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==Signs and symptoms==
The symptoms of an episode of diabetic ketoacidosis usually evolve over a period of about 24 hours. Predominant symptoms are [[nausea]] and vomiting, pronounced thirst, [[polyuria|excessive urine production]] and [[abdominal pain]] that may be severe. In severe DKA, breathing becomes rapid and of a deep, gasping character, called "[[Kussmaul breathing]]".<ref name=NelsonEss7e>{{cite book|last1=Kliegman|first1=[edited by] Karen J. Marcdante, Robert M.|title=Nelson essentials of pediatrics|date=2015|isbn=9781455759804|pages=573–576|edition=7th}}</ref><ref name=Powers2005>{{cite book |author=Powers AC |veditors=Kasper DL, Braunwald E, Fauci AS |title=Harrison's Principles of Internal Medicine|edition=16th |year=2005 |publisher=McGraw-Hill |location=New York, NY |isbn=978-0-07-139140-5 |pages=2152–2180|display-editors=etal}}</ref> The abdomen may be tender to the point that a [[acute abdomen|serious abdominal condition]] may be suspected, such as [[acute pancreatitis]], [[appendicitis]] or [[gastrointestinal perforation]].<ref name=Powers2005/> [[Coffee ground vomiting|Vomiting altered blood that resembles coffee grounds]] occurs in a minority of people and tends to originate from erosion of the [[esophagus]].<ref name=Eledrisi/> In severe DKA, there may be confusion or a marked decrease in [[level of consciousness|alertness]], including [[coma]].
On [[physical examination]] there is usually clinical evidence of [[dehydration]], such as a dry mouth and decreased [[skin turgor]]. If the dehydration is profound enough to cause a decrease in the circulating blood volume, a [[tachycardia|rapid heart rate]] and [[hypotension|low blood pressure]] may be observed. Often, a "ketotic" odor is present, which is often described as "fruity" or like "pear drops".<ref name=BMJ2015/><ref name=Powers2005/> The smell is due to the presence of [[acetone]].<ref>{{cite book |last1=Elzouki |first1=A. Y. |last2=Harfi |first2=H. A. |last3=Nazer |first3=H. |last4=Oh |first4=William |last5=Stapleton |first5=F. B. |last6=Whitley |first6=R. J. |title=Textbook of Clinical Pediatrics |date=2011 |publisher=Springer Science & Business Media |isbn=9783642022012 |page=2567 |url=https://books.google.com/books?id=FEf4EMjYSrgC&pg=PA2567 |language=en}}</ref> If Kussmaul respiration is present, this is reflected in an [[tachypnea|increased respiratory rate]].<ref name=Powers2005/>
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