Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 5. Lymphatic System

EQUIPMENT

image Centimeter ruler

image Skin-marking pencil

EXAMINATION

The lymphatic system is examined by inspection and palpation, region by region, during the examination of other body systems, as well as with palpation of the spleen.

Lymph Nodes Most Accessible to Inspection and Palpation

The more superficial the node, the more accessible it is to your palpation.

“Necklace” of Nodes

Parotid and retropharyngeal (tonsillar)

Submandibular

Submental

Sublingual (facial)

Superficial anterior cervical

Superficial posterior cervical

Preauricular and postauricular

Occipital

Supraclavicular

Arms

Axillary

Epitrochlear (cubital)

Legs

Superficial superior inguinal

Superficial inferior inguinal

Occasionally, popliteal

TECHNIQUE

FINDINGS

HEAD AND NECK

Inspect visible nodes

Ask if patient is aware of any lumps.

UNEXPECTED:Edema, erythema, red streaks, or lesions.

image

Palpate superficial nodes; note size, consistency, mobility, tenderness, warmth

Bend patient’s head slightly forward or to side. Palpate gently with pads of second, third, fourth fingers.

 

HEAD AND NECK

image Occipital nodes at base of skull

image Postauricular nodes over mastoid process

image Preauricular nodes in front of ears

image Parotid and retropharyngeal nodes at angle of mandible

image Submandibular nodes between angle and tip of mandible

image Submental nodes behind tip of mandible

EXPECTED:Nodes accessible to palpation but not large or firm enough to be felt.

UNEXPECTED:Enlarged, tender, red or discolored, fixed, matted, inflamed, or warm nodes; increased vascularity.

image

NECK

image Superficial cervical nodes at sternocleidomastoid

image Posterior cervical nodes along anterior border of trapezius

image Deep cervical nodes along anterior border of trapezius

EXPECTED:Nodes accessible to palpation but not large or firm enough to be felt.

UNEXPECTED:Enlarged, tender, red or discolored, fixed, matted, inflamed, or warm nodes; increased vascularity.

imageSupraclavicular areas
If enlarged nodes are found, inspect regions drained by nodes for infection or malignancy and examine other regions for enlargement.

UNEXPECTED:Detection of Virchow nodes.

Note: A palpable supraclavicular node should always make you suspect the probability of a malignancy.

image

AXILLAE

Inspect visible nodes

Ask if patient is aware of any lumps.

UNEXPECTED:Edema, erythema, red streaks, or lesions.

Palpate superficial nodes for size, consistency, mobility, tenderness, warmth

Using firm, deliberate, gentle touch, rotate fingertips and palm.

 

Attempt to glide fingers beneath nodes.

 

Axillary nodes

Support patient’s forearm with your contralateral arm, and bring palm of examining hand flat into axilla.

If enlarged nodes are found, inspect regions drained by nodes for infection or malignancy, and examine other regions for enlargement.

EXPECTED:Nodes accessible to palpation but not large or firm enough to be felt.

UNEXPECTED:Enlarged, tender, red or discolored, fixed, matted, inflamed, or warm nodes; increased vascularity.

image

OTHER LYMPH NODES

Inspect visible nodes

Ask if patient is aware of any lumps.

UNEXPECTED:Edema, erythema, red streaks, or lesions.

Palpate superficial nodes for size, consistency, mobility, tenderness, warmth

Systematically palpate other areas, moving hand in circular fashion, probing without pressing hard.

EXPECTED:Nodes accessible to palpation but not large or firm enough to be felt.

UNEXPECTED:Enlarged, tender, red or discolored, fixed, matted, inflamed, or warm nodes; increased vascularity.

imageEpitrochlear nodes
Support elbow in one hand while exploring with other.

 

image

imageInguinal and popliteal area
Have patient lie supine with knee slightly flexed.

 

image image

If enlarged nodes are found, inspect regions drained by nodes for infection or malignancy and examine other regions for enlargement.

 

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Acute lymphangitis

Subjective Data:Pain, malaise, illness, possibly fever.

Objective Data:Red streak (tracing of fine lines) may follow course of lymphatic collecting duct. Inflamed area indurated and palpable to gentle touch. Related infection possible distally, particularly interdigitally.

Non-Hodgkin lymphoma

Subjective Data:Painless enlarged lymph node(s); fever, weight loss, night sweats, abdominal pain or fullness.

Objective Data:Nodes may be localized in the posterior cervical triangle or may become matted, crossing into the anterior triangle nodes; usually well defined and solid.

Hodgkin disease

Subjective Data:Painless progressive enlargement of cervical lymph nodes. Generally asymmetric.

Objective Data:Nodes sometimes matted and generally very firm, almost rubbery.

Epstein-Barr virus; mononucleosis

Subjective Data:Pharyngitis, fever, fatigue, malaise.

Objective Data:Frequently splenomegaly and/or rash. Palpable nodes generalized but more commonly in anterior and posterior cervical chains. Nodes vary in firmness, are generally discrete, are occasionally tender.

Streptococcal pharyngitis

Subjective Data:Sore throat. Often runny nose. Sometimes headache, fatigue, abdominal pain.

Objective Data:Firm, discrete, often tender anterior cervical nodes generally felt.

Herpes simplex

Subjective Data:Burning, itching lesions; enlarged lymph nodes.

Objective Data:Discrete labial and gingival ulcers, high fever, enlargement of anterior cervical and submandibular nodes. Nodes tend to be firm, quite discrete, movable, tender.

Human immunodeficiency vius/acquired immunodeficiency syndrome (HIV/AIDS)

Subjective Data:Severe fatigue, malaise, weakness, persistent diarrhea; arthralgias.

Objective Data:Lymphadenopathy, fever, unexplained weight loss.

Some Conditions Simulating Lymph Node Enlargement

Lymphangioma

Hemangioma (tends to feel spongy; appears reddish blue, depending on size and extent of angiomatous involvement)

Branchial cleft cyst (sometimes accompanied by tiny orifice in neck on line extending to ear)

Thyroglossal duct cyst

Laryngocele

Esophageal diverticulum

Thyroid goiter

Graves disease

Hashimoto thyroiditis

Parotid swelling (e.g., from mumps or tumor)

Pediatric Variations

EXAMINATION

TECHNIQUE

FINDINGS

HEAD AND NECK

Palpate superficial nodes

image Occipital nodes at base of skull

image Postauricular nodes over mastoid process

EXPECTED:In children, small, firm, discrete, nontender, nonmovable nodes in occipital, postauricular chains.

OTHER LYMPH NODES

Palpate superficial nodes

imageInguinal and popliteal areas

EXPECTED:In children, small, firm, discrete nodes; nontender, movable in inguinal chain.

SAMPLE DOCUMENTATION

Subjective.A 25-year-old woman complains of difficulty swallowing and sore throat for 3 days, now subsiding. Fever to 38° C (100.5° F) for 2 days. Has been using acetaminophen and throat lozenges for pain relief.

Objective.No visible enlargement of lymph nodes in any area. Enlarged node (2 cm in diameter) palpated in left posterior cervical triangle; firm, nontender, movable, no overlying warmth, erythema, or edema. A few shotty nodes palpated in posterior cervical triangles bilaterally and in femoral chains bilaterally.