What are the key components of documenting a physical exam for a nontoxic but ill 2-year-old?

Documenting Physical Examination of a Nontoxic but Ill 2-Year-Old

Document vital signs completely (heart rate, respiratory rate, blood pressure, oxygen saturation, temperature) and note the child's general appearance, activity level, and interaction with caregivers as the foundation of your examination. 1, 2

Essential Vital Signs Documentation

• Record all five vital signs: heart rate, respiratory rate, blood pressure, room air oxygen saturation, and temperature 1
• If the child is uncooperative and vital signs cannot be obtained, explicitly document this circumstance rather than leaving fields blank 1
• Blood pressure documentation is particularly important starting at age 2, as hypertension screening is recommended from 3 years onward 3

General Appearance Assessment

• Document the child's overall appearance, activity level, and interaction with caregivers as these observations distinguish ill-appearing from well-appearing children 2, 4
• Note whether the child appears ill or well using objective descriptors (e.g., playful vs. lethargic, interactive vs. withdrawn) 5
• The distinction between ill-appearing and well-appearing significantly affects the predictive value of physical findings—abnormal findings in ill-appearing children have 79% positive predictive value for serious illness versus only 25% in well-appearing children 5

Head-to-Toe Physical Examination Components

Skin and General

• Assess skin color, perfusion, and presence of rashes or lesions 2
• Perform complete skin examination looking for bruising in unusual locations or patterned injuries, as any concerning findings in a 2-year-old warrant consideration of non-accidental trauma 6

Head and Neurological

• Examine fontanelles (if still open), head shape, and any abnormalities 2
• Evaluate tone, posture, primitive reflexes (if still present), and spontaneous movements 2
• Document any involuntary movements or coordination impairments 2

Eyes

• Perform red reflex testing bilaterally to detect ocular media abnormalities 2
• Conduct external inspection of ocular and periocular structures 2
• Assess pupillary examination and fixation/following behavior 2

Ears, Nose, Throat

• Examine tympanic membranes 2
• Assess nares for patency and discharge 2
• Examine oral cavity including palate and tongue 2

Cardiovascular and Respiratory

• Auscultate heart for rate, rhythm, and presence of murmurs 2
• Auscultate lungs for air entry and abnormal sounds 2
• Document respiratory rate and pattern separately from just counting respirations 2

Abdomen

• Palpate for organomegaly, masses, or tenderness 2

Genitourinary

• Examine external genitalia for abnormalities 2
• Assess urinary stream in males and genital appearance in females 2

Musculoskeletal

• Examine hips for signs of developmental dysplasia 2
• Assess all extremities for range of motion and any abnormalities 2

Critical Documentation Pitfalls to Avoid

• Never leave vital signs fields blank without explanation—documentation of complete vital signs occurs less frequently in children than adults, creating gaps in clinical assessment 7
• Document specific objective findings rather than general statements like "normal exam"—abnormal physical examination findings have significantly different predictive values depending on whether the child appears ill or well 5
• Include developmental observations appropriate for age 2 (should be walking, beginning to run, using 2-word phrases) as part of routine documentation 2
• If the history or mechanism of illness seems inconsistent with findings, explicitly document this discrepancy and consider non-accidental trauma 6

Special Considerations for Age 2

• Growth parameters (weight, length, head circumference) should be plotted on appropriate growth charts 2
• For premature infants, use corrected age for developmental assessments through 24 months 2
• Document immunization status as part of the encounter 2