By Dr. Marcus Judge

OSCE

In any OSCE examination, you need to understand the pathology and reasoning behind each sign and symptom you elicit, even if the patient is ‘normal’. This article explains how to perform a lymphoreticular examination (a check of the lymph nodes, liver and spleen) and the key findings you should look for, showing you what each sign means and what conditions it may indicate.

The lymphoreticular examination is usually performed when there is a clinical suspicion of haematological disease (disease of the blood, bone marrow or lymph nodes), such as lymphoma or leukaemia, or an underlying infection or inflammatory condition. Its purpose is to detect lymphadenopathy (enlarged lymph nodes) and hepatosplenomegaly (enlargement of the liver and spleen), which are the hallmark signs of pathology affecting the lymphoreticular system. The examination therefore combines a systematic survey of the major lymph node groups with a focused examination of the abdomen.

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 (have a weakened immune system).

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

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

Obtain consent for the examination by explaining what it will involve, including that you will need to feel several areas such as 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. Look for signs of weight loss or cachexia (severe wasting of muscle and fat), which are common in advanced lymphoma and other malignancies. Unexplained weight loss is also one of the lymphoma ‘B symptoms’ (fever, drenching night sweats and weight loss, described fully at the end of this article).

Look at the colour of the patient. Pallor (abnormal paleness) of the skin may indicate anaemia. In haematological malignancy, anaemia can result from bone marrow infiltration (invasion of the marrow by abnormal cells), which crowds out normal red cell production. Anaemia can also result from chronic disease. Jaundice, a yellow discolouration of the skin and sclerae (the whites of the eyes), 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 (larger purple-red patches). 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 (loss of the angle at the nail bed, with bulbous fingertips). 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 (scratch marks).

Koilonychia SimpleMed

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

SimpleMed original

Finger Clubbing SimpleMed

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. This is an oncological (cancer-related) emergency. It can be caused by a large mass of enlarged lymph nodes in the mediastinum (the central chest, between the lungs) compressing the superior vena cava (SVC).

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

Scleral Jaundice SimpleMed

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

SimpleMed original

Inspect the mouth. Look for gum hypertrophy, which is a classic feature of acute myeloid leukaemia (a cancer of the myeloid line of white blood cells), particularly the monocytic subtypes (those involving monocyte-type cells), 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. Compare both sides systematically for asymmetry, but examine the anterior cervical chains near the carotid arteries one side at a time to avoid simultaneous carotid compression. For every palpable node assess:

  • Site: which node group is involved
  • Size: nodes larger than 1 cm are commonly considered enlarged, although what counts as normal varies with the site and the patient’s age (an epitrochlear node, for example, is judged against a smaller cut-off, see below)
  • 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 (irregular, like rough rock)
  • 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: at the angle of the mandible
  • Pre-auricular (and parotid): 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 (the large neck muscle running from behind the ear to the breastbone and collarbone)
  • Posterior cervical chain: along the back border of the sternocleidomastoid
  • Supraclavicular and infraclavicular: in the hollows just above and below the clavicle

Cervical Lymph Node Levels SimpleMed

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

SimpleMed original

The supraclavicular nodes deserve special attention. An enlarged left supraclavicular node is known as Virchow’s node. Its presence (Troisier’s sign) raises suspicion of intra-abdominal malignancy (cancer arising in the abdomen or pelvis), particularly gastric cancer. This is because the thoracic duct (the large lymph vessel that returns most of the body’s lymph to the bloodstream) drains abdominal lymph into the venous system at this point. Cancers inside the chest, such as lung cancer, can involve a supraclavicular node on either side. Enlargement of the right supraclavicular node may suggest malignancy of the lung or oesophagus.

Cervical Lymphadenopathy SimpleMed

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:

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

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, the bony bump on the inner side of the elbow. A convenient technique is to support the patient’s slightly flexed elbow by cupping your hand behind the olecranon (the point of the elbow). 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.

Palpability alone does not establish abnormality. In an adult, an epitrochlear node larger than 5 mm (a lower threshold than the usual 1 cm) is generally considered enlarged; interpret its size alongside tenderness, persistence, other examination findings and the clinical history. Because it drains the ulnar side of the forearm and hand, localised enlargement may simply reflect a hand infection. However, epitrochlear lymphadenopathy can occur in a wide range of conditions, including lymphoma, sarcoidosis (an inflammatory condition in which small clumps of immune cells form in organs such as the lungs and lymph nodes), infectious mononucleosis (glandular fever) and other infections such as HIV, tuberculosis and cat-scratch disease, 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 group, which lies in a row just below the inguinal ligament (the band at the crease of the groin, running from the front of the hip bone to the pubic bone)
  • The vertical group, which lies along the line of the great saphenous vein, found roughly 3 to 4 cm lateral to the pubic tubercle (the small bony bump at the front of the pelvis) and palpated downwards over the saphenous opening (the opening in the upper thigh where the great saphenous vein drains into the femoral vein)

Both groups are superficial, which distinguishes them from the deep inguinal nodes.

Small, soft inguinal nodes can be a normal finding in healthy adults because the legs and perineum (the area between the genitals and anus) 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 (areas that are not next to each other) is termed generalised lymphadenopathy. This substantially raises the suspicion of a systemic process (one affecting the whole body) 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 (an enlarged liver) and splenomegaly (an enlarged spleen), 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 (the joint at the front of the pelvis), 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 (surgical removal of the spleen).

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 (the percussion note over the flank changes when the patient rolls onto their side, because free fluid moves). Ascites can develop when malignant nodes block the drainage of lymph, or when liver involvement causes portal hypertension (raised pressure in the portal vein, which carries blood from the gut to the liver).

Liver Palpation

Before palpating, ask again about any pain and watch the patient’s face throughout. Begin palpation in the right iliac fossa (the lower right part of the abdomen) and work upwards towards the right costal margin (the lower edge of the ribcage), 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 tapping against your fingers as it moves down.

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. Note whether the edge is smooth or irregular and whether it is tender or pulsatile (pulsing with the heartbeat).

In the context of the lymphoreticular examination, hepatomegaly may be caused by infiltration in lymphoma and leukaemia. It may also be caused 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 ask 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-sized spleen is usually not palpable in adults, so a spleen that can be felt at the left costal margin is usually enlarged. Occasionally a normal spleen can be felt because of the patient’s body build or chest wall shape.

If the spleen is not palpable but you still suspect mild splenomegaly, roll the patient onto their right side and palpate again. This position 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 leukaemia, where splenomegaly is common and can be massive, and chronic lymphocytic leukaemia, where the spleen is usually only mildly to moderately enlarged but can also become massive). Other causes include infections such as glandular fever and malaria, haemolytic anaemias (anaemias in which red cells break down early) and portal hypertension. Enlargement of both organs together (hepatosplenomegaly) should raise suspicion of a systemic haematological or infective process, although other causes, such as chronic liver disease with portal hypertension, also need to be considered.

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. 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 above 38 °C, drenching night sweats, and unexplained weight loss of more than 10% of body weight within the preceding 6 months. These are important for staging (working out how far the disease has spread) and for prognosis in lymphoma
  • Examination of Waldeyer’s ring and a full ENT (ear, nose and throat) assessment if not already performed
  • Bedside tests including basic observations and a urine dip
  • Blood tests including a full blood count (to look for abnormal cell counts) and blood film (blood cells examined under a microscope), renal and liver function, lactate dehydrogenase (LDH) and urate (a waste product that can be raised with high cell turnover). If glandular fever is suspected, a monospot (heterophile antibody) test is used from the second week of illness, because it can be falsely negative earlier; Epstein-Barr virus (EBV) antibody tests are used instead in children under 4 years and in immunocompromised people
  • Imaging such as a chest X-ray and CT scanning to assess for mediastinal (central chest) and intra-abdominal (inside the abdomen) lymphadenopathy and for organomegaly (enlarged organs)
  • Lymph node biopsy: an excision biopsy (surgical removal of a whole enlarged node) is usually the first diagnostic procedure to consider when lymphoma is suspected, and the tissue is then examined in the laboratory to diagnose and classify the lymphoma. A needle core biopsy (a sample taken through a hollow needle) is an alternative when the risk of surgery outweighs the benefit. A bone marrow biopsy may also be required

Quiz

Preview the Lymphoreticular OSCE Examination quiz

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