Is it normal to palpate lymph nodes

Rick Hodes. Happy Halloween! What is it? An interesting illustration of the physical exam If you put your stethoscope over this, what will you hear? A patient presents with foot pain and these chronic findings? This patient presents with chest pain. Website Reaches Half a Million Visitors!

A patient asks you… what is this? Verghese Welcome New Stanford Interns!!!! Teaching the teachers… Our methods. Do you know Marcus Gunn? Abdominal Wall Pain Do you know what this is??? When examined, these nodes should be small less than 1 cm , non-tender and mobile. Remember to correlate findings from the medical history and general appraisal of the patient to the observations made during the head and neck examination. For example, a previous history of cancer should cause the clinician to be more suspicious of newly appearing palpable nodes than if there is no history of cancer.

If suspicious nodes are discovered, the patient should be referred to a physician for immediate evaluation. Figures 11 through 18 depict the examination techniques for the following lymph nodes. You did not finish creating your certificate. Failure to complete ALL the steps will result in a loss of this test score, and you will not receive credit for this course. Save your progress. Previous Next Lymph Nodes. When palpable nodes are found in the lymph drainage pathways from a known primary cancer site, thorough investigation may help in deciding between palliative and curative treatment.

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Twitter Facebook. This Issue. Stony-hard nodes are typically a sign of cancer, usually metastatic. Very firm, rubbery nodes suggest lymphoma. Softer nodes are the result of infections or inflammatory conditions. Suppurant nodes may be fluctuant. The anatomic location of localized adenopathy will sometimes be helpful in narrowing the differential diagnosis. For example, cat-scratch disease typically causes cervical or axillary adenopathy, infectious mononucleosis causes cervical adenopathy and a number of sexually transmitted diseases are associated with inguinal adenopathy Table 4.

Supraclavicular lymphadenopathy has the highest risk of malignancy, estimated as 90 percent in patients older than 40 years and 25 percent in those younger than age Lymphadenopathy of the right supraclavicular node is associated with cancer in the mediastinum, lungs or esophagus. The left supraclavicular Virchow's node receives lymphatic flow from the thorax and abdomen, and may signal pathology in the testes, ovaries, kidneys, pancreas, prostate, stomach or gallbladder.

Although rarely present, a paraumbilical Sister Joseph's node may be a sign of an abdominal or pelvic neoplasm. In patients with generalized lymphadenopathy, the physical examination should focus on searching for signs of systemic illness. The most helpful findings are rash, mucous membrane lesions, hepatomegaly, splenomegaly or arthritis Table 4. Splenomegaly and lymphadenopathy occur concurrently in many conditions, including mononucleosis-type syndromes, lymphocytic leukemia, lymphoma and sarcoidosis.

Laboratory tests that may be useful in confirming the cause of lymphadenopathy are listed in Table 4. The presence of certain characteristic clinical syndromes may help the physician determine a suspected cause of lymphadenopathy. Patients with these syndromes present with lymphadenopathy, fatigue, malaise, fever and an increased atypical lymphocyte count.

Mononucleosis is most commonly due to Epstein-Barr virus infection. The presence of the typical syndrome and positive results on a heterophilic antibody test Monospot test confirms the diagnosis. The most common cause of heterophil-negative mononucleosis is early Epstein-Barr virus infection.

False-negative results on heterophilic antibody tests are especially common in patients younger than four years of age. Epstein-Barr virus infection may be confirmed by repeating the Monospot test in seven to 10 days. Rarely is it necessary to confirm the diagnosis with IgM viral capsid antigen or early antigen antibody titers. If Epstein-Barr virus antibodies are absent, other causes of the mononucleosis syndrome should be considered. These include toxoplasmosis, cytomegalovirus infection, streptococcal pharyngitis, hepatitis B infection and acute human immunodeficiency virus HIV infection.

Acute infections with cytomegalovirus and Toxoplasma may be identified with IgM serology for those organisms. This syndrome is defined by the presence of a skin lesion with associated regional lymphadenopathy. The classic cause is tularemia, acquired by contact with an infected rabbit or tick; more common causes include streptococcal infection e. This syndrome involves the combination of conjunctivitis and associated preauricular nodes. Common causes include viral kerato-conjunctivitis and cat-scratch disease resulting from an ocular lesion.

Enlargement of the lymph nodes that persists for at least three months in at least two extrainguinal sites is defined as persistent generalized lymphadenopathy and is common in patients in the early stages of HIV infection. Other causes of generalized lymphadenopathy in HIV-infected patients include Kaposi's sarcoma, cytomegalovirus infection, toxoplasmosis, tuberculosis, cryptococcosis, syphilis and lymphoma. The decision will depend primarily on the clinical setting as determined by the patient's age, the duration of the lymphadenopathy and the characteristics and location of the nodes.

Because generalized lymphadenopathy almost always indicates that a significant systemic disease is present, the clinician should consider the diseases listed in Table 4 and proceed with specific testing as indicated. If a diagnosis cannot be made, the clinician should obtain a biopsy of the node. The diagnostic yield of the biopsy can be maximized by obtaining an excisional biopsy of the largest and most abnormal node which is not necessarily the most accessible node.

If possible, the physician should not select inguinal and axillary nodes for biopsy, since they frequently show only reactive hyperplasia. If the lymphadenopathy is localized, the decision about when to biopsy is more difficult.

Patients with a benign clinical history, an unremarkable physical examination and no constitutional symptoms should be reexamined in three to four weeks to see if the lymph nodes have regressed or disappeared. Patients with unexplained localized lymphadenopathy who have constitutional symptoms or signs, risk factors for malignancy or lymphadenopathy that persists for three to four weeks should undergo a biopsy.

Biopsy should be avoided in patients with probable viral illness because lymph node pathology in these patients may sometimes simulate lymphoma and lead to a false-positive diagnosis of malignancy. Many patients worry about the cause of their abnormal lymph nodes. To adequately address their fears, the physician should ask the patient about his or her concerns and respond to questions about specific diagnoses.

When biopsy is deferred, the physician should explain to the patient the rationale for waiting. Patients should be cautioned to remain alert for the reappearance of the nodes because lymphomatous nodes have been known to temporarily regress.

In most patients, lymphadenopathy has a readily diagnosable infectious cause. A diagnosis of less obvious causes can often be made after considering the patient's age, the duration of the lymphadenopathy and whether localizing signs or symptoms, constitutional signs or epidemiologic clues are present.

When the cause of the lymphadenopathy remains unexplained, a three- to four-week observation period is appropriate when the clinical setting indicates a high probability of benign disease. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Address correspondence to Robert Ferrer, M. Reprints are not available from the author. Lymphadenopathy in a family practice. Lymphadenopathy in a family practice: a descriptive study of cases.

J Fam Pract ;— Primary care medicine: office evaluation and management of the adult patient.