A diabetic patient with flu-like symptoms, warm dry skin, rapid respirations, a sweet-smelling breath and a glucometer reading HIGH. What should you suspect?

A diabetic patient with flu-like symptoms, warm dry skin, rapid respirations, a sweet-smelling breath and a glucometer reading HIGH. What should you suspect?

• A. Diabetic ketoacidosis
• B. Hyperglycemic hyperosmolar non-ketotic syndrome
• C. Severe metabolic alkalosis
• D. Insulin shock

Answer: (A)

The situation points to diabetic ketoacidosis. When insulin is deficient during illness, the body can’t use glucose properly, so it increases fat breakdown and produces ketone bodies. This creates metabolic acidosis, which drives the characteristic rapid, deep, labored breathing (Kussmaul respirations) as the body tries to blow off CO2. The high glucose you see on the meter fits with hyperglycemia from insufficient insulin. Dehydration from osmotic diuresis makes the skin warm and dry, and the fruity or sweet-smelling breath comes from acetone ketones produced in the liver. This picture is distinct from other possibilities. A hyperglycemic hyperosmolar state involves very high glucose and severe dehydration but little to no ketones, so you wouldn’t expect the fruity breath or marked acidosis. Severe metabolic alkalosis would present with a high pH and different clinical cues, not the ketotic, acidotic picture here. An insulin deficiency causing hypoglycemia (insulin shock) would show low glucose, sweating, and confusion, not a high glucose level with ketosis.

The situation points to diabetic ketoacidosis. When insulin is deficient during illness, the body can’t use glucose properly, so it increases fat breakdown and produces ketone bodies. This creates metabolic acidosis, which drives the characteristic rapid, deep, labored breathing (Kussmaul respirations) as the body tries to blow off CO2. The high glucose you see on the meter fits with hyperglycemia from insufficient insulin. Dehydration from osmotic diuresis makes the skin warm and dry, and the fruity or sweet-smelling breath comes from acetone ketones produced in the liver.

This picture is distinct from other possibilities. A hyperglycemic hyperosmolar state involves very high glucose and severe dehydration but little to no ketones, so you wouldn’t expect the fruity breath or marked acidosis. Severe metabolic alkalosis would present with a high pH and different clinical cues, not the ketotic, acidotic picture here. An insulin deficiency causing hypoglycemia (insulin shock) would show low glucose, sweating, and confusion, not a high glucose level with ketosis.