Sepsis physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2] Jason Le, B.S.[3]
Synonyms and keywords: sepsis syndrome; septic shock; septicemia
Sepsis physical examination
The physical examination in sepsis has three principal purposes: detect organ dysfunction and hypoperfusion, localize a potential infectious source, and provide repeatable bedside findings for serial assessment of response to resuscitation. No single physical finding is pathognomonic, and early sepsis may be subtle or atypical, particularly in older, immunocompromised, or beta-blocked patients. Findings should therefore be interpreted serially and in conjunction with vital signs, laboratory findings, and the clinical course.[1]
Among infected patients, altered mentation, tachypnea, and hypotension are particularly suggestive of sepsis, although their absence does not exclude the diagnosis.[1]
General appearance
Patients may appear acutely ill, obtunded, or mottled, but the appearance can be deceptively unremarkable early in sepsis or in vulnerable hosts. Fever and a toxic appearance are not required; afebrile, hypothermic, or relatively well-appearing patients may still have clinically important sepsis.[1]
Vital signs
Common abnormalities include:
Temperature: fever (>38.3 °C) or hypothermia (<36 °C). Hypothermia and normothermia may occur in severe disease and are associated with worse outcomes.[1] Tachypnea: often an early abnormal vital sign and one of the three physical findings most suggestive of sepsis.[1] Tachycardia: sensitive but nonspecific. Tachycardia may be blunted by beta-blockers and may be absent in some patients.[1] Hypotension: systolic blood pressure <90 mm Hg, mean arterial pressure <65 mm Hg, or a decrease in systolic blood pressure >40 mm Hg may indicate cardiovascular dysfunction or shock. Hypotension can be a late finding; normal early blood pressure does not exclude sepsis.[1][2]
Vital signs may be confounded by medications and comorbidities, reducing the sensitivity of tachycardia, fever, and tachypnea.[1]
Peripheral perfusion
Bedside assessment of peripheral perfusion is an important component of the examination because sepsis may produce clinically important microcirculatory dysfunction despite apparently preserved conventional vital signs.[3][4]
Capillary refill time (CRT): assess by applying firm pressure to the distal phalanx for several seconds and timing return of color. Prolonged CRT is associated with increased mortality; a 2026 meta-analysis reported a pooled odds ratio of approximately 3.3 for 28-day mortality.[4] CRT-guided resuscitation in the ANDROMEDA-SHOCK trial resulted in less fluid administration and less organ dysfunction than lactate-targeted resuscitation, with numerically lower mortality.[4][5] A larger confirmatory trial, ANDROMEDA-SHOCK-2, found that a personalized hemodynamic resuscitation protocol targeting CRT normalization improved a hierarchical composite of mortality, duration of vital support, and hospital length of stay at 28 days compared with usual care (win ratio 1.16, 95% CI 1.02–1.33).[6] A Bayesian reanalysis of the original ANDROMEDA-SHOCK trial found a greater than 90% posterior probability of lower mortality with CRT-guided resuscitation.[7] Mottling: patchy, non-blanching skin discoloration, typically around the knees, reflecting skin hypoperfusion. Higher mottling scores are associated with worse microcirculation and mortality; the pooled odds ratio for 28-day mortality was approximately 2.3.[4][8] Skin temperature gradient/cool acral extremities: cool acral skin reflects peripheral vasoconstriction and may precede more overt shock findings. In meningococcal disease, this finding has been reported to precede classic shock findings by several hours.[8][3] Peripheral perfusion index (PPI): reduced PPI is associated with increased mortality; the supplied meta-analysis reported a pooled odds ratio of approximately 5.[4]
CRT measurement is not fully standardized, including variation in pressure, duration, technique, and cutoff values. Mottling scores and skin-temperature gradients have prognostic associations but lack standardized intervention thresholds.[5][4]
The 2021 Surviving Sepsis Campaign suggests using CRT to guide resuscitation as an adjunct to other measures of perfusion. Physical examination alone should not be used to determine fluid responsiveness; dynamic measures such as passive leg raise, stroke-volume variation, or response to a fluid challenge are preferred over static examination findings alone.[9] The 2026 Surviving Sepsis Campaign reaffirms this position, noting that CRT can change within approximately 10 minutes of a resuscitative intervention, allowing more timely assessment of response than lactate, and that pooled randomized-trial data favor CRT-guided resuscitation (28-day mortality risk ratio 0.82, 95% CI 0.65–1.04).[10]
Source-directed examination
Examine systematically for localizing findings at common infectious sources and for occult sources that may require urgent intervention:
Pulmonary: rales, bronchial breath sounds, dullness to percussion, and hypoxemia may support a pulmonary source. Abdominal: focal tenderness, guarding, rebound, or distension may indicate an intra-abdominal source. Skin and soft tissue: erythema, warmth, or fluctuance may indicate infection. Pain out of proportion, crepitus, bullae, or rapidly advancing skin margins should raise concern for necrotizing soft-tissue infection.[8][11] Central nervous system: meningismus or focal neurologic deficits may identify a potential CNS source or alternative neurologic process. Cardiac: a new regurgitant murmur may suggest infective endocarditis, particularly when accompanied by compatible peripheral stigmata such as splinter hemorrhages, Janeway lesions, or Osler nodes. Devices and wounds: inspect all indwelling lines, catheters, drains, wounds, and insertion sites for erythema, purulence, or tenderness.[1]
Signs of organ dysfunction
Physical examination may identify clinically important organ dysfunction:
Neurologic: altered mentation, including obtundation, delirium, or agitation, is a prominent and prognostically important finding and may reflect sepsis-associated encephalopathy. The abnormality is typically nonfocal.[3][2] Respiratory: tachypnea, increased work of breathing, hypoxemia or cyanosis, and findings compatible with acute respiratory distress syndrome may occur.[2] Cardiovascular: hypotension, cool or mottled skin, prolonged CRT, and weak peripheral pulses may indicate impaired perfusion.[3][2] Renal: oliguria may be recognized at the bedside, including by assessment of urinary catheter output.[2] Hepatic/hematologic: jaundice, petechiae, purpura, or bleeding from puncture sites may occur, particularly with advanced coagulopathy; laboratory testing is required to characterize the underlying abnormality.[2]
Serial reassessment and bedside priorities
Perform and repeat a structured examination of mentation, respiratory effort, blood pressure, CRT, mottling, and skin temperature in patients with suspected sepsis.[3][9] Treat altered mentation, tachypnea, and hypotension as high-priority findings prompting immediate evaluation for sepsis.[1] Fully expose and examine the skin, wounds, and indwelling devices to avoid missing soft-tissue, necrotizing, or device-associated infection.[1][8] Do not use the physical examination alone to assess fluid responsiveness; incorporate dynamic measures when guiding fluid therapy.[9] Reassess serially. The trajectory of examination findings is generally more informative than a single isolated measurement.[3][12]
Formal SIRS, SOFA, qSOFA, Sepsis-3, and other operational diagnostic criteria are addressed in Sepsis diagnostic criteria rather than this physical examination microchapter.
High-yield clinical pearls
Altered mentation, tachypnea, and hypotension are the three examination findings most suggestive of sepsis, but their absence does not exclude sepsis.[1] Prolonged CRT and persistent mottling provide inexpensive, noninvasive bedside prognostic information and should be assessed serially.[4][3] CRT can change rapidly after resuscitative interventions and may therefore be useful for serial bedside assessment.[10] Cool acral skin and mottling may precede overt shock by hours.[8] Normal early blood pressure and absence of fever do not exclude sepsis, particularly in older, immunocompromised, or beta-blocked patients.[1][2] Always inspect the skin, wounds, and indwelling devices when searching for an occult infectious source.[1]
Common pitfalls
Anchoring on a febrile, toxic-appearing presentation and missing afebrile, hypothermic, or relatively well-appearing patients with sepsis.[1] Being falsely reassured by normal early blood pressure or heart rate, particularly when medications blunt expected physiologic responses.[1] Using the physical examination alone to determine fluid responsiveness rather than incorporating dynamic measures.[9] Omitting the peripheral perfusion examination and thereby missing prognostically important abnormalities in CRT, mottling, or skin temperature.[4] Failing to fully expose the patient and inspect for necrotizing soft-tissue infection, device-related infection, or purpura.[8] Attributing new confusion to baseline dementia, intoxication, or another chronic condition without considering sepsis-associated encephalopathy.[3]
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 Meyer NJ, Prescott HC (2024). "Sepsis and Septic Shock". The New England Journal of Medicine. 391 (22): 2133–2146. doi:10.1056/NEJMra2403213. PMID 39774315 Check
|pmid=value (help). - ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Angus DC, van der Poll T (2013). "Severe Sepsis and Septic Shock". The New England Journal of Medicine. 369 (9): 840–851. doi:10.1056/NEJMra1208623. PMID 23865408.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Postelnicu R, Evans L (2017). "Monitoring of the Physical Exam in Sepsis". Current Opinion in Critical Care. 23 (3): 232–236. doi:10.1097/MCC.0000000000000403. PMID 28306558.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Shi LJ, Ke SF, Fu LS; et al. (2026). "Meta-Analysis of the Prognostic Value of Skin Perfusion Parameters in Sepsis Patients: Evidence Integration Based on the Mottling Score, Capillary Refill Time, and Peripheral Perfusion Index". Shock (Augusta, Ga.). 66 (2): 303–314. doi:10.1097/SHK.0000000000002885. PMID 42258324 Check
|pmid=value (help). - ↑ 5.0 5.1 Machado FR, Semler MW (2025). "Capillary Refill Time in Sepsis—Searching for the Holy Grail". JAMA. 334 (22): 1983–1985. doi:10.1001/jama.2025.20518.
- ↑ ANDROMEDA-SHOCK-2 Investigators for the ANDROMEDA Research Network, Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), and Latin American Intensive Care Network (LIVEN); et al. (2025). "Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial". JAMA. 334 (22): 1988–1999. doi:10.1001/jama.2025.20402.
- ↑ Zampieri FG, Damiani LP, Bakker J; et al. (2020). "Effects of a Resuscitation Strategy Targeting Peripheral Perfusion Status Versus Serum Lactate Levels Among Patients With Septic Shock. A Bayesian Reanalysis of the ANDROMEDA-SHOCK Trial". American Journal of Respiratory and Critical Care Medicine. 201 (4): 423–429. doi:10.1164/rccm.201905-0968OC. PMID 31574228.
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Pulido-Pérez A, Bergón-Sendín M, Suárez-Fernández R, Muñoz-Martín P, Bouza E (2021). "Skin and sepsis: contribution of dermatology to a rapid diagnosis". Infection. 49 (4): 617–629. doi:10.1007/s15010-021-01608-7.
- ↑ 9.0 9.1 9.2 9.3 Evans L, Rhodes A, Alhazzani W; et al. (2021). "Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021". Critical Care Medicine. 49 (11): e1063–e1143. doi:10.1097/CCM.0000000000005337.
- ↑ 10.0 10.1 Prescott HC, Antonelli M, Alhazzani W; et al. (2026). "Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026". Critical Care Medicine. 54 (4): 725–812. doi:10.1097/CCM.0000000000007075.
- ↑ Gauer R, Forbes D, Boyer N (2020). "Sepsis: Diagnosis and Management". American Family Physician. 101 (7): 409–418. PMID 32227831 Check
|pmid=value (help). - ↑ Yealy DM, Mohr NM, Shapiro NI; et al. (2021). "Early Care of Adults With Suspected Sepsis in The Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report". Annals of Emergency Medicine. 78 (1): 1–19. doi:10.1016/j.annemergmed.2021.02.006.
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