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Practice case P2-30 · Face-to-face · simulated patient
“Which tablets do I stop before my operation?” — pre-operative assessment
A 71-year-old woman is listed for a total hip replacement in three weeks. She has come to the pre-operative assessment clinic with her medicines and a list of questions, and wants to know which tablets to stop and when.
Reviewed and kept current
Station family: Explanation and counselling — medicines before elective surgery · 8-minute station · 1 min 30 s reading · Last editorial review: 16 October 2026 · Next scheduled refresh: 11 April 2027.
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 the pre-operative assessment clinic. The clinic anaesthetist and the pre-assessment pharmacist are available, and the clinic issues every patient written instructions before surgery. |
| Patient | Mrs Patricia Lowe, 71, retired librarian |
| Reason for attendance | Pre-operative assessment, three weeks before a planned right total hip replacement for osteoarthritis. The pre-assessment nurse has recorded her observations and bloods and asks you to go through her medicines with her. |
| Records | Atrial fibrillation (permanent) — apixaban 5 mg twice a day; CHA₂DS₂-VASc 4. Type 2 diabetes — metformin 1 g twice a day and empagliflozin 10 mg once a day; HbA1c 58 mmol/mol last month. Hypertension — ramipril 5 mg once a day. Aspirin 75 mg once a day “for the heart” (started by a previous GP; no stent, heart attack or stroke recorded). Atorvastatin 20 mg at night. No allergies. Weight 74 kg, height 1.62 m. Today: BP 138/82, pulse 76 irregular, SpO₂ 97%. Bloods last week: creatinine 86 micromol/L, eGFR 59 mL/min/1.73 m² (creatinine clearance 62 mL/min, Cockcroft–Gault, actual weight), haemoglobin 131 g/L, potassium 4.4 mmol/L. The surgeon’s letter: “high bleeding-risk procedure; spinal anaesthesia planned.” |
Your task
•
Take a brief, focused history relevant to her operation and her medicines.
•
Explain which of her medicines she should stop before surgery, when, and why — and which she should carry on taking.
•
Address her questions and concerns, and agree a plan with her. You are not required to examine her.
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
- Patricia Lowe, 71, a retired librarian. Widowed; you live alone in a bungalow and your son Malcolm lives twenty minutes away. Organised and a little anxious: you have brought all your boxes in a carrier bag and a handwritten list of questions.
- You are polite and listen carefully, but you want specifics — “which day, exactly?” — and you will say so if the doctor is vague.
Opening line — say this verbatim
- “The nurse said you’d go through my tablets. I’ve got a list — I need to know exactly which ones to stop and when, because last time nobody told me anything.”
Volunteer freely if given the space
- You take everything in the bag every day, from a weekly pill organiser that Malcolm fills.
- The hip is the worst thing in your life: you cannot walk to the shops and you sleep badly because of the pain.
- “Last time” was a cataract operation two years ago — nobody told you anything about your tablets.
Only if asked
- Atrial fibrillation for six years — it was found when you had palpitations; you have never had a stroke or a mini-stroke that you were told of. You have taken apixaban ever since and have never missed it except that week before the cataract. If asked what happened last time, or whether you have ever stopped or missed a tablet: you stopped the apixaban yourself for a week “to be safe”; nobody picked it up.
- Diabetes for nine years; metformin from the start, the “newer one” (empagliflozin) for two years. No insulin. No hypos. You check your sugar occasionally and it is “sevens and eights”.
- Blood pressure tablet for years. The aspirin: “a doctor put me on it years ago for my heart. I don’t know why, exactly.” No stent, no heart attack. You have never been told to stop it.
- No bleeding problems: no nosebleeds, no black stools, no bruising. No indigestion. Periods stopped years ago.
- No chest pain, no breathlessness lying flat, no ankle swelling, no fainting. You can climb a flight of stairs slowly — the hip, not your breathing, stops you.
- Teeth: your own, no loose ones. No previous problems with anaesthetics; your late husband had none either.
- Smoking: never. Alcohol: a sherry at Christmas. No herbal remedies or supplements. You do not take ibuprofen or any painkiller except paracetamol.
- The funny turn — only if asked directly about stroke, mini-stroke, weakness, speech or “any episodes”: “About three weeks ago my right arm went heavy and my words came out wrong — it lasted twenty minutes and then went. I thought it was the heat.” You told nobody. If the doctor does not ask directly, keep it for the ‘anything to add’ moment.
Impact on daily life — home and work (only if asked)
- You have stopped going to the garden centre and the church flower rota, which were your life after your husband died.
- You sleep four or five hours because of the hip; you have moved your bed downstairs.
- Malcolm will stay with you for the first week after the operation; after that you will be on your own, which worries you more than the operation itself.
Ideas, concerns and expectations
- Idea: you have read that “blood thinners must be stopped for a week” and you planned to stop the apixaban a week before, like last time.
- Concern: that stopping it will give you a stroke — your sister had one; and that stopping your diabetes tablets will send your sugar “sky high”.
- Expectation: a written list — which tablet, which day — and to be told whether you will be put to sleep.
Cues to deliver, timed
- Minute 2: “I was going to stop the blood thinner a week before, like last time. That’s right, isn’t it?”
- Minute 4, if the diabetes tablets have not been discussed: “And the sugar tablets — do I just carry on?”
- Minute 6, if nothing has been said about who will give you the instructions in writing: “Will somebody write this down for me?”
If the doctor summarises and asks whether you want to add anything
- If the funny turn has not come out: “There is one thing. A few weeks ago my arm went heavy and my words came out wrong, for about twenty minutes. It went away. Should I have said?”
- If it has: “Will they still do my hip, after what I told you?”
How to respond to the doctor
- If the doctor says a week is too long and gives a number of days or doses: relieved — “So not a week. Good.”
- If the doctor says “stop it a week before” or agrees with your plan: “That’s what I thought.” (You accept it; the examiner marks it.)
- If the doctor explains that the newer diabetes tablet is paused for the day before and the day of the operation because of a rare but serious acid build-up when you are not eating, and that metformin carries on: “Only two days? That’s manageable.” If told to stop all your diabetes tablets for a week: worried — “My sugar will go sky high.”
- If the doctor explains the aspirin should carry on for now but that they will ask why you are on it alongside the blood thinner: “Nobody’s ever asked that before.”
- If told the blood-pressure tablet is missed on the morning of the operation and why: you nod and write it down.
- When the funny turn comes out: if the doctor says “mini-stroke”, “TIA” or “stroke” and says you must be seen urgently: frightened but grateful — “I nearly didn’t say.” If the doctor says “it was probably nothing” and moves on: “Are you sure?”
- If the doctor gives vague instructions (“the hospital will tell you nearer the time”): “That’s what they said last time.”
- If jargon is used (“DOAC”, “neuraxial”, “euglycaemic DKA”): “I’m sorry, I don’t follow.”
Do not
- Volunteer the funny turn unless asked directly as scripted, or invited to add anything.
- Volunteer that you stopped the apixaban for a week before the cataract unless the doctor asks what happened last time or whether you have ever missed doses — then tell them.
- Say “mini-stroke” or “TIA” before the doctor does.
Findings to give the candidate — only if asked for
If the candidate asks to examine you, or asks for observations or examination findings, read these out. Do not offer them otherwise. (Where a separate examiner is present, the examiner reads them.)
Only if asked: no bruising or bleeding; no signs of heart failure; chest clear; right hip painful on movement, no other findings. Capillary glucose (if asked): 7.8 mmol/L. Capillary ketones (if asked): 0.1 mmol/L.
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
| ☐ | ☐ | ☐ | ☐ | /4 |
2 · Clinical management skills
| ☐ | ☐ | ☐ | ☐ | /4 |
3 · Interpersonal skills
| ☐ | ☐ | ☐ | ☐ | /4 |
| Station total | /12 |
Domain score (educational construct):
| Score | Descriptor |
|---|---|
| 1 | Unsatisfactory (did not achieve safe FY2 standard) |
| 2 | Borderline (just achieving minimum safe FY2 standard) |
| 3 | Satisfactory (competent and safe FY2 standard) |
| 4 | Good (exceeds FY2 standard) |
This 1–4 domain score and its descriptors are an Acumen educational construct: the GMC publishes the three marking domains and the four-mark maximum, but not the descriptors its examiners use, and it does not publish station mark sheets. See Legal & Regulatory.
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 FY2 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 |
|
|
|
| 3 | Medicines reconciled, bleeding and diabetes history taken, the self-stopped apixaban found, the funny turn found (even if only at the summary); one of the aspirin indication, anaesthetic history or impact on daily living missing. | Correct advice for apixaban, empagliflozin and metformin, with reasons and a written plan promised; the TIA recognised and referred; one of the ramipril, the aspirin query, the restart plan or the ketone symptoms missing. | Clear and kind; a little too much detail in one go, or one cue missed. |
| 2 | Goes through the list but does not ask about adherence, previous surgery or stroke symptoms; the funny turn found only because she offers it; ICE perfunctory. | Advice broadly right but hedged (“the hospital will tell you”), or one drug wrong (metformin stopped for days; empagliflozin stopped for a week); the TIA referred but the anaesthetist not told; plan not written. | Accurate but delivered as a list; the stroke fear or the previous bad experience not acknowledged; jargon (“DOAC”, “neuraxial”). |
| 1 | No real history — reads the record aloud and starts advising. Or unsafe: does not ask about bleeding, stroke symptoms or what happened last time; reads out the record and starts advising. | Apixaban advice right but most other drugs wrong or omitted; the funny turn noted but not acted on; no written plan. Or unsafe: agrees to a week off apixaban, or stops everything “to be safe”, or swaps apixaban for aspirin; tells her to continue empagliflozin through the operation; dismisses the episode (“probably the heat”); or cancels the operation herself. | Vague and hurried; her questions deflected to “the hospital”; she leaves no clearer than she came. Or unsafe: dismissive of her fear or her list; blames her for stopping the apixaban last time; or frightens her about the TIA with no plan. |
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 | Starts advising from the record before asking her anything; tablets taken in random order; no summary before the plan. |
| 2 · Issues | Key issues or priorities not recognised | Treats the station as “recite stop days” and never asks what happened last time or whether she has had stroke symptoms — so the self-stopped apixaban and the TIA are missed. |
| 3 · Time | Poor time management | Six minutes on the apixaban; empagliflozin, ramipril and the written plan never reached. |
| 4 · Findings | Abnormal findings or results, or their implications, not identified | Does not use the record: “high bleeding-risk procedure; spinal anaesthesia planned”, the creatinine clearance of 62, the HbA1c of 58; or hears the 20-minute arm-and-speech episode and calls it “the heat”. |
| 5 · Examination | Physical examination or use of instruments not competent | No examination is required — but does not ask about bruising and bleeding, and does not mention that blood ketones will be checked in hospital while the empagliflozin is stopped. |
| 6 · Diagnosis | Working diagnosis or differential diagnoses not correct | No formulation: cannot say whether she is suitable for the pathway, or why the episode is a probable TIA rather than a faint, hypoglycaemia or migraine. |
| 7 · Management | Management plan not reflecting current best practice | “Stop the blood thinner a week before, like last time”; metformin stopped for days; empagliflozin continued; the aspirin never questioned; nothing about ketone symptoms, stroke symptoms or when to ring; no TIA referral; no written plan. |
| 8 · Rapport | Rapport and sensitivity to the patient’s feelings and concerns not shown | Talks to the list rather than to her; brushes off “last time nobody told me anything”; lectures her about stopping the apixaban two years ago. |
| 9 · Listening | Verbal and non-verbal cues not used; poor active listening | Misses “I was going to stop the blood thinner a week before, like last time. That’s right, isn’t it?”; never invites her to add anything, so the funny turn stays hidden. |
| 10 · Language | Language or explanations not understandable; understanding not checked | “Your DOAC is held for five doses because of the neuraxial block; the SGLT2 inhibitor is omitted for euglycaemic DKA risk and we’ll check ketones post-op.” |
5 · Examiner points of fact and guidelines
Points of fact the examiner should have to hand
- Apixaban before elective surgery (UK Clinical Pharmacy Association, Handbook of Perioperative Medicines — apixaban monograph, last reviewed March 2024): minor bleeding risk — usually no interruption, timing the procedure 12 hours after the last dose; low or moderate bleeding risk — omit day −1 and the morning dose (three doses); high bleeding risk, and any neuraxial (spinal or epidural) anaesthesia — continue day −3, omit day −2, day −1 and the morning of surgery (five doses, roughly 60–67 hours). Bridging with treatment-dose heparin is not required. Restart: low risk 6–12 hours; low or moderate 24 hours; high risk 48–72 hours, with prophylactic low-molecular-weight heparin from 6–12 hours after surgery until apixaban restarts. The schedule is not varied by creatinine clearance, but a clearance below 30 mL/min, weight below 50 kg or an interacting drug needs haematology advice. Hip replacement is a high bleeding-risk operation, and the surgeon has asked for a spinal.
- Why a week is wrong: apixaban has a half-life of about 12 hours, so five omitted doses already exceed five half-lives; every further day without anticoagulation adds stroke risk (CHA₂DS₂-VASc 4 — age, female sex, hypertension, diabetes) for no reduction in bleeding. Aspirin is not a substitute for anticoagulation in atrial fibrillation. The handbook asks that the surgical team make sure the patient knows when to restart.
- SGLT2 inhibitors (multi-society consensus statement, Anaesthesia 2025, El-Boghdadly and colleagues — Association of Anaesthetists, Association of British Clinical Diabetologists, Centre for Perioperative Care, Joint British Diabetes Societies, Royal College of Anaesthetists, UKCPA and others): omit on the day before and the day of surgery, after discussing the ketoacidosis risk; follow normal fasting guidance without prolonged starvation; restart in day-case patients once eating and drinking normally (typically 24–48 hours) and in inpatients when capillary ketones are below 0.6 mmol/L; provide written sick-day rules. The UKCPA handbook’s empagliflozin monograph (reviewed February 2024) says the same — omit the day before and the day of surgery, monitor blood ketones during the interruption, and restart only when eating and drinking normally, volume replete, off any insulin infusion, ketones normal and medically stable. International bodies recommend longer omission (three days or more) — UK practice is the consensus statement until it is revised, so local pre-assessment protocols are followed; check the current consensus statement (Anaesthesia 2025, doi 10.1111/anae.16541) for the exact wording before teaching it. MHRA Drug Safety Update (18 March 2020): interrupt SGLT2 inhibitors in patients admitted for major surgery or acute serious illness, measure blood ketones (urine ketones are unreliable with these drugs) even when glucose is near normal, and restart once ketones are normal and the patient is stable; tell patients the symptoms of ketoacidosis.
- Metformin (UKCPA handbook monograph, last reviewed March 2021): take as normal the day before; on the day of surgery, continue once- or twice-daily dosing whatever the eGFR if no contrast is planned (omit only the lunchtime dose of three-times-daily dosing; omit on the day if eGFR is below 60 and contrast is used); restart once eating and drinking normally and any variable-rate insulin infusion has stopped, checking renal function. The Centre for Perioperative Care diabetes guideline (2021) suggests a pragmatic HbA1c below 69 mmol/mol (8.5%) before elective surgery where safe and achievable — hers is 58.
- ACE inhibitors (UKCPA handbook — ramipril monograph; marked ‘under review’ after updated Association of Anaesthetists blood-pressure guidance): evidence is limited and local consensus is recommended; the handbook’s practical approach is to omit ramipril on the morning of surgery (some centres omit for up to 48 hours) because of hypotension at induction, especially with diuretics; restart once blood pressure and volume are stable, withholding if acute kidney injury develops. Tell the patient what the local written plan says rather than quoting a universal rule.
- Aspirin (UKCPA handbook — aspirin monograph): for antiplatelet use at 150 mg or less, continue for non-cardiac surgery; consider stopping for seven days only for high bleeding-risk procedures such as spinal surgery, some ophthalmic and neurosurgical operations, or in people who refuse transfusion; restart as early as possible once haemostasis is secure. Separately, an anticoagulant plus aspirin without an indication (no stent, acute coronary syndrome or arterial disease) increases major bleeding substantially without reducing stroke — the right response at an FY2 pre-assessment is to continue it for the operation and ask the pharmacist, anaesthetist or GP to review the indication, not to stop it on the day.
- Suspected TIA (NICE NG128, stroke and TIA in over 16s): rec 1.1.5 — refer immediately for specialist assessment and investigation, to be seen within 24 hours of symptom onset; rec 1.1.6 — do not use ABCD2 to decide urgency; rec 1.1.4 — aspirin 300 mg daily started immediately unless contraindicated. CKS (revised June 2026): TIA more than 7 days ago → TIA clinic within 7 days, no driving until seen, 999 for new symptoms. Anticoagulated patients with a TIA in the last 7 days need emergency admission for CT head to exclude haemorrhage. DVLA (neurological conditions): after a TIA, must not drive for one month but need not notify for a single Group 1 TIA. If the episode is confirmed as a TIA, her CHA₂DS₂-VASc rises from 4 to 6. A TIA while anticoagulated is a reason to look for a cause (adherence, dose, carotid disease) and for the surgical team and anaesthetist to reconsider the timing of elective surgery — their decision, after specialist review.
- Sick-day rules before surgery: an intercurrent illness with vomiting, diarrhoea or fever in the weeks before surgery is a reason to ring the clinic — medicines may need pausing (SGLT2 inhibitor, metformin, ACE inhibitor) and the date may need review. After hip replacement NICE NG89 recommends pharmacological VTE prophylaxis; in a patient already anticoagulated the ward’s plan for restarting apixaban replaces it, with prophylactic heparin only for the gap.
- Good practice: pre-operative instructions about medicines must be given in writing by the clinic (Royal College of Anaesthetists and CPOC pre-operative guidance); verbal advice from an FY2 is confirmed, not freelanced, and the anaesthetist decides the type of anaesthesia and the fasting plan. GMC Good medical practice (2024): work within the limits of your competence and make sure information is shared with those who need it — here the anaesthetist, the pharmacist and the surgeon, today.
Where candidates lose marks at this station
- Agreeing to “a week off the blood thinner, like last time”.
- Stopping metformin for days — or empagliflozin for a week.
- Never asking why she takes aspirin as well as apixaban.
- Not asking about stroke symptoms in a woman with atrial fibrillation.
- Hearing the twenty-minute arm-and-speech episode and saying “probably the heat”.
- Giving the plan from memory with nothing in writing.
Guidelines for this station
- UKCPA — Handbook of Perioperative Medicines: apixaban
- UKCPA — Handbook of Perioperative Medicines: empagliflozin
- UKCPA — Handbook of Perioperative Medicines: metformin
- UKCPA — Handbook of Perioperative Medicines: ramipril
- UKCPA — Handbook of Perioperative Medicines: aspirin
- Centre for Perioperative Care — Elective peri-operative management of adults taking GLP-1 receptor agonists, GIP agonists and SGLT2 inhibitors: multidisciplinary consensus (2025)
- El-Boghdadly K et al. — Elective peri-operative management of adults taking GLP-1 receptor agonists, GIP agonists and SGLT2 inhibitors: multidisciplinary consensus statement. Anaesthesia 2025 (primary source; check for updates)
- MHRA Drug Safety Update (March 2020) — SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgery or acute illness
- Centre for Perioperative Care — Guidelines and resources (including the 2021 guideline for perioperative care for people with diabetes)
- NICE NG128 — Stroke and transient ischaemic attack in over 16s: diagnosis and initial management
- NICE NG89 — Venous thromboembolism in over 16s: reducing the risk of hospital-acquired DVT or PE
6 · MLA content map tags for this case
| MLA content map | This station |
|---|---|
| Domain 1 · Areas of clinical practice | Perioperative medicine and anaesthesia · Cardiovascular · Endocrine, diabetes and metabolic |
| Domain 3 · Clinical and professional capabilities | Safe prescribing · Communication with patients, relatives and carers · Managing risk · Using guidelines and evidence · Chronic condition management plans |
| Domain 5 · Patient presentations | Peri-operative patient |
| Domain 6 · Conditions | Tachyarrhythmias (including atrial fibrillation, atrial flutter, supraventricular tachycardia, torsades de pointes, ventricular tachycardia, ventricular fibrillation) · Diabetes mellitus · Transient ischaemic attacks (TIA) |
| Station family | Explanation, counselling and breaking bad news — Explanation and counselling — medicines before elective surgery |
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 P2-30
Revision link for this case: mdacumen.com/plab-2-osce/case-30-pre-operative-assessment-tablets
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. This course never provides, and will never ask you to share, real GMC exam content — full regulatory statement: Legal & Regulatory.
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