Documenting a Normal Neurological Examination in a Pediatric Patient with Lightheadedness

Introduction to Neurological Examination

The American Heart Association recommends documenting mental status, cranial nerves, motor function, sensory testing, coordination, gait, and reflexes systematically for a pediatric patient presenting with lightheadedness and a normal neurological examination, noting all findings as normal or within age-appropriate parameters 1

The American College of Cardiology suggests that the patient's alertness and orientation should be documented, stating that the patient is alert, oriented to person/place/time (age-appropriate), and has returned to baseline mental status 1
The patient's behavior and cooperation with the examination should be recorded, as this helps interpret results and compare findings over time, according to the American Academy of Ophthalmology 2

The American College of Radiology recommends documenting visual acuity, visual fields by confrontation, and fundoscopic examination showing normal optic discs with sharp margins and no papilledema for CN II (Optic) 4
The American College of Emergency Physicians suggests recording pupils equal, round, reactive to light and accommodation (PERRLA), extraocular movements intact (EOMI) without nystagmus, and normal gaze in all directions for CN III, IV, VI (Oculomotor) 5

The American College of Emergency Physicians recommends documenting normal tone in all extremities, no rigidity or spasticity (age-appropriate), and using standard grading (5/5) for all major muscle groups bilaterally 5

The American College of Emergency Physicians suggests documenting intact light touch in all extremities bilaterally and recording intact joint position sense in fingers and toes 5

The American College of Emergency Physicians recommends documenting smooth, accurate movements without dysmetria or intention tremor bilaterally for finger-to-nose testing, and smooth, coordinated movements bilaterally for heel-to-shin testing 5
The American College of Radiology suggests noting normal speed and rhythm with hand patting for rapid alternating movements, and documenting no limb ataxia 5, 6

The American College of Emergency Physicians recommends documenting steady, coordinated gait with normal base and arm swing, and stating able to perform tandem walking without difficulty 5
The American Heart Association suggests recording blood pressure and heart rate supine and standing, and documenting no orthostatic hypotension 1

The American College of Cardiology recommends explicitly documenting that the patient has returned to baseline mental status and neurological function, as this is critical for disposition decisions, with a strength of evidence level of high 7