Asthma Management and Visual Impairment — Free SCA Practice Case
Asthma Management and Visual Impairment
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Eleanor Vance
Age
42 years
Consultation Type
TelephoneAge
42
Situation
Telephone Consultation.
Reason for Encounter
"Patient booked a telephone review. Diagnosed with asthma 3 weeks ago by an Out-of-Hours doctor. Prescribed a Salbutamol inhaler. Reception note states: 'Chest still tight, inhaler isn't working.'"
Medical Records
- ●PMH: Bilateral blindness (Retinitis Pigmentosa, registered severely sight impaired since age 25).
- ●Medications: Salbutamol 100mcg CFC-free inhaler (pMDI) 2 puffs PRN.
- ●Allergies: NKDA.
Recent Notes
- ●3 weeks ago (OOH Clinic): Seen with acute wheeze and breathlessness post-viral illness. Peak flow reduced. Diagnosed with suspected asthma. Salbutamol prescribed. Discharged back to GP for formal diagnostic follow-up.
Patient Script
For the friend playing the patient role
Character Overview: You are Eleanor, a 42-year-old music teacher who is completely blind. You are fiercely independent, living alone with your guide dog. Your recent "asthma" diagnosis has left you feeling uniquely vulnerable. You were handed a Salbutamol inhaler by a rushed OOH doctor three weeks ago. You cannot see the instructions, there is no braille on the box, and you cannot coordinate pressing the canister while simultaneously taking a slow, deep breath. You are just spraying it into your mouth, tasting the chemical, and getting no relief. Furthermore, you have no way of knowing if the canister is empty. Currently, you are waking up twice a week coughing, and your chest feels tight when you walk your dog. You are calling because you feel the medication is "useless." You will not volunteer that you are struggling to press and breathe at the same time, or that you don't know how to check if the inhaler is empty, unless the doctor specifically asks you to describe exactly how you use the inhaler.
ICE — Ideas, Concerns, Expectations
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Ideas: You think the inhaler itself might be faulty or empty — you have no way to check. You also wonder whether the OOH doctor got the diagnosis right in the first place, since you were unwell with a cold at the time and had never had breathing problems before. You don't really understand what asthma is or why it would suddenly appear at your age.
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Concerns: You are worried that your breathing is getting worse rather than better despite using the inhaler. You are anxious about being left to manage a condition you don't fully understand with a device you physically cannot use properly. Underneath that, you are concerned about losing the independence you have fought so hard to maintain — if your breathing deteriorates, walking your guide dog and getting to work become genuinely difficult.
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Expectations: You want someone to actually listen to what is going wrong, explain whether you really have asthma, and give you something that works — an inhaler you can actually use independently. You would appreciate practical, hands-on support rather than just being told to try again with the same device.
Consultation Flow & Responses:
- ●The Opening:
- ●If the doctor asks an open question: "Hi Doctor. Look, I'm calling about this asthma inhaler I was given a few weeks ago. It's completely useless. My chest is still tight, I'm coughing at night, and honestly, the medication just makes the back of my throat taste foul without helping my breathing at all."
- ●Data Gathering (The Layers):
- ●Layer 1: Symptom Control (RCP 3 Questions):
- ●If asked about nighttime waking/daytime symptoms: "Yes, I'm waking up coughing at least two or three times a week. My chest feels tight every morning, and I'm having to stop halfway when walking my guide dog because I'm out of breath."
- ●Layer 2: Auditing Inhaler Technique (The Physical Barrier):
- ●If asked HOW you use the inhaler: "I take the cap off, shake it, put it in my mouth, and press the top while I breathe in. But the spray hits the back of my throat, and I invariably end up coughing it back out."
- ●Layer 3: Exploring the Diagnostic Gap:
- ●If asked if you have ever had breathing tests/blown into a machine at the surgery: "No, the doctor at the walk-in center just listened to my chest, gave me the inhaler, and told me to call you."
- ●Layer 4: Exploring the Empty Canister Trap:
- ●If asked how many puffs you are taking a day: "Honestly? I've been pressing it six or seven times a day. But now it feels really light, and I have absolutely no way of knowing if there's any medicine left in it because I can't see the little counter on the back."
If Asked — Medical History and Medications
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If asked about your eyesight / blindness / Retinitis Pigmentosa: "I've been blind since my mid-twenties — it's a condition called Retinitis Pigmentosa. My sight went gradually over a few years and then it was gone completely. I've been registered severely sight impaired for about seventeen years now. I manage very well on my own, but things like reading labels, checking devices, and following written instructions — that's obviously impossible for me."
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If asked about your Salbutamol / current inhaler: "It's the one the out-of-hours doctor gave me. A little blue one — at least that's what I was told. I've been using it several times a day but honestly I don't think it's doing anything. Nobody actually showed me how to use it — they just handed it over and said to take two puffs when I need it."
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If asked about any other medications: "No, that's the only thing I take. I've never really needed medication before all this started."
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If asked about the OOH visit three weeks ago: "I'd had a bad cold for about a week, and then one night I started wheezing really badly and couldn't catch my breath. My neighbour drove me to the out-of-hours clinic. The doctor listened to my chest, said it sounded like asthma, gave me the inhaler, and told me to follow up with my own GP. The whole thing was very quick — I don't think I was in there for more than ten minutes."
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If asked about allergies: "No, no allergies that I know of. Nothing to medications, nothing to food."
Social History and Lifestyle Impact
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Occupation and daily life: You are a piano and vocal coach — you teach privately from your home and also work two days a week at a local secondary school. You live alone with your guide dog, Finn. You are extremely self-sufficient: you cook, clean, do your own shopping with Finn, and navigate public transport independently. Your independence is central to your identity.
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Lifestyle impact of the condition: The breathing problems are starting to interfere with your teaching. You are finding it hard to demonstrate vocal techniques to your students because you run out of breath mid-phrase and have to stop. At school, you are struggling to project your voice across the classroom. Walking Finn has become something you dread rather than enjoy — you used to walk him for forty minutes twice a day but now you are cutting it short because you get so breathless. You have also noticed that climbing the stairs in your house leaves you winded, which never used to happen. The lack of sleep from the nighttime coughing is making you exhausted during the day, and you are worried your students are noticing.
If Asked — Associated Symptoms
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If asked about wheeze: "Yes, I can hear myself wheezing sometimes, especially when I'm walking Finn or going up the stairs. It's a sort of whistling sound when I breathe out."
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If asked about sputum / phlegm: "No, not really. Maybe a tiny bit of clear stuff when I cough in the morning, but nothing coloured or thick."
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If asked about blood in the sputum / coughing up blood: "No, nothing like that at all."
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If asked about fever or feeling unwell: "No, I feel fine in myself now. The cold cleared up a couple of weeks ago. It's just the breathing that's still a problem."
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If asked about weight loss: "No, my weight's been steady. If anything, I've probably put on a bit because I'm not walking as much."
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If asked about chest pain: "No pain, no. Just tightness — like someone's pressing on my chest."
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If asked about palpitations / heart racing: "No, nothing like that."
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If asked about ankle swelling: "No, my ankles are fine."
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If asked about heartburn / acid reflux: "No, I don't get any heartburn or anything coming back up."
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If asked about nasal symptoms / runny nose / post-nasal drip: "Now you mention it, my nose does feel a bit blocked quite a lot of the time, and I sometimes get a tickle at the back of my throat. But I just put that down to the tail end of the cold."
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If asked about eczema or skin problems: "No, I've never had eczema or anything like that."
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If asked about hay fever: "No, I've never had hay fever."
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If asked about family history of asthma, eczema, or allergies: "My mum had hay fever, but nobody in the family has asthma as far as I know."
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If asked about pets / animal exposure: "Just Finn, my guide dog. He's a Labrador. I've had guide dogs for years and never had any problems. Finn's been with me for three years."
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If asked about smoking: "No, I've never smoked."
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If asked about occupational exposures / triggers: "I can't think of anything specific. The house is the same as it's always been. I don't use any strong cleaning products — I'm quite careful about that because of the fumes."
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If asked about exercise tolerance beyond walking: "I don't do anything strenuous — walking Finn is my main exercise. But even that's become hard now."
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If asked about whether symptoms are worse at any particular time: "Mornings are the worst. The tightness is always there when I wake up, and the coughing is worse at night. Cold air seems to set it off too — walking Finn first thing on a cold morning is awful."
Negotiation & Collaborative Management Plan:
- ●If the Doctor just prescribes more Salbutamol or tells you to "try harder":
- ●Reaction: "But I just told you I can't coordinate the spray! Giving me more of the same isn't going to fix my breathing." (Candidate critically fails for ignoring the accessibility barrier and under-treating asthma).
- ●If the Doctor changes the inhaler but doesn't arrange diagnostic testing:
- ●Reaction: "Okay, so this new inhaler will fix it. Does this mean I definitely have asthma for the rest of my life?" (Candidate fails the diagnostic pathway by accepting an unconfirmed OOH diagnosis).
- ●If the Doctor explains the need for Spirometry and FeNO testing:
- ●Reaction: "More tests? I thought the other doctor already diagnosed me. What are these machines going to tell you that my coughing doesn't?"
- ●If the Doctor refers you to the Asthma Clinic / Respiratory Nurse:
- ●Reaction: "So the nurse will actually sit with me, let me feel the different devices, and run these breathing tests properly? That sounds incredibly helpful. I feel like I've just been left to figure it out on my own until now."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Confirming the Diagnosis: Objective Testing is Mandatory
A clinical impression formed during an acute presentation — especially during a viral illness — does not constitute a confirmed asthma diagnosis. Under current NICE CKS and BTS-SIGN 2023 guidelines, asthma in adults must be supported by objective physiological evidence before a lifelong diagnosis is coded.
- ●FeNO (Fractional exhaled Nitric Oxide): Measures eosinophilic airway inflammation. A level ≥ 40 ppb in an adult is a positive result supporting an asthma diagnosis; 25–39 ppb is intermediate and should prompt further assessment rather than dismissal.
- ●Spirometry with bronchodilator reversibility (BDR): Demonstrates obstructive physiology. A positive BDR requires an improvement in FEV1 of ≥ 12% and ≥ 200 ml following inhaled Salbutamol.
- ●Both tests should be arranged before committing a patient to long-term treatment. Initiating interim therapy while awaiting results is appropriate — but the diagnostic question must remain open and explicitly communicated to the patient.
- ●If both tests are negative or equivocal, alternative diagnoses — including vocal cord dysfunction, cardiac cause, chronic rhinosinusitis with post-nasal drip, or inducible laryngeal obstruction — must be reconsidered before confirming a lifelong asthma label.
Assessing Asthma Control: The RCP 3 Questions
The Royal College of Physicians (RCP) 3 Questions are the validated primary care tool for quantifying asthma symptom burden. Ask at every asthma review:
- ●Have you had difficulty sleeping because of your asthma symptoms (including cough)?
- ●Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness, breathlessness)?
- ●Has your asthma interfered with your usual activities (housework, work, school, sport)?
- ●A positive answer to any one question indicates suboptimally controlled asthma. Two or three positive answers indicate poor control requiring prompt escalation.
- ●In this case, Eleanor has nighttime waking 2–3 nights per week, daily chest tightness, and significant activity limitation — this is poorly controlled asthma requiring step-up of therapy.
- ●The diurnal pattern she describes — worst on waking, triggered by cold morning air — is characteristic of asthma physiology and adds weight to the provisional diagnosis while objective testing is awaited.
The SABA-Only Danger
- ●Treating symptomatic asthma with a Short-Acting Beta-Agonist (SABA) alone is clinically unsafe and contrary to both NICE CKS and BTS-SIGN 2023 guidelines.
- ●Asthma is a chronic inflammatory disease. Reliever-only treatment masks worsening inflammation, promotes beta-receptor downregulation, and significantly increases the risk of a severe or fatal attack.
- ●BTS/NICE/SIGN 2024 recommend initiating a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief (as-needed AIR therapy) to all children and adults above the age of 12.
- ●The ICS should be started at the time of the consultation as an interim measure, with a clear explanation that it treats the underlying airway inflammation rather than providing immediate relief.
- ●Do not conflate ICS preventers with MART (Maintenance and Reliever Therapy) regimens at this stage. MART uses a single fixed-dose combination ICS/LABA inhaler as both preventer and reliever and is a Step 3 strategy — it is not appropriate for a patient in whom the diagnosis is unconfirmed and baseline control is not yet established.
Inhaler Device Selection for Visually Impaired Patients
Standard pressurised metered-dose inhalers (pMDIs) require simultaneous canister depression and slow, deep inhalation — a coordination task that is inherently visual and extremely difficult without sighted instruction or physical demonstration.
- ●Dry Powder Inhalers (DPIs) — such as the Turbohaler, Nexthaler, or Ellipta — are often the device of choice for visually impaired patients. They require no hand-breath coordination: the patient primes the device and takes a fast, deep breath. Many DPIs provide tactile and auditory feedback (a distinct click on priming, a change in resistance when empty), enabling non-visual dose monitoring.
- ●Breath-Actuated Inhalers (BAIs) — such as the Autohaler or Easi-Breathe — are triggered automatically by inspiratory flow, removing the need for manual coordination. Check whether the dose counter on the specific BAI model is accessible by touch before prescribing.
- ●Large-volume spacers can eliminate the coordination barrier if a pMDI must be used for clinical reasons, though they introduce different practical challenges for a patient managing independently at home.
- ●Device choice must be a collaborative decision. Refer the patient to the asthma nurse or respiratory pharmacist for hands-on, tactile device training with multiple options before a final selection is made. Do not prescribe a replacement device over the phone without arranging this training.
Non-Visual Dose Monitoring: A Patient Safety Issue
An empty inhaler used during an acute attack delivers only propellant — no medication. For a patient who cannot read a dose counter, this is a significant and underappreciated safety risk.
- ●When prescribing any inhaler device to a visually impaired patient, explicitly confirm whether the dose indicator is accessible without sight.
- ●DPIs with tactile end-of-dose indicators (e.g., the Turbohaler empty indicator, the Ellipta counter with a raised tactile marker) are preferred.
- ●Advise the patient on pragmatic non-visual monitoring strategies: counting doses from a new inhaler, tracking usage by day, or asking a pharmacist to check remaining doses at each dispensing.
Personalised Asthma Action Plan (PAAP): Accessible Format
A written Personalised Asthma Action Plan significantly reduces hospital admissions and asthma deaths. NICE CKS and Asthma + Lung UK recommend that every asthma patient receives one.
- ●A standard paper PAAP is inaccessible to a severely sight-impaired patient. The plan must be provided in a format the patient can use independently.
- ●Options include: a verbal walkthrough with opportunity to ask questions, a digital version compatible with screen-reader software (Asthma + Lung UK provides accessible digital versions), an audio recording, or referral to a service that provides braille health materials.
- ●The PAAP for a patient with poorly controlled asthma should specify: what to do if symptoms worsen acutely, when to use the reliever, when to start a course of oral prednisolone (if prescribed), and when to call 999.
- ●Do not end a telephone consultation with a visually impaired patient by directing them to a website or written leaflet. Verbal confirmation of understanding is the minimum standard.
Comorbid Upper Airway Disease
The upper and lower airways are anatomically and physiologically linked. Allergic rhinitis and chronic rhinosinusitis are common comorbidities in asthma and can drive poor symptom control if untreated — a relationship explicitly recognised in the BSACI and NICE CKS rhinitis guidelines.
- ●Eleanor discloses persistent nasal blockage and a throat tickle when directly asked — features consistent with comorbid rhinitis contributing to her symptom burden.
- ●Per NICE CKS and BSACI guidance, untreated rhinitis impairs lower airway disease control. A trial of a topical intranasal corticosteroid (e.g., mometasone 50 mcg or fluticasone propionate 50 mcg nasal spray, 2 sprays each nostril once daily) is appropriate first-line management for persistent rhinitis.
- ●Post-nasal drip from rhinitis is also a recognised cause of chronic cough and throat irritation — symptoms Eleanor has attributed to her asthma and to the residual viral illness. Treating rhinitis may improve both her upper and lower airway symptoms.
- ●This can be initiated at the same consultation or deferred to the asthma clinic, but the symptom should be acknowledged and a management plan agreed rather than dismissed as a viral tail.
Red Flags in a New Adult Respiratory Presentation
Before attributing all symptoms to asthma in an adult with a new, unconfirmed respiratory diagnosis, exclude features that would suggest an alternative serious diagnosis:
- ●Haemoptysis — warrants urgent investigation to exclude malignancy or pulmonary embolism
- ●Significant unintentional weight loss — raises concern for malignancy
- ●Symptoms present for more than 3 weeks without clear viral trigger in a smoker or ex-smoker — consider lung malignancy and refer via the 2WW pathway
- ●Stridor or inspiratory wheeze — raises the possibility of upper airway obstruction or inducible laryngeal obstruction rather than asthma
- ●In a 42-year-old non-smoker with a clear post-viral onset and a classical diurnal pattern, these features are absent and the presentation is reassuring — but exclusion should be documented.
Safety Netting: Acute Asthma Deterioration
Safety netting must be specific and actionable. For a patient with poorly controlled asthma who cannot verify their inhaler dose, clear escalation guidance is particularly important.
- ●Call 999 or go to ED immediately if:
- ●Breathlessness is severe and coming on rapidly
- ●Unable to complete a sentence in one breath
- ●Lips or fingertips turn blue (cyanosis)
- ●The reliever inhaler provides no relief within 15 minutes, or relief lasts less than 4 hours
- ●Symptoms are worsening rapidly despite using the inhaler
- ●Seek same-day GP or urgent care review if:
- ●Nighttime waking increases in frequency
- ●The reliever is being used more than 3 times a week
- ●Breathlessness prevents normal daily activity
- ●Safety netting delivered verbally must be clear, jargon-free, and confirmed understood before the consultation ends. Direct the patient to a specific point of contact — do not leave escalation routes vague.
Common Candidate Mistakes in This Case
- ●Accepting the OOH diagnosis without question. The OOH assessment during an acute viral exacerbation was a working diagnosis only. Failing to arrange FeNO and spirometry means the patient may be committed to a lifelong label and long-term steroids without objective justification.
- ●Prescribing a replacement inhaler without checking dose accessibility. Swapping the pMDI for another device solves the coordination problem but replicates the dose-monitoring safety hazard unless the replacement device has a non-visual dose indicator.
- ●Continuing SABA monotherapy. Eleanor has multiple markers of poor asthma control. Failing to initiate an ICS preventer at this consultation is a clinically significant error — not a borderline one.
- ●Failing to identify the empty canister as a patient safety issue. Eleanor has been pressing the inhaler six or seven times daily and reports it now feels very light, with no way to check the dose counter. A candidate who does not directly ask how many doses have been used, or who prescribes a replacement without addressing how Eleanor will independently monitor remaining doses on any new device, leaves a recurring safety hazard unresolved.
- ●Failing to explore the nasal symptoms as a potential driver of the presentation. Eleanor volunteers a persistently blocked nose and post-nasal drip when specifically asked. Allergic rhinitis and upper airway disease are recognised contributors to cough and breathlessness, and in a patient whose diagnosis is unconfirmed, failing to consider upper airway disease as a differential or contributing factor represents an incomplete clinical assessment.
The MDT Role: Asthma Clinic and Respiratory Nurse
Referring Eleanor to the Practice Asthma Nurse or a specialist Respiratory Clinic serves several functions that cannot be delivered in a single telephone consultation:
- ●Performing FeNO and spirometry with bronchodilator reversibility testing in a controlled setting
- ●Tactile, hands-on device training with multiple inhaler types, allowing Eleanor to select the device she can manage most independently
- ●Constructing and delivering an accessible PAAP
- ●Assessing and addressing comorbid conditions including rhinitis
- ●Providing structured follow-up to monitor response to interim therapy and refine the long-term management plan
The referral should explicitly flag Eleanor's visual impairment so that the clinic can prepare accessible resources and allocate adequate appointment time for hands-on device education.
Mapped to the RCGP curriculum topic: Respiratory Health.
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