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So I, I actually have a uh one second once again. Sorry, sorry, this is the last minute. Um I do have a presentation that I would like to share with you guys. It's on Ovarian torsion. So uh if you guys have any questions, please just save it for the end or whenever in the middle, if I ask you or if you really have to ask me a question, you can definitely ask me on that and I'll try my best to answer. So, so let me just get this up. Uh First of all, do any of you guys know uh or have heard of Ovarian torsion in? Yes, Mohammad. Yes. Mohammed Monica's okay. Okay. I'm going to try to share my screen here and then start just one moment. Okay. I've sorry, I'm working at a really old. All right. That's almost up my apologies for this delay. Yeah, just one moment. All right, I'm just trying to work on getting this share screen. I'm not sure why it's not working just um bear with me. Um All right. So some of you guys said that you guys know what um Ovarian torsion is. So what have you, um, learned or have you ever come into a clinical scenario with, uh, ovarian torsion? Mm. Never. Okay. All right. So it is a clinical emergency. I'll tell you guys that much and if you ever see it, um, it's actually, uh, it doesn't exactly present as, um, it should but I'm going to go through some things that, uh, will help you be able to identify it and then be able to treat it because um okay, so it's going to take a little time. I'm trying to do it at the same time here. Uh trying to put it up, right. All right. So I guess I'll show you my screen when it, when it's up. But as of right now, I want to go through this. So there's uh the objective for this class is going to be that by the end of it, you'll be able to understand what the condition is, how to identify it and be able to manage it. Okay. So the ovarian torsion actually affects 5% of the people that or the women that actually present to an emergency department. It will be presented as an acute abdomen. So if you guys know acute abdomen actually has um several different um uh diagnoses that can happen. There's differential diagnosis of many things that can present as. But when it comes to um identifying this, you have to be really um it has to, you have to be like point on to be like, okay, this is ovarian torsion and we have to check it and we have to get it corrected because if it's not, um, identified, you'll actually have to, um, well, it leads to further problems and the person that, uh, it's happening to actually can, uh lose their ovaries, one or the other or they can actually become infertile. So, um, and the, this actually happens to, um, like for Children that have just started uh to go into puberty. Uh Once again, is it showing it, is anything showing yet? OK. Fly. All right. So I'm gonna try to show it from my screen just one moment. I'm gonna try to do this way. It's not, it's not going on. So let's see if I can show it. Okay. That's fine. Okay. So sorry about this, but I'm going to try to do it this way so you can see it. Maybe it's all right. Hey Sana, it's Doctor Raymond here. I think the best thing is if you, if you read from your slides, if you pop your camera on, so people can see you if that's possible. And if you read from your slides and what we can do in the meantime, if you email them to us, I've asked your sister and we will try and get them on in a different way cause you're not managing. Yeah, I'm just trying actually just asking for the meeting code now in here to transfer it. Let me just okay, but it's not very steady views so it might be distracting for people. Yeah. Can I just have a few more seconds? So I'm going to try one more time. I'm not sure. Thank you. As I, I think we had it. Okay. Uh, can you hear me? Yes, I'm about to share my screen. Okay. Let's see. All right. I think if it doesn't work out, as we said before, if you just read out whatever you have on the slides and pop your camera on so people can see you. I think that will be fine. Yeah, I'll do that one moment. I think best to do that. Yeah. Okay. Are you able to do that, son? Are you? It's so diff it's difficult. Uh It looks like there is some issues on sharing screen but we do have um Doctor Sane. She will be um just going through her slides. Okay. Yeah. All right. My apologies. Sorry. Okay. Um I tried my best. Um but I'm having trouble here. Okay. Uh Let me go through this. Um I started out a thing where um the objectives for today or basically you'll be able to understand um what the condition is and you'll be able to identify and be able to manage it. Okay. So we'll also look at the causes the symptoms, the diagnoses of how to um find out what it is and um the treatment options that can come So, as I said, it was about 5% of the women that present to the, the uh emergency department will actually um come in with an acute abdomen where it could be a different thing. But you have to try to identify this because it's an emergency. So what is very interaction exactly? It's where you can see the ovaries. We have the uh the fallopian tubes when they go out like this, when you look at the fallopian tubes, they also have um the ovaries there. So the anatomy, if you look at the anatomy of it, uh they should be the fallopian tubes and you see the, the ovaries and then there's a ligament that actually are supporting ligaments for the uh the whole um uterine area. And what happens there is those ligaments actually start twisting off and they twist the ovaries and that cuts off the blood supply. And then this is where the emergency part. So this is where a prompt diagnosis is needed and um treatments are needed to prevent the loss of an ovary or even affecting, you know, both ovaries. Um So this is why it's an emergency. So I wish I could show you the how it looks. But um um I'm going to try to describe it as well as I can. So when it comes to the etiology of it, um or how it happens, uh the, it can actually happen from the, the surroundings because they become inflamed or um the ligaments when they're holding that you can see like here is um uh if we see the uterus and then there are the fallopian tubes and the ligaments that are behind that actually hold it. What happens is um you can have assist in the ovaries or a tumor growth or even an ectopic pregnancy. Can I actually cause this, the weight um of assist or um where it's uh I'm trying to say like where it starts taking in a lot of the, the water or uh having uh the drainage, having the weight of the cyst or the tumor or the pregnancy can actually start pulling on it and it will actually look like a torsion. So that's uh that's where the ovarian torsion comes in the name. And many uh things can actually cause that other than um these three things, but the most common ones would be these where you see an ectopic pregnancy, your c uh assist or a uh a tumor. But um even non um anything that actually causes uh like some type of, you know, water to come into that area or some type of um fluid to come into that area would make it loose and easy for the torsion to happen. And um the age groups that I was talking about earlier from 9 to 14 is when uh when when girls actually start becoming into puberty and that area hamza more fluid and because they're your, they're young, they actually, it's more loose and um it, and you know, it can actually twist that area. So, um there are, uh those have a lot of chances of happening around that time. But more than that, it would also go up to the women that are um at, at bearing age. So childbearing age that is when it can happen and when it comes to the development or like what, uh like the after uh torsion has happened, uh what happens to the, the blood supply to the area? And that, that effect is what is the real emergency. So when it twists, uh if I can, I don't know if I can show you this picture. But um let me see if I can, it would be a nice one. But let's see, I wanted to show you, is it focusing? So if you look this, actually, I don't know if you can see this, this white area is actually um the ovary and then the fallopian tube you can see comes this way, the back part there is that ligament. So this is normal and then when a torsion starts happening, it actually, if there's a cyst, it starts turning and eventually it becomes like a big ball where all of the uh you know, the fluids, the the oxygen supply, the blood supply is reduced, which in turn um is damaging or leading to damage to the tissues. And necrosis is happening. The death of the cells or the tissue in the area. So that is the reason that it, it causes uh the ovaries to either um partially be roomed or generally they, they take out the whole ovary or it depends on if there's polycystic. Um and there these assists caused on both sides or there's many tumor's. Um that also would be a really, you know, um a cause of it. So the signs and symptoms of this, as I said, there's many differential diagnoses of you'll come with an acute abdomen, but the things that you need to look for are the pain. It can be on both sides, but generally ends up being on one side. Um because uh there are, you know, that, that twisting has caused it to uh have uh that sharp pain will be in that area and because of the, that it would cause nausea and then eventually vomiting. Now, fever would be caused also because of the amount of pain that the body is going through. And then there would be an abdominal swelling, the pain, um maybe intermittent meaning it would come and go, but eventually it becomes constant. And um, and that, um really, uh when you see that in this age range, you start thinking okay, we need to find out what it is. Most likely it could be that and when and also different symptoms could be where the, where the pain on which side it is starts um becoming uh too much for them to bear. So, so then in that their bowel movements, um, there's a change in that as well. And then you really have to just, um, you know, do a scan and the scan is after a physical exam first, you'll see the little swelling, you can see the pain area and then you would go for imaging and soon as you do imaging, you would be able to see the classical signs of it. You'll actually see, uh, the area to be twisted. It's a whirlpool sign. So even in your, your exams, you see the Whirlpool sign and an engorged, uh, ovary, that those are the key words that you would be looking for, for it to be a, a torsion, so enlarged ovary and, um, or engorged, they use those words and the world pool signs in a ct scan of the ovaries or, um, you will be able to, to identify it like that. And once it's identified, most likely, and generally it has to be, it will be a surgery where they Untwist ID and once they Untwist ID, they would be able to see if it's going to be, um, if they have to remove all of it or if it's become necrosis or, or not. So, let me quickly see if I can show you this. I know it might be a little difficult. See this is the ovary and if you see this, it's not normal, like it's twisted. So that, and when you see it on the CT scan, you will, you would see it like around area and it's just enlarged and you won't really see the blood supply because generally you would also look for the blood blood supply there won't be much blood supply there because it's being, uh, cut off. So, if you see that, actually, I don't know if you understand if I can show you there that right there, um, is where the ultrasound would, um, would really, um, you know, be able to identify right away. And then next steps, take it to the surgery and untwist it and then the severity of the damage and the necrosis will be determined at that point. I actually have a case here, um, that I wanted to share with you guys. Um, I'll give you guys the, the option or I'll go through it. So if, how it would present in an emergency department. So, if a 27 year old I'm going to go through this, um, case, uh, presents with an acute onset of right pelvic pain nausea. So, these are the things you're looking for. There's pelvic pain in that area, nausea and has start and said that it started six hours ago. It was almost like constant pain and it comes off and on. But it's, it's there like she can't, um, say that she didn't have pain. So you have to look for them she reports too prior episodes of this similar pain. But the symptoms of this episode resolved within an hour, see when that happens, this person is more likely to have um uh this Torshin because it happened before. So there was a reason that it just untwist it on its own probably. But this time it's six hours of constant pain and now she's feeling nauseous. So these are the keywords that you have to kind of look for on the examination also. So one on the examination, she appeared uncomfortable and mildly Tecca Kartik, obviously because of the pain um and tenderness and fell on palpitation of the area. And um I see there's some questions all at once a day and uh when you do the examination, you do a CT scan, uh ovarian torsion is found. So the most likely um thing that you would see on there is on the CT scan in order to find that it is ovarian torsion would be uh the ovaries, enlargement, the enlargement of that area. Okay. Um One second. So I had some, I think I have some questions, right? How differentiated between appendicitis? Okay. Yeah. All right. So this is a good question. Pattama appendicitis, you actually, when you feel the abdomen area, you will not um there won't be much um swelling there. It like this. When you see a a torsion, you would actually find it much uh elevated like the swelling will be there it'll be, it could be even kind of like um describing if, you know, ascites, you know, uh that area would be feeling like it has fluid in it. But when it comes to peasants, itis, um the person also will be kind of like in a fetal position, they won't want to open up. But in this, they do have pain but they, they are with acute abdomen, you can actually open up and show it like this and the pain is different and they would be actually able to walk around. Um but not in, in uh appendicitis. It would be like, you know, you're picking up a huge person with a feeding, that's a fetus. So that is their end with also with um appendicitis. The pain can actually radiate to the uh umbilical area. So, and it will have tenderness. Um can it present in both? Yes, it can present in growth though. That is rare. Um And any more questions like that I missed. Uh No, it's there. Okay. So I'm going to go on to the, this next one. I would like to show you guys a quick reminder, Doctor Senna. Um and everyone, uh we do have about seven minutes left. We do apologize for the technical difficulties before um just giving it a reminder, all of the links are in the chat as well and I will put in my presentation, I'll be sending it to them so that you guys can go through it. It's actually um it's quite, just simple and I did put some references there that are good to read up on this. Um Okay. So, uh the treatment, um as I said, when it comes to treatment, you would um have to go for surgery and generally they do laproscopic, they don't do a full open. So in laproscopic, you can go through and one second, let me show you this. I will put this up where this ovary it's necrotic right there. So they came in and then they will untwist it. That's the first thing to do is untwist it and then they will cut it off and then suture it up. So you'll be able to see this. Once I send to the, um, the presentation, you'll see it. So it has to be promptly removed, untwist it. And once you untwist it, the second phase is that they have to decide whether they're going to remove it or they just have to remove some tissues. And just depends on how fast it was discovered. And there's also ways you can prevent it when it's, um, women that have had this, um, portion. They, and they've gone through the untwisting of it and maybe their, their ovaries were saved or, and they can actually, um, have it once they're past the stage or they have to, uh, either decide whether they want to have their ovaries removed this with, they would have to consult it, and it's all case by case. So if this is in the case of, if they have a history of this in their family or if they have a history of it in, um, in their own case that they've had it before and then again it presents. So that's, um, one thing to do to prevent it. Now, when it comes to other high risk women, it's basically if they have, uh, cysts or tumor's or if they have, um, you know, uh some type of family history of a cancer in that area that is a growth cancer also that can also cause these, um, that's the most prevention's that can happen. All right. So I have like five minutes, I think, um I'm going to go through uh just some key points that I want you guys to remember uh, the ovarian torsion. It is uh an emergency. So most likely it would be presented in um the emergency department. It is a rare um, incident like it can happen rarely, but it is something that does happen. So whenever it happens, it is an emergency and remember that it's the twisting of the ovaries around the supporting ligaments. Okay. And what happens is the cut off of the blood supply things to remember in um uh anything like uh Whirlpool, uh sign on a CT scan in that area or blood. Um You can see that's the twisting actually, you see, and the engorgement of the ovaries, uh, that is, um, clinical presentation on the CT scans. And if that, when you ask for history, if they say, if they say they have, um, you know, they're, they have polycystic or if they have a one or two cyst somewhere in that area, then you have to start thinking okay, this, it could be most likely this because it's showing as acute Abdin. And, uh, if they said they have tumor's or if they, they, that they might be pregnant because they have taken a test and suddenly this is hurting. So then you have to look for ectopic pregnancy. And then actually, at the same time, you would look for this because it would, um, present that way as well. Um, any sudden pelvic pains, these are the symptoms to look for, uh, nausea and vomiting fever is usually due to, uh, that pain, not because of infection, uh, abdominal swelling. So this is the difference between that and, um, the appendicitis appendicitis, it could be even flat. So you won't even know, um, if it is swollen because of that, you know. So there's the swelling is the most, um, different thing. And also in the umbilical umbilical area, you would feel you can actually, the radiation pain can happen for appendicitis, not for, um, this, it, it might be just the whole area that will be swollen for, um, uh, ovarian torsion and remember it has to be prompt. Um, surgery has to happen and untwisting and then they determine what they want to do with it. Depending on, depending on how much there is damage. Or if there's much damage and management with, after, you know, surgery, it would be depending on if they did, um, just twisting or if they removed it accordingly, they would get their medications for that. And, um, there are two sources, um, that I've gone through in this and that, um, that I used, the references are from, uh, the American College of Obstetrics and, uh, the OBGYN. And I've put the reference there and there's another website for ovarian torsion. Um, and I've put that as well here. So that right there, I would like to wrap up with any, any questions you guys have. I hope you guys had a good learning experience in this. And, uh, I'm sorry for if, if there were any shortfalls from my side, technical difficulties because I, I wasn't able to put it up. But hopefully, I hope you get through and see these, um, uh, slides and it would help you guys to, um, um, to know, to put in, you know, the presentation. If you see it, it will help you a lot on there. Okay. Any else anybody else? Um All right. Thank you. Thank you so much, Doctor Sana. Uh, perfect timing. Um, everyone who participated. Thank you and thank you for your patience while we had some technical difficulties in, in the middle. Um I have posted the certificate, you can download it and you can edit it. Um And I have posted the whatsapp link for the group as well. If you haven't already joined, please do join all the information will be, the slides will be emailed to you as well as um uh there will be a link posted in the group as well. So do keep an eye out for that. Um And thank you guys for joining. Huge. Thank you uh to Sana Hussein who has been absolutely brilliant in stepping in uh at short notice because unfortunately, our original lecturer had quite a few technical difficulties and could not join. Uh And we usually appreciate her input. It was an excellent lecture and now without further ado do, we will start our next lecture. Thank you very much.