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Examination of the lymph nodes. A thorough clinical examination should
usually include both the systematic inspection and palpation of the
clinically relevant lymph node stations. The most important stations are: the head
and neck area, the axilla, and the inguinal area.
Consequently, the lymph nodes are usually examined from cranial to caudal.
Around one-third of all lymph nodes are located in the head and neck area where
they can be found superficially and are therefore easily palpable. The following
lymph nodes should be included in every palpation: sub-occipital, retro- and
pre-auricular, submandibular, sub-mental, posterior triangle of the neck,
and those within the area of the internal jugular vein, which lie deep
within the neck and may be palpated ventral or dorsal to the
sternocleidomastoid muscle. Additionally, the supraclavicular lymph
nodes should be palpated as well, since enlargement of these lymph nodes is
often associated with malignancies. Abdominal tumors that metastasize by the
lymphatic system, such as gastric cancer, will often result in an enlarged Virchow
node in the left supraclavicular fossa. Carefully palpate the individual lymph
node stations. To facilitate differentiation between
lymph nodes and muscles, the area that is palpated should be as relaxed as
possible. Every palpable lymph node is considered
enlarged. If there is enlargement, pay attention to
consistency, tenderness, mobility, the number of enlarged lymph nodes, and any
erythema in the affected area. Multiple fused lymph nodes are referred
to as conglomerates and are highly suspicious for malignancy. After palpating the head and neck,
continue by examining the axillary lymph nodes, which can be divided into
different groups as well. The pictorial or anterior group is
located in the anterior axillary fold and is responsible for the majority of
lymphatic drainage of the chest and chest wall. The subscapular or posterior lymph node
group is palpable deep within the posterior axillary fold. It drains parts
of the arms and the chest wall. The brachial or lateral lymph nodes
drain the majority of the arms and can be palpated in the area of the proximal
humerus. All of the lymph node groups just
mentioned then drain into the central group, which is palpable at the base of
the axilla. The sub clavicular or apical group represents the last lymph node
station before the lymphatic vessels drain into the venous system. This group
should be examined together with the cervical or axillary lymph nodes. In this
patient the examiner starts by palpating the pectoral group behind the lateral
aspect of the pectoralis major muscle. Afterwards, he palpates the central group,
followed by the posterior group in the area of the posterior axillary fold and
the brachial group of the upper arm. Distinguishing between lymph nodes and
surrounding muscles is best achieved when the arm is relaxed and lowered. Afterwards, the superficial lymph nodes
of the inguinal area should be palpated. They are divided into a horizontal and a
vertical group. The horizontal group lies below the
inguinal ligament and can therefore be palpated parallel to its course.
This group is responsible for draining parts of the external genitalia, trunk,
and lower back. The vertical group is located adjacent
to the great proximal saphenous vein and drains lymphatic fluid from the lower
extremity. Examination of the inguinal lymph nodes
is best performed with the patient lying down. As a lymphatic organ, the spleen should
always be a part of the lymph node assessment since splenomegaly can hint
at a systemic inflammatory or malignant illness. The spleen is generally not palpable in
healthy adults. A pathologically enlarged spleen is palpated under the left costal
margin during inspiration, as the inferior edge descends to the examiners
fingertips. If an enlarged spleen is already suspected, palpation should begin
further down. The examination may be facilitated by
gently lifting the left flank of the patient ventrally.

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