A girl was married at the age of 15 years to a man who was marrying for the second time as his first wife had expired. The man had no children with the first wife.


                   She had regular menstrual cycles of 30 days with 3 days of moderate blood loss. Inspite of regular cycles she could not conceive for many years. She consulted a doctor who prescribed her medications to conceive but her husband did not want her to take the medications and conceive, so he threw the medications. The couple has no not conceived a child since then. 

                                       The lady at the age of 45 years developed shortness of breath on exertion for 2 months followed by pain in the ?left hypochondrium ? left thoracic cavity  which was stabbing type for 1 month. The pain aggravated on walking and had no relieving factors. She was taken to a hospital where she was told that she had pericardial effusion and needed to get operated. She was evaaluated, a 2D echo was done which showed a tricuspid stenosis, Mitral regurgitation.

                                            4 days later she was operated via a midline sternal incision and the mitral valve was replaced by a artificial valve. She was started on medications which she was regukarky taking since then.

                                             Since the past 1 year she has not been mensturating. She noticed darkening of her complexion since the past 2-4 months. Later now since 20 days she developed facial puffiness, nausea on and off episodes of cough followed by abdominal distention which was gradual in onset. Also complained of pedal edema which was pitting in type and decreased urine output . Complains of shortness of breath initially on exertion but later progressed to shortness of breath even at rest. She later complained of irregular bowel habits with hard stools every 2-3 days since 5 days. The abdominal distension gradually increased in the past 20 days.

General Examination:

The patient is conscious, oriented with 
facial puffiness
elevated JVP
distended neck veins
abdominal distension
pedal edema 

VITALS
Temperature: Afebrile
Blood pressure: 100/60 mmhg in the supine position in the right arm
Pulse Rate: 68 bpm in the right radial artery
Respiratory rate: 22 cycles per minute


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