Physical Examination Guidelines for a Nontoxic but Ill 2-Year-Old

Essential Vital Signs Documentation

The American Academy of Pediatrics recommends recording 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

Document the child's overall appearance, activity level, and interaction with caregivers as these observations distinguish ill-appearing from well-appearing children 2

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 3
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
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
Examine tympanic membranes 2
Assess nares for patency and discharge 2
Examine oral cavity including palate and tongue 2
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
Palpate for organomegaly, masses, or tenderness 2
Examine external genitalia for abnormalities 2
Assess urinary stream in males and genital appearance in females 2
Examine hips for signs of developmental dysplasia 2
Assess all extremities for range of motion and any abnormalities 2

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 3

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