Sticking your nose in


COMMENT Physiotherapists need to be keen observers, good listeners and possess a deft touch, but Dianne Sfiligoi suggests a good sense of smell could come in handy too.

I bet you know the smell of ketosis, that dastardly morning fruity breath determined not to relent until you feed it breakfast.

Your sense of smell has just diagnosed a fat-burning metabolic state called ketosis. Low in carbs after a night’s sleep your body switches mainly to burning fats. Ketones, a by product of this metabolic state, build up in your blood. High ketone levels often cause bad breath. This same ketosis-breath can be a sign of an acute complication of diabetes—ketoacidosis.

Fruity breath can also be the smell of diabetic-breath—low blood sugar is on the cards.

In clinical practice, we are highly aware of what we see, hear and feel. We call upon these essential senses to help us discern what is going on with our client. These senses play a large part in our clinical reasoning process. But how important is our sense of smell in this process?

Can we smell a urinary tract infection of an elderly client sitting in wet pants? Can we smell a cry for help in someone who reeks of alcohol every time she comes to the clinic? Can we smell an infected surgical wound hidden in the cast of a little boy with intellectual challenges?

Yes is the answer to all of these. We may even be able to smell Parkinson’s disease without knowing it.

Interestingly, we do not speculate on these diagnoses using our eyes, ears or hands—after all we do not hear the incontinence, we did not feel the drinking problem and we may not see the infected site.

We use our noses for this job. But how many of us actually write our olfactory observations in our clinical notes?

Dianne Sfiligoi, APAM, was a practising physiotherapist before becoming a career pathway advisor for the APA.


‘You can smell when someone’s sick— here’s how’. The case of a woman who can smell Parkinson’s disease, published in National Geographic in January 2018.

‘Scent of a patient: an underestimated role in clinical practice?’ A brief review published in the British Journal of General Practice, July 2012:


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