Chronic fatigue and post-viral fatigue syndromes OSCE — validation, energy management and school reintegration

Station objectives

1. Validate chronic fatigue as a real, multi-system illness and recognise post-exertional malaise as the hallmark. [1]
2. Distinguish CFS/ME from depression and deconditioning, and confirm the focused exclusion of mimics. [1]
3. Co-build a function-first plan — energy management within the energy envelope, CBT, individualised activity. [2]
4. Decline rigid graded exercise clearly and empathically, and treat school reintegration as a clinical outcome. [4] [6]

Candidate brief

You are the paediatric doctor in adolescent clinic. You have 10 minutes for Station A (post-glandular-fever fatigue, half-days at school, father wants her to push through) and 12 minutes for Station B (established CFS/ME with new weight loss and night sweats, family told it is part of her syndrome). Examiners score validation, recognition of PEM, function-first framing, and partnership language. [1] [6]

Station A — Post-viral fatigue, half-days at school, father wants her to push through

Setup: A 14-year-old, four months after confirmed EBV infection. Fatigue, 11 hours of unrefreshing sleep, and a two-day crash after PE. Attending school only half-days. Targeted bloods normal. She desperately wants to return to sport and friends. Her father believes she should push through with a structured exercise programme. [1]

Expected actions:

• Greet the adolescent first; see her alone; state conditional confidentiality with its lawful limits. [1]
• Validate the fatigue as a real, multi-system illness and not her fault; take a fatigue and activity history and a HEEADSSS-tailored psychosocial history; screen for suicidality. [1]
• Identify and name post-exertional malaise as the discriminating feature; confirm the focused blood exclusion is complete and avoid a further cascade. [1]
• Explain the energy envelope and pacing; co-build a function-first plan: energy management, CBT, individualised activity, graded return-to-school. Set functional goals, not a cure promise. [2]
• Respond to the father's "push through" request directly and empathically: explain that rigid graded exercise can trigger PEM and that current guidance withdrew fixed-dose GET; activity is escalated only as tolerated, with her in control. [4]

Station B — Established CFS/ME with new weight loss and night sweats

Setup: A 15-year-old with established CFS/ME managed for eight months with energy management and CBT, now attending school four days a week. She presents with new weight loss, night sweats and a palpable cervical node. The family has been told by a clinician that this is "part of her fatigue syndrome." [6]

Expected actions:

• Validate the family's concern and take a targeted history of the new symptoms; do not attribute them to the CFS/ME label. [1]
• Name diagnostic overshadowing explicitly: new red flags are reassessed on their own merits regardless of an existing functional diagnosis. [1]
• Re-enter the diagnostic pathway with targeted investigation — inflammatory markers, LDH, directed imaging, considering malignancy and inflammatory illness — and arrange prompt review. [1]
• Reassure the family that you are taking the new symptoms seriously while continuing the function-first plan if organic disease is again excluded; document the reasoning and the safety-net. [6]
• Address the school trajectory positively — she has improved to four days a week — and continue the graded, school-led return-to-school plan. [6]

Marking anchors

Clear pass: validates the illness as real; recognises and defines PEM; confirms the focused exclusion of mimics; co-builds a function-first plan with energy management and CBT; declines rigid graded exercise clearly and empathically; treats school reintegration as a clinical outcome; in Station B, immediately recognises the red flags and avoids diagnostic overshadowing. [1] [2] [4] [6] Borderline: validates well but defers school reintegration to "later," offers vague follow-up, or avoids the graded-exercise conversation. Fail: dismisses the fatigue as stress or laziness; prescribes a fixed graded-exercise increment for all; promises a cure; ignores the new red flags in Station B; uses stigmatising language. [1]

Debrief pearls

• The explanation of PEM and the energy envelope is itself a treatment — it changes the trajectory. [1]
• Energy management within the envelope, not push-through exercise, is the active treatment. [4]
• School attendance is a clinical outcome, not an administrative detail. [6]
• A functional label never exempts a new red flag from investigation. [1]