Neurological examination report of neonate of 4 day duration
Name: Baby Doe
Age: 4 days
Date of Examination: [Date]
Chief Complaint:
The neonate was brought in for a routine neurological examination.
History of Present Illness:
The neonate was born at full term via normal l delivery. The mother had an uneventful pregnancy and prenatal care was satisfactory. The neonate has been feeding well and passing urine and meconium normally.
Physical Examination:
Upon examination, the neonate appeared well-nourished and in no acute distress. Vital signs were stable. The head circumference, weight, and length were within normal limits for age.
Neurological Examination:
Mental Status: The neonate was alert and responsive to stimuli.
Cranial Nerves: Pupils were equal, round, and reactive to light. No nystagmus or ptosis noted.
Motor Function: Muscle tone was normal with symmetric movements of all extremities. The neonate was able to grasp the examiner's finger.
Reflexes: Moro reflex was present and symmetric. Sucking reflex was strong. Babinski reflex was negative.
Sensory Function: The neonate responded to touch and showed appropriate withdrawal reflex.
Assessment:
The neurological examination of the neonate was within normal limits for age. No abnormalities were noted on examination.
Plan:
Continue routine follow-up care and monitor for any developmental milestones. Educate parents on normal growth and development. No further interventions are required at this time.
Follow-up:
The neonate will have a routine pediatric visit scheduled in 2 weeks for further evaluation of growth and development.
Provider Signature:
[Signature]
[Date]