Approach+to+a+patient+with+lymphadenopathy

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Approach+to+a+patient+with+lymphadenopathy

  1. 1. Lymphadenopathy• Enlargement of the lymph nodes due to specific or nonspecific causes.• LYMPHADENITIS:• Genaralised or local Lymphadenopathy.
  2. 2. • Can be considered normal: 1) soft, flat, submandibular nodes (<1cm) in healthy children and young adults; 2) palpabale inguinal lymph nodes of up to 2cm in diameter in healthy adults.• May be a primary or secondary manifestation of numerous disorders, both benign and malignant.
  3. 3. • 2/3 of causes are non specific, & less than 1% are malignant.
  4. 4. Clinical Assessment Medical History Physical Examination Laboratory Tests Excisional LN Biopsy
  5. 5. Medical History Reveals the setting in which lymphadenopathy is occuring. General information, accompanying symptoms, personal and social history.
  6. 6. GENERAL INFORMATIONI. Age: Young age: TB, Syphilis, primary malignant lymphoma. Old age; secondary metastatic carcinoma.II. Occupation: BrucellosisIII. Socio economic status;
  7. 7. accompanying symptomsI. FeverII. Soar throatIII. CoughIV. FatigueV. Wt lossVI. Increased night sweatingVII. Pressure effects
  8. 8. History of presentingcomplaintsI. DurationII. Which group was 1st affected?III. PainIV. FeverV. Primary focusVI. Loss of appetite & waitVII. Pressure effects
  9. 9. Past historyI. h/o TB,Syphilis, any URTI,II. h/o recent blood transfusion.III. immuno suppression.IV. Any viral infectionV. HISTORY OF MEDICATION: phenytoin, cyclosporin,allopurinol ,carbamazepine, hydralazine
  10. 10. Personal history h/o exposure to pets h/o tobacco use, alcohol, smoking, i/v drug abbuse h/o travel to any endemic area
  11. 11. Family history h/o any TB in family, any malignancy (lymphoma)
  12. 12. HISTORY WITH SPECIALFINDINGS FEVER:lymphoma,TB,SLE,IMN, AIDS Petechial H’agein palate in a young boy with cervical lymphadenopathy:IMN Hard lump in breast +ipsilateral axillary lymphadenopathy :CA BREAST NON PITTING oedema with inguinal adenopathy :FILARIASIS Fever,WT loss loss appetite night sweat lymphadenopathy:TB ,AIDS,MALINGNANCY
  13. 13.  PROLONGED MEDICATION LYMPHADENOPATHY with SKIN lesion :SLE ,SARCOIDOSIS,
  14. 14. General examinationI. MalnutritionII. AnaemiaIII. IcterusIV. LymphadenopathyV. Edema
  15. 15. Physical Examination Introduce yourself Consent Position: cervical, axillary and inguinal
  16. 16.  Palpate normal side first Clean, dry warm hands (gloves).
  17. 17. General principles of exam Before the exam, ask the patient to identify painful areas so that you can examine those areas last During the exam pay attention to their facial expression to assess for sign of discomfort
  18. 18. Remember: Normal lymph nodes are not palpable Examine the draining lymph nodes area of any lesion Examine the area drained by affected lymph nodes
  19. 19. Examination of the lymphnodes follow the same stepsused in every examination:InspectionPalpationPercussionAuscultation
  20. 20. Inspection
  21. 21. An examination of the lymph nodes forms part of the routine for most body systems.As there is no need to percuss or auscultate, examination involves inspection followed by palpation
  22. 22. The following groups of lymph nodes are to be examined:1- Cervical groups2- Axillary groups3- Inguinal groups4- Epitrochlear lymph nodes.5-popleteal lymph nodes5- Remember that the liver and spleen are parts of the lymphoid tissue
  23. 23. Exposure: Cervical: all head and neck to clavicles Axillary: stripped to the waist Inguinal: umblicus to knee
  24. 24. Dont forget to examine the draining areas
  25. 25. The following points are tobe fulfilled duringinspection:
  26. 26.  SSSSS (5S):1- Site.2- Shape.3- Size.4- Surface: Smooth, nodular, irregular.5- Skin overlying the swelling (scars, colour…).6- Other draining lymph nodes.7- Number8- pressure effect
  27. 27. Palpation Technique: use the pads of the index and middle finger to move the skin in circular motions over the underlying tissues in each area
  28. 28. Technique
  29. 29. Cervical Lymph nodes1- seat the patient in a chair2- palpate from behind (?): right hand for right side and vice versa3- slightly bend the neck towards the side to be examined3- use one hand at a time4- Bimanual examination may be employed
  30. 30.  Elevated shoulders facilitate palpation of supraclavicular LN Deep nodes are deep to sternomastoid Virchow nodes
  31. 31. The following points are to befulfilled during palpation: Confirm your inspection Temprature Tenderness Consistency Mobility Special signs Draining area Matted or not
  32. 32. Axillary group From front: apical, central and pectoral From side: lateral group From behined: posterior and supraclavicular groups
  33. 33. Palpation of Axillary, Infraclavicular and Supraclavicular Lymph NodesExamine the sitting patient by palpating the left axilla with yourright hand and vice versa.Relax the patient’s left arm and axillary muscles by holding the lefwrist with your left hand and elevating the upper arm toward thechest wall.Place your hand in the axilla with the fingers together and thepalm toward the chest wall.Point your fingers obliquely toward the apex of the axilla.
  34. 34.  Now, have the patient rest their left hand on your examining right arm, while your left hand supports the shoulder. Gently, but firmly, rake the pulps of your examining fingers along the thoracic cage to feel for enlarged lymph nodes.
  35. 35. Palpation of Axillary, Infraclavicular and Supraclavicular Lymph NodesThe central group of nodes occurs near the middle of the thoracicwall of the axilla.The lateral axillary group is located near the upper part of thehumerus and is best demonstrated by having the patient’s armelevated so that you can feel along the axillary vein.With the patient’s arm still elevated, feel along beneath the lateraledge of the pectoralis major muscle for the pectoral group.
  36. 36.  Palpate the subscapular nodes from behind the patient with the arm raised, palpating with the left hand under the anterior edge of the latissimus dorsi muscle. Palpate under the clavicle for the infraclavicular group. Enlargement in the supraclavicular group is sought by feeling the soft tissues above and behind the clavicle
  37. 37.  Epitrochlear nodes: Approximately 3 cm proximal to the medial humeral epicondyle, in the groove between the biceps and triceps brachii.
  38. 38.  Palpation of the Inguinal Nodes:A horizontal group lies along the inguinal ligament (both above and over) and,A vertical group is beside the great saphenous vein in the proximal thigh.Iliac nodes: aboveand deep to inguinal ligament
  39. 39. Palpation of a lymph node: TT SSSS CE SSS (2T, 4S, CE, 3S).- Temperature of skin over swelling: normal, warm,cold (compare with contra-lateral side).- Tenderness (look to the patient’s face).- Site.- Shape.- Size.
  40. 40. - Surface: Smooth, nodular, irregular.- Consistency: Soft, firm, hard, cystic.- Edge: Well-defined, ill-defined.- Surrounding structures and mobility of the swelling: Relation to muscles etc.- Special signs: e.g. are pulsations transmittedor expansile?.- (Other) Swellings.
  41. 41. Relation of a swelling to adjacent muscle by inspection: The patient is asked to contract the muscles against resistance: If the swelling becomes MORE apparent it isSUPERFICIAL to the muscles. If the swelling becomes LESS apparent it is DEEPto the muscles. If the swelling is NOT AFFECTED it is IN the muscle.
  42. 42. OTHER SYSTEMS RESP ...SYSTEM CVS CNS GIT
  43. 43. At the end: Cover the patient Thank the patient
  44. 44. DDs IMN SLE FILARIASIS LYMPHOMA AIDS
  45. 45. Follow-up and Treatment• Follow-up at 2-4 weeks interval for benign causes.• Antibiotics are given only if there is strong evidence of bacterial infection.• DO NOT USE GLUCOCORTICOIDS-might obscure diagnosis or delay healing in cases of infection (EXCEPTION: life-threatening pharyngeal obstruction by enlarged lymph tissue in Waldeyer’s ring caused by IM.)
  46. 46.  CONCLUSSION
  47. 47. Thank you

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