How do you document a normal neuro exam for a pediatric patient presenting with lightheadedness (dizziness) and a normal past medical history?

Documenting a Normal Neurological Examination in a Pediatric Patient with Lightheadedness

For a pediatric patient presenting with lightheadedness and a normal neurological examination, document mental status, cranial nerves, motor function, sensory testing, coordination, gait, and reflexes systematically, noting all findings as normal or within age-appropriate parameters.

Mental Status and Level of Consciousness

• Document alertness and orientation: State that the patient is alert, oriented to person/place/time (age-appropriate), and has returned to baseline mental status 1
• Note behavior and cooperation: Record the child's level of cooperation with the examination, as this helps interpret results and compare findings over time 1
• Example: "Patient alert, oriented x3 (age-appropriate), interactive, cooperative with examination, returned to baseline mental status"

Cranial Nerve Examination

• CN II (Optic): Document visual acuity, visual fields by confrontation, and fundoscopic examination showing normal optic discs with sharp margins and no papilledema 1
• CN III, IV, VI (Oculomotor): Record pupils equal, round, reactive to light and accommodation (PERRLA), extraocular movements intact (EOMI) without nystagmus, and normal gaze in all directions 1
• CN V (Trigeminal): Note facial sensation intact to light touch bilaterally, corneal reflexes present 1
• CN VII (Facial): Document facial symmetry at rest and with movement, no facial droop or asymmetry 1
• CN VIII (Vestibulocochlear): State hearing grossly intact bilaterally, no nystagmus on lateral gaze 2, 3
• CN IX, X (Glossopharyngeal/Vagus): Record palate elevates symmetrically, gag reflex present 1
• CN XI (Accessory): Note normal shoulder shrug and head turn strength 1
• CN XII (Hypoglossal): Document tongue midline without fasciculations 1
• Example: "Cranial nerves II-XII intact. PERRLA 3mm→2mm. EOMI without nystagmus. Face symmetric. Hearing grossly intact. Palate elevates symmetrically. Tongue midline."

Motor Examination

• Document tone: State normal tone in all extremities, no rigidity or spasticity (age-appropriate) 4
• Record strength: Use standard grading (5/5) for all major muscle groups bilaterally - shoulder abduction/adduction, elbow flexion/extension, wrist extension, hip flexion/extension, knee flexion/extension, ankle dorsiflexion/plantarflexion 1
• Note bulk: Document normal muscle bulk without atrophy 1
• Assess drift: State no pronator drift with arms extended at 90 degrees (sitting) or 45 degrees (supine) for 10 seconds 1
• Example: "Normal tone throughout. Strength 5/5 in all major muscle groups bilaterally. No pronator drift. Normal muscle bulk."

Sensory Examination

• Document light touch: State intact to light touch in all extremities bilaterally 1
• Note proprioception: Record intact joint position sense in fingers and toes 1
• Example: "Sensation intact to light touch throughout. Proprioception intact in fingers and toes bilaterally."

Coordination and Cerebellar Function

• Finger-to-nose testing: Document smooth, accurate movements without dysmetria or intention tremor bilaterally 1
• Heel-to-shin testing: State smooth, coordinated movements bilaterally 1
• Rapid alternating movements: Note normal speed and rhythm with hand patting 1
• Assess for ataxia: Document no limb ataxia 1
• Example: "Finger-to-nose and heel-to-shin testing smooth and accurate bilaterally. Rapid alternating movements normal. No ataxia."

Gait and Station

• Normal gait: Document steady, coordinated gait with normal base and arm swing 1
• Tandem gait: State able to perform tandem walking without difficulty 1
• Romberg test: Note stands steady with feet together, eyes open and closed, no loss of balance 2, 3
• Orthostatic vital signs: Record blood pressure and heart rate supine and standing (critical for lightheadedness evaluation) - document no orthostatic hypotension 1, 2
• Example: "Gait steady with normal base. Tandem gait intact. Romberg negative. Orthostatic vitals: BP 110/70 supine, 108/68 standing; HR 80 supine, 95 standing (normal response, no orthostatic hypotension)."

Deep Tendon Reflexes

• Document reflexes: Use standard grading (0-4+) for biceps, triceps, brachioradialis, patellar, and Achilles reflexes bilaterally 1
• Plantar response: State downgoing toes bilaterally (Babinski negative) - note this is age-dependent and may be normal as extensor in young infants 4
• Example: "DTRs 2+ and symmetric throughout (biceps, triceps, brachioradialis, patellar, Achilles). Plantar responses downgoing bilaterally."

Special Considerations for Lightheadedness

• Dix-Hallpike maneuver: If vertigo component suspected, document negative Dix-Hallpike (no nystagmus or vertigo provoked) 2, 3
• Nystagmus evaluation: Specifically state no spontaneous nystagmus, no gaze-evoked nystagmus 2, 3
• Return to baseline: Explicitly document that patient has returned to baseline mental status and neurological function, as this is critical for disposition decisions 5, 6

Complete Documentation Example

"Neurological examination: Alert, oriented x3 (age-appropriate), cooperative, returned to baseline. Cranial nerves II-XII intact. PERRLA 3mm→2mm. EOMI without nystagmus. No spontaneous or gaze-evoked nystagmus. Face symmetric. Hearing grossly intact bilaterally. Palate elevates symmetrically. Tongue midline. Normal tone throughout all extremities. Strength 5/5 in all major muscle groups bilaterally. No pronator drift. Sensation intact to light touch and proprioception throughout. Finger-to-nose and heel-to-shin testing smooth and accurate bilaterally. Rapid alternating movements normal. No ataxia. Gait steady with normal base. Tandem gait intact. Romberg negative. Orthostatic vitals: BP 110/70 supine, 108/68 standing; HR 80 supine, 95 standing (no orthostatic hypotension). DTRs 2+ and symmetric throughout. Plantar responses downgoing bilaterally. Dix-Hallpike maneuver negative bilaterally."

Common Pitfalls to Avoid

• Do not omit orthostatic vital signs in any patient with lightheadedness or dizziness, as orthostatic hypotension is a common and treatable cause 1, 2
• Always document return to baseline explicitly, as failure to return to baseline within several hours warrants emergent neuroimaging even with otherwise normal examination 5, 6
• Do not forget age-appropriate norms - extensor plantar responses may be normal in preterm infants but abnormal at several months of age 4
• Document nystagmus evaluation specifically rather than just stating "cranial nerves intact," as nystagmus patterns help differentiate peripheral from central causes of dizziness 2, 3