A 10-year-old girl presents to your District Hospital ED with lethargy, subjective fevers, vomiting, diarrhoea and upper abdominal pain worsening over 1 week. She has no background history of note and has been otherwise well apart from a recent URTI. She is taken directly to resus as she is very lethargic, pale and ashen coloured. Vitals : GCS 13, HR 120, SBP 80/-, RR 22, Sats 92%RA, Temp 36.5 Clinical findings : CR 4secs centrally, HSDNM ?S3 Moderate accessory muscle use, Occ scattered crepitations bilat Palpable liver edge 3-4 cm below costal margin, Slight tenderness RUQ otherwise soft / non-tender

10yo lethargic after recent URTI

1. Give (3) salient findings on the ECG 3 marks

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2. What’s your overall impression of this case? 1 mark

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A CXR was obtained.

3. Give (2) salient findings from the chest xray and your interpretation 3 marks

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4. What is your differential diagnosis? 5 marks

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5. List and justify (6) further investigations you would order 6 marks

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