ℹ️ This is the case information for the doctor.
Name
Emily Foster
Age
10 years old
Address
12 Willow Lane, Swindon, SN3 2JR
Social history
• Living arrangements: Lives with mum, dad, and older brother (age 14).
• School: Year 6 at local primary.
Past history
• History of “viral wheeze” since infancy, typically with colds, described as getting tight or wheezy.
• No hospital admissions
Investigation results
None
Medication
• Salamol (Salbutamol) inhaler, used as needed, usually for exercise or when wheezy with colds.
• Previously prescribed Aerochamber 3 years ago (not used regularly now).
• No inhaled steroids or other regular medication.
Booking note
Mum requesting further medication.
ℹ️ This is the information for the person role playing the patient.
Name
Emily Foster
Age
10 years old
Address
12 Willow Lane, Swindon, SN3 2JR
Social history
• Living arrangements: Lives with mum, dad, and older brother (age 14).
• School: Year 6 at local primary.
Past history
• History of “viral wheeze” since infancy, typically with colds, described as getting tight or wheezy.
• No hospital admissions
Medication
• Salamol (Salbutamol) inhaler, used as needed, usually for exercise or when wheezy with colds.
• Previously prescribed Aerochamber 3 years ago (not used regularly now).
• No inhaled steroids or other regular medication.
We’re here because we tried to order two of Emily’s blue inhalers online—one for home and one for school—but the surgery wouldn’t give them, and they told us to make an appointment. We just need the inhalers really, as school are asking for one to keep there and to know if Emily’s asthmatic and needs a plan.”
Symptom history
• Emily’s always had “a bit of a wheeze” since she was a baby, mainly with colds.
• Uses the inhaler before netball and P.E., as she can get wheezy or tight-chested, especially when running.
• She often has to stop during P.E. lessons to have a puff and then feels better afterwards, but it happens most weeks.
Expectations
The school want confirmation if she has asthma and an asthma plan on file.
Symptom history
• No problems at times other than sport —doesn’t cough or wheeze while sleeping, and does not wake at night.
• Emily says she feels tight in her chest, sometimes a bit coughy, but usually sorts itself if she has the inhaler.
• During matches, she takes two puffs before playing and sometimes needs to stop mid-game.
• She has had “wheezy chest” with viral infections since she was little, but gets better without hospital or steroid medicine.
• No inhalers or treatments other than Salamol, not on any preventer.
• Never had to go to A&E for breathing, never needed steroids.
• Emily is generally fit and well, does not miss school, sleeps well.
• No formal diagnosis of asthma ever made.
• Otherwise well. No other chronic medical problems.
Risk factors
• No pets at home.
• Mum smokes 10 a day, dad does not. Mum doesn’t smoke in the house.
• Sport: On the school netball team, participates in P.E. twice weekly.
• Allergies: Mild hayfever in summer months.
• History of “viral wheeze” since infancy, typically with colds, described as getting tight or wheezy.
Ideas
• Mum is wondering if Emily actually has asthma, as school keep asking.
• Emily thinks her breathing is “just the way I am” but is worried about not having an inhaler for netball.
Concerns
• Mum is anxious about the long-term effects if she ends up being given a steroid inhaler for Emily, particularly about it stunting her growth or causing problems in the future.
• Emily is worried that without her inhalers she won’t be able to play netball, which is her favourite thing.
Expectations
• Mum would like two Salamol inhalers prescribed (home and school) and added to Emily’s repeat prescriptions.
• School have asked for a written confirmation if Emily has asthma and whether she needs an asthma plan.
• Mum would like to know if Emily needs a stronger inhaler and if so, wants reassurance about safety of steroids.
• Would like some guidance on when to use the inhaler and if Emily should avoid P.E. or sport.
Family history
• Mum’s brother (Emily’s uncle) has asthma.
• Emily’s brother has eczema and food allergies.
• No family history of cystic fibrosis or other lung disease.
• Mum is polite, focused, and assertive—she is here practically to get a solution, but is also quite anxious about her daughter possibly being labelled as asthmatic and about starting regular medication.
• Shows concern if the doctor mentions the possibility of steroids, asking about side effects and growth, but is not hostile if explanations are reasonable.
• Will become frustrated if the doctor seems dismissive or won’t provide a clear answer for the school; expects the doctor to explain next steps and “who decides if someone is asthmatic.”
• Calms if the doctor acknowledges her concerns and explains asthma diagnosis, treatment, and safety of medications, and what the school needs.
• Emily is not present as she is at school club. Her biggest concern is missing out on school games.
• Mum is generally cooperative and wants clear pratical guidance.
ℹ️ To mark data gathering & diagnosis select from the descriptors below.
Positive descriptors
Negative descriptors
Data gathering was systematic and targeted ensuring patient safety.
• Opens with broad questions about Emily’s breathing difficulties, their onset, frequency, and pattern (triggers, resolution).
• Progresses to targeted questions on inhaler use, school activity limitations, symptom-free intervals, and clarifies concerns about current prescription denial.
Data gathering was incomplete, lacking structure and focus.
• Fails to clarify the pattern or triggers for Emily’s symptoms, missing detail on exercise-induced symptoms and wheeze with viral infections.
• Does not systematically explore inhaler usage, school impact, or background to the prescription request.
Makes effective use of existing information and considers the wider context.
• Reviews prescription history (repeated Salamol, past aerochamber, lack of preventer) and uses this to guide questioning.
• Explores Emily’s sport involvement, family smoking habits, and school requests, putting her symptoms in social and contextual perspective.
Fails to use the information provided or understand the wider context.
• Ignores existing prescription records and does not reference school’s request for an asthma plan.
• Omits questions about family smoking or the significance of school-based activity.
The presence or absence of relevant red flags was established.
• Systematically checks for red flags such as nocturnal symptoms, persistent cough, weight loss, hospital admissions, and severe breathlessness.
• Elicits whether Emily ever needed emergency care, oral steroids, or missed school due to respiratory symptoms.
Fails to assess key information necessary to determine risk.
• Omits enquiry about nocturnal symptoms, exercise limitation, or severe/recurrent attacks.
• Fails to check for prior hospitalisation, A&E attendance, or steroid courses.
Information gathered placed the problem in its psychosocial context.
• Explores how Emily’s symptoms affect her daily life, participation in netball, and peer interaction.
• Considers Emily’s and mum’s anxieties about labelling, exclusion from activity, or side effects of treatments.
The social and psychological impact of the problem was not adequately determined.
• Neglects discussing Emily’s sporting concerns, or how symptoms affect her emotions and school involvement.
• Does not address mum’s fears regarding medication or diagnosis.
A working diagnosis was reached using a structured, evidence-based approach.
• Collects relevant data (pattern of symptoms, triggers, relief with bronchodilator, family/atopic history) to build a structured case for asthma or alternative diagnoses.
• Considers both classic and exercise-induced asthma in light of current evidence.
The evidence collected was inadequate to support the conclusions reached.
• Draws conclusions about asthma without clarifying episodic pattern, triggers, atopy, or response to treatment.
• Assumes diagnosis or prescribes without sufficient history or risk assessment.
Uses an understanding of probability based on prevalence, incidence, and natural history to aid decision-making.
• Recognises asthma is common in this age group, particularly with family atopy and exercise limitation, and weighs this appropriately against other causes.
• Understands the likelihood of asthma given triggers, atopic history, and response to bronchodilator.
Choice of diagnosis and/or investigations does not reflect disease likelihood.
• Suggests rare diagnoses without reasonable evidence, or ignores asthma as a likely cause despite suggestive history.
• Proposes inappropriate investigations or management inconsistent with case prevalence.
ℹ️ To mark clinical management & medical complexity select from the descriptors below.
Positive descriptors
Negative descriptors
Offers management options that are safe and appropriate
• Explains the need for an assessment to formally confirm or exclude asthma before adding inhalers to repeat and discusses the risks of supplying regular relievers without a diagnosis or monitoring.
• Outlines immediate safe steps (issue a single prescription short-term with safety-net advice) and the need for objective assessment (e.g., peak flow diary, possible spirometry/FeNO, review after monitoring).
Fails to provide appropriate or safe management choices
• Adds salbutamol to repeat prescriptions without establishing a diagnosis or monitoring plan, risking inappropriate treatment and missing alternative diagnoses.
• Neglects to consider or arrange objective testing or structured assessment, or fails to give clear immediate advice on medication use.
Prescribes safely considering local and national guidance
• In the well child arranges objective asthma assessment prior to prescribing inhaled steroids ; ensures safe reliever use, considers school policy for emergency inhaler.
• Considers potential smoking exposure, cautions on overuse of SABA, explains appropriate dosing.
Unsafe prescribing ignoring best practice
• In the well child prescribes reliever inhalers continuously or starts inhaled steroids without confirming asthma.
• Ignores safe use instructions, risk of overuse, or necessary review for new or ongoing inhaler therapy.
Arranges appropriate follow-up
• Organises an asthma review or diagnostic assessment (with results/diary/logs), including a plan for re-evaluation once further information is available.
• Gives clear safety-net advice (when to seek immediate help, what to monitor for) and ensures continuity.
Unclear or inadequate follow-up
• Fails to arrange timely review or follow-up to confirm diagnosis and monitor response.
• Leaves the family uncertain about what to do next if symptoms worsen or remain uncontrolled.
Tailors management options responsively according to circumstances, priorities, and preferences
• Involves both Emily and her mum in the decision-making, allows time for their queries about medication, diagnosis, and sport, and considers Emily’s desire not to miss netball.
• Discusses school needs (spare inhaler, asthma plan), provides documentation or advice in line with school policies.
Management options fail to adequately consider patient preference and circumstance
• Leaves Emily and her mum out of the decision-making or ignores their expressed concerns about growth and steroids.
• Offers rigid, one-size-fits-all care plan without clarifying school policies or Emily’s sport participation needs.
Practises holistically, promoting health and safeguarding
• Advises on general well-being (impact of hayfever, effects of sport on health), recognises the significance of family history and psychosocial wellbeing.
• Explores safeguarding aspects of passive smoke exposure, parental concerns, and psychological impact of limiting a child’s activities.
Fails to safeguard patient welfare
• Omits practical advice on lifestyle, environmental hazards, or fails to identify/explore psychosocial or safeguarding risks (e.g., secondhand smoke).
• Focuses solely on medication without addressing wider health implications.
Continuity of care is prioritised
• Emphasises importance of ongoing monitoring and regular review of symptoms; invites feedback at follow-up to assess need for escalating therapy.
• Supports close liaison with school, practice team, and family, particularly if diagnosis is confirmed.
Ongoing care is uncoordinated
• No structured plan for follow-up or monitoring.
• Neglects importance of sharing information with the school; does not ensure a joined-up approach to care.
ℹ️ To mark relating to others select from the descriptors below.
Positive descriptors
Negative descriptors
Shows ability to communicate in a person-centred way:
• Acknowledges Emily’s worry about not being able to play netball and her mum’s practical concern over not getting an inhaler for school.
• Adapts language and discussion—clarifies details directly with mum andensures explanations are understand.
Communication is doctor-centred and lacks empathy:
• Questiosn address mum's concerns and fail to explore Emily’s concerns.
• Focuses on clinical requirements or prescription policies without inquiring or responding to their emotional concerns.
Recognises what matters to the patient and works collaboratively to enhance patient care:
• Invites mum's views on activity limitation and symptom management, and jointly develops an interim plan that enables Emily to keep playing sport safely while awaiting assessment.
• Offers to involve school health staff and provide documentation to facilitate school support.
Fails to work with the patient to plan care:
• Imposes a management plan about inhalers or testing without soliciting input or discussing mum's / Emily's goals.
• Ignores concern about missing out on netball or being stigmatised at school.
Works collaboratively in a team showing respect for colleagues:
• Recognises the role of the school in managing Emily’s health and agrees to share information with them appropriately.
• Advises how practice asthma nurse or pharmacist might be involved in supporting Emily’s inhaler technique or follow-up.
Fails to work effectively with team members to deliver optimal care:
• Refuses or delays information needed for the school’s medical care or fails to direct family to the practice asthma nurse for ongoing support.
• Does not recognise the contributions of others involved in Emily’s care.
Respectfully challenges unhelpful health beliefs or behaviours:
• Addresses concerns about inhaled steroids honestly, explaining evidence about growth and safety in an age-appropriate way.
• Corrects the belief that inhaler use alone is enough without assessment, and gently discusses secondhand smoke.
Fails to maintain a productive therapeutic relationship:
• Dismisses mum’s worries about medication or school bureaucracy, potentially provoking anger or mistrust.
• Uses a lecturing tone or challenges beliefs harshly, creating tension.
Takes ownership of decisions, whilst being aware of personal limitations:
• Explains the scope and limitations of what can be decided today (no formal asthma diagnosis), and sets out clear next steps for assessment and shared decision-making.
• Offers to involve a senior GP/asthma nurse if needed.
Does not take ownership or show awareness of personal limitations:
• Presents decisions as arbitrary (“the system won’t let me prescribe”) rather than taking responsibility for patient care.
• Fails to signpost to further assessment or support if unable to conclude today.
The language and content was appropriate for the patients level of understanding:
• Adjusts explanations and questions appropriately for a 10-year-old girl and her mother, using clear and accessible language.
• Assesses their health literacy and delivers information in manageable bites, checking understanding as they go.
Questions were not tailored to the patients level of understanding:
• Uses medical jargon or, conversely, oversimplifies discussing only with the mother, overlooking what Emily can understand.
• Delivers explanations without regard for the family’s needs or preferences.
ℹ️ Insights from the examiner
Case at a glance
Emily is a 10-year-old girl whose mother is requesting inhalers for recurrent exercise-induced wheeze or tight chest. Emily is currently well and has no formal asthma diagnosis.
The consultation should not simply issue inhalers. It should clarify the symptom pattern, impact, current inhaler use and risk history, then arrange appropriate asthma diagnostic assessment while ensuring Emily has a safe interim plan for school and sport.
GP trainee performance focus
A strong GP trainee should demonstrate that they can:
What this case is testing
Patient and parent priorities and concerns
Emily’s mother may want:
Emily’s priorities may include being able to take part in PE, netball and activities with friends without embarrassment or breathlessness.
Central challenge
The central challenge is to balance the mother’s reasonable request for practical support with the need to confirm the diagnosis before starting regular treatment.
The clinician should avoid:
Must-not-miss issue or diagnosis
The key issue is possible asthma presenting with exercise-induced symptoms, particularly given symptoms with running and viral infections, and family history is relevant.
Important risks to clarify include whether Emily has had:
Red flags or high-risk features
Features to ask about include:
Common GP trainee pitfalls
What good looks like
A strong consultation is structured, practical and reassuring. The trainee recognises possible asthma, explains why testing is needed, continues safe interim reliever use, and supports Emily’s participation in school and sport.
“Because Emily mainly gets symptoms with exercise and sometimes with coughs and colds, it sounds similar to asthma. But to be sure, we usually need to confirm the diagnosis before adding medicines regularly.”
Learner checkpoint
Have I supported Emily’s current school and exercise needs while also arranging proper asthma diagnosis?
Start with an open question
After a standard opening, use a focused open question:
“Can you tell me about any breathing problems Emily has had since she was a baby?”
Or:
“Can you tell me about when Emily feels tight-chested or wheezy?”
This gives the mother space to explain the pattern while keeping the consultation focused.
Time-efficient data gathering
Use open questions first, then targeted questions to clarify:
High-yield questions
Symptom pattern
Severity and risk
Current inhaler use
Impact
Parent concerns
Functional, psychosocial or contextual assessment
Explore impact on:
Explore ideas, concerns and expectations
A helpful summary to check agenda:
“So, you’d like inhalers for home and school and some clarity for the school plan. You’d also like to know if this is definitely asthma, and whether regular inhalers are safe for Emily — have I got that right?”
This helps avoid managing the wrong problem.
Recognise and respond to cues
The mother may be worried about:
Validate concerns:
“I can see you’re keen to understand the possible risks and benefits of steroid inhalers. It is important to make sure Emily is on the right treatment — shall we go through them?”
Useful consultation phrases
“Having breathing symptoms only with exercise is quite common in asthma.”
“Shall I explain how we usually diagnose asthma, and then discuss what the options might be for helping at school and with netball?”
“Just to make sure I’ve understood — Emily sometimes has to stop PE to use her inhaler, but otherwise her breathing is fine?”
“You mentioned it’s mainly with running, so that sounds like it might be a trigger. Does anything else bring on her symptoms?”
Consultation flow and signposting
Summarising and checking understanding
Before management, summarise:
“Emily gets wheezy or tight-chested mainly with running and sometimes with coughs and colds. She is well between episodes, but symptoms can interrupt PE or netball. There has not yet been a formal asthma diagnosis, so we need to arrange testing while making sure she has a safe plan for school.”
Check:
Data gathering self-check
Before moving to management, the trainee should know:
Assessment domain mapping
Data gathering
Clinical management
Relating to others
Prioritised differential diagnosis or clinical reasoning
This case focuses on possible asthma in a well child with recurrent exercise-induced wheeze. The clinical reasoning task is to confirm whether this is asthma rather than treating presumptively without diagnosis.
Consider:
Do not start regular asthma treatment without confirming the diagnosis where testing can be arranged and the child is currently well.
Clinical reasoning script
“Emily’s symptoms sound similar to asthma because they happen with exercise and sometimes with coughs and colds. She is well between episodes, so we have time to arrange the right tests before adding regular medicines. In the meantime, she can continue using the reliever inhaler as advised.”
Red flags and risk assessment
Assess for:
These influence urgency and whether treatment needs to be escalated before diagnostic confirmation.
Decision points
Key decisions include:
Management priority
The management priority is to keep Emily safe and active while arranging appropriate asthma diagnostic testing.
Management options
1. Continue PRN reliever inhaler
Continue the PRN reliever inhaler while arranging diagnostic tests.
Give advice on use before or during exercise to manage exercise-induced symptoms, tailored to her school situation.
2. Arrange diagnostic testing
Emily is asymptomatic between games, so there is time to bring her in for diagnostic testing.
Offer an appointment during the week for FeNO testing.
3. Treatment if asthma is confirmed
If asthma is confirmed, consider starting inhaled steroid as part of anti-inflammatory reliever therapy in a combination inhaler.
Explain that regular medication should be based on confirmed diagnosis and symptom pattern.
4. School support
Offer emotional support and discuss the role of school in providing care during school time.
This may include:
5. Written asthma plan
Offer to provide a written asthma plan to keep:
6. Smoking discussion
Raise smoking as a possible contributory factor with the mother and discuss support for smoking cessation.
Do this non-judgementally.
7. Vaccinations
Check that Emily is up to date with vaccinations.
8. Allergy avoidance
Offer advice on allergy avoidance where relevant.
9. Resources
Provide advice about reliable support, including:
Personalised plan
A plan tailored to Emily might include:
Example phrase:
“Because Emily is well between episodes, we have time to test properly. In the meantime, she should have her reliever inhaler available for PE and netball, and we can make sure school knows what to do.”
Shared decision-making
Involve the mother by asking:
Safety-netting
Give guidance on recognising worsening asthma and what action to take.
Advise review if:
Ensure the mother knows how to seek help.
Documentation points
Document:
Common unsafe management plans
Avoid:
Follow-up and coordination with other professionals
Arrange follow-up to:
Learner checkpoint
Have I kept Emily safe today while arranging the right diagnostic pathway before regular asthma treatment?
Relevant guidance areas
NICE guidance
BNF references
RCGP and SCA resources
Patient information websites
Key principles to remember
Transferable learning for future cases
In children with possible asthma:
Supervisor or examiner lens
A supervisor or examiner is likely to look for:
Final learner takeaway
In a well child with exercise-induced wheeze, support current activity and safety, but confirm asthma before committing to regular treatment.
