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Step 1: View clinicals

A 40 year old lady presents with intermittent vaginal bleeding and irregular menstruation for two months. She also complains of an intermittent non-productive cough for six months. She has had two previous pregnancies, which were uncomplicated. Her last delivery was approximately a year ago. She is not on any contraceptives.

Step 2: Order all relevant investigations

Transvaginal Ultrasound Scan

An ill-defined intrauterine mass is noted. Multiple small and unilocular cysts are noted in both ovaries.

Chest X-Ray

The chest x-ray shows a few shadows in both lung fields.

Tuberculin test & Sputum smear

The tuberculin test is negative. 3 early morning sputum smears are obtained (following nebulization) - all are negative for acid-fast bacilli.

Serum beta-hCG levels

The serum beta-hCG level is 450,000 mIU/ml (normal range in non-pregnant females: < 5.0 mIU/ml)

Step 3: Select appropriate management

Pelvic Radiotherapy
Exploratory laparotomy
Antituberculous therapy

Score: ★★☆