Pre-operative assessment clinic — communication and optimisation station

Mrs Pamela Wright, a 64-year-old woman, is referred to the pre-admission clinic for elective total abdominal hysterectomy and bilateral salpingo-oophorectomy for a 14-week fibroid uterus causing menorrhagia and pressure symptoms. Past history: type 2 diabetes on metformin (HbA1c 8.6 percent), hypertension on atenolol, previous myocardial infarction 5 years ago, BMI 33, current smoker 15 cigarettes per day for 35 years, alcohol 8 standard drinks per week, Hb 96 g/L, ferritin 22 microgram per litre, creatinine 158 micromol per litre. She lives alone, walks with a stick, and reports she cannot climb two flights of stairs without stopping. She has never had an operation and is anxious about 'going under'. You are the registrar in the pre-admission clinic; the consultant is in the next room and the anaesthetist is available by phone.