Lymphoreticular OSCE Examination

Contents

1. Introduction
2. General Inspection
3. Hands and Arms
4. Face, Eyes and Mouth
5. Cervical Lymph Nodes
6. Axillary Lymph Nodes
7. Epitrochlear Lymph Nodes
8. Inguinal Lymph Nodes
9. Abdominal Inspection
10. Liver Palpation
11. Spleen Palpation
12. Completing the Examination
13. Quiz

Introduction

Wash your hands thoroughly before approaching the patient to minimise the risk of cross-infection – this is particularly important as many of these patients may be immunocompromised.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient’s details taking 3 points of identification usually; full name, date of birth and NHS/hospital number.

Obtain consent for the examination ensuring to explain what the examination will entail, mentioning that you will need to feel several areas including the neck, armpits, groin and tummy.

Offer a chaperone, as this examination involves exposure of the trunk and groin, and document who is present.

Ask the patient if they have any pain anywhere before you begin, so that you can avoid causing discomfort.

Position the patient sitting upright on the bed initially to inspect and palpate the lymph nodes, and adequately expose the patient so that the neck, arms and trunk are visible. The patient will need to lie flat with the abdomen exposed for the abdominal portion of the examination, which can be done afterwards. Always maintain the patient’s dignity and only expose what is necessary at each stage.

General Inspection

Begin by standing back and observing the patient from the end of the bed. Look for clues that may point towards a haematological diagnosis. Assess whether the patient appears well or unwell, and look for signs of weight loss or cachexia, which are common in advanced lymphoma and other malignancies and form part of the ‘B symptoms’.

Look at the colour of the patient. Pallor of the skin may indicate anaemia, which can occur in haematological malignancy due to bone marrow infiltration crowding out normal red cell production, or due to chronic disease. Jaundice, a yellow discolouration of the skin and sclerae, may suggest haemolysis (where excess breakdown of red cells produces bilirubin) or liver involvement.

Inspect the skin for bruising, petechiae (pinpoint red spots) or purpura. These suggest a low platelet count (thrombocytopenia), which can result from bone marrow failure or infiltration. Also look for any obvious scratch marks, as generalised itch (pruritus) is a recognised feature of Hodgkin lymphoma.

Look around the bedside for objects that give diagnostic clues, such as medications, fluid or blood product bags, a wig or head covering (which may indicate hair loss from chemotherapy), or mobility aids. Note whether the patient is comfortable at rest, and whether they appear to be in any distress.

Hands and Arms

Take the patient’s hands and inspect them. Look for pallor of the palmar creases, which is a useful sign of anaemia – the creases lose their normal pink colour when haemoglobin is low.

Examine the nails for koilonychia (spoon-shaped nails), which is associated with chronic iron deficiency anaemia, and for signs of clubbing. Whilst clubbing is more classically a cardiovascular or respiratory sign, it can occasionally accompany chronic systemic disease.

Inspect the skin of the hands and forearms for bruising and petechiae, again reflecting possible thrombocytopenia. Note any excoriations from scratching.

Image - Koilonychia, where the nails become thinned and spoon-shaped. This is a sign of chronic iron deficiency anaemia

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Image - Finger clubbing, where the angle at the nail bed is lost and the fingertips appear bulbous. Clubbing is occasionally seen in lymphoma and chronic disease

Creative commons source by Bobjgalindo [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Face, Eyes and Mouth

Inspect the face for any obvious swelling. Marked swelling of the face and neck, sometimes with distended veins, may indicate superior vena cava obstruction – an oncological emergency that can be caused by a large mediastinal mass of lymphadenopathy compressing the SVC.

Ask the patient to gently pull down their lower eyelid and inspect the conjunctiva. Conjunctival pallor suggests anaemia. Inspect the sclerae for jaundice, which as above may reflect haemolysis or hepatic involvement.

Image - Jaundice of the sclera, where bilirubin gives the white of the eye a yellow tinge. In this context it may point to haemolysis or liver involvement

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Inspect the mouth. Look for gum hypertrophy, which is a classic feature of acute myeloid leukaemia (particularly the monocytic subtypes) due to infiltration of the gums by leukaemic cells. Look for oral ulceration and signs of infection such as oral candidiasis (white plaques), which are more common in immunocompromised patients. Anaemia may also produce angular stomatitis (cracking at the corners of the mouth) and glossitis (a smooth, sore tongue).

Do not forget to examine Waldeyer’s ring – the ring of lymphoid tissue in the pharynx that includes the tonsils. Inspect the tonsils for asymmetric enlargement, as lymphoma can present here.

Cervical Lymph Nodes

The examination of the lymph nodes is the central component of the lymphoreticular examination. Use the pads of your middle three fingers to gently roll each node group against the underlying tissue, rather than poking with the fingertips. Examining both sides at once allows you to compare for asymmetry. For every palpable node assess:

• Site – which node group is involved
• Size – nodes larger than 1 cm are generally considered abnormal
• Consistency – reactive nodes from infection tend to be soft and tender; lymphoma nodes are characteristically rubbery and non-tender; and metastatic carcinoma nodes are typically hard and craggy
• Mobility – whether the node is freely mobile or fixed (tethered) to surrounding tissue, as fixation suggests malignant infiltration
• Tenderness – tender nodes usually indicate acute infection or inflammation

It is best to examine the cervical nodes from behind the seated patient, asking them to relax and slightly flex their neck to loosen the overlying muscles. Palpate each of the cervical node groups in turn, in a logical order so that none are missed:

• Submental – beneath the point of the chin
• Submandibular – below the body of the mandible
• Tonsillar (and parotid) – at the angle of the mandible
• Pre-auricular – in front of the ear
• Post-auricular – behind the ear
• Occipital – at the base of the skull
• Anterior cervical chain – along the front border of the sternocleidomastoid
• Posterior cervical chain – along the back border of the sternocleidomastoid
• Supraclavicular and infraclavicular – in the hollows just above and below the clavicle

Image - The levels and groups of cervical lymph nodes. Working through them in a set order ensures no group is missed during the examination

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The supraclavicular nodes deserve special attention. An enlarged left supraclavicular node is known as Virchow’s node, and its presence (Troisier’s sign) is a classic indicator of intra-abdominal malignancy, particularly gastric cancer, because the thoracic duct drains abdominal lymph into the venous system at this point. Enlargement of the right supraclavicular node may suggest malignancy of the lung or oesophagus.

Image - Cervical lymphadenopathy in the right side of the neck (arrows). Enlarged, persistent cervical nodes warrant investigation for infection or malignancy

Creative commons source by Coronation Dental Specialty Group [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Axillary Lymph Nodes

To examine the axilla, support the weight of the patient’s arm with one of your hands and use your other hand to palpate inside the armpit. Supporting the arm allows the muscles around the axilla to relax, making the nodes easier to feel. It is conventional to examine the patient’s right axilla with your left hand and their left axilla with your right hand.

Palpate all five groups of axillary nodes to ensure a thorough examination:

• Apical (medial) – high up at the apex of the axilla
• Anterior (pectoral) – behind the front fold of the armpit
• Posterior (subscapular) – against the back fold of the armpit
• Medial – along the chest wall
• Lateral (humeral) – against the upper arm

The axillary nodes drain the arm, the breast and the chest wall. Enlargement here may therefore reflect lymphoma, breast cancer, or infection or injury of the upper limb. As with the cervical nodes, assess the size, consistency, mobility and tenderness of any palpable node.

Epitrochlear Lymph Nodes

The epitrochlear node lies just above the medial epicondyle of the elbow. A convenient technique is to support the patient’s slightly flexed elbow by cupping your hand behind the olecranon, then reach your thumb across to feel in the groove just above the bony prominence on the inner aspect of the arm. Roll the soft tissue here gently to detect any enlarged node.

A palpable epitrochlear node is abnormal. Because it drains the ulnar side of the forearm and hand, localised enlargement may simply reflect a hand infection. However, epitrochlear lymphadenopathy is also associated with systemic conditions including lymphoma, sarcoidosis, infectious mononucleosis (glandular fever) and certain other infections, so it should not be overlooked.

Inguinal Lymph Nodes

With the patient lying flat and the groin appropriately exposed, palpate the inguinal lymph nodes. There are two groups:

• The horizontal (superficial) group, which lies just below the inguinal ligament
• The vertical group, which lies along the line of the great saphenous vein, found roughly 3 cm lateral to the pubic tubercle and palpated downwards over the saphenous opening

Small, soft inguinal nodes can be a normal finding in healthy adults because the legs and perineum are frequent sites of minor trauma and infection. Significant or generalised enlargement, however, may reflect lymphoma, leukaemia, sexually transmitted infection, or infection of the lower limb. Always assess these nodes in the same systematic way for size, consistency, mobility and tenderness.

The combination of enlarged nodes in two or more separate, non-contiguous regions is termed generalised lymphadenopathy and substantially raises the suspicion of a systemic process such as lymphoma, leukaemia, a viral infection (e.g. glandular fever or HIV), tuberculosis or sarcoidosis.

Abdominal Inspection

The abdominal examination is performed to assess for hepatomegaly and splenomegaly, both of which are common in haematological disease. Reposition the patient so that they are lying flat with their head supported on a single pillow and their arms by their sides, which relaxes the abdominal wall. Expose the abdomen from the nipples to the pubic symphysis, maintaining dignity.

Inspect the abdomen for distension, which may be due to a grossly enlarged organ or to ascites (fluid in the peritoneal cavity). Look for any visible masses or asymmetry, and inspect the skin for scratch marks, bruising and surgical scars. A scar in the left upper quadrant may indicate a previous splenectomy.

Before examining the individual organs, gently palpate each of the nine regions of the abdomen, watching the patient’s face for any sign of discomfort. This light palpation screens for areas of tenderness and any obvious masses before you move on to the more focused examination of the liver and spleen.

If the abdomen appears distended, test for ascites using shifting dullness, as fluid can accumulate when malignant nodes obstruct lymphatic drainage or when there is associated liver involvement and portal hypertension.

Liver Palpation

Before palpating, ask again about any pain and watch the patient’s face throughout. Begin palpation in the right iliac fossa and work upwards towards the right costal margin, asking the patient to take a deep breath in with each step. As the patient breathes in, the diaphragm pushes the liver downwards, so an enlarged liver edge may be felt to flick against your fingers.

A normal liver edge is usually not palpable, although it may be felt at the costal margin in thin individuals on deep inspiration. If the liver is enlarged (hepatomegaly), assess how many centimetres it extends below the costal margin, and note whether the edge is smooth or irregular and whether it is tender or pulsatile.

In the context of the lymphoreticular examination, hepatomegaly may be caused by infiltration in lymphoma and leukaemia, by infections such as infectious mononucleosis, viral hepatitis or malaria, or by congestion and other causes of liver disease. A hard, irregular, knobbly liver suggests metastatic infiltration.

You should also percuss the liver to confirm its size and define its upper and lower borders, which helps distinguish true enlargement from a liver that is simply displaced downwards.

Spleen Palpation

The spleen enlarges towards the right iliac fossa, so begin palpation in the right iliac fossa and work diagonally towards the left costal margin, again asking the patient to take a deep breath in with each step so that the descending spleen may be felt against your fingers.

The spleen has several distinguishing features that separate it from an enlarged left kidney: it has a palpable notch on its medial border, it is dull to percussion, you cannot get above it (you cannot feel its upper border beneath the costal margin), and it moves down on inspiration. A normal spleen is not palpable; for it to be felt at the left costal margin it must be enlarged to roughly three times its normal size.

If the spleen is not palpable but you still suspect mild splenomegaly, roll the patient onto their right side and palpate again, as this manoeuvre can bring a modestly enlarged spleen within reach. As with the liver, percuss over the spleen to help confirm enlargement.

Splenomegaly in this context may be due to lymphoma or leukaemia (especially chronic myeloid and chronic lymphocytic leukaemia, which can cause massive splenomegaly), infections such as glandular fever and malaria, haemolytic anaemias, and portal hypertension. The finding of enlargement of both organs together (hepatosplenomegaly) is highly suggestive of a systemic haematological or infective process.

Completing the Examination

Thank the patient, help them to re-dress, and wash your hands.

Summarise your findings, clearly stating the distribution of any lymphadenopathy and the presence or absence of hepatosplenomegaly, and offer a brief differential diagnosis (for example lymphoma, leukaemia, or an infective or inflammatory cause).

To complete the examination, suggest the following further assessments and investigations:

• A full history, including specifically asking about B symptoms (unexplained fever, drenching night sweats and weight loss of more than 10% of body weight), as these are important for staging and prognosis in lymphoma
• Examination of Waldeyer’s ring and a full ENT assessment if not already performed
• Bedside tests including basic observations and a urine dip
• Blood tests including a full blood count and blood film, renal and liver function, lactate dehydrogenase (LDH) and urate (which can be raised with high cell turnover), and a monospot/EBV test if glandular fever is suspected
• Imaging such as a chest X-ray and CT scanning to assess for mediastinal and intra-abdominal lymphadenopathy and organomegaly
• Lymph node biopsy – an excision biopsy of an enlarged node is the definitive investigation for diagnosing and classifying lymphoma, and a bone marrow biopsy may also be required

Quiz

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