Patient 1 – A 26-year-old woman presents to her primary care physician for an annual exam. She currently does not have any acute concerns and says her health has been generally well. Medical history is significant for asthma, which is managed with an albuterol inhaler. Her last pap smear was unremarkable. She is currently sexually active with one male and consistently uses condoms. She occasionally smokes marijuana and drinks wine once per week. Her mother recently passed away from advanced ovarian cancer. Her sister is 37-years-old and was recently diagnosed with breast cancer and ovarian cancer. Physical examination is remarkable for a mildly anxious woman. Patient 2 – A 27-year-old woman presents to her primary care physician for an annual exam. She says that she would like to be screened for breast cancer since two of her close friends were recently diagnosed. She noticed she has a small and mobile mass on her left breast, which increases in size and becomes tender around her time of menses. Family history is remarkable for hypertension in the father. The physical exam is significant for a small, well-defined, and mobile mass on her left breast that is not tender to palpation. Which of the following is the best next step in management for patient 1 and 2?

Patient 1 – BRCA testing. Patient 2 – Breast ultrasound

Patient 1 – Breast ultrasound. Patient 2 – Return in 3 months for a clinical breast exam

Patient 1 – Reassurance. Patient 2 – Breast ultrasound

Patient 1 – CA-125 testing. Patient 2 – BRCA testing

Patient 1 – Breast and ovarian ultrasound. Patient 2 – Mammography

A 32-year-old man visits his primary care physician for a routine health maintenance examination. During the examination, he expresses concerns about not wanting to become a father. He has been sexually active and monogamous with his wife for the past 5 years, and they inconsistently use condoms for contraception. He tells the physician that he would like to undergo vasectomy. His wife is also a patient under the care of the physician and during her last appointment, she expressed concerns over being prescribed any drugs that could affect her fertility because she would like to conceive soon. Which of the following is the most appropriate action by the physician regarding this patient's wish to undergo vasectomy?

Explain the procedure's benefits, alternatives, and potential complications

Refer the patient to a psychotherapist to discuss his reluctance to have children

Discourage the patient from undergoing the procedure because his wife wants children

Insist that the patient returns with his wife to discuss the risks and benefits of the procedure together

Call the patient's wife to obtain her consent for the procedure

A 62-year-old woman presents to her primary care physician for a routine physical exam. The patient has no specific complaints but does comment on some mild weight gain. She reports that she recently retired from her job as a math teacher and has taken up hiking. Despite the increase in activity, she believes her pants have become "tighter." She denies headaches, urinary symptoms, or joint pains. She has a history of hypertension, type 2 diabetes, and rheumatoid arthritis. Her medications include aspirin, lisinopril, rovastatin, metformin, and methotrexate. She takes her medications as prescribed and is up to date with her vaccinations. A colonoscopy two years ago and a routine mammography last year were both normal. The patient’s last menstrual period was 10 years ago. The patient has a father who died of colon cancer at 71 years of age and a mother who has breast cancer. Her temperature is 98.7°F (37°C), blood pressure is 132/86 mmHg, pulse is 86/min, respirations are 14/min and oxygen saturation is 98% on room air. Physical exam is notable for a mildly distended abdomen and a firm and non-mobile right adnexal mass. What is the next step in the management of this patient?

Exploratory laparotomy and debulking

Four hours after undergoing an abdominal hysterectomy, a 43-year-old woman is evaluated in the post-anesthesia care unit because she has only had a urine output of 5 mL of blue-tinged urine since surgery. The operation went smoothly and ureter patency was checked via retrograde injection of methylene blue dye mixed with saline through the Foley catheter. She received 2.4 L of crystalloid fluids intraoperatively and urine output was 1.2 L. She had a history of fibroids with painful and heavy menses. She is otherwise healthy. She underwent 2 cesarean sections 8 and 5 years ago, respectively. Her temperature is 37.4°C (99.3°F), pulse is 75/min, respirations are 16/min, and blood pressure is 122/76 mm Hg. She appears comfortable. Cardiopulmonary examination shows no abnormalities. There is a midline surgical incision with clean and dry dressings. Her abdomen is soft and mildly distended in the lower quadrants. Her bladder is slightly palpable. Extremities are warm and well perfused, and capillary refill is brisk. Laboratory studies show: Leukocyte count 8,300/mm3 Hemoglobin 10.3 g/dL Hematocrit 31% Platelet count 250,000/mm3 Serum _Na+ 140 mEq/L _K+ 4.2 mEq/L _HCO3+ 26 mEq/L _Urea nitrogen 26 mg/dL _Creatinine 1.0 mg/dL Urine _Blood 1+ _WBC none _Protein negative _RBC none _RBC casts none A bladder scan shows 250 mL of retained urine. Which of the following is the next best step in the evaluation of this patient?

Return to the operating room for emergency surgery

Perform ultrasound of the kidneys

Administer 20 mg of IV furosemide

Administer bolus 500 mL of Lactated Ringers

A 39-year-old man presents with painless swelling of the right testis and a sensation of heaviness. The physical examination revealed an intra-testicular solid mass that could not be felt separately from the testis. After a thorough evaluation, he was diagnosed with testicular seminoma. Which of the following group of lymph nodes are most likely involved?

Superficial inguinal lymph nodes (lateral group)

Superficial inguinal lymph nodes (medial group)

A 54-year-old male carpenter accidentally amputated his right thumb while working in his workshop 30 minutes ago. He reports that he was cutting a piece of wood, and his hand became caught up in the machinery. He is calling the emergency physician for advice on how to transport his thumb and if it is necessary. Which of the following is the best information for this patient?

Wrap thumb in saline-moistened, sterile gauze and place in sterile bag

Place thumb in cup of cold milk

Wrap thumb in sterile gauze and submerge in a cup of saline

There is no need to save the thumb

Place thumb directly into cooler of ice

Ovarian cystectomy and oophorectomy for USMLE Step 2 CK: High-Yield Surgery Lessons

🗺️ Anatomy - Know Your Globes

Location: Ovaries reside in the ovarian fossa on the lateral pelvic wall.
Key Ligaments:
- Suspensory (IP) Ligament: Connects ovary to pelvic wall. Contains the ovarian artery, vein, nerves, and lymphatics.
- Ovarian Ligament: Connects ovary to the uterus.
Blood Supply:
- Artery: Ovarian artery (from abdominal aorta).
- Vein: Right ovarian vein → IVC; Left ovarian vein → Left renal vein.

Female Pelvic Anatomy: Ovaries, Ligaments, and Ureter

⭐ "Water under the bridge": The ureter passes under the ovarian vessels at the pelvic brim. It is at high risk of injury during oophorectomy when clamping the IP ligament.

🧐 Clinical manifestations - Cystic Conundrums

Asymptomatic: Most common; often an incidental finding on imaging.
Symptomatic (Non-acute):
- Dull, aching pelvic pain or pressure.
- Bloating, early satiety, dyspareunia.
- Menstrual irregularities (e.g., from hormone-producing cysts).
Acute Complications (Surgical Emergencies):
- Torsion: Sudden, severe unilateral pain, nausea/vomiting.
- Rupture: Abrupt pain onset, potential peritoneal signs.
- Hemorrhage: Into cyst or peritoneum, may cause hypovolemia.

⭐ Ovarian torsion is a "don't miss" diagnosis. Risk ↑ with cysts >5 cm. Doppler US may show decreased or absent blood flow (whirlpool sign).

🧐 Diagnosis - Peeking at Pelvis

Initial Imaging: Transvaginal Ultrasound (TVUS) is the primary modality to characterize adnexal masses.
- Benign Features: Simple, unilocular, thin-walled, anechoic, no solid components, typically <10 cm.
- Suspicious Features: Complex (solid & cystic), thick septations (>3 mm), papillary projections, solid nodules, increased vascularity on Doppler, ascites.

Transvaginal US of complex ovarian cyst features

Tumor Markers: Used adjunctively, not for screening.
- CA-125: Elevated in epithelial ovarian cancer.
- Germ Cell Tumors: Consider AFP, β-hCG, LDH in younger patients.

⭐ CA-125 is most useful in postmenopausal women. In premenopausal women, it's non-specific and can be elevated by endometriosis, fibroids, or PID.

✂️ Management - Snip or Spare?

Ovarian Cystectomy (Spare):
- "Shells out" the cyst, preserving ovarian tissue.
- Goal: Maintain fertility & hormonal function.
- Indicated for: Benign-appearing cysts (e.g., dermoid, endometrioma) in premenopausal women.
Salpingo-oophorectomy (Snip):
- Removal of ovary and fallopian tube.
- Indicated for: High suspicion of malignancy, most masses in postmenopausal women, or necrotic ovary post-torsion.

⭐ Intraoperative Frozen Section: Crucial for suspicious masses. If malignancy is found, the procedure may be staged to a full gynecologic cancer surgery (e.g., hysterectomy, BSO, lymphadenectomy).

Types of Oophorectomy Procedures

⚠️ Complications - Post-Op Pitfalls

Hemorrhage: From the ovarian pedicle (infundibulopelvic or utero-ovarian ligament).
Adjacent Organ Injury: High risk to the ureter, which runs near the infundibulopelvic ligament; also bladder, bowel.
↓ Ovarian Reserve: Inadvertent removal of healthy tissue during cystectomy, impacting fertility.
Surgical Menopause: Abrupt onset with bilateral oophorectomy (BSO) in premenopausal women.
Adhesions: Can cause chronic pain or bowel obstruction.

⭐ Ovarian Remnant Syndrome (ORS): Presents as cyclical pelvic pain post-BSO. Diagnosed via imaging and labs (↓FSH, ↑estradiol) confirming functional remnant tissue.

⚡ Biggest Takeaways

Cystectomy is the standard for premenopausal women to preserve fertility and ovarian function, especially for benign-appearing cysts.

Oophorectomy is indicated for high suspicion of malignancy, complex masses in postmenopausal women, or a non-viable torsed ovary.

Laparoscopy is the preferred surgical approach over laparotomy due to lower morbidity.

Ovarian torsion is a surgical emergency requiring prompt detorsion; cystectomy or oophorectomy is performed based on ovarian viability.

Bilateral oophorectomy induces surgical menopause; counsel on and consider hormone replacement therapy.

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