Woman Ordering Her Third Reliever Inhaler in 2 Months — Free SCA Practice Case

Character Overview: You are Sadie, a 27-year-old primary-school teaching assistant. You have had asthma since childhood and think of yourself as "fine, as long as I've got my blue inhaler". You have been using the blue inhaler several times a day for the last couple of months and have gone through three in that time — you assumed that was normal and were surprised to be asked for a phone call about it. You wake coughing at night three or four times a week, your chest feels tight when you climb the stairs at school, and you get a wheeze. You stopped using your brown preventer inhaler months ago — you did not think it did anything, because it does not give you instant relief. Your new partner smokes indoors at home. You have just started a couch-to-5K running group with friends, which matters to you, and you are frustrated that you are struggling with it. You are pleasant and cooperative but genuinely surprised that any of this is a problem.

Opening Sentence: "Hi Doctor. I only rang for my blue inhaler really — I've run out again. I got a message saying someone needed to speak to me first. Is there a problem? I'm fine as long as I've got the blue one."

History if Asked (Data Gathering Phase)

• ●Reliever use: "I use the blue one several times a day at the moment — more if I've been rushing about at school. Three inhalers in a couple of months, yes. I thought that was just how it is."
• ●Night symptoms: "I wake up coughing three or four nights a week. I'm knackered, if I'm honest."
• ●Exertional symptoms: "My chest goes tight on the stairs at school, and when I'm running."
• ●Preventer inhaler: "The brown one? I stopped it months ago. It didn't seem to do anything — you don't feel it working, do you? The blue one actually helps."
• ●Home environment: "My partner smokes in the flat. I've not really thought about it as a problem."
• ●What matters to her: "I've started a couch-to-5K with friends and I'm struggling to keep up. That's annoying me more than anything."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

• ●Ideas: Sadie believes her asthma is fine because the blue inhaler works, and that the preventer is pointless because she cannot feel it working. "I thought I was fine — the blue one does the job. The brown one never seemed to do anything."
• ●Concerns: She has few concerns about her asthma; what she is bothered about is not keeping up with her running group, and (once raised) being tired from the night waking. "Honestly, my worry is that I can't keep up on the runs."
• ●Expectations: She expects a prescription for her blue inhaler. "I just want my inhaler sorted."

If Asked — Asthma Control, Trigger, and Risk Screen

The patient answers these only when directly asked.

• ●If asked to quantify reliever use (times per day/week): "Several times a day most days. I keep one in my bag and one at school."
• ●If asked about night waking: "Three or four nights a week, coughing."
• ●If asked about exercise limitation: "Yes — the stairs, and I can't keep up on the runs."
• ●If asked about preventer adherence: "I stopped it months ago. I don't take it at all now."
• ●If asked about inhaler technique / whether it has ever been checked: "Nobody's checked how I use it since I was a child, I don't think."
• ●If asked about triggers (smoke, pets, cold air, exercise, pollen, dust): "My partner smokes indoors. Cold air sets me off. Exercise too."
• ●If asked about occupation as a trigger: "I work in a primary school — nothing chemical, just lots of rushing about."
• ●If asked about previous exacerbations, oral steroids, A&E attendance, or hospital/ITU admission: "I had steroid tablets from the out-of-hours service last winter. Never been admitted or in intensive care." (Prior oral steroid course — a risk marker.)
• ●If asked about NSAIDs/aspirin or beta-blockers: "I take ibuprofen for period pain sometimes — it doesn't seem to affect my chest."
• ●If asked about atopy and family history: "I've got eczema, and my mum has asthma."
• ●If asked about smoking herself, alcohol, or vaping: "I don't smoke or vape myself."
• ●If asked about peak flow: "I haven't got a peak flow meter and I don't know my usual reading."
• ●If asked about an asthma action plan or annual review: "I've never had a written plan, and I haven't been for a review in ages."
• ●If asked about current acute severity (talking in sentences, symptoms right now): "I'm fine talking to you now, no attack at the moment."

Responses to Management (The Negotiation Phase)

• ●If the Doctor explains that heavy reliever use is a warning sign — key: "Really? I thought needing the blue one meant it was working. You're saying it's actually a sign my asthma isn't controlled?" (The tested point is reframing SABA over-reliance as a marker of poor control and increased risk, not of successful treatment.)
• ●If the Doctor explains why the preventer matters: "So the brown one treats the inflammation even though I can't feel it working? Nobody's ever explained it like that." (The tested point is the preventer-adherence conversation — explaining the mechanism so it makes sense to her.)
• ●If the Doctor proposes a combination inhaler (AIR/MART): "One inhaler that does both — treats it and relieves it? That sounds much more manageable than two." (The tested point is offering ICS/formoterol-based anti-inflammatory reliever/MART therapy in line with current guidance.)
• ●If the Doctor raises the smoking at home: "I hadn't connected the smoke in the flat with my chest. I could ask him to smoke outside." (The tested point is trigger modification, including second-hand smoke.)
• ●If the Doctor offers a review, action plan, and technique check: "So a proper review, a written plan, and someone checking how I use it? Fine, yes."
• ●If the Doctor links it to her running: "If getting this right means I can keep up on the runs, I'm definitely in." (The tested point is motivating adherence through what matters to her.)