Dr Qamar Shahzad Joia General Surgeon

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Dr Qamar Shahzad Joia General Surgeon qamarjoia@gmail.com

Alvarado Score for Acute Appendicitis
16/02/2026

Alvarado Score for Acute Appendicitis

Differential Diagnosis of a Neck Lump (Based on Cervical Lymph Node Levels)Evaluation of a neck lump with anatomical lo...
08/02/2026

Differential Diagnosis of a Neck Lump (Based on Cervical Lymph Node Levels)
Evaluation of a neck lump with anatomical localisation according to cervical lymph node levels, as each region has characteristic differential diagnoses.

IA (Submental)
Common causes include:
-Reactive/enlarged lymph node
-Thyroglossal duct cyst
-Dermoid cyst
-Plunging ranula

IB (Submandibular)
Differentials include:
-Submandibular gland pathology (sialadenitis, neoplasm)
-Lymphadenopathy
-Cystic hygroma / lymphangioma (may involve extensive neck spaces)

II (Upper Jugular)
Important considerations:
-Metastatic or reactive lymph node
-Parotid gland pathology
-Branchial cleft cyst
-Parapharyngeal space lesions (e.g., paraganglioma, nerve sheath tumours)

III (Mid Jugular)
Possible causes:
-Lymph node enlargement
-Branchial cyst
-Parapharyngeal pathology
-Laryngocoele

IV (Lower Jugular)
Includes:
-Lymphadenopathy
-Virchow’s node (left-sided) suggesting possible abdominal/thoracic malignancy

V (Posterior Triangle)
Differentials:
-Lymph node enlargement
-Lipoma
-Cervical rib

VI (Anterior Compartment)
Usually related to thyroid and central neck structures:
-Thyroid gland pathology
-Thyroglossal duct cyst
-Parathyroid neoplasm
-Lymph node metastasis
-Direct extension of laryngeal malignancy

A structured approach based on neck level anatomy helps narrow the differential diagnosis and guides appropriate investigations such as ultrasound, FNAC, and cross-sectional imaging.

NIPAH VIRUS INFO
30/01/2026

NIPAH VIRUS INFO

ACG- Quality Indicators for ERCPAnderson, et al.📕 doi.org/10.14309/ajg.0…
29/01/2026

ACG- Quality Indicators for ERCP
Anderson, et al.
📕 doi.org/10.14309/ajg.0…

It is important to know how long the small bowel limbs are
29/01/2026

It is important to know how long the small bowel limbs are

To all surgical interns and residents 👨‍⚕️👩‍⚕️, confidence in the operating room starts with preparation. 🎬 BEFORE FIRST...
29/01/2026

To all surgical interns and residents 👨‍⚕️👩‍⚕️, confidence in the operating room starts with preparation. 🎬 BEFORE FIRST CUT is a new YouTube channel dedicated to real surgical learning—focusing on core concepts, clinical clarity, and building true confidence before you step into the OR. Launching soon 🚀, by Dr. Qamar Shahzad. Stay connected and be ready to learn where every great surgery begins.

Scalpel-holding position . Dinner knife position-Scalpel is held like a table knife-Handle rests in the palm with the in...
07/01/2026

Scalpel-holding position
. Dinner knife position
-Scalpel is held like a table knife
-Handle rests in the palm with the index finger extended along the blade
-Provides strong grip,control and power
-Used for lengthy, firm incisions (e.g. skin, fascia)

. Pen holding position/ Written position:
-Scalpel held like a pen between thumb, index, and middle fingers
-Wrist and fingers allow fine, controlled movements
-Used for precise and superficial incisions,over vessels/ nerves/ tumour
- Widely use in head neck surgery.
-Common in plastic and delicate surgeries like skin flap

. Fiddle bow position
-Scalpel held lightly between thumb and fingers, similar to holding a violin bow
-Ring finger often rests on the surface for stability
-Use to make incisions with less pressure on delicate structures.
-Less pressure, fine dissection is done with firm grip.
-Used in fine dissection and near vital structures

. Stab position
-Scalpel held vertically with a firm grip
-Blade directed perpendicular to the surface
-Used for puncture incisions (e.g. abscess drainage, trocar entry)
-No 11 blade is usually use.

Diagnosis of Acute AppendicitisAcute appendicitis is primarily a clinical diagnosis supported by laboratory and imaging ...
30/12/2025

Diagnosis of Acute Appendicitis

Acute appendicitis is primarily a clinical diagnosis supported by laboratory and imaging findings. The aim is to identify the disease early while minimizing unnecessary negative appendicectomies.

History:

Pain characteristics: Typically starts as vague, peri-umbilical pain migrating to the right iliac fossa (RIF) due to visceral → parietal peritoneal irritation (The initial pain is visceral in origin, referred via T10 (same dermatome as the umbilicus).

As inflammation spreads and irritates the parietal peritoneum overlying the appendix, the pain localizes to the RIF.

Associated symptoms: Nausea, vomiting, anorexia, low-grade fever.

Differential pointers:

Upper respiratory or urinary symptoms may suggest alternative pathology.

Detailed gynaecological history and pregnancy test essential in women of child-bearing age — pregnancy must be excluded first.

Ask about bowel changes and family history of inflammatory bowel disease.

Clinical Scoring:

Alvarado score (Migration, , Nausea, Tenderness, Rebound, Elevated temperature, Leukocytosis, Shift to left) may guide decisions but is not diagnostic.

Primarily used to support admission vs discharge decisions in borderline cases.

Examination:

Typical findings:

RIF tenderness

Rebound tenderness

Rovsing’s sign: RIF pain when pressing LIF

Psoas sign: Pain on right hip extension suggests retrocecal appendix

Obturator sign: Pain on internal rotation of flexed right hip (pelvic appendix)

Cough test: Localizes peritoneal irritation
These signs support, but none are individually diagnostic.

Investigations

Bloods: Neutrophilia and elevated CRP support inflammation, but normal values do not exclude appendicitis.

Urine dipstick: Exclude UTI; pregnancy test mandatory in women of reproductive age.

Imaging

Ultrasound:

First-line in females to rule out tubo-ovarian pathology.

Limited utility in males except in equivocal cases.

CT scan:

Highly accurate but use selectively.

Use caution in young patients (radiation).

Low threshold in patients >40 years to exclude malignancy or identify alternate causes.

Clinical judgment remains central. Scores, labs, and scans support but never replace bedside assessment.

Based on ultrasound reports a tubular blind dilated structure seen in the RIF with mild fluid around denoting likely appendicitis, the patient is been booked and consented for laparoscopic appendicectomy, a 36 years old male, 2/7 history of RIF pain, examined the patient very mildly tender RIF no rebound, not clinically convinced, CRP 20, WCC 11.9, normal Urine Dip

To resolve this, patient has been offered watchful waiting till tomorrow with re-examine and re-blood tests, vs CT AP, they opted CT Abdo pelvis which luckily showed no acute appendicitis, and patient went home.

SHARP - ProtocolThe pain in the right zduhvinníj area in a young woman is still that quest. The highest number of negati...
28/12/2025

SHARP - Protocol

The pain in the right zduhvinníj area in a young woman is still that quest. The highest number of negative appendectomies are in female patients, so always be careful with the diagnosis when examining.

Smart doctors thought of and invented the SHARP protocol:
S - Size of O***y
H - Hydronephrosis
A - Appendicitis
R - RUQ free fluid
P - Pregnancy

S - size. The dimensions of an ovarian. Over 5cm itself o***y (turn), additional structure (cyst, formation? )
H - Hydronephrosis (expansion of the kidney bowl), indicates the kidney block, from which there may be kidney colic.
A - appendix (thickened, tubular structure by over 6 mm) - indicates appendicitis.
R is fluid in the upper right quadrant, Morrison's pocket
(hemoperitonium, perforative expression and more.
P - pregnancy (gestacíjnij bag and more)

Experienced doctors have done it all anyway, but the algorithm will allow you to expand the horizons of your initial examination.
Source: https://ojs.library.queensu.ca/index.php/pocus/article/view/18493/12934

Small bowel obstruction 🆚 Large bowel obstruction
14/12/2025

Small bowel obstruction 🆚 Large bowel obstruction

Zones of the Neck (for Cervical Trauma)Neck contains 3 main anatomic systems:1.Vascular: carotid, vertebral, subclavian ...
14/12/2025

Zones of the Neck (for Cervical Trauma)

Neck contains 3 main anatomic systems:
1.Vascular: carotid, vertebral, subclavian arteries; jugular & subclavian veins
2.Digestive (aerodigestive): pharynx, oesophagus
3.Respiratory: larynx, trachea

Classification :Roon & Christensen Classification (Most used)
Neck divided into 3 trauma zones
All zones contain major vascular & aerodigestive structures
Zones I and III injuries are harder to evaluate and operate.

Zone Boundaries
Zone I
Sternal notch / clavicle → cricoid cartilage
Lower neck / thoracic inlet area

Zone II
Cricoid cartilage → angle of mandible
Mid-neck

Zone III
Angle of mandible → base of skull
Upper neck

Clinical importance
Zones I & III = more diagnostic + surgical challenge
(due to deep location and difficult access)

Address


Opening Hours

Monday 09:00 - 17:00
Tuesday 09:00 - 17:00
Wednesday 09:00 - 17:00
Thursday 09:00 - 17:00
Friday 09:00 - 17:00
Saturday 09:00 - 17:00

Telephone

+923009455521

Website

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