A comprehensive clinical examination is the basis for selecting further diagnostic steps:
- General physical examination – including blood pressure, pulse, body temperature* , body weight, body height; furthermore:
- Inspection (viewing).
- Skin, mucous membranes, and sclerae (white part of eye) [cyanosis (bluish discoloration of skin and central mucous membranes, e.g., tongue)?]
- Determination of capillary refill time, also known as recapillarization time (RKZ; capillary refill time (CRT)) to assess microcirculation and circulatory situation; RKZ = time needed for the capillary bed to refill after external application of pressure (3-5 sec); measurement on finger or sternum under optimal light conditions; normal RKZ:
- In neonates: – 3 sec.
- For children 2-3 sec.
- Notice: In the guideline on sepsis in children, a RKZ > 2 sec on the body trunk is given as a criterion for SIRS with organ complication
- Determination of capillary refill time, also known as recapillarization time (RKZ; capillary refill time (CRT)) to assess microcirculation and circulatory situation; RKZ = time needed for the capillary bed to refill after external application of pressure (3-5 sec); measurement on finger or sternum under optimal light conditions; normal RKZ:
- Abdomen (abdomen)
- Shape of the abdomen?
- Skin color? Skin texture?
- Efflorescences (skin changes)?
- Pulsations? Bowel movements?
- Visible vessels?
- Scars? Hernias (fractures)?
- Skin, mucous membranes, and sclerae (white part of eye) [cyanosis (bluish discoloration of skin and central mucous membranes, e.g., tongue)?]
- Auscultation (listening) of the heart.
- Auscultation of the lungs
- Palpation (palpation) of the abdomen (tenderness?, knocking pain?, coughing pain?, defensive tension?, hernial orifices?, kidney bearing knocking pain?)
- Inspection (viewing).
- Assessment of consciousness using the Glasgow Coma Scale (GCS).
- Assessment of organ function using the SOFA score (for: “Sequential (Sepsis-Related) Organ Failure Assessment Score”) [see classification below].
* Note: Hyperthermia or hypothermia (fever or hypothermia) temperatures are among the cardinal symptoms for the presence of infection!
Square brackets [ ] indicate possible pathological (pathological) physical findings.Glasgow Coma Scale (GCS) – scale for estimating a disorder of consciousness.
Criterion | Score | |
Eye opening | spontaneous | 4 |
on request | 3 | |
on pain stimulus | 2 | |
no reaction | 1 | |
Verbal communication | conversational, oriented | 5 |
conversational, disoriented (confused) | 4 | |
incoherent words | 3 | |
unintelligible sounds | 2 | |
no verbal reaction | 1 | |
Motor response | Follows prompts | 6 |
Targeted pain defense | 5 | |
untargeted pain defense | 4 | |
on pain stimulus flexion synergisms | 3 | |
on pain stimulus stretching synergisms | 2 | |
No response to pain stimulus | 1 |
Assessment
- Points are awarded for each category separately and then added together. The maximum score is 15, the minimum 3 points.
- If the score is 8 or less, a very severe brain dysfunction is assumed and the there is a risk of life-threatening respiratory disorders.
- With a GCS ≤ 8, securing the airway by endotracheal intubation (insertion of a tube (hollow probe) through the mouth or nose between the vocal folds of the larynx into the trachea) must be considered.