Lymphatic System

HISTORY

    • Age-

    • Duration-

    • Which group was first affected?-

    • Pain-

    • Fever-

    • Primary focus-

    • Loss of appetite & weight-

    • Pressure effects-

    • Past history-

    • Family history-

PHYSICAL EXAMINATION

GENERAL SURVEY : Malnutrition, cachexia, anemia and loss of weight are often seen in cases of tuberculous lymphadenitis, primary and secondary malignant lymphadenopathies.

LOCAL SURVEY

    • INSPECTION: Swellings at the known sites of the lymph nodes should be considered to have arisen from them unless some outstanding clinical findings prove their origin to be otherwise.

      • Swellings- It is examined in usual format that means the number, position, size, surface, etc are noted. Of these the position is important, as it will not only give an idea as to which group of lymph nodes is affected, but also the diagnosis. eg-Hodgkin's disease and tuberculosis affect the cervical group of lymph nodes in the beginning; filariasis and lymphogranuloma inguinale affect the inguinal group of nodes; secondary stage of syphilis involves the epitrochlear and occipital groups. Number is important- whether single or multiple groups are involved. A few conditions are known to produce generalized involvement of lymph nodes. These are Hodgkin's disease, tuberculosis, lymphosarcoma, lymphatic leukemia, brucellosis sarcoidosis etc.

      • Skin over the swelling- In acute lymphadenitis the skin becomes inflamed with redness, edema and brwany induration. In chronic lymphadenitis the skin over the swelling does not show such angriness. Skin over tuberculous lymphadenitis and cold abscess remains 'cold' in the true sense till they reach the point of bursting when the skin becomes red and glossy. Over a rapidly growing lymhosarcoma the skin becomes tense, shining with dilated subcutaneous vein. In secondary carcinoma, though the skin remains free in the early stage, yet it becomes fixed to the swelling at the later stage when the disease has gone beyond the scope of surgery. Not infrequently a scar, a sinus or an ulcer may be present by the side of or over the swelling.Scar often indicates previous bursting of cold abscess or a previous operation.

      • Pressure effects- Swelling and venous engorgement of face and neck may occur due to pressure effect of lymph nodes at the root of the neck.

    • PALPATION:

      • Number-

      • Situation-

      • Local temperature-

      • Tenderness-

      • Surface-

      • Margin-

      • Consistency- Enlarged lymph nodes should be carefully palpated with palmar aspects of the 3 fingers. It must be remembered that normal lymph nodes without enlargement are not palpable. Enlarged lymph nodes may be soft (fluctuating) or elastic and rubbery (Hodgkin's disease) or firm, discrete and shotty(syphilis) or stony hard ( secondary carcinoma) or variable consistency - soft, firm and hard in places depending on the rate of growth( lymphosarcoma).

      • Whether the nodes are Matted or not?

      • Fixity to surrounding structures-

      • Drainage area-

GENERAL EXAMINATION

    • Lymph nodes in other parts of the body-

    • Always examine (a) Spleen, (b) Liver, (c) Mesenteric & Iliac lymph nodes-

    • Examine the lungs for tuberculosis & Secondary metastasis-

    • Syphilitic stigmas-

    • Parotid & Lacrimal glands-

CAUSES OF ENLARGEMENT OF LYMPH NODES

    1. INFLAMMATORY

      • Acute Lymphadenitis

      • Chronic Lymphadenitis

      • Granulomatous Lymphadenitis

    2. NEOPLASTIC

      • Primary-

        • Malignant Lymphoma, undifferentiated type

        • Malignant Lymphoma, histiocytic type

        • Malignant Lymphoma, lymphocytic type (poorly differentiated)

        • Malignant Lymphoma, lymphocytic type (well differentiated)

        • Malignant Lymphoma, mixed type

        • Malignant Lymphoma, Hodgkin's type- a) Lyphocytic predominance b) nodular sclerosis

      • Secondary-

    3. LYMPHATIC LEUKAEMIA

    4. AUTOIMMUNE DISORDERS

Causes of generalised lymph nodes enlargement:-

    1. Tuberculosis

    2. Syphilis- secondary stage

    3. Infectious mononucleosis

    4. Sarcoidosis

    5. Brucellosis

    6. Toxoplasmosis

    7. Hodgkin's disease

    8. Lymphosarcoma

    9. Lymphatic leukaemia