Fatigue and lethargy in children and adolescents — viva

Opening (must-hit)

"I separate emergency lethargy from fatigue with preserved interaction. Unstable or poorly interactive children get ABCDE first. Stable children get a mechanism-based differential and directed tests." [4] [6]

Branch A — Infant lethargy

Examiner: The febrile infant is poorly interactive.
Candidate: I treat this as lethargy, not tiredness. I run ABCDE, check glucose, consider sepsis, get senior help, and do not reframe as chronic fatigue. [4] [6]

Branch B — Caregiver concern

Examiner: Observations are only mildly abnormal but the parent says "not my child."
Candidate: Caregiver concern is data associated with critical illness risk. I escalate assessment rather than reassure on numbers alone. [4]

Branch C — School-age snoring

Examiner: The 11-year-old snores and fails PE.
Candidate: I keep OSA high on the list, examine the airway and growth context, and refer along sleep/ENT pathways while I still screen for anaemia and red flags. [5] [3]

Branch D — Malignancy worry

Examiner: There is night pain and unexplained bruising.
Candidate: I prioritise urgent FBC and senior review. Childhood leukaemia often starts with non-specific fatigue and pallor before classic clusters fully form. [1]

Branch E — ME/CFS pattern

Examiner: Months of post-exertional crashes, normal first-line tests.
Candidate: After directed exclusion I use energy management and education support. I do not prescribe forced graded exercise as default. Severe disease needs active service planning. [2]

Branch F — Iron deficiency

Examiner: An adolescent sister in the waiting room has heavy periods and similar fatigue.
Candidate: I take a menstrual history, check FBC/iron studies, and treat iron deficiency with a complete follow-up plan rather than vague advice. [3]

Branch G — Handover

Examiner: You transfer the infant to another team.
Candidate: I hand over representation, actions, response and residual risks with a structured tool so uncertainty is not lost. [7]