Symptom: Breath Smells Fruity

Initial Grading Reminder

A marker of ketoacidosis

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Do you have diabetes? Are you taking steroids? Is this a new or worsening symptom? When did it start or get worse? Has the symptom developed gradually or suddenly? How strong is the odor?

Note: More sudden onset would be suggestive of an endocrinopathy.

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have excessive thirst? Have you had any frequent urination; nausea and vomiting; abdominal (belly) pain; weakness; tremor, shortness of breath; or confusion?”

For patients with known diabetes:

Ask what their blood sugar level is and whether they have checked urine ketones.

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    A patient with diabetic ketoacidosis should be seen immediately.

    If patients have any of the red-flag symptoms, they should also be seen immediately.

    Patients with known diabetes who are symptomatic and/or have high blood glucose and/or urine ketone levels should be seen. Patients should be instructed to go to the ED if blood glucose is >300 mg/dL or if there are multiple symptoms.

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    Differential Diagnosis

    What do you suspect is the cause of the fruity breath?