterior pharynx or uvula.
Normally this will elicit the gag reflex.
3. Note: Taste sensation from the
posterior 1/3 of the tongue is also
innervated by CN IX
(Glossopharyngeal).

H. Cranial Nerve XI – Accessory Nerve

 Assessment:
Look for asymmetry and atrophy of the Trapezius and Sternocleidomastoid Muscle.

Test for SCM Muscle:

Place hand on above patient’s ear then ask patient to turn his or her head against
resistance. Observe the action of the Contralateral Sternocleidomastoid Muscle.
Note: Normally, if the patient turns his or her head, the left SCM muscles will tighten.

Test for Trapezius Muscle:

Place hands on top of patients shoulders and ask patient to shrug shoulders against
resistance.
Interpretation:
Ipsilateral damage to spinal accessory nerve will result to diminished shoulder
elevation.

Two Roots of the CN XI

a. Cranial Root (special visceral efferent) – Innervates muscles of the larynx and
pharynx.
b. Spinal Root – Innervates the trapezius and SCM Muscles.

I. Cranial Nerve XII – Hypoglossal

1. Evaluate the strength, bulk and dexterity of the tongue. Note weakness, atrophy and
any abnormal movements.
2. Note position of tongue at rest then ask patient to protrude tongue moving it in and
out, side to side and upward and downward. Slowly and rapidly.
3. Test muscle strength by asking patient to press the tip of the tongue against cheek
as you try to dislodge it with finger pressure. Normally, the tongue can’t be dislodge.
MOTOR

Observation:
1. Note any involuntary movements.
Fibrillations – Contractions of the individual muscle fibres and are not visible through the
skin.
Fasciculation – Spontaneous visible muscle twitches due to contractions of the muscle fibres
to a motor unit.
Asterixis – is a flapping tremor of the wrist upon extension (dorsiflexion), commonly seen in
metabolic encephalitis.
Tics – are rapid, repeated, involuntary contractions of a group of muscle that esult inn
movement.
Myoclonus – Refers to a sudden, involuntary jerking of a group of muscle or group of
muscles.
Dystonia – is characterized by over activity of a specific muscle or group of muscle.
Athetosis – is continuous stream of slow, sinous, writhing movements, typically of the hands
and feet.
Chorea – is an irregular, uncontrolled, involuntary, excessive movement that seem to move
randomly from one part of the body to another.
Hemiballismus – is a violent flinging of the other half of the body.

2. Assess size, shape and symmetry of Muscle. Compare left versus right, proximal
versus distal.
Atrophy – is a decrease in muscle volume or bulk.
Hypertrophy – is an increase in muscle size.
Pseudohypertrophy – is an increase in muscle size due to infiltration by fibrous or fatty
tissues and is usually associated with decrease in strength.

3. Palpation
This is useful in adjunct in examining the muscle. In patients who complain of muscle
tenderness and nodules, palpation can help ascertain that these findings arise from the
muscle itself and not overlying tissues.

Atrophy – Muscle losses its normal texture and becomes soft and flabby.
Hypertrophy – Muscles are firm and resilient.
Pseudohypertrophy – Muscles takes on a rubbery and woody consistency and texture.

4. Muscle Tone – Muscle tone is the permanent state of partial contraction of a muscle.
It can be assessed by:
a. Instructing the patient to relax.
b. Passively flexing and extending the patient’s fingers, wrist and elbow then
ankle and knee. Normally, you will feel a small continuous resistance to
passive movement.
c. Observe for decreased (flaccid) or increased (rigid / spastic) tone.

Hypotonia – decreased tone.

Hypertonia – Increased tone. May manifest spasticity or rigidity.
Spastic – resistance to passive movement with sudden giving way (clasp-
knife like phenomenon).
Rigid – muscle stiffness or inflexibility (throughout the whole ROM of a joint).
It may be cogwheel (stepwise) or lead pipe (uniform) resistance to passive movement.

Manual Muscle Testing

1. Test muscle strength by having the patient move against your resistance comparing
one side to the other.
2. Grades strength on a scale of 0 – 5 “out of five” ex. 4/5.

Muscle Grading Scale:

5 – Normal (complete ROM against full resistance for 5 seconds).
4 - Good (complete ROM against some resistance).
3 – Fair (complete ROM against Gravity).
2 – Poor (complete ROM gravity eliminated).
1 – Trace (slight muscle contraction, no joint movement).
0 – Zero (no evidence of contraction).
COORDINATION
Evaluate coordination by testing the patient’s ability to perform rapidly alternating and point
to pint movements correctly.

1. Rapid Alternating Movements

a. Instruct the patient to strike one hand on the thigh, raise the hand, turn it over and
strike it down as fast as possible.
b. Instruct the patient to tap your hand with the ball of each foot as fast as possible.
Dysdiadochokynesis – is the clinical term for the inability to perform rapid alternating
movements.

2. Point To Point Movements

a. Instruct patient to touch your index finger and their nose alternately several times.
Move your finger about as the patient performs this task.
b. Instruct patient to place one heel on the opposite knee and run it down the shin to
the big toe. Repeat with the patient eyes closed.
Dysmetria – is the clinical term for the inability to perform point to point movements due to
over or under projecting fingers.

3. Romberg
Instruct the patient to stand with the feet together and eyes closed for 5 -1 0 seconds without
support.
Note: Be prepared to catch the patient because they might FALL if unstable.
Interpretation: This test is said to be positive if the patient becomes unstable.

GAIT

Observe patient gait and note any abnormal characteristics.

Instruct patient to:
Walk across the room, turn and back.
Walk heel to toe in a straight line.
Walk in their heels in a straight line.
Walk on their toes in a straight line.
Do a shallow knee bend.
Rise from sitting position.
REFLEXES

Components of the Reflexes Arc

1. Receptor
2. Sensory Neuron
3. Integration Center
4. Motor Neuron
5. Effector
Procedures in eliciting Deep Tendon Reflexes (DTR)
1. The patient should be relax.
2. When eliciting a reflex use no more force than you need.
3. Reinforce reflexes by asking patient to perform isometric contraction of other muscles
(clenched teeth). This is known as Jendrassik Maneuver.
4. Reflexes are graded on a 0 -4 plus scale.

Deep Tendon Reflexes:

BICEPS (C5 and C6)

1. Position patient wilt elbow partially flexed.
2. Place your thumb or finger firmly on the biceps tendon.
3. Strike your thumb or finger with the reflex hammer.
4. You should fell the response even if you can’t see it.

TRICEPS (C6, C7 and C8)

1. Hold the upper arm and instruct the patient to let his/her forearm hang free.
2. Use the broad side of the hammer to strike the triceps tendon near its insertion just
above the elbow.
3. Watch for the extension of the elbow.

BRACHIORADIALIS (C5, C6)

1. Have the patient rest the forearm on the abdomen or lap.
2. Strike the radius about 1-2 inches above the wrist.
3. Watch the flexion and supination of the forearm.
PATELLAR (L2, L3 and L4)
1. Position patient in sitting or supine with the knees flexed.
2. Strike the patellar tendon just below the patella.
3. Note contraction of the quadriceps and extension of knee.

ACHILLES
1. Dorsiflexion the foot at the ankle.
2. Strike the Achilles tendon.
3. Watch and feel the plantar flexion at the ankle.

CLONUS

Test for ankle clonus if the reflexes seem hyperactive.

1. Support the knee in a partly flexed position.
2. Instruct the patient to relax then quickly dorsiflex the foot.
3. The test is positive if rhythmic oscillation is observed.

PLANTAR RESPONSE (BABINSKI)

1. Stroke the lateral aspect of the sole of each foor using the end of a reflex hammer or
key.
2. Note movement of toes:
Interpretation:
a. Normal – Flexion
b. Abnormal – Extension of the big toe with fanning of the other toes

SENSORY
General
Compare asymmetrical areas on the two sides of the body. Also compare distal and
proximal areas of the extremities. When sensory loss is detected map out its boundaries in
detail.

SUPERFICIAL SENSORY LOSS

Pain
Use suitable sharp object to test “sharp” and “dull” sensation.
Test the following areas: Shoulder, inner and outer aspects of the forearms, thumb and little
fingers, front of both thighs, medial and lateral aspects of the calves and little toes.

Temperature
Often omitted when pain sensation is normal. Use a test tube filled with hot and cold water
and ask patient to identify hot and cold sensation. Test the same testing areas for pain.

Light Touch
Use a fine wisp of cotton, or fingers to touch the skin lightly. Ask the patient to respond
whenever touch is felt. Test the same testing areas for Pain.

Vibration
1. Place the stem of the tuning fork (128Hz) over the distal interphalangeal joint of the
patients index fingers or big toes.
2. Ask the patient to tell you if the fell the vibration. If vibration senses is impaired
proceed proximally: Wrists, Elbows, Medial Malleioli , Patella)

Position Sense:
1. Grasp the patients big toe or fingers and show patient the “up” and “down Position”.
 2. Instruct patient to close eyes then ask the patient to identify the position of the big toe
(up or down). If position sense is impaired proceed proximally: ankle,
metacarpopharangeal joints, wirst and elbows.)

Discrimination

Graphesthesia – using blunt end of pen, draw circle in the patients palm then ask patient to
identify figure.
Stereognosis – place a familiar object in patient’s hand (coin, pencil or key) then ask patient
to identify object.

Two point discrimination:

1. Use an opened paper clip to touch the patient finger pads in two places
simultaneously.
2. Alternate irregularly with one point touch then ask the patient identify one or two. Find
the minimal distance at which patient can discriminate.
Note: if test for vibration position sense and subjectively light touch are normal in the fingers
and toes you may assume the rest of this exam will be normal.
III. Response / Reaction

1. Fill the Table: Cranial Nerves

Number: Name: Type: (sensory, motor or

mixed)

Identification:

_________________________ 1.
_________________________ 2.
_________________________ 3. Three Cranial nerves for eye movements.
_________________________ 4.
_________________________ 5.
_________________________ 6. The three Divisions of the trigeminal nerve.
_________________________7. Cranial Nerve for Hearing Loss Screening and
Assessment.
_________________________ 8. Cranial Nerve responsible for the Sternocleidomastoid
and Trapezius Muscle.
_________________________ 9. Cranial Nerve responsible for the strength, bulk and
dexterity of the tongue.
_________________________10 . Cranial Nerve responsible for Eyesight and vision.
IV. Summative Assessment