Lymph Node Examination and Organomegaly — Viva Defence

Viva — The Lymph Node and Organomegaly Short-Case Defence

The routine (examiner: "Examine this patient's lymph nodes")

I would introduce myself, confirm the patient's identity, request permission, and position the patient sitting upright at 45 degrees for the head and neck nodes, then supine with one pillow for the remaining regions. I would ensure good lighting, warm my hands, and stand on the patient's right side for the abdominal examination. [1]

I perform the head-to-toe lymph node routine: [1]

Head and neck. I palpate the head and neck nodes systematically with the pads of my index and middle fingers, the patient's neck slightly flexed: submental, submandibular, pre-auricular, post-auricular, occipital, tonsillar, the anterior cervical chain along the anterior border of sternocleidomastoid, the posterior cervical chain along the posterior border. I move behind the patient to palpate the supraclavicular fossae, placing my fingers deep into the angle between the clavicle and the sternocleidomastoid with the shoulders relaxed, on each side. I then palpate the pre-tracheal nodes. In this patient there are bilateral, rubbery, mobile, non-tender nodes in the anterior and posterior cervical chains, the largest 2 by 2 centimetres. There is a similar rubbery node in the left supraclavicular fossa — rubbery rather than hard, more consistent with lymphoma than a Virchow node from carcinoma. [1]

Axillary. I support the patient's arm to relax the axillary muscles and place my examining hand high into the axillary apex, drawing it downward against the chest wall. I examine all five groups: the apical, the anterior (pectoral), the posterior (subscapular), the lateral (humeral), and the central. In this patient there are matted, firm, mobile masses up to 3 centimetres in both axillae. [1]

Epitrochlear. I cup the patient's elbow and palpate with the thumb or fingers in the groove above and 3 cm proximal to the medial epicondyle, between biceps and triceps, the elbow flexed to 90 degrees. The epitrochlear nodes are palpable bilaterally. [1]

Inguinal. With the patient supine and the hip slightly flexed, I palpate along the inguinal ligament (the horizontal group) and along the saphenous vein in the upper medial thigh (the vertical group). The inguinal nodes are small, mobile, and shotty — consistent with reactive change. [1]

Popliteal. I palpate deeply in the popliteal fossa behind the slightly flexed knee. The popliteal nodes are not palpable. [1]

Abdomen for organomegaly. I examine the spleen, the liver, and the kidneys. The spleen is palpable 6 centimetres below the left costal margin, smooth, with a notch. I confirm this is the spleen: I cannot get above it, it is dull to percussion, and it has a notch. This is moderate splenomegaly. The liver is not enlarged, with a percussion span of 13 centimetres. The kidneys are not ballotable. [1]

The presentation (examiner: "Present your findings")

My findings are: generalised lymphadenopathy with moderate splenomegaly. At the end of the bed the patient is pale but not cachectic or jaundiced. There are bilateral, rubbery, mobile, non-tender nodes in the anterior and posterior cervical chains, with similar nodes in both axillae and the epitrochlear regions. The inguinal nodes are small and reactive. The spleen is moderately enlarged. The most likely diagnosis is lymphoma — the rubbery consistency, the generalised distribution, the epitrochlear involvement, and the splenomegaly all support this. I would investigate with a full blood count and film, a lactate dehydrogenase, an HIV test and EBV serology, and an excisional biopsy of the most abnormal node for histology, flow cytometry, and immunohistochemistry, followed by a staging CT and a PET scan. [1]

Probing questions

Q: Why do you say the consistency is rubbery, and what does rubbery mean? [1]

Rubbery means dense and firm but slightly bouncy, like a piece of india rubber. It is the classic consistency of Hodgkin lymphoma, reflecting the orderly proliferation of the Reed-Sternberg cells within a background of reactive inflammatory cells, which preserves some nodal architecture while expanding it. This differs from the hard, stony node of metastatic carcinoma and the soft, tender node of acute infection. [1]

Q: How do you examine the supraclavicular fossae, and why from behind? [1]

I move behind the patient, flex the neck forward, and ask the patient to shrug the shoulders and let them drop (or to take a deep breath and relax), which relaxes the sternocleidomastoid and the scalenes. I place my fingers deep into the angle between the clavicle and the sternocleidomastoid, pressing downward and inward. Examining from behind allows me to relax the overlying muscles and reach deeply into the fossa. A hard, fixed left supraclavicular node is a Virchow node (Troisier sign) — a sentinel node for intra-abdominal malignancy via the thoracic duct. In this patient the node is rubbery rather than hard, which favours lymphoma over carcinoma. [1]

Q: How do you confirm the mass is the spleen and not the kidney? [1]

Three features. First, I cannot get above the spleen — its upper border is continuous with the diaphragm. Second, the spleen is dull to percussion because it lies behind the stomach; the kidney is resonant because of the overlying stomach and splenic flexure gas. Third, the spleen has a notch on its medial border. The spleen also moves with respiration and cannot be ballotted; the kidney can be ballotted. The Grover systematic review found these manoeuvres have moderate sensitivity and a non-palpable spleen does not exclude splenomegaly [1].

Q: Name the causes of massive splenomegaly. [1]

Chronic myeloid leukaemia, myelofibrosis, chronic malaria (hyperreactive malarial splenomegaly), visceral leishmaniasis (kala-azar), Gaucher disease, and primary hypersplenism. Massive splenomegaly narrows the differential immediately — these are the only diagnoses to recite when the spleen crosses the midline. [1]

Q: When is a node biopsy indicated, and why excisional rather than fine needle aspiration? [1]

Biopsy is indicated for a supraclavicular node of any size, a hard or fixed node, a node over 2 cm that persists, a progressively enlarging node, or any node with B symptoms. The gold standard is excisional biopsy of the most abnormal node, because it preserves nodal architecture for histological subtyping and provides sufficient tissue for flow cytometry and immunohistochemistry. Fine needle aspiration destroys architecture and is inadequate for lymphoma diagnosis. When no node is dominant, the supraclavicular and cervical nodes give the highest yield, and the inguinal nodes the lowest [3][4].

Q: What does a palpable liver edge in a patient with COPD mean? [1]

It may simply reflect downward displacement of a normal-sized liver by a hyperinflated chest and a depressed diaphragm. The resolution is to measure the liver span by percussion — percuss from the right third intercostal space down to the dull upper border, and from below the costal margin up to the dull lower border. A normal span is 12 to 15 cm. In COPD the span is normal. The Naylor systematic review found the percussion span is the more reliable bedside measure than the palpable edge alone [2].