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Lymph node examination

Introduction

  • Wash hands; Introduce self; ask Patient’s name, DOB and what they like to be called; Explain examination and obtain consent
  • Get a chaperone
  • General inspection: well/unwell, pain/discomfort, cachexia
  • For each lymph node group
    • Local inspection: obvious lymphadenopathy, surgical scars, overlying skin (erythema, rashes)
    • Palpation (technique discussed below): determine site, size (diameter <1cm is normal), shape, consistency (hard = malignancy; rubbery = lymphoma), tethering to other structures (malignancy)

Work down the body feeling each lymph node group:

Cervical lymph nodes

  • Sit patient upright in a chair and stand behind them to palpate the following groups of nodes in order: submental, submandibular, jugulodigastric/tonsillar (commonly palpable), anterior cervical chain (shotty nodes common), posterior cervical chain, occipital, postauricular, preauricular
  • These groups are palpated with finger pulps (do not ‘play the piano’, i.e. palpate using finger tips). Palpate as if you are giving a massage, and feel each group thoroughly – especially the anterior and posterior cervical chains, for which your whole hand should be placed around the patient’s neck. Roll the lymph nodes over the deep muscles/bone to feel them (don’t just press the superficial soft tissues).
  • From in front of the patient, palpate the supraclavicular nodes with your fingertips in the supraclavicular fossae – Virchow’s node is left supraclavicular (classically gastric cancer metastasises here)

Axillary lymph nodes

  • To examine the right: ask the patient to hold your right biceps muscle while you support the weight of their right arm at the elbow with your right hand. Now place your left arm over your right and place your left hand into the patient’s axilla. Palpate the apical, lateral, medial, anterior and posterior lymph node groups by firmly pressing the soft tissues and rolling them over the underlying harder tissues.
  • Repeat on left

NB: to feel the medial lymph node group, you really have to push your hand high up into the axilla and press it firmly medially, rolling the nodes across the ribs with all your fingers. It helps if you bring the patient’s elbow closer to their chest at this point.

Epitrochlear lymph nodes

  • To examine the right: hold the patient’s right wrist with your left hand and their right elbow in your right palm. Use your right thumb to feel for lymph nodes.
  • Repeat on left
Lymph node groups of the head and neck
Lymph node groups of the head and neck 

Inguinal lymph nodes

  • Palpate horizontal chain (inferior and parallel to inguinal ligament) and vertical chain (alongside terminal great saphenous vein) 
  • Lymph nodes here are normal up to 1.5cm in diameter 

Popliteal lymph nodes

  • Flex knee and palpate in popliteal fossa

Finally

To complete

  • Thank patient and restore clothing
  • Summarise and suggest further investigations you would consider after a full history
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