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Clinical Skills: Lymph Nodes - Coggle Diagram
Clinical Skills: Lymph Nodes
Two Main Thoracic Ducts
Right Lymphatic Duct
The Right Lymphatic Duct drains the
Right Upper Limb
Right Side of the Thorax
Right halves of the head and neck
And leads into the Right Subclavian and Right Internal Jugular Vein
Thoracic Duct
Thoracic Duct is larger
The Thoracic Duct drains the rest of the body
And leads into the Brachiocephalic Vein
List the Palpable and Non-palpable Lymph Nodes
Palpable Lymph Nodes
Non-palpable Lymph Nodes
What happens if the Lymphatic Fluid is not drained ?
If the lymphatic fluid is not drained then Lymphoedema will occur.
This is the swelling of the Lymph Nodes
Indications of a Lymphatic Examination
Why do we have to exam Lymph Nodes ?
We are required to examine the Lymph Nodes because:
It is part of the general examination
It forms parts of a specific examination of the nodes associated with the area being examined
When a patient has Lymphadenopathy (enlarged lymph nodes)
It may be the presenting symptom of the illness or may be an incidental finding
Patient may have Lymphoedema if Lymph Flow is impaired e.g. Cellulitis
Lymphatic Examination
Describe the characteristics of normal Lymph Nodes
Normal lymph nodes are discreet, non-tender and mobile with no fixation to underlying tissue
List the sizes of normal lymph nodes
Normal size of lymph nodes:
1 cm in Cervical and Axilla region
1.5 cm in Inguinal area
0.5 cm in Epithrochlear
When are Lymph nodes impalpable ?
Lymph Nodes are usually impalpable unless recurrent infection has left scarring.
Factors causing Lymphadenopathy
Outline Lymphadenitis (Infection/Inflammation)
Lymphadenitis is a localized response from Lymphocytes and macrophages
The lymph nodes become enlarged, hard and tender (painful)
As the patient recovers the lymph nodes become small and hard before becoming impalpable again
List the factors causing lymphadenopathy
Lymphadenopathy can be caused by either:
Infections
Malignancy
Systemic Disease
List the factors causing lymphadenopathy under Infections
Viral Infections
Acute Viral Infection: Cytomegalovirus (CMV), EBV
HIV
Bacterial Infection
Extra Pulmonary TB (Cervical)
Local Infection
Yeast
Cryptococcal
Inhalation from birds, soil, eucalyptus
Protozoal
Toxoplasma
Cat feaces, Infected raw meat
Factors causing Lymphadenopathy
List the factors causing lymphadenopathy under Malignancy
Malignancy
The Inflammation of certain Lymph nodes is a predisposition of Malignant conditions such as:
Metastatic disease
Haematological
Lymphocytic Leukaemia
Lymphoma
Others such as Kaposi's Sarcoma
List the different lymph nodes region affected during each stage of Malignancy
Stage 1
Stage 2
Stage 3
Stage 4
Systemic Diseases
List the Systemic Diseases that cause Lymphadenopathy
Certain Systemic Disease can cause Generalised Lymphadenopathy
Sarcoidosis
Autoimmune disease
Systemic Lupus Erythematous
Rheumatoid arthritis
Medications
List the medications that can be used against Lymphadenopathy
Anti-epileptics
Phenytoin
Carbamezapine
Associated Splenomegaly
Outline the Functions of the Spleen
Spleen is responsible for the phagocytosis of Red blood cells (RBCs), cellular material and microbes
Lymphocyte proliferation in Infection
Production of RBC in the Foetus
List the factors causing Splenomegaly with Lymphadenopathy
Infection
EBV
HIV
TB
Toxoplasma
Haematological Malignancy
Lymphoma
Leukaemia
Autoimmune diseases
SLE
Rheumatoid arthritis
Scarring
Lymph Nodes may become permanently palpable due to recurring infections and then become scarred.
Cancer
Proliferation of neoplastic lymphocytes or macrophages causes enlarged and hard but not inflamed and usually non-tender lymph nodes
History Taking
Outline the relevant aspects in patient's history to review
Presenting Problem
Enlarged lymph nodes
Swelling extremity
Bleeding
Past medical history
TB and other skins test
Transfusions
Chronic illness
Cardiac, Renal, Malignancy
Surgery
Recurrent infections
Exposures
Animals
Travel
Sexual
IV Drugs
Medications
Occupational exposure
Family History
Malignancy
Anaemia
Recent infections
TB
Systemic Symptoms
Weight loss
Night sweats
Joint pains
Shortness of breath (SOB)
Fatigue
Age
Children and young adults it is usually an infectious cause
Adults older than 50 years of age are at a greater risk of malignancy
Clinical Assessments
Describe the Clinical Assessment used in the Lymph Node Examination
The clinical assessments utilizes inspection and palpation
Lymph Nodes are generally examined region by region during the examination of other body systems
Always ask patients if they are aware of any "lumps"
Inspection
Begin head to toe
Inspect head and neck region for: Symmetry, Swelling, Changes in Skin Colour or Pigmentation
Inspect movement of head and neck when asked to look both ways
General Appearance
What's the patient's weight/ nutritional status ?
Do you observe any signs of distress: Coughing, Shortness of Breath (SOB), or Joint Pain ?
Any signs of skin pallor or flushed appearance ?
Does the patient have any rashes ?
Is there local abnormality with regional lymphadenopathy ?
Palpation
Palpate either from in front or behind with the examiner standing and the patient seated
Ideally start with the Occipital Lymph Nodes and work down
Palpate carefully with Palmar Aspect of the 2-3 Fingers
Roll fingers with slight pressure to determine consistency
Nodes are not normally palpable
Palpate for
Consistency
Size
Tenderness
Fixity to surrounding structures
Describing your findings on palpation of the Lymph Nodes
Explain how to describing your findings on palpation of the Lymph Nodes
ALWAYS refer to the site
Localised to a specific region or Generalised
Comment on the following:
Consistency
Size
Tender or Non-tender
Moveable or Fixed
Texture
Co-existence of Splenomegaly which suggests systemic illness
Tenderness is usually found when the node has enlarged rapidly
Nodes containing metastatic cancer are often Hard, Non-tender and Unmovable due to fixation to the underlying tissue
Consistency
Outline the Factors Influencing the Consistency of lymph Nodes
Soft
Suggesting infection or inflammation
Stony Hard
Typical of cancer, usually metastatic
Firm
Lymphoma, EBV, Malignancy
Fluctuant
Suppurated
Fixity
Fixity to skin, deep fascia and muscles may be due to a Carcinoma
Matted
TB, Lymphoma, Metastatic Cancer and Sarcoidosis
Rubbery
Can suggest Lymphoma, Epstein Barr Virus
List the factors that must be examined when an enlarged Lymph Node is found
If an enlarged Lymph Node is found examine the following:
P: Primary Site
A: ALL associated lymph nodes
L: Liver
S: Spleen
Understanding Concept: Regional vs Generalized Lymphadenopathy
Outline the meaning of Regional vs Generalized Lymphadenopathy
Regional/ Localized Lymphadenopathy is the enlargement of one or more lymph nodes in one nodal area
Pre-auricular or Posterior cervical chain
Generalized lymphadenopathy is the enlargement of one or more lymph nodes in 2 or more different nodal areas
Left Axilla and Right Axilla
Localized Lymphadenopathy
List the causes of Localized Lymphadenopathy
Ineffective/ impaired drainage of one region
Site provides clue of causes
Infection
Trauma
Malignancy
For example:
Occipital lymphadenopathy may indicate scalp lesion
Pre-auricular lymphadenopathy may suggest an infection in the eye
List the suspicious findings of Lymph Nodes
Size: Pathological nodes have a size greater than 1 cm
Firmness: Malignant nodes feel harder
Quantity: The larger the number of palpable lymph nodes the more likely true pathology
Pain: Often associated with inflammation (Infection)
Fixation: Lymph Nodes fixed to each other or surrounding structure are more likely to be malignant
Changes over time: Increase in size, number or appearing in new locations are all worrying signs
Site:
Bilateral Epitrochlear: Lymphoma, Syphilis
Infraclavicular: Lymphoma
Left Supraclavicular: Virchow's node associated with Gastric Cancer
Order of Lymph Node Palpation
List the Head and Neck Lymph Nodes
Occipital
Posterior Auricular
Pre-auricular
Posterior Cervical (Superficial and Deep)
Anterior Cervical (Superficial and Deep)
Submandibular
Submental
Supraclavicular
Infraclavicular
Differential Diagnosis of the Head and Neck enlarged Lymph Nodes
List the regions that each nodal region drains, Differential diagnosis and Malignancies for the Pre-auricular nodes, and Submandibular Nodes
Pre-auricular Nodes
Drains scalp and skin
Differential diagnosis
Scalp Infections
Mycobacterial infections
Malignancies
Skin neoplasm
Squamous cell carcinoma of the Head and Neck
Lymphomas
Submandibular Lymph Nodes
Drains oral cavity
Differential diagnosis
Mononucleosis
Upper respiratory viral/ bacterial infection
Mycobacterial infection
Toxoplasma
Cytomegalovirus
Dental Disease
Rubella
Malignancies
Leukemias
Squamous cell carcinoma of the head and neck
Lymphomas
List the regions that each nodal region drains, Differential diagnosis and Malignancies for Anterior and Posterior Cervical Chain, Supraclavicular Lymph Nodes
Anterior Cervical Nodes
Drains Tongue, Larynx, Oropharynx and Anterior Neck
Differential diagnosis
Mononucleosis
Upper respiratory viral/bacterial infection
Mycobacterial Infection
Toxoplasma
Cytomegalovirus
Dental disease
Rubella
Posterior Cervical Nodes
Drains Scalp, Neck and Upper thoracic Skin
Differential diagnosis
Scalp Infections
Mycobacterial Infection
Supraclavicular Lymph Nodes
Drains Gastrointestinal Tract, Genitourinary Tract, and Pulmonary
Differential diagnosis
Abdominal/Thoracic Neoplasms
Thyroid/Laryngeal disease
Mycobacterial/Fungal infections
Axillary Lymph Nodes
Outline the characteristics of Axillary Lymph Nodes
Axillary Lymph Nodes are generally, not visible, or palpable
Expect tenderness while palpating in the high axilla
Note any enlarged or tender lymph nodes
The Axilla consists of 5 groups of nodes
Anterior
Posterior
Lateral
Medial
Apical
List the regions drained by the Axillary Lymph Nodes
The Axilla drains the:
Breasts
Upper Limb
Thoracic Wall
Differential Diagnosis of the Infraclavicular Nodes, Axillary Nodes and Epitrochlear Nodes enlarged Lymph Nodes
List the regions that each nodal region drains, Differential diagnosis and Malignancies of the Infraclavicular Nodes, Axillary Nodes and Epitrochlear Nodes
Infraclavicular Nodes
Differential diagnosis
Highly suspicious for Non-Hodgkin's Lymphoma
Axillary Nodes
Drain the Breast, Upper Limbs and Thoracic Wall
Differential Diagnosis
Skin Infections/trauma
Cat-scratch disease
Tularemia
Sarcoidosis
Syphilis
Leprosy
Brucellosis
Epithrochlear Nodes
Drains Ulnar forearm and Hand
Differential Diagnosis
Skin infections
Skin Malignancies
Lymphoma
Epithrochlear Lymph Nodes
Outline the characteristics of Epitrochlear Lymph Nodes
Consists of 3-4 groups
Epitrochlear Nodes
Lateral axillary Nodes
Central axillary Nodes
Infraclavicular Nodes
It is located 3cm above Medial Epicondyle
Can be palpated between biceps and triceps
Can be enlarged in:
Hodgkin's Lymphoma
IV drug abuse
Lesions and infections of the Hand and forearm
HIV and Syphilis
Inguinal/ Femoral Lymph Nodes
List the types of Inguinal/Femoral Lymph Nodes
Superficial Lymph Nodes
Deep Lymph Nodes (situated near the Femoral Artery and Vein)
Outline the regions drained by the Inguinal/Femoral Lymph Nodes
Superficial Inguinal Lymph Nodes drain:
External Genitalia
Lower Limbs
Deep Inguinal Lymph Nodes drain:
External Genitalia
Lower Anterior Abdominal Wall
Lower Limbs
Inguinal Lymphadenopathy
List the causes of Inguinal Lymphadenopathy
Infection
Sexual
Skin
Malignancy
Skin cancer of genitalia area
Genitalia and Anal cancer
Lymphoma
Differential Diagnosis of the Inguinal Lymph Nodes
List the regions that each nodal region drains, Differential diagnosis and Malignancies of the Inguinal Lymph Nodes
Horizontal/Superficial Node Group & Vertical/Deep Node Group
Differential diagnosis
Skin Infections
Benign reactive lymphadenopathy
Sexually transmitted disease
Malignancies
Skin Neoplasms
Squamous Cell Carcinoma of the Penis, Vulva and Anus
Lymphomas
Kaposi's Sarcoma
Popliteal Lymph Nodes
Outline the characteristics of Popliteal Lymph Nodes
Rarely examined
6-7 Groups of Deep and Superficial Lymph Nodes
Found in the Popliteal Fossa (behind knee)
Can be enlarged in:
Lower limb cancer
Inflammation
Rheumatoid Arthritis