Cases/Respiratory Health

Woman Who Stopped Her Preventer Inhaler Because It Gives Her A Sore Throat — Free SCA Practice Case

Woman who stopped her preventer inhaler because it gives her a sore throat

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12:00

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

12:00

Golden Minute

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A live 12-minute consultation with an AI patient, marked. You see your verdict before we ask for anything.

Materials for Candidate

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Patient Profile

Full Name

Abena Mensah

Age

33 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"Salbutamol repeat request. Seventh in five months. No beclometasone for six months."

Medical Records

●PMH: Asthma, diagnosed age 17 on spirometry. Seasonal rhinitis.
●Medications: Salbutamol 100 micrograms inhaler, 2 puffs when required. Beclometasone (standard particle) 100 micrograms inhaler, 2 puffs twice daily, last issued 6 months ago. No spacer.
●Allergies: NKDA.
●Social: Non smoker.

Recent Notes

●Out of hours, 3 months ago: Wheeze after a cold. Prednisolone 40 mg for 5 days. No review since.
●Asthma review, 14 months ago: Good control. No technique check or action plan documented.

Patient Script

For the friend playing the patient role

Character Overview: You are Abena Mensah, a 33 year old HR adviser at a housing association, taking this call in your car in the work car park on your lunch break, a little rushed. You are warm, chatty and a bit sheepish, because you have ordered a lot of blue inhalers and half expect to be told off.

You have had asthma since you were 17. You had a brown steroid inhaler and a blue reliever, and were always on and off with the brown one. After a bad cold seven months ago you took the brown one properly for a couple of months, then your voice went croaky, your throat was sore and you got white patches in your mouth. You stopped it about five months ago without telling anyone, and have used only the blue inhaler since, more and more. Singing in your community choir is what you love most, and you have your first solo at the choir's concert in the cathedral in about six weeks. You do not volunteer why you stopped the brown inhaler, how often you really use the blue one, or how frightened you were by the attack three months ago, until the doctor asks.

Opening Sentence: "Hi, thanks for calling. The receptionist said I had to speak to a doctor before they'd do my blue inhaler again. I'm nearly out, so I really need it sorting today."

History if Asked (Data Gathering Phase)

●How often she uses the blue inhaler: "Honestly? Most days four or five times, two puffs each time. More on choir nights, a couple of puffs before we start and again halfway through." If asked for a number: "Probably eight to ten puffs on a normal day, more on a Tuesday or Thursday."
●Nights and activity: "I wake up coughing and wheezy two or three nights a week, in the early hours, and sit up with a couple of puffs. I stopped my Saturday dance class about three months ago, and I get tight walking up the hill from the car park on cold mornings."
●The brown inhaler and what happened: "After a horrible cold I took the brown one properly, morning and night. After a couple of months my voice went croaky, my throat was sore, and I got white patches on my tongue and inside my cheeks. My voice kept cracking on the high notes at choir, so I just stopped it, about five months ago. The patches went in a week or two and my voice came back after about three weeks."
●Whether she told anyone: "No. I just stopped ordering it. I didn't think it mattered much, because the blue one is the one that actually helps."
●The attack three months ago: "My chest got really tight with a cold and I couldn't get a full sentence out. I rang 111 and was seen at out of hours that evening. They gave me steroid tablets for five days. I felt better after a couple of days, so I never booked the follow up."
●Hospital and right now: "I've never been admitted or in intensive care. That night was the worst it's been." Right now: "I'm fine. I had a couple of puffs just before you called. I can talk fine, I'm not out of breath sitting here."
●Triggers: "Colds, definitely. Cold air. And singing long phrases, especially because the church hall where we rehearse is freezing. My hay fever makes it a bit worse in the summer."

Ideas, Concerns, Expectations

Gating note: Abena does not volunteer any of the following. Each part comes out only when the doctor directly explores her perspective.

●Ideas: She thinks the brown inhaler does not agree with her and somehow burnt her throat, and that the blue one is the real treatment because it works straight away. She puts the wheeze down to the weather and the singing. "I think the brown one just doesn't agree with me. It never felt like it did anything anyway."
●Concerns: Her voice. "I've got a solo in about six weeks and I can't have it cracking again." Underneath, the attack three months ago frightened her far more than she has admitted, and her voice goes quieter and slower when she talks about it. If the doctor asks how it felt: "That night really scared me. I couldn't get my words out. I haven't even told Daniel how frightened I was."
●Expectations: She wants the blue inhaler issued today and does not want to go back on the brown one. "If there's something that won't wreck my voice, I'm all ears. But I'm not going back on the brown one."

If Asked: Medical History and Medications

Gating note: Abena answers direct questions plainly. She knows she has asthma and describes her inhalers by colour, in everyday words.

●Asthma: "Since about 17. They did the blowing test. It was well behaved for years. My older brother had it as a child."
●How she took the brown inhaler: "Shake it, press and breathe in quickly, then the second puff straight after, in the bathroom before work. I've never had one of those plastic tube things, and I never rinsed my mouth. Nobody told me to."
●The blue inhaler: "It lives in my bag. I take a big quick gasp. It works within a couple of minutes, which is why I trust it." She put nothing on the white patches.
●Other medicines and allergies: Steroid tablets once, three months ago. Cetirizine from the supermarket for summer hay fever. Nothing else. No drug allergies.
●Contraception and pregnancy: "We use condoms. We're not trying for a baby at the moment."
●Last asthma check: "I saw the nurse over a year ago. She just asked a few questions. Nobody gave me a written plan."

Social History and Lifestyle Impact

●Home, work and choir: Office three days a week, home two. Lives with her partner Daniel in a second floor flat, no pets, no damp, no dust or fumes at work. Sings soprano in a choir that rehearses Tuesday and Thursday evenings in a cold church hall.
●Lifestyle impact: "I've had to step outside in rehearsal to use my inhaler, which is embarrassing. I'm shattered at work because I'm up in the night coughing."
●Smoking, vaping and alcohol: "Never smoked, never vaped, and Daniel doesn't smoke either. A couple of glasses of wine at the weekend."

If Asked: Associated Symptoms

Gating note: Answers are brief and natural. She has a dry cough and tight, wheezy chest, mainly at night and after singing, and is breathless only on hills or singing. "Tightness, not pain." After a few puffs she sometimes feels shaky with a fast heart. Her voice and mouth are completely fine now. Negative: fever, coloured phlegm, coughing blood, chest pain, difficulty swallowing, neck lump, heartburn, weight loss, night sweats. Nose stuffy some mornings. Stressed about the concert and tired but not low. One day off work after the attack.

Responses to Management (The Negotiation Phase)

●
If the doctor simply reissues the blue inhaler, or explains that her asthma is not controlled and that relying on the blue inhaler alone is risky:
- ●Reaction: If simply reissued, pleased: "Brilliant, thank you." If told her asthma is uncontrolled, defensive: "But the blue one is the one that actually works." If told it does not treat the inflammation: "So it's just been papering over the cracks? That would explain why I'm needing it more." If told of the risk of a serious attack, quieter: "Is this actually dangerous? How worried should I be?" She settles with an honest answer and a clear plan.
●
If the doctor suggests going back on the same brown inhaler, or says she needs an inhaled steroid:
- ●Reaction: Resistant. "It wrecked my voice last time and I've got a solo in about six weeks." Hopeful of a way out: "Isn't there a tablet that isn't a steroid? Would that stop the night time coughing, though?"
●
If the doctor proposes a single combination inhaler that she uses daily and also when she has symptoms, or only when she has symptoms, in place of the blue one:
- ●Reaction: Cautious. "So it's still got steroid in it? Won't my throat go the same way?" She will try it if told why her throat was affected last time and how to stop it happening again. If told she no longer needs the blue inhaler: "But the blue one's my safety blanket. What if I get tight halfway through a rehearsal? Does the new one work as quickly?"
●
If the doctor advises rinsing, gargling or brushing her teeth, suggests a spacer, or asks her to demonstrate her technique on the video:
- ●Reaction: Rinsing: "Nobody ever told me that. I can do that, it's easy." Spacer: "Is that the big plastic tube? I'm not carrying that to choir." She accepts it for home doses, or a device needing none. She declines to demonstrate: "I'm sat in the car park with people walking past. Could someone show me face to face?" If a nurse or pharmacist check is arranged: "Yes, please. Can it be early or after work, though?"
●
If the doctor gives vague safety netting, or explains limits and warning signs:
- ●Reaction: Vague advice such as "come back if it gets worse": "Worse how? I'm already using it all the time." With clear limits: "Can I have that written down? I won't remember all of that." If told what to do if her voice goes croaky: "So this time I don't just stop it, I let you know?"
●
If the doctor suggests steroid tablets today, a hospital referral, or agrees a plan, or offers the flu vaccine:
- ●Reaction: Steroid tablets today: "I'm not in a bad way right now. Do I really need them?" Immediate referral: "Is it that bad? Can't we try sorting it out here first?" Once a plan is agreed: "Will I be alright for the concert? And will I have to be on it forever?" Flu vaccine: "I didn't know I could have that free. Yes, fine."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Abena has asthma confirmed by spirometry at 17. She stopped her inhaled corticosteroid (ICS) because of hoarseness and oral thrush and has since relied on salbutamol alone, ordering one inhaler about every three weeks. The request is a repeat prescription. The real task is to recognise uncontrolled, higher risk asthma, find out why she stopped her preventer, and move her onto current treatment in a way she will accept.
●Model plan: quantify control, explain the risk of reliever only treatment, reframe the side effects as preventable, change to one inhaled steroid and formoterol inhaler as her only reliever, protect mouth and voice, check technique in person, write an action plan, review in 8 to 12 weeks and give specific safety netting.
●Also acceptable: maintenance and reliever therapy (MART) or as needed anti inflammatory reliever (AIR) therapy, with AIR reviewed early. Not acceptable: salbutamol alone, or the same beclometasone and salbutamol as before.

Recognising Uncontrolled Asthma and the Reliever Risk

●The 2024 joint guideline from the British Thoracic Society, NICE and SIGN (NICE NG245) defines uncontrolled asthma as any attack needing oral steroids, a reliever on 3 or more days a week, or night waking on 1 or more nights a week. Abena meets all three. At each review check time off work, reliever use against the prescription record, oral steroid courses and emergency attendances, and use a validated questionnaire such as the Asthma Control Test.
●Salbutamol relaxes airway muscle for a few hours but does not touch inflammation, so symptom relief feels like treatment. NG245 lists more than two reliever inhalers a year, non adherence and oral steroid courses as risk factors, and says never to prescribe a short acting reliever without an inhaled steroid.
●The National Review of Asthma Deaths (2014) found 39% of those who died had been prescribed more than 12 relievers in the previous year, and over 40% had no general practice asthma review in their last year.
●Abena is on course for about 17 relievers a year, had an attack needing steroids with no follow up, and has had no review for 14 months. Explain this honestly and pair it straight away with a plan.

Why Inhaled Steroids Cause Hoarseness and Thrush

●Oral candidiasis and voice change are listed as common side effects of inhaled steroids in the British National Formulary (BNF). They are local effects of drug deposited in the mouth and throat. A fast breath through a metered dose inhaler without a spacer, two puffs fired back to back and no rinsing all increase deposition.
●Dysphonia is mainly a dose related, reversible effect on the muscles closing the vocal folds. It can take weeks to settle, as hers did.
●None of this is an allergy. The side effects are a reason to change how she takes an ICS, not a reason to go without one.
●Prevention (NICE Clinical Knowledge Summaries, CKS): good technique, rinse, gargle or brush the teeth after each ICS dose, a spacer with a metered dose inhaler, and the lowest effective dose. On MART, rinse after the maintenance doses as a minimum, and after reliever doses too if thrush occurs, but never delay a reliever dose for it.
●If thrush recurs, treat it without stopping the inhaler. CKS gives miconazole oral gel first line, or nystatin if miconazole is unsuitable. Avoid miconazole with warfarin or a statin.

The Current Pathway: AIR and MART

●For people aged 12 and over NG245 uses an inhaled steroid and formoterol combination inhaler. Used only as needed it is AIR. Used daily plus as needed it is MART. People using either do not need a separate salbutamol.
●NG245 moves people with confirmed asthma on a reliever alone to as needed AIR, and considers low dose MART for people not controlled on low dose ICS plus a reliever. For people who are highly symptomatic, for example with regular night waking, or after a severe attack, it recommends starting with low dose MART. CKS advises moving from AIR to low dose MART if the reliever is still needed 3 or more times a week.
●Abena fits both routes: she was uncontrolled on low dose ICS plus salbutamol, and has used salbutamol alone for five months. Her night waking and recent steroid course make low dose MART the better fit, but AIR is guideline supported if reviewed early and stepped up when needed.
●Formoterol works within minutes, so it relieves symptoms as quickly as salbutamol while delivering ICS each time.
●The Medicines and Healthcare products Regulatory Agency advises prescribing beclometasone inhalers by brand, because extra fine particle products are about twice as potent as standard particle ones. Hers is standard particle, so 400 micrograms a day was low dose.
●Licensing varies. In the November 2025 dose guide only budesonide with formoterol inhalers were licensed for AIR, and for MART from age 12; beclometasone with formoterol 100/6 inhalers are licensed for MART from age 18.

Prescribing in Practice

●Low dose MART example: budesonide with formoterol 200/6 dry powder inhaler, one inhalation twice daily plus one as needed, up to 6 on any one occasion, normally no more than 8 a day in total (BNF). An alternative is beclometasone with formoterol 100/6 inhaler with a spacer, one puff twice daily plus one as needed, maximum 8 puffs a day. For AIR, one inhalation as needed with the same limits.
●Remove salbutamol from repeat so she carries one inhaler. Use a dose before rehearsal if singing sets her off.
●Device choice rests on technique, preference, environmental impact and a dose counter. A dry powder inhaler needs no spacer and has a lower carbon footprint, but leaves more drug in the mouth than a metered dose inhaler with a spacer, so rinsing still matters. Agree the choice with her.
●NG245 asks you to observe technique at every review and whenever the device changes. That cannot be done over video from a car park, so arrange a check with the practice nurse or community pharmacist; the NHS New Medicine Service can support the first weeks.

The Voice: Singing and When to Worry

●Building the plan around her voice makes her willing to take an ICS again.
●If croakiness returns despite rinsing and good technique, review rather than stop: check technique, confirm the lowest effective dose, consider another device and treat thrush.
●NICE NG12 advises a suspected cancer pathway referral for persistent unexplained hoarseness in people aged 45 and over. It does not apply at 33 with a clear, resolved cause. Below 45 practice varies, but laryngoscopy is reasonable if hoarseness persists for about 3 to 4 weeks despite these measures, sooner with difficulty swallowing, a neck lump, coughing blood or noisy breathing, and with a lower threshold for a committed singer.

Action Plan, Safety Netting and Follow Up

●NG245 recommends a written personalised action plan matching her regimen, with any daily doses, extra doses, the daily limit and attack steps. Asthma + Lung UK publishes MART and AIR templates.
●In an attack on MART or AIR, sit upright and take one inhalation every 1 to 3 minutes up to 6, then call 999 if no better, or sooner if worse. Call 999 for severe breathlessness, inability to finish sentences, blue lips or drowsiness. Seek same day advice if she needs more than 8 inhalations in 24 hours or night symptoms increase. See her within 48 hours of any attack, which did not happen three months ago.
●Review 8 to 12 weeks after a change, and at least annually and after any exacerbation. Consider fractional exhaled nitric oxide (FeNO) before and after the change if available.
●If AIR still leaves her needing it 3 or more times a week or waking, move to low dose MART. If uncontrolled on low dose MART with good technique and adherence, move to moderate dose MART, then check FeNO and eosinophils and consider specialist referral or a leukotriene receptor antagonist or long acting muscarinic antagonist. Once controlled for 8 to 12 weeks, step down, which answers her question about being on it forever.
●Asthma needing repeated steroids puts her in a clinical risk group for the annual flu vaccine (Green Book chapter 19).

Common Mistakes in This Station

●Reissuing salbutamol on its own because she feels well and is in a hurry.
●Labelling her non adherent without asking why she stopped.
●Restarting the same beclometasone with the same technique, or accepting that she cannot have an ICS at all.
●Prescribing MART or AIR but leaving salbutamol on repeat.
●Choosing AIR with no early review despite night waking.
●Offering a leukotriene receptor antagonist or long acting bronchodilator in place of an inhaled steroid.
●Starting steroid tablets today for a stable patient, or referring before the basics are tried.
●Judging technique over video instead of arranging an in person check.
●Telling her she could die without context, or never mentioning risk.
●Generic safety netting with no limits, no 999 criteria and no plan if hoarseness returns.

Mapped to the RCGP curriculum topic: Respiratory Health.

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