Phys · general-medicine
Lymph Node Examination and Organomegaly — The DCE Short-Case Systematic Approach
Also known as lymph node examination · examination of lymph nodes · examine this patient's lymph nodes · lymphadenopathy examination · cervical lymph node examination · axillary lymph node examination · inguinal lymph node examination · epitrochlear lymph node · Virchow node · Troisier sign · supraclavicular lymph node · splenomegaly examination · examine for organomegaly · hepatosplenomegaly examination · spleen versus kidney · massive splenomegaly · liver span · hepatomegaly examination · grading of splenomegaly · rubbery lymph node
Consultant-physician-depth guide to the systematic examination of lymph nodes and organomegaly (splenomegaly and hepatomegaly) for the DCE short case and MRCP PACES. Covers the reproducible head-to-toe lymph node routine (head and neck, axillary, epitrochlear, inguinal, popliteal), the five characteristics of every palpable node (size, consistency, mobility, tenderness, overlying skin), the interpretation of node consistency (soft reactive, firm lymphoma, rubbery Hodgkin, hard metastatic, matted TB or lymphoma), the significance of the Virchow node, the correct technique for splenomegaly (start in the right iliac fossa, move diagonally toward the left costal margin along the tenth rib, left hand behind the ribs to lift the spleen forward), the differentiation of spleen from kidney (cannot get above, dull to percussion, notch, moves with respiration), the grading of splenomegaly and the causes of massive splenomegaly (CML, myelofibrosis, chronic malaria, visceral leishmaniasis, Gaucher disease), the examination and description of hepatomegaly, the standard oral presentation template, and the discussion questions the examiner will ask. Structured for FRACP DCE and MRCP PACES. Every sign is referenced to the JAMA Rational Clinical Examination series and the foundational lymphadenopathy reviews.
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Target exams
Red flags
- A hard, fixed left supraclavicular node (Virchow node, Troisier sign) is metastatic intra-abdominal malignancy until proven otherwise — classically gastric cancer; this single finding mandates urgent endoscopy and cross-sectional imaging
- A hard, irregular, fixed cervical node in an older patient with a smoking and alcohol history is metastatic squamous cell carcinoma of the head and neck until proven otherwise — do not delay referral
- Massive splenomegaly crossing the midline into the right iliac fossa is a myeloproliferative neoplasm (CML or myelofibrosis), chronic malaria, visceral leishmaniasis, or a storage disorder (Gaucher) until proven otherwise
- Generalised lymphadenopathy with B symptoms (fever, drenching night sweats, weight loss) is lymphoma until proven otherwise — excisional biopsy of the most abnormal node is the diagnostic gold standard
- A rapidly enlarging, matted, fixed supraclavicular or cervical node mass with Horner syndrome suggests a superior sulcus tumour (Pancoast) or advanced malignancy invading the sympathetic chain
- Acute severe left upper quadrant pain with a rapidly enlarging spleen and signs of shock is splenic rupture — this is a surgical emergency, particularly in infectious mononucleosis, malaria, or after minor trauma
Meet the patient
A pale, tired 62-year-old man is your short case. The instruction is "examine this patient for organomegaly." At the end of the bed he is pale but not cachectic. Your hands find a large, smooth mass in the left upper quadrant crossing the midline toward the right iliac fossa — you cannot get above it, it is dull to percussion, and there is a notch on its medial border.[1]
Two questions decide the mark. Is this mass the spleen or the kidney (three differentiators, each stated aloud)? And what grade of splenomegaly is it, and what does the grade do to the differential? Hold those two and the short case is won before you open your mouth to present.[1]
References4ShowHide
- [1]Grover SA, Barkun AN, Sackett DL The rational clinical examination. Does this patient have splenomegaly? JAMA, 1993.PMID 8411607
- [2]Naylor CD The rational clinical examination. Physical examination of the liver JAMA, 1994.PMID 8196144
- [3]Ferrer R Lymphadenopathy: differential diagnosis and evaluation Am Fam Physician, 1998.PMID 9803196
- [4]Habermann TM, Steensma DP Lymphadenopathy Mayo Clin Proc, 2000.PMID 10907389