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

• From in front of the patient, palpate the supraclavicular nodes with your fingertips in the supraclavicular fossae

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

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

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

• Palpate for hepatosplenomegaly (see notes on abdominal examination)
• Examine any areas drained by palpable lymph nodes 

To complete

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

Try some viva style questions