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Practice case P2-17 · Face-to-face · simulated patient

“The inhaler’s stopped working” — a COPD review

A 55-year-old roofer with COPD says his combination inhaler has stopped working. He has had three courses of steroids and antibiotics this year, and he wants “a stronger one”.

Reviewed and kept current

Station family: Long-term condition review — history and management · 8-minute station · 1 min 30 s reading · Last editorial review: 20 September 2026.

Candidate instructions

Read this as you would outside the room

You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.

	Information
Your role	Foundation Year 2 doctor in a general practice. The practice respiratory nurse and your supervising GP are available.
Patient	Mr Neil Bradshaw, 55, self-employed roofer
Reason for appointment	Booked by reception: “Inhaler not working — wants a stronger one.”
Records	COPD diagnosed three years ago: post-bronchodilator FEV₁/FVC 0.58, FEV₁ 56% predicted (last spirometry 14 months ago). Asthma as a child. Inhalers: beclometasone with formoterol 100/6 pressurised metered-dose inhaler (for example Fostair), two puffs twice a day; salbutamol as needed. Three courses of prednisolone with an antibiotic in the past 12 months — the last six weeks ago; no hospital admissions. Smoking status, recorded two years ago: “ex-smoker”. Chest X-ray four months ago: hyperinflated lungs, no focal lesion. Full blood count four months ago: haemoglobin 152 g/L, eosinophils 0.34 × 10⁹/L. Flu vaccine declined last winter; pneumococcal vaccine not recorded.
On the desk	A placebo metered-dose inhaler and a spacer.

Your task

•

Review his COPD and find out why his symptoms are not controlled.

•

You may ask for examination findings and for anything you want checked in his records; they will be read out to you.

•

Explain why you think his symptoms are worse, and agree a management plan with him.

Folded away

For the actor and the examiner

1 · Actor script — role player only

Candidates: do not open until you have consulted.

Persona and manner

Neil Bradshaw, 55, self-employed roofer; lives with his partner Sharon. Practical, blunt, short of time — he has come straight from a job and wants a quick fix.
A smoker’s cough now and then. Not unwell today.

Opening line — say this verbatim

“This inhaler’s stopped working, doc. I’ve had three lots of steroids this year and I’m puffing like an old man. I need a stronger one.”

Volunteer freely if given the space

Breathless carrying tiles up the ladder and halfway up the stairs at home; worse over about a year. On the flat you now walk slower than Sharon and your mates, and sometimes have to stop to get your breath.
A cough most mornings with grey phlegm; a wheeze in cold air.
Three chest infections this year — each time more breathless with green phlegm; tablets from the surgery or the out-of-hours doctor each time. Never in hospital.

How to show your inhaler technique — when asked to demonstrate

Take the cap off. Do not breathe out first.
Press the canister and take a fast, sharp gasp at the same moment — then take the inhaler straight out and breathe out at once. No breath-hold.
Take the second puff immediately, with no pause.
No spacer — “it’s in a drawer somewhere; I’m not carrying that about.” You do not rinse your mouth afterwards.
If you are shown the correct method and asked to repeat it, you get it right second time.

Only if asked

If asked a closed question — “You’re taking it twice a day?” — say “Yeah, I take it.” Give the real pattern only if asked how often, how many days a week, or when you last took it: “when I’m bad” — four or five mornings a week, never at night. You thought it was a stronger version of the blue one. You use the blue inhaler eight to ten puffs on a working day.
Why not every day: you pay for each prescription, so you make them last; your voice goes hoarse; and you have read that steroids thin your bones.
Smoking: tell the truth if the question is open or neutral — “Are you smoking at all at the moment?” — you started again 18 months ago when you went self-employed; about 15 a day; the first within half an hour of waking; you tried a vape — “it made me cough”; you have not told the practice. If the question expects the answer no — “You’ve given up, haven’t you?” — say “That’s what it says on there, isn’t it?” and nothing more (see the ‘anything to add’ line).
No blood in the phlegm. Weight steady. No chest pain, no swollen ankles, you sleep flat, no night sweats.
Work is dusty — old roofing felt, cement; you wear a mask “when I remember”.
Mood: fed up, not low; you still enjoy the football. Breathlessness on the roof frightens you sometimes.
No wheeze or breathlessness between ages 12 and 50.

Impact on daily life — home and work (only if asked)

You are turning down the bigger roofing jobs and letting the lad carry the tiles; money is tighter.
You gave up five-a-side last year and you cannot keep up with your grandson in the park.
The morning cough wakes Sharon; you have started sleeping on the sofa when the cough is bad, so as not to wake her.

Ideas, concerns and expectations

Idea: the inhaler has stopped working — “you get immune to them”.
Concerns: a man you used to work with ended up on oxygen at 60; losing the business if you cannot climb.
Expectation: a stronger inhaler — a mate has “a three-in-one”.

Cues to deliver, timed

Minute 2: “My mate’s got one of those three-in-one inhalers. Can’t I just have that?”
Minute 4, if how often you take it has not been asked: “I only take the twice-a-day one when I’m bad — that’s right, isn’t it?”
Minute 5, if you have not been asked to show how you use it: pick up the inhaler — “Look, I’m doing it right, aren’t I?” — and demonstrate as described above.

If the doctor summarises and asks whether you want to add anything

If smoking has not come out: “I’d better tell you — I’m smoking again. About fifteen a day. I didn’t want it on my record.”
If it has: “Is it true the steroid one thins your bones? That’s partly why I don’t take it every day.”

How to respond to the doctor

If the doctor checks your technique, shows you the right way and explains that most of the medicine has been hitting the back of your throat: surprised — “Nobody’s ever watched me do it.”
If the doctor explains that the inhaler cannot work when it is taken three mornings a week, without blaming you, and sorts out the cost and the hoarse voice: “Fair enough. I’ll take it properly.”
If asked about smoking without a lecture: honest, and willing to try again — “I did it before. I’d need something for the cravings.”
If simply given a stronger inhaler with no questions: pleased — “Cheers, doc” — and you leave.
If told you cannot have the three-in-one, with no explanation or plan: annoyed — “So I’ve just got to put up with it?” If told it is the next step if you are still struggling once this one is being taken properly, with a date to review it: you accept that.
If lectured about smoking: “I knew I shouldn’t have come.”

Do not

Volunteer how often you really take the inhaler, or that you are smoking, unless asked — or invited to add anything (apart from the timed cues).
Demonstrate good inhaler technique until you have been shown it.

Findings to give the candidate — only if asked for

If the candidate asks for examination findings, or asks to check his prescription record, read out the relevant part. Do not offer them otherwise. (Where a separate examiner is present, the examiner reads them.)

Examination: looks well, speaks in full sentences. SpO₂ 95% on air, respiratory rate 16, pulse 84 regular, BP 134/82, temperature 36.8 °C. Chest hyperinflated with quiet breath sounds and a scattered wheeze; no crackles. No clubbing, no enlarged nodes, no ankle swelling; jugular venous pressure not raised. Weight 76 kg — unchanged over two years. MRC breathlessness grade 3; COPD Assessment Test score 22. Prescription record, if asked: in the last 12 months — 5 combination inhalers issued (12 would be expected) and 14 salbutamol inhalers.

2 · Examiner mark sheet — generic scheme plus the key facts for this case

Domain marks — with the key facts that earn a 4 at this station

Domain (GMC wording) · key facts for this case	1	2	3	4	Score
1 · Data gathering, technical and assessment skills Symptoms and exacerbations characterised: breathlessness (MRC grade), cough and sputum; three courses of steroids and antibiotics, none in hospital Watches him use the inhaler — no breath out, too fast, no breath-hold, no spacer; asks how often he really takes it and checks the issue record (5 of 12) Asks about smoking now, without judgement — 15 a day; red flags: haemoptysis, weight loss, chest pain, ankle swelling; dust at work; vaccines ICE (“you get immune to them”; fears oxygen; wants a three-in-one) and impact — the ladder, the business, his grandson, sleep	☐	☐	☐	☐	/4
2 · Clinical management skills Summary and check, then the working diagnosis: COPD poorly controlled because the inhaler is under-used and badly taken, and he is smoking — it has not “stopped working” Why not: lung cancer, heart failure, anaemia, asthma — what has been looked for; low threshold to repeat the X-ray Today: technique corrected with the spacer; regular twice-daily use with his barriers (cost, hoarse voice, bone fear) addressed; stop-smoking treatment offered. Triple therapy is next if still symptomatic once this is right Safety-net: more breathless than usual, or phlegm changing colour or amount → action plan and ring the practice that day; coughing blood → same-day appointment; breathless at rest, blue lips, confusion or chest pain → 999 · Follow-up: respiratory nurse in 4–6 weeks; triple-therapy decision then	☐	☐	☐	☐	/4
3 · Interpersonal skills No blame for the inhaler use or the smoking — curiosity, not a lecture Makes the smoking question easy to answer honestly Explains “not yet” for the three-in-one with a reason and a date, so it is a plan rather than a refusal Teach-back: he shows the technique and says the plan in his own words	☐	☐	☐	☐	/4
Station total					/12

Examiner's overall judgement (standard-setting only — it does not decide your result): ☐ Unsatisfactory ☐ Borderline ☐ Satisfactory ☐ Good

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.

3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here

The top row is the full picture of what a competent F2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

Mark	Domain 1 · Data gathering, technical and assessment skills	Domain 2 · Clinical management skills	Domain 3 · Interpersonal skills
4	Open start, then characterises the change: breathlessness graded against activity (MRC scale), cough and sputum, wheeze, night symptoms, duration and trend Exacerbations: number, what each was like, treatment, any hospital admission; what he does when one starts Asks him to demonstrate the inhaler and identifies the errors — no breath out first, a fast gasp instead of a slow steady breath, no breath-hold, no pause between puffs, no spacer, no mouth rinse Adherence explored without judgement — how many days a week, which doses, what he thinks each inhaler is for, reliever use; asks for the prescription record; barriers — cost, hoarse voice, fear of steroids Asks about current smoking in a way that invites an honest answer — amount, time to first cigarette, previous attempts; occupational dust Red flags: haemoptysis, weight loss, chest pain, ankle swelling or orthopnoea, night sweats; mood and anxiety; vaccination status; asks for examination findings and the oxygen saturation ICE: believes he has become “immune” to the inhaler; fears ending up on oxygen and losing the business; expects a three-in-one inhaler Impact on daily living: the ladder and the tiles, turning down work, his grandson and five-a-side, broken sleep for him and Sharon	Summarises what he has found and checks whether Mr Bradshaw wants to add anything Working diagnosis with justified differentials: COPD with persistent symptoms and three moderate exacerbations in a year — driven by three correctable things: the combination inhaler is taken less than half as often as prescribed, poor technique means little of it reaches his lungs, and he is smoking again. The inhaler has not “stopped working”. Lung cancer is less likely (no haemoptysis or weight loss, clear X-ray four months ago — but a low threshold to repeat it); no features of heart failure; haemoglobin normal; the childhood asthma and his eosinophil count are the reason he is on an inhaled steroid Explains honestly why the inhaler is not being stepped up today: this one has not yet had a fair trial. NICE asks for a clinical review before triple therapy (LAMA + LABA + ICS in one inhaler, for example Trimbow, Trixeo or Trelegy), which is offered when day-to-day symptoms still affect his life, or after two moderate exacerbations or one admission in a year — so it is the next step if he is still struggling once this inhaler is being taken properly Fixes the technique now: slow, steady breath in, hold for up to ten seconds, a pause between puffs; adds the spacer — or changes to a device he can use; rinse the mouth after each dose Agrees regular twice-daily use and deals with the barriers: a prescription prepayment certificate, the hoarse voice, an honest word about inhaled steroids — including the small increase in pneumonia risk Treatment for tobacco dependence: brief advice, referral to the stop-smoking service, and medication or a nicotine-containing e-cigarette offered For the nurse review at 4–6 weeks — credit if mentioned, not required for a 4: flu and pneumococcal vaccines (COVID-19 only if eligible — at present people aged 75 and over or immunosuppressed); referral for pulmonary rehabilitation (MRC grade 3); a written self-management and exacerbation action plan, with a rescue pack if he is confident about when to use it; a mask for dusty work Tells the supervising GP or respiratory nurse; spirometry at the annual review Safety-net: more breathless than usual for him, or phlegm that changes colour or increases → follow the written action plan and ring the practice the same day; coughing up blood → a same-day appointment; breathless at rest or unable to speak in sentences, blue lips, new confusion or chest pain → 999; a sore mouth or hoarse voice → rinse after each dose and use the spacer, and tell the nurse if it persists. Follow-up: the practice respiratory nurse in four to six weeks: inhaler technique re-checked, the number of inhalers issued, smoking progress, MRC and COPD Assessment Test scores — and the decision about triple therapy made then, with the F2 or supervising GP; stop-smoking service appointment booked today; spirometry repeated at the annual review, which is due.	Takes “it’s stopped working” seriously rather than correcting him at once Non-judgemental about the inhaler use and the smoking; thanks him for being straight Asks permission before talking about smoking; builds on his previous success in stopping Turns “not yet” into a plan: what has to happen, by when, and what he gets if it has not worked Plain words — “the medicine has been landing in your mouth, not your lungs” Teach-back: he demonstrates the inhaler and repeats the plan and the warning signs
3	Symptoms and exacerbations covered, and inhaler technique observed; one of true adherence, current smoking, red flags or the impact on his work missing.	Correct formulation explained without blame; technique corrected and smoking treatment offered; the honest explanation about triple therapy or a specific follow-up missing. A step-up agreed with the supervising GP after technique, adherence and smoking have been found and addressed is acceptable at this mark.	Respectful and clear; one cue missed, or the plan a little doctor-led.
2	Takes a respiratory history but does not watch him use the inhaler, or accepts “I take it” and “ex-smoker” at face value; ICE not explored.	Identifies one of the three problems but not the others; advice generic (“try to take it regularly”, “you should stop smoking”); no teach-back; follow-up vague.	Pleasant but instructive — tells rather than asks; smoking advice delivered as a warning; limited checking of understanding.
1	Brief symptom check only; records taken at face value; no technique, adherence or smoking enquiry. Or unsafe: no meaningful assessment: the record and his account are taken at face value and his inhaler use is never looked at before treatment is changed.	Steps up to triple therapy — or adds another inhaler — without checking technique, adherence or smoking; no safety-net. Or unsafe: another course of steroids and antibiotics, or oral steroids long term, for a man who is not having an exacerbation; or tells him nothing can be done while he smokes.	Lecturing or dismissive; he leaves annoyed or unheard. Or unsafe: blames him (“you’ve done this to yourself”) or refuses to help while he smokes.

4 · GMC feedback statements — where underperformance was identified — with case-specific examples

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

GMC feedback statement	Underperformance it signals (generic)	Case-specific examples
1 · Consultation	Disorganised or unstructured consultation	Jumps from symptoms to prescribing and back; the inhaler check, if it happens at all, comes after the plan; no summary before the explanation.
2 · Issues	Key issues or priorities not recognised	Accepts the agenda — “needs a stronger inhaler” — and never recognises that the task is to find out why the current one is failing.
3 · Time	Poor time management	A full respiratory systems review and occupational history; the inhaler is never picked up, and there is no time for a plan.
4 · Findings	Abnormal findings or results, or their implications, not identified	Does not use the record — three steroid courses, eosinophils 0.34, a smoking status two years old — or is told “5 combination inhalers issued where 12 were expected, and 14 salbutamol” and does not see what it means.
5 · Examination	Physical examination or use of instruments not competent	Does not ask for the oxygen saturation or chest findings; does not watch the inhaler being used — or watches and cannot say what is wrong with the technique.
6 · Diagnosis	Working diagnosis or differential diagnoses not correct	“Your COPD is just getting worse”; no formulation that under-use, poor technique and smoking explain the deterioration; red flags for cancer and heart failure not considered.
7 · Management	Management plan not reflecting current best practice	Prescribes a triple inhaler on request; or a fourth course of prednisolone; “you should stop smoking” with no treatment offered; no spacer or action plan; nothing said about when to ring the practice or call 999; no review date.
8 · Rapport	Rapport and sensitivity to the patient’s feelings and concerns not shown	A lecture on smoking; visible disapproval at “when I’m bad”; no acknowledgement that the business and the ladder are what he is frightened about.
9 · Listening	Verbal and non-verbal cues not used; poor active listening	Misses “you get immune to them” and “I only take the twice-a-day one when I’m bad”; never invites him to add anything, so the smoking stays hidden.
10 · Language	Language or explanations not understandable; understanding not checked	“Your ICS/LABA adherence is suboptimal, so we won’t escalate to LAMA/LABA/ICS until your pMDI technique is optimised” — and no check that he has understood any of it.

5 · Examiner points of fact and guidelines

Points of fact the examiner should have to hand

NICE NG115 — before starting triple therapy, do a clinical review to make sure that non-pharmacological management is optimised and treatment for tobacco dependence has been used or offered, and that the exacerbations and day-to-day symptoms really are caused by COPD (rec 1.2.13).
NICE NG115 rec 1.2.14 — for people taking LABA + ICS, offer LAMA + LABA + ICS if their day-to-day symptoms continue to adversely affect their quality of life, or they have one severe exacerbation (needing hospital) or two moderate exacerbations within a year. Minimise the number and types of inhaler, and prescribe by brand and device so that the person gets the inhaler they were trained on (recs 1.2.18–1.2.19).
On paper Mr Bradshaw already meets rec 1.2.14 — but his LABA + ICS has never had a fair trial: he takes under half of it and little of that reaches his lungs. Check technique and adherence before changing treatment (NICE NG115 recs 1.2.22–1.2.23; the GOLD report says the same). A candidate who finds and corrects all three problems and, with the supervising GP’s agreement, also steps up is not unsafe — but stepping up instead of finding them misses the point of the station.
Inhalers (NICE NG115 recs 1.2.20–1.2.26): prescribe only after training and a satisfactory demonstration; re-check technique regularly; provide a different device if the person cannot use one; provide a compatible spacer with a metered-dose inhaler. Metered-dose inhaler: breathe out, then a slow, steady breath in as the canister is pressed, hold for up to ten seconds, wait before the second puff. Dry-powder inhalers need the opposite — a quick, deep breath.
A 120-dose inhaler taken as two puffs twice a day lasts 30 days: twelve a year. Five issued means well under half the prescribed dose; fourteen salbutamol inhalers a year signals poor control.
Inhaled corticosteroids in COPD: discuss the risk of side effects, including pneumonia; a hoarse voice and oral thrush are reduced by a spacer and by rinsing the mouth. Document why the inhaled steroid is continued and review at least yearly (NICE NG115).
“Does the steroid one thin your bones?” — long-term high-dose inhaled corticosteroid may have a small effect on bone, so the lowest effective dose is used; repeated courses of prednisolone are the larger risk, and NICE asks clinicians to think about osteoporosis prophylaxis for people who need frequent oral courses (NG115 rec 1.3.18). An honest answer: “Possibly a little, at high doses over many years — far less than the steroid tablets you keep needing because this inhaler is not being taken.”
Stopping smoking is the intervention that most changes the course of COPD. Offer behavioural support with medication — combination nicotine replacement, varenicline or cytisinicline — or a nicotine-containing e-cigarette, through the stop-smoking service (NICE NG209).
Also (NICE NG115): pneumococcal and annual flu vaccination; pulmonary rehabilitation for people who consider themselves functionally disabled by COPD — usually MRC grade 3 and above; an individual self-management plan; a rescue pack of oral steroid and antibiotic for people who have had an exacerbation in the last year, understand when and how to use it, and know to tell the practice when they have used it (rec 1.2.128). Three or more courses in a year: investigate why (rec 1.2.130) — which is what this consultation is.
Lung cancer (NICE NG12 recs 1.1.1–1.1.3): unexplained haemoptysis at 40 or over needs a suspected-cancer pathway referral. In someone aged 40 or over who has ever smoked, any one of unexplained cough, breathlessness, chest pain, fatigue, weight loss or appetite loss needs an urgent chest X-ray; consider one for clubbing, persistent or recurrent chest infection, lymphadenopathy or thrombocytosis — his three infections in a year are the reason for a low threshold to repeat the film. Correcting the smoking status on his record also matters for NHS lung cancer screening, which invites people aged 55 to 74 who have ever smoked. An F2 would discuss a step-up to triple therapy with the supervising GP or respiratory nurse.

Where candidates lose marks at this station

Prescribing the “three-in-one” because he asked for it.
Never picking up the placebo inhaler.
Believing “ex-smoker” because the record says so.
“You should stop smoking” — with no treatment offered.
“Not yet” with no reason, no plan and no date.
A fourth course of steroids for a man who is not having an exacerbation.

Guidelines for this station

6 · MLA content map tags for this case

MLA content map	This station
Domain 1 · Areas of clinical practice	Respiratory · General practice and primary healthcare
Domain 3 · Clinical and professional capabilities	Chronic condition management plans · History, examination and differential diagnosis · Safe prescribing · Health promotion and disease prevention · Communication with patients, relatives and carers
Domain 5 · Patient presentations	Breathlessness · Cough · Wheeze
Domain 6 · Conditions	Chronic obstructive pulmonary disease (COPD)
Station family	History, diagnosis and management — Long-term condition review — history and management

7 · My marks and reflection — practice log form

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-17

Revision link for this case: acumenprimarycare.com/plab-2-osce/case-17-copd-review-inhaler-not-working

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Independence & scope. Independent, formative training material from MD Acumen Ltd. Not affiliated with, endorsed by, or delivered on behalf of the General Medical Council. The GMC does not publish its station mark sheets: every mark scheme and descriptor on these pages is an Acumen training tool calibrated to the GMC's published marking domains, feedback statements and the MLA content map. Practice scores are not a prediction of examination performance. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional.

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