MRCGP SCA Consultation Skills Course
Station 8 · Asthma
Video consultation · Long-term conditions · Young people · Prescribing · Circuit 2 · 11:20–12:45 · 14-minute station
A 19-year-old student has used three blue inhalers in two months, does not take the brown one, and has just come out of the emergency department.
Candidate brief
Read this as you would in the exam. One to two minutes' reading, then ten minutes. You may ask the patient for examination findings; there is no reference material.
| Patient | Jamie Whitlock, 19, first-year university student (home for the summer) |
| Reason for appointment | "Inhaler" — repeat request refused by pharmacist; ED discharge letter |
| PMH | Asthma since childhood. Hay fever. Eczema (mild) |
| Medication | Salbutamol 100 mcg inhaler — three issued in 8 weeks; beclometasone 200 mcg bd — last issued 9 months ago. Allergies: none |
| Recent entries | ED letter 5 days ago: 'Acute asthma, PEF 55% predicted, sats 94%, nebulised, prednisolone 40 mg for 5 days, discharged, GP review within 2 days.' No annual review for 18 months. No personalised asthma action plan on record. Smoking status: 'vapes' |
Role-player script — tutors only
Delegates: please do not open this section until you have consulted at this station.
Open the role-player script (584 words)
Persona and manner
- Easy-going, a bit sheepish about the ED visit, wants the consultation over quickly; phone in hand; answers honestly when asked directly.
- Believes the blue inhaler is the 'real' treatment and the brown one is 'for when it's bad', which it never is 'until it is'.
Opening line — say this verbatim
- "Hi — I just need my blue inhaler, the pharmacy wouldn't give me one. I was in A&E last week but I'm fine now, honestly, they gave me steroids and I'm all good."
Volunteer freely if given the space
- Wheezy 'most days' over the summer — 'it's the pollen'; uses the blue 'a few times a day', more at night.
- The ED visit: 'a bad night', couldn't finish sentences, friend drove him in. 'It was scary at the time.'
- Steroid tablets finished two days ago; feels 'back to normal'.
Only if asked
- Night waking with wheeze three or four nights a week before the attack; still one or two nights now.
- Blue inhaler: 8–10 puffs a day at worst; 'a couple' on good days. Three canisters in two months.
- Brown inhaler: 'I stopped it because it does nothing you can feel, and I heard steroids are bad for you.' Uses it 'when I'm bad for a few days'.
- Vapes 'quite a lot', nicotine; smoked a few cigarettes at festivals; cannabis occasionally at parties.
- Two previous ED visits as a teenager; one course of steroids last winter from a walk-in.
- Inhaler technique: has never been shown; no spacer.
- Triggers: pollen, dust in his student flat, cold air, running for the bus. Cat at his girlfriend's house.
- Lives with parents in summer, student flat in term time; exams in January; works shifts in a bar.
- Hay fever: takes cetirizine 'sometimes'.
- No peak flow meter at home. Cannot name what he would do if it got bad again — 'go to A&E again, I suppose'.
Ideas, concerns and expectations
- Idea: 'my asthma's mild, it's just the summer'.
- Concern: none volunteered; if asked what worried him about the attack — 'I couldn't breathe, I thought I was going to pass out' — then shrugs it off.
- Expectation: a blue inhaler and to go.
Cues to deliver, timed
- Minute 1: 'the pharmacy wouldn't give me one' — indignant.
- Minute 4: 'I heard steroids are bad for you' — only when the brown inhaler is raised.
- Minute 7: 'I thought I was going to pass out' — quiet, if asked about the attack.
How to respond to the doctor's plan
- If the doctor treats this as uncontrolled asthma after a life-threatening-range attack, explains the difference between reliever and preventer in his terms, offers the current first-line approach (an ICS-formoterol combination inhaler as reliever with or without maintenance — 'one inhaler that treats and prevents'), or if not available a daily preventer with the blue kept for emergencies, checks and teaches inhaler technique, gives a written action plan with peak flow, addresses vaping and the cat, arranges follow-up in 2–4 weeks and an annual review, and safety-nets with specific triggers to call 999: he is surprised — 'so I can bin the blue one?' — and engages.
- If the doctor issues salbutamol and says 'take your brown one': 'yeah, OK' — and leaves; the examiner will not.
- If the doctor lectures about steroids being safe without addressing his belief: 'that's what they all say'.
Examination findings if requested
- Talks in full sentences; RR 16; sats 97%; chest: scattered expiratory wheeze; PEF today 380 L/min (predicted 590 — about 65%); inhaler technique: fires before inhaling, no breath-hold.
Do not
- Volunteer the night waking, the puff count, or the previous ED visits unless asked.
- Argue about the steroid belief beyond one repetition; he yields to a good explanation.
Mark scheme
Delegates: open after your consultation. Examiner-observers: open during it.
Generic mark scheme — identical at every station
Domain grades
| Domain | CF (0) | F (1) | P (2) | CP (3) | Points |
|---|---|---|---|---|---|
| Data Gathering and Diagnosis | ☐ | ☐ | ☐ | ☐ | /3 |
| Clinical Management and Medical Complexity (×1.5) | ☐ | ☐ | ☐ | ☐ | /4.5 |
| Relating to Others | ☐ | ☐ | ☐ | ☐ | /3 |
| Total | /10.5 |
Global rating: ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass (CF Clear Fail · F Fail · P Pass · CP Clear Pass)
Feedback statement(s) — tick the one (at most two) you would attach
| Domain 1 | Domain 2 | Domain 3 |
|---|---|---|
| ☐ 1.1 Insufficient data | ☐ 2.1 Referral | ☐ 3.1 Cues / listening / formulaic |
| ☐ 1.2 Notes not used | ☐ 2.2 Prescribing | ☐ 3.2 Agenda / beliefs |
| ☐ 1.3 Psychosocial | ☐ 2.3 Investigations | ☐ 3.3 Circumstances / culture |
| ☐ 1.4 Unsystematic | ☐ 2.4 Prevention | ☐ 3.4 Explanations |
| ☐ 1.5 Prioritisation | ☐ 2.5 Risk management | ☐ 3.5 Judgemental |
| ☐ 1.6 Implications of findings | ☐ 2.6 Co-morbidity | ☐ 3.6 Respect / sensitivity |
| ☐ 1.7 Differentials | ☐ 2.7 Uncertainty | ☐ 3.7 Ownership |
| ☐ 1.8 Diagnosis / decision | ☐ 2.8 Follow-up / safety-net | ☐ 3.8 Teamwork |
| ☐ 2.9 Time management | ☐ 3.9 Safeguarding |
Timing checkpoints (Observer)
| Checkpoint (10-minute frame) | Done | Minute |
|---|---|---|
| Patient allowed to open without interruption (≈1 min) | ☐ | |
| ICE and psychosocial context elicited by 3:30 | ☐ | |
| Red flags covered; examination findings requested by 5:00 | ☐ | |
| Working diagnosis verbalised; gear change by 5:00–5:30 | ☐ | |
| Options shared; patient's preference used | ☐ | |
| Specific safety-net and follow-up by 9:30 | ☐ | |
| Understanding checked; finished inside 10:00 | ☐ |
Key points for this station — customised standard
Key points for this station
| Domain | Pass requires | Clear Pass adds | Fail if |
|---|---|---|---|
| Data Gathering & Diagnosis |
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| Clinical Management & Medical Complexity |
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| Relating to Others |
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Global rating guide: Pass = uncontrolled asthma recognised after a severe attack, SABA over-reliance addressed with an ICS-containing regimen, technique and action plan, follow-up.
Teaching points
- NICE/BTS/SIGN joint guideline NG245 (November 2024): for ages 12 and over, first-line is low-dose ICS-formoterol used as needed (AIR); step up to MART; SABA alone is no longer recommended as first-line. Anyone using three or more SABA canisters a year needs urgent review.
- The National Review of Asthma Deaths: most who died had markers of poor control — excess SABA, insufficient ICS, no action plan, recent attack — that were visible in the record.
- The belief 'steroids are bad' is the single obstacle; the answer is inhaled dose, local effect, and the harm of the alternative — not reassurance.
Guidelines for this station
Your reflection
Record your grades, the statement attached, what you will keep and change, and your own reflection. Your entry is emailed to you as a record of this station; this page stays live so you can revisit the full case during revision.
Write my reflection for Station 8
Revision link for this case: mdacumen.com/sca-station8-asthma
Editorial stamp · MRCGP SCA Consultation Skills Course · Station pages v1.0 · 11 September 2026 · Prof Rajesh Varma, Course Director · MD Acumen. Formative training material; not a prediction of exam performance. Not for onward distribution.