Counselling · Intermediate · Surgery

Pre-Operative Assessment for Elective Surgery

Practise this PLAB 2 counselling station on Pre-Operative Assessment. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor conducting a pre-operative assessment in the surgical pre-assessment clinic. Mrs Sylvia Lowe, a 71-year-old woman, is scheduled for elective removal of an ankle fixation pin. Please conduct the assessment, discuss anaesthetic implications, VTE prophylaxis, fasting requirements, and obtain informed consent.

Background notes: PMH: Hypertension, Osteoporosis, Previous ankle fracture, Mild osteoarthritis (knees, hips)

What this station tests

  • Systematic pre-operative assessment: PMH, medications, allergies, previous anaesthetics, functional capacity, ASA grading
  • NICE-appropriate investigations: ECG for age >65 with hypertension, not routine CXR without indication
  • Fasting instructions: 6 hours food, 2 hours clear fluids
  • VTE prophylaxis: LMWH and compression stockings for surgical patients
  • Addressing anaesthetic anxiety in an elderly patient: modern anaesthesia safety, spinal as alternative to GA

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

Pre-operative assessment stations test systematic risk stratification and clear communication about anaesthesia, fasting, and VTE prophylaxis. Mrs Lowe is 71, scheduled for elective removal of an ankle fixation pin under GA. She is a retired nurse with hypertension and osteoporosis. She is anxious about anaesthesia at her age. Open with: 'Mrs Lowe, this appointment is to make sure we have everything in place for your surgery. What questions or concerns do you have about the operation?'

Core approach

Systematic pre-operative assessment. PMH: hypertension (controlled, on amlodipine), osteoporosis (on bisphosphonate), mild OA. No diabetes, no cardiac history, no respiratory disease. Previous anaesthetic: appendicectomy decades ago without problems. Allergies: none. Medications: amlodipine, alendronate, calcium/vitamin D. Functional capacity: she can walk to the shops (>4 METs, good). ASA grade 2 (mild systemic disease, well-controlled hypertension).

Investigations: FBC, U&E, ECG (age >65 with hypertension). Chest X-ray only if clinically indicated (not routine per NICE). Group and save if significant blood loss expected (unlikely for pin removal).

Address her specific concerns. She is worried about GA at 71 ('popping my brain'): explain that modern anaesthesia is very safe, and the anaesthetist will assess her individually. She is worried about blood clots: she will receive VTE prophylaxis (LMWH and compression stockings). She is worried about bone density: her osteoporosis does not significantly increase surgical risk for this procedure.

Fasting instructions: no food for 6 hours, clear fluids until 2 hours before. Medication advice: continue amlodipine on the morning of surgery with a sip of water. Hold alendronate.

Closing and safety netting

Summarise the plan clearly. 'Your health is well-suited for this operation. Your blood pressure is controlled, your heart and lungs are healthy, and you have good fitness. The anaesthetist will see you on the day and can discuss whether a general or spinal anaesthetic is better for you.'

VTE prophylaxis explained: 'You will have a blood-thinning injection and special stockings to prevent blood clots.' Post-operative: pain management plan, physiotherapy, expected recovery. Day case: she should go home the same day with a responsible adult. Safety net: signs of wound infection, DVT symptoms to watch for. Follow-up wound check in 7 to 10 days.

How examiners mark this station

Examiners will assess your ability to explain pre-operative assessment and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Systematic assessment: PMH, medications, allergies, anaesthetic history, functional capacity. ASA grading. Appropriate investigations (ECG, FBC, U&E). No unnecessary CXR.

Costs marks: Incomplete assessment. Ordering routine CXR. Wrong ASA grade. Missing medication review.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Fasting instructions given. Medication advice for day of surgery. VTE prophylaxis planned. Post-operative plan. Day case criteria confirmed.

Costs marks: No fasting instructions. Wrong medication advice. No VTE plan. No post-op plan.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Addressing anaesthetic anxiety directly. Explaining safety of modern anaesthesia. Offering spinal as alternative. Using her nursing background constructively.

Costs marks: Ignoring her anxiety. Being dismissive of her concerns. Not involving her in decision-making.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Ordering routine CXR without indication. NICE does not recommend routine pre-operative chest X-ray. It is only indicated if there are respiratory symptoms or signs. Candidates who order CXR for all elderly patients demonstrate over-investigation.
  2. Not addressing her anaesthetic concerns. She is a retired nurse who is frightened of GA at 71. Candidates who complete the medical assessment without acknowledging her anxiety miss the interpersonal dimension.
  3. Not explaining fasting instructions clearly. '6 hours food, 2 hours fluids' is simple but commonly omitted. Candidates who do not specify this leave the patient uncertain about preparation.

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

How should I approach pre-Operative assessment counselling in this PLAB 2 station?

Pre-operative assessment stations test systematic risk stratification and clear communication about anaesthesia, fasting, and VTE prophylaxis. Mrs Lowe is 71, scheduled for elective removal of an ankle fixation pin under GA. She is a retired nurse with hypertension and osteoporosis.

What are examiners marking in this pre-Operative assessment station?

Marks are won for: Systematic assessment: PMH, medications, allergies, anaesthetic history, functional capacity. ASA grading. Appropriate investigations (ECG, FBC, U&E). No unnecessary CXR. Marks are lost for: Incomplete assessment. Ordering routine CXR. Wrong ASA grade. Missing medication review.

What is the most common mistake candidates make in this pre-Operative assessment station?

Ordering routine CXR without indication. NICE does not recommend routine pre-operative chest X-ray. It is only indicated if there are respiratory symptoms or signs.

How do I prepare for this station if I have not managed pre-Operative assessment in clinical practice?

This station rewards process over personal experience. The skill being assessed: NICE-appropriate investigations: ECG for age >65 with hypertension, not routine CXR without indication. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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