Lymphoreticular examination – OSCE guide

Examination of the lymphoreticular system is often performed when a clinician has concerns regarding an underlying haematological malignancy in a patient. This examination is also useful to monitor for response to treatment, disease progression or relapse in patients with known haematological malignancies. The purpose of the examination is to assess whether a patient has evidence of lymphadenopathy or hepatosplenomegaly which are common clinical findings seen in conditions such as lymphomas and leukaemias. You can check out the lymphoreticular examination OSCE mark scheme here.

Symptoms that raise the concern of a haematological malignancy include:

• Fatigue, breathlessness, dizziness – anaemia
• Easy bruising or bleeding (eg. epistaxis) – thrombocytopenia
• Recurrent or atypical infections – impaired immune response
• B-symptoms – weight loss, night sweats, pyrexia

 

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Introduction

• Wash hands
• Introduce yourself
• Confirm patient details – name/DOB
• Explain examination
• Gain consent
• Offer a chaperone

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General inspection

General appearance

Cachexia – underlying malignancy

Rashes – cutaneous manifestations of lymphoma

Evidence of bleeding or bruising – thrombocytopenia

Petechiae in the mouth – thrombocytopenia

Vital signs – pyrexia

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Lymph nodes

Lymph nodes can become enlarged for a wide variety of reasons. They may be reactive and become enlarged due to infection, or more concerningly they may be enlarged due to malignancy (either primary haematological malignancy or metastatic spread of cancer).

 

Assessing lymphadenopathy

It is important to examine for lymphadenopathy in a systematic manner. There are several chains that can be easily palpated on clinical examination. Remember, there are chains of lymph nodes which cannot be palpated on clinical examination such as mediastinal or mesenteric nodes.

 

For any palpable lymph node, it is important to assess the following characteristics to help determine the likely cause:

• Site (location related to other structures)
• Size
• Shape (regular or irregular)
• Consistency (soft, hard, rubbery)
• Tenderness
• Mobility/Tethering
• Overlying skin changes (e.g. erythema)

 

Interpretation of lymph node findings:

• Benign: Less than 1cm, smooth, rounded, non-tender and mobile.
• Reactive: Associated infective symptoms, smooth, rounded, tender and mobile.
• Haematological malignancy: Localised, regional or generalised lymphadenopathy. Rubbery.
• Metastases: Regional lymphadenopathy present in areas of drainage from affected organ. Typically hard, firm, irregular and tethered.

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Cervical lymph nodes

1. Position the patient sitting upright and examine from behind if possible. Ask the patient to tilt their chin slightly downwards to relax the muscles of the neck and aid palpation of lymph nodes. You should also ask them to relax their hands in their lap.

2. Inspect for any evidence of lymphadenopathy or irregularity of the neck.

3. Stand behind the patient and use both hands to start palpating the neck.

4. Use the pads of the second, third and fourth fingers to press and roll the lymph nodes over the surrounding tissue to assess the various characteristics of the lymph nodes. By using both hands (one for each side) you can note any asymmetry in size, consistency and mobility of lymph nodes.

5. Start in the submental area and progress through the various lymph node chains. Any order of examination can be used, but a systematic approach will ensure no areas are missed:

• Submental
• Submandibular
• Tonsillar
• Parotid
• Pre-auricular
• Post-auricular
• Superficial cervical
• Deep cervical
• Posterior cervical
• Occipital
• Supraclavicular – left supraclavicular region is where Virchow’s node may be noted (associated with upper gastrointestinal malignancy)

Take caution when examining the anterior cervical chain that you do not compromise cerebral blood flow (due to carotid artery compression). It may be best to examine one side at a time here.

A common mistake is a “piano-playing” or “spider’s legs” technique with the fingertips over the skin rather than correctly using the pads of the second, third and fourth fingers to press and roll the lymph nodes over the surrounding tissue.

 

An example of logical systematic examination of the lymph nodes is shown below:

1. Start under the chin (submental lymph nodes), then move posteriorly palpating beneath the mandible (submandibular), turn upwards at the angle of the mandible (tonsillar and parotid lymph nodes) and feel anterior (preauricular lymph nodes) and posterior to the ears (posterior auricular lymph nodes).

2. Follow the anterior border of the sternocleidomastoid muscle (anterior cervical chain) down to the clavicle, then palpate up behind the posterior border of the sternocleidomastoid (posterior cervical chain) to the mastoid process.

3. Palpate over the occipital protuberance (occipital lymph nodes).

4. Ask the patient to tilt their head (bring their ear towards their shoulder) each side in turn, and palpate behind the posterior border of the clavicle in the supraclavicular fossa (supraclavicular and infraclavicular lymph nodes).

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Axillary lymph nodes

1. You may wish to wear gloves for this part of the examination.

2. Ask the patient to remove their top.

3. Ask the patient to lie down on the examination couch at 30-45 degrees.

4. Ask about pain in either shoulder before moving the arm.

5. Inspect both axilla (scars/masses/skin changes)

6. When examining the right axilla, hold the patient’s right forearm in your right hand and instruct them to relax it completely, allowing you to support the weight. This allows the axillary muscles to relax.

7. Palpation should then be performed with the left hand. The reverse is applied when examining the left axilla.

8. Examination of axilla should cover the pectoral (anterior), central (medial), subscapular (posterior), humoral (lateral), and apical groups of lymph nodes. An example of a systematic routine you could follow is listed below:

• With your palm facing towards you, palpate behind the lateral edge of pectoralis major (pectoral/anterior).
• Turn your palm medially and with your fingertips at the apex of the axilla palpate against the wall of the thorax (central/medial) using the pulps of your fingers.
• Facing your palm away from you now, feel inside the lateral edge of latissimus dorsi (subscapular/posterior).
• Palpate the inner aspect of the arm in the axilla (humoral/lateral).
• Reach upwards into apex of the axilla with fingertips (warn the patient this may be uncomfortable)

 

Epitrochlear lymph nodes

• This is rare, but usually very obvious when lymphadenopathy is present here (the patient will often point this out if present).
• Hold the wrist of the side to be examined with your corresponding hand (right to right).
• Using your opposite hand, grasp behind the olecranon with your fingers.
• Your thumb should reach across the crease of the elbow to palpate the inner aspect of the arm just above the medial epicondyle of the humerus
• Assess for the presence of lymphadenopathy (sometimes seen in metastatic melanoma of the arm and in generalised lymphadenopathy).

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Inguinal lymph nodes

You are unlikely to be asked to perform this as part of your OSCE. It is, however, important to be aware how to complete this part of the examination.

1. You may wish to wear gloves for this part of the examination.

2. Ask your patient to lower their trousers and underwear to expose the inguinal region.

3. Lower the couch so the patient is lying flat.

4. Inspect for any obvious swellings or irregularities.

5. Palpate immediately inferior to the inguinal ligament (horizontal group/chain of superficial inguinal), which runs between the anterior superior iliac spine (ASIS) and pubic tubercle.

6. Palpate 3cm lateral to the pubic tubercle, vertically down over the saphenous opening and the proximal portion of the great saphenous vein (vertical group/chain of superficial inguinal).

 

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Abdominal exam

Both lymphomas and leukaemias can cause hepatomegaly and splenomegaly, so abdominal examination should always be performed.

Assess the abdomen

1. The patient should be positioned lying flat on the examination couch.

2. Ensure the abdomen is fully exposed. Ask the patient if they have abdominal discomfort.

3. Inspect the abdomen for evidence of bruising or distension.

4. Perform general palpation of the 9 regions of the abdomen to assess for discomfort or underlying masses.

 

Assess for hepatomegaly

1. Begin palpation in the right iliac fossa using the flat edge of your hand (radial side of your right index finger).

2. Ask the patient to take deep breaths in and out (warn them to stop if they begin to feel dizzy).

3. Gradually move your hand from the right iliac fossa towards the right hypochondrium up to the right costal margin in small steps (approx. 2cm), lifting off (not sliding) during each (the liver moves down during inspiration as the diaphragm flattens and pushes the liver downwards within the abdomen). You are trying to feel for the liver edge pressing against your hand during inspiration.

4. A liver edge is not palpable below the costal margin in most patients. If hepatomegaly is present, it should be quantified using fingerbreadths or centimetres from the costal margin. The size of the liver can be further assessed using percussion to identify the upper and lower border. The liver’s regularity, tenderness, and pulsatility should also be noted when hepatomegaly is present.

 

Assess for splenomegaly

1. Starting in the right iliac fossa percuss for the spleen moving towards the left hypochondrium.

2. Press the flat edge of your hand into their abdomen as they inhale. You are trying to feel for the edge of the spleen pressing against your hand.

3. Move the hand 1-2cm proximally with each inhalation unless the edge of the spleen is felt.

4. Quantify splenomegaly using fingerbreadths or centimetres measured from the costal margin.

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To complete the examination

Thank the patient.

Allow the patient time to re-dress.

Wash hands.

Summarise findings.

You may wish to discuss further investigations such as obtaining a full blood count, blood film, further imaging (e.g. CXR/Ultrasound/CT) and biopsy of the lymph node.

If there were concerns that lymphadenopathy was due to metastatic spread then an examination of the relevant organs would be indicated. For example, detection of axillary lymphadenopathy in a patient may warrant a breast examination.

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CO-AUTHORED BY

Samantha Ellis

Junior doctor and Teaching Fellow in Haematology

 

Chris Warner

Medical student at the University of Manchester

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ILLUSTRATED BY

Aisha Ali

Medical student and illustrator

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REVIEWED BY 

Dr Adam Gibb

Clinical Research Fellow in Lymphoma at The Christie Hospital

Dr Mark Rafferty

Haematology Registrar (ST7)

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References

1. Bromberg, M. 2017. Assessment of lymphadenopathy. BMJ Best Practice. Accessed Jan 2018. http://bestpractice.bmj.com/topics/en-gb/838.

2. Tidy, C. 2014. Generalised Lymphadenopathy. Patient UK. Accessed Jan 2018. https://patient.info/doctor/generalised-lymphadenopathy.

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