What's the best approach for a patient with suspected hand, foot, and mouth disease?

SOAP Template for Hand, Foot, and Mouth Disease

SUBJECTIVE

Chief Complaint:

• Document onset and duration of symptoms (fever, oral pain, rash) 1

History of Present Illness:

• Constitutional symptoms: Fever (typically low-grade), malaise, sore throat, irritability 2, 3
• Oral symptoms: Painful mouth sores, difficulty eating/drinking, dysphagia 1
• Skin symptoms: Rash on hands, feet, buttocks; note if vesicular or maculopapular 3
• Associated symptoms: Cough, rhinitis, nausea, vomiting, diarrhea 2
• Timeline: When fever started, when rash appeared, progression of lesions 2

Exposure History:

• Recent contact with sick children or adults 4
• Daycare or school attendance 1
• Known HFMD outbreak in community 3

Past Medical History:

• Immunocompromised status (higher risk for severe disease) 1
• Previous episodes of HFMD 5

OBJECTIVE

Vital Signs:

• Temperature (document fever if present) 2
• Heart rate, respiratory rate, blood pressure 3

Oral Examination:

• Location: Tongue, buccal mucosa, palate, gingiva 1
• Appearance: Vesicles, ulcerations, erythema 3
• Severity: Number and size of lesions 1

Skin Examination:

• Distribution: Palms, soles, dorsal hands/feet, buttocks, legs (may be widespread) 1, 3
• Morphology: Maculopapular vs. vesicular vs. papulovesicular 3
• Stage: Fresh vesicles vs. crusted lesions vs. healing 1
• Secondary changes: Signs of secondary bacterial infection (increased erythema, warmth, purulent drainage) 1

Neurological Examination (if indicated):

• Mental status, neck stiffness, focal deficits (to rule out encephalitis/meningitis) 1

Hydration Status:

• Mucous membrane moisture, skin turgor, capillary refill 3

ASSESSMENT

Primary Diagnosis:

• Hand, Foot, and Mouth Disease (clinical diagnosis) 3

Differential Diagnoses to Consider:

• Herpes simplex virus infection (has antiviral treatment options, unlike HFMD) 1
• Drug hypersensitivity reaction (can present with palmar-plantar rash) 1
• Kawasaki disease (diffuse erythema vs. vesicular lesions in HFMD) 1
• Erythema multiforme, varicella, measles 3
• In atypical presentations: syphilis, meningococcemia, Rocky Mountain spotted fever 1

Severity Assessment:

• Mild: Able to maintain hydration, no complications 3
• Moderate: Difficulty eating/drinking, risk of dehydration 1
• Severe: Signs of neurological complications (encephalitis, meningitis, acute flaccid paralysis) or cardiopulmonary involvement 1

Diagnostic Testing (if needed):

• RT-PCR of vesicle fluid (highest viral load, most sensitive) 1
• RT-PCR of respiratory samples or stool (alternative if vesicle fluid unavailable) 1
• Laboratory confirmation typically not needed for routine cases 3

PLAN

Symptomatic Management

Pain and Fever Control:

• Acetaminophen or NSAIDs for limited duration to relieve pain and reduce fever 1
• Avoid oral lidocaine (not recommended) 3

Oral Lesion Management:

• Mild cases: Gentle oral hygiene with mild toothpaste 1
• Moderate cases:
  • White soft paraffin ointment to lips every 2 hours 1
  • Warm saline mouthwashes or oral sponge for comfort 1
  • Benzydamine hydrochloride oral rinse/spray every 3 hours, especially before eating 1
  • Chlorhexidine oral rinse twice daily 1
• Severe cases:
  • Betamethasone sodium phosphate 0.5 mg in 10 mL water as rinse-and-spit 1-4 times daily 1
  • Barrier preparations (Gengigel mouth rinse/gel or Gelclair) for pain control 1
  • May dilute mouthwashes by 50% to reduce discomfort 1

Dietary Modifications:

• Eliminate tomatoes, citrus fruits, hot drinks, spicy/hot/raw/crusty foods 1
• Encourage ample fluid intake to maintain hydration 1
• Soft, bland, cool foods as tolerated 3

Skin Care:

• Hand and foot lesions: Intensive moisturizing with urea-containing creams 1
• For itchiness: Zinc oxide 20% applied in thin layer after gentle cleansing; can repeat as needed 1
• For nighttime relief: Apply zinc oxide followed by loose cotton gloves to create occlusive barrier 1
• Avoid zinc oxide on open or weeping lesions 1

Open Sores on Feet:

• Wash feet daily with careful drying, especially between toes 1
• Avoid walking barefoot; wear appropriate cushioned footwear 1
• Do NOT soak feet in footbaths (causes maceration) 1
• Do NOT use topical antiseptic or antimicrobial dressings routinely 1
• Do NOT use chemical agents or plasters to remove corns/calluses 1

Infection Control and Prevention

Hand Hygiene (Most Important Preventive Measure):

• Thorough handwashing with soap and water is more effective than alcohol-based sanitizers 1, 6
• Wash hands before and after contact with patient or their environment 6

Environmental Cleaning:

• Clean and disinfect toys, doorknobs, tabletops, and objects that may be placed in mouths 1, 6
• Virus remains viable on surfaces for several hours 6

Isolation Precautions:

• Avoid close contact (within few feet) with others until fever resolves and mouth sores heal 1, 6
• Avoid sharing utensils, cups, or food 1, 6
• Healthcare workers should follow standard precautions 6
• Avoid direct contact with vesicle fluid (extremely high viral loads) 6

Infectious Period:

• Most infectious during first week, particularly with fever and skin lesions 2
• Viral shedding continues up to 5 days after symptom onset in adults, 7 days in children 2
• Exclude from swimming pools during acute illness 2

Return to Activities

Return to Daycare/School/Work:

• Can return once fever resolves and mouth sores heal, even if skin rash still present 1
• Exclusion based solely on healing skin lesions is not necessary 1
• By time of diagnosis, patient has likely been infectious for days with limited additional risk 1

Monitoring and Follow-Up

Red Flags Requiring Immediate Re-evaluation:

• Signs of secondary bacterial infection: increased redness, warmth, purulent drainage, worsening pain 1
• Neurological symptoms: severe headache, neck stiffness, altered mental status, weakness 1
• Signs of dehydration: decreased urine output, dry mucous membranes, lethargy 3

Routine Follow-Up:

• Reassess after 2 weeks if lesions not improving with standard care 1
• Re-evaluate after 4 weeks if evidence of infection has not resolved; consider alternative diagnoses 1

Expected Course:

• Lesions typically resolve in 7-10 days 3
• Late manifestations may include:
  • Beau's lines (nail grooves) appearing 1-2 months after fever onset 1
  • Periungual desquamation beginning 2-3 weeks after fever onset 1

Patient Education

Reassurance:

• Self-limiting disease with excellent prognosis in immunocompetent patients 3, 5
• Most cases resolve without complications 7

Self-Monitoring:

• Daily foot examination for signs of secondary infection 1
• Monitor hydration status 3

Prevention of Spread:

• Meticulous hand hygiene is the single most important measure 1, 6
• Avoid contact with vesicle fluid 6
• Clean contaminated surfaces regularly 6