Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Initial Stabilization
Immediate priorities
Airway patency
Stridor
Drooling with inability to handle secretions
Breathing status
Work of breathing
Hypoxemia
Circulation and perfusion
Capillary refill delay
Hypotension
Neurologic status
Altered mental status
Seizure
Dehydration risk
Unable to tolerate oral fluids
Reduced urine output
Escalation triggers
If toxic appearance, sepsis pathway
Blood cultures
Broad spectrum antibiotics per local protocol
If respiratory distress or hypoxemia, resuscitation bay
Supplemental oxygen
Chest imaging based on exam
If neurologic signs, emergent pediatric or neurology consult
Concern for enterovirus neurologic complication
Consider ICU
Infection control
Contact precautions
Gloves and gown for direct contact
Dedicated equipment when feasible
Droplet precautions if prominent respiratory symptoms
Surgical mask for close contact
Cohorting if outbreak setting
Hand hygiene emphasis
Soap and water after diapering
Alcohol based hand rub for routine use
Key Decision Points
Severity stratification
Uncomplicated HFMD
Normal mental status
Adequate oral intake
Moderate dehydration risk
Pain limiting intake
Mild clinical dehydration
High risk or complicated disease
Dehydration with failed oral rehydration
Neurologic symptoms
Cardiopulmonary symptoms
Diagnostic posture
Clinical diagnosis in typical cases
Oral enanthem with extremity rash pattern
Known exposure or daycare cluster
Targeted testing in atypical or severe cases
Alternate diagnosis concern
Complication concern
History
Symptom Pattern and Timeline
Core history elements
Symptom onset day
Fever duration
Rash onset relative to fever
Oral pain
Refusal to drink
Refusal to eat
Rash description
Vesicles
Painful lesions
Exposure context
Daycare or school attendance
Household contact illness
Hydration and Complication Screen
Intake and output
Oral fluid intake
Ability to swallow
Vomiting
Urine output
Wet diapers count
Dark urine
Red flag symptoms
Neurologic
Headache
Neck stiffness
Myoclonus or tremor
Ataxia
Respiratory
Shortness of breath
Persistent tachypnea
Cardiac
Chest pain
Palpitations
Host factors
Age under 2 years
Higher dehydration risk
Limited oral reserve
Immunocompromised state
Transplant
Chemotherapy
Pregnancy status in adolescents
Third trimester symptoms
Close household exposure
Physical Exam
Vitals and Hydration
Global assessment
Toxic appearance
Lethargy
Poor perfusion
Fever pattern
Persistent high fever
Afebrile
Hydration status
Mucous membranes
Dry mouth
Saliva pooling
Tears
Present
Absent
Capillary refill
Normal
Prolonged
Heart rate relative to fever
Disproportionate tachycardia
Normal
Weight based comparison when available
Recent weight loss
Baseline weight unknown
Skin and Oropharynx
Lesion characterization
Oral enanthem
Vesicles and ulcers on buccal mucosa
Posterior oropharyngeal lesions
Extremity rash distribution
Palms
Soles
Typical additional sites
Buttocks
Perioral skin
Severity markers
Uncontrolled drooling
Unable to manage secretions
Dehydration risk
Extensive blistering
Coxsackie A6 pattern concern
Secondary infection risk
Neurologic and Cardiopulmonary
Neurologic exam
Mental status
Irritability
Lethargy
Meningeal signs
Neck stiffness
Photophobia
Cerebellar findings
Ataxia
Tremor or myoclonus
Respiratory and cardiac exam
Work of breathing
Retractions
Grunting
Auscultation
Crackles
Wheeze
Perfusion
Cool extremities
Mottling
Differential Diagnosis
Vesicular Rash With Oral Lesions
Mimics and alternatives
Herpangina
Posterior pharyngeal vesicles predominance
Minimal hand and foot rash
Primary HSV gingivostomatitis
Diffuse gingival inflammation
Perioral grouped vesicles
Varicella
Trunk predominant lesions
Lesions in multiple stages
Impetigo bullous
Honey crusting
Localized lesions
Eczema herpeticum
Atopic dermatitis background
Monomorphic punched out lesions
Erythema multiforme
Target lesions
Medication or infection trigger
Stevens Johnson syndrome
Mucosal involvement severity
Systemic toxicity
Mpox
Deep seated umbilicated lesions
Exposure risk context
High Consequence Diagnoses to Exclude
Dangerous rash syndromes
Meningococcemia
Petechiae or purpura
Rapid progression
Kawasaki disease
Conjunctivitis
Strawberry tongue
Extremity swelling
Toxic shock syndrome
Hypotension
Multisystem involvement
Laboratory Tests
Routine Testing Strategy
Typical uncomplicated cases
No routine laboratory tests
Clinical diagnosis
Self limited course
Focus on hydration assessment
Oral intake trial response
Urine output trend
Dehydration and Severe Illness Evaluation
Dehydration concern
Basic metabolic panel for moderate to severe dehydration
Sodium abnormalities
Potassium abnormalities
Glucose point of care for poor intake or lethargy
Hypoglycemia
Stress hyperglycemia
Serum ketones when prolonged poor intake
Starvation ketosis
Alternate diagnosis consideration
Systemic toxicity concern
Complete blood count when bacterial infection concern
Neutrophilia
Thrombocytopenia
C reactive protein when inflammatory differential broad
Limited specificity
Trend support only
Blood cultures if sepsis concern
Before antibiotics when feasible
Do not delay stabilization
Neurologic or Cardiac Complication Workup
CNS involvement concern
Lumbar puncture studies when meningitis encephalitis concern
Cell count and differential
Protein
Glucose with paired serum glucose
CSF enterovirus PCR when available
Supports enterovirus etiology
Does not exclude alternate pathogens
Myocarditis concern
Troponin if chest pain or arrhythmia
Myocardial injury marker
Requires clinical correlation
BNP or NT proBNP if heart failure signs
Volume status interpretation challenge
Adjunct only
Diagnostic Tests
Scoring Systems
Clinical risk and monitoring tools
Dehydration severity clinical assessment
Mild
Thirst
Slightly dry mucosa
Moderate
Decreased tears
Sunken eyes
Reduced urine output
Severe
Lethargy
Weak pulses
Prolonged capillary refill
Pediatric early warning approach when admitted
Heart rate trend
Respiratory rate trend
Mental status trend
MRI
Neuro complication imaging
Brain MRI indications
Myoclonus
Ataxia
Persistent altered mental status
Brainstem encephalitis features
Brainstem lesions
Cerebellar involvement
Spine MRI indications
Acute flaccid weakness
Reflex changes
CT
Time sensitive neuro evaluation
Head CT indications
Altered mental status with focal deficit
Concern for intracranial process before lumbar puncture
Limitations
Low sensitivity for early brainstem encephalitis
Radiation risk in pediatrics
Ultrasound (or US)
Point of care applications in complications
Lung ultrasound for respiratory deterioration
B lines consistent with pulmonary edema
Pleural effusion assessment
Focused cardiac ultrasound for myocarditis concern
Global systolic function
Pericardial effusion
Volume status adjunct
IVC variability interpretation limits in children
Clinical correlation required
Disposition
Level of Care Decisions
Discharge criteria
Adequate oral hydration
Successful oral fluid challenge
Caregiver able to continue oral rehydration
No red flag symptoms
No neurologic signs
No respiratory distress
Reliable follow up
Primary care access
Caregiver return precautions understood
Admission criteria
Moderate to severe dehydration
Failed oral rehydration
IV fluids required
Uncontrolled pain limiting intake
Persistent refusal of fluids
Recurrent vomiting
Complication concern
Altered mental status
Suspected meningitis encephalitis
Suspected myocarditis
ICU criteria
Cardiopulmonary instability
Hypoxemia
Shock
Severe neurologic disease
Seizure
Brainstem signs
Transfer criteria
Need for pediatric ICU not available
Escalating respiratory support
Continuous vasoactive infusions
Return to School or Childcare Considerations
Attendance guidance
Afebrile
No fever without antipyretics
Fever resolved at least 24 hours
Able to participate
Energy adequate for routine activities
Pain controlled
No uncontrolled drooling
Secretions manageable
Oral lesions not causing constant drool
Treatment
Supportive Care Core
Mainstay management
Hydration strategy
Oral rehydration solution for mild dehydration
Frequent small volumes for oral pain
Analgesia and antipyresis
Acetaminophen oral
Dose 15 mg per kg every 4 to 6 hours
Maximum 75 mg per kg per day
Ibuprofen oral age over 6 months
Dose 10 mg per kg every 6 to 8 hours
Maximum 40 mg per kg per day
Oral comfort measures
Cool liquids
Popsicles
Pruritus management when needed
Cetirizine oral
Age based dosing per local formulary
Sedation counseling
Diphenhydramine oral
Avoid in very young infants unless clinician directed
Paradoxical agitation risk
Hydration Protocols
Oral rehydration pathway
Mild dehydration
Oral rehydration solution 5 to 10 mL every 1 to 2 minutes
Escalate volume as tolerated
Moderate dehydration
Oral rehydration solution 10 to 20 mL every 5 minutes
Reassess hydration status every 30 minutes
Antiemetic support when vomiting limits rehydration
Ondansetron oral disintegrating tablet
Weight based dosing per local protocol
Single dose then oral rehydration trial
IV fluid pathway
If moderate to severe dehydration with failed oral rehydration, initiate IV isotonic fluid
Normal saline bolus 20 mL per kg
Reassessment after each bolus
Repeat bolus based on perfusion and hydration
Maintenance fluids after resuscitation
Isotonic maintenance per pediatric protocol
Electrolyte monitoring if ongoing losses
Medications to Avoid
Safety prohibitions
Oral lidocaine preparations
Seizure risk with toxicity
Aspiration risk from numbing
Aspirin in children
Reye syndrome risk
Use acetaminophen or ibuprofen instead
Secondary Infection and Dermatologic Care
Skin care
Gentle cleansing
Mild soap and water
Avoid lesion de roof
Barrier protection for diaper area lesions
Zinc oxide
Frequent diaper changes
Bacterial superinfection concern
Localized impetigo treatment
Mupirocin topical
Apply thin layer 2 to 3 times daily
Duration 5 days
Cellulitis concern
Oral antibiotics per local pediatric pathway
Culture if purulence present
Severe EV71 Associated Complications
Specialist guided management
Suspected brainstem encephalitis
ICU monitoring
Airway protection planning
IVIG consideration in severe neurologic disease
Evidence base primarily observational
Infectious disease consult
Milrinone consideration for autonomic instability and neurogenic pulmonary edema patterns
ICU protocol dosing only
Cardiology and critical care oversight
Special Populations
Pregnancy
Pregnancy considerations
Maternal disease in adolescents and adults
Usually self limited
Hydration priority
Fetal risk counseling
Limited evidence for major congenital risk
Emphasis on fever control and hydration
Medication safety
Acetaminophen preferred antipyretic
NSAID avoidance in third trimester
Geriatric
Older adult considerations
Atypical presentation
Less prominent rash
Higher complication concern with comorbidity
Dehydration vulnerability
Baseline renal impairment
Polypharmacy considerations
Alternate diagnoses threshold
Drug eruption
Bullous pemphigoid
Pediatrics
Pediatric specifics
Highest incidence age under 5 years
Daycare clusters common
Household spread common
Dehydration monitoring priority
Wet diaper frequency
Oral intake targets
Return to school or childcare guidance
Afebrile
No uncontrolled drooling
Able to participate
Background
Epidemiology
Population patterns
Typical age distribution
Predominantly children under 5 years
Adolescents and adults possible
Seasonal pattern
Summer and early fall peaks in many regions
Year round transmission possible
Outbreak settings
Childcare centers
Schools
Clinical course expectations
Incubation period
Typically 3 to 6 days
Exposure to symptom onset variability
Illness duration
Lesions typically resolve within 7 to 10 days
Prolonged course possible with extensive disease
Pathophysiology
Virology and transmission
Causative agents
Coxsackievirus A16
Enterovirus 71
Coxsackievirus A6
Transmission routes
Fecal oral
Respiratory droplets
Direct contact with vesicle fluid
Viral shedding
Respiratory shedding early
Stool shedding for weeks
Complication mechanisms
Dehydration
Odynophagia limiting intake
Fever related insensible losses
Neuroinvasive disease in EV71
Brainstem encephalitis
Acute flaccid paralysis
Neurogenic pulmonary edema patterns in severe EV71
Autonomic dysregulation
Rapid respiratory decompensation
Therapeutic Considerations
Evidence framing
Supportive care as standard of care
Hydration and pain control as primary interventions
Self limited viral illness in most cases
Antivirals
No routinely recommended antiviral therapy
Management remains symptomatic
Evidence based cautions
Oral lidocaine not recommended
Aspiration and toxicity risks
Severe EV71 disease
ICU supportive management central
IVIG and inotrope strategies based on limited evidence and regional protocols
Patient Discharge Instructions
copy discharge instructions
Home care plan
Fluids frequently
Small sips every few minutes
Oral rehydration solution preferred if intake low
Pain and fever control
Acetaminophen or ibuprofen as directed by clinician
No aspirin
Mouth pain strategies
Cold drinks
Popsicles
Skin care
Keep lesions clean and dry
Avoid picking blisters
Infection spread reduction
Handwashing with soap and water after diaper changes
Do not share cups or utensils
Clean high touch surfaces
Return now or go to emergency department
Dehydration signs
No urine for 8 hours
Very dry mouth
No tears when crying
Breathing problems
Fast breathing
Working hard to breathe
Neurologic symptoms
Severe headache
Stiff neck
Trouble walking
Seizure
Persistent fever
Fever lasting more than 3 days
Fever with worsening appearance
Worsening rash
Rapid spreading bruising like spots
Signs of skin infection with increasing redness or pus
Return to school or childcare
Fever free
No fever for 24 hours
No fever medicines needed
Well enough for normal activities
Drinking adequately
Comfortable with pain control
No uncontrolled drooling
Able to manage secretions
Mouth sores not causing constant drool
References
Key Sources
Clinical guidance sources
Centers for Disease Control and Prevention hand foot and mouth disease overview and return to school guidance updated May 7 2024
American Academy of Pediatrics Red Book section on modes of spread and school attendance guidance for HFMD
American Academy of Pediatrics HealthyChildren hand foot and mouth disease guidance updated Dec 15 2025
American Academy of Family Physicians hand foot and mouth disease rapid evidence review 2019
Public Health Agency of Canada information sheet on HFMD related to enterovirus 71 updated Jul 19 2017
Complication evidence sources
Huang CC et al Neurologic complications in children with enterovirus 71 infection New England Journal of Medicine 1999
Lee KY review of enterovirus 71 neurologic complications and management recommendations 2016
StatPearls Hand Foot and Mouth Disease NCBI Bookshelf updated 2023
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.