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

• 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

Palpation technique

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

• Flex the patient’s elbow slightly
• Support their forearm so they are relaxed
• Use your index and middle fingers to palpate in a circular motion in the area above the medial epicondyle

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

Visible posterior cervical lymphadenopathy

Try some viva style questions

What is Virchow’s node? What is the clinical significance?

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Please list some causes of localised lymphadenopathy

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Please list some causes of generalised lymphadenopathy

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