Introduction
Lymph node examination is tested across general medicine, haematology, and surgical OSCEs. The key skill is to examine all node groups systematically and characterise each enlarged node using five descriptors. A single set of findings can narrow the differential diagnosis considerably.
💎 Clinical Pearl
Examine cervical nodes from behind the seated patient. For axillary nodes, support the patient's arm to relax the pectoral muscles. Always examine the spleen when you find lymphadenopathy.
Five Characteristics of a Lymph Node
🧠 Mnemonic
STCMT — Size, Tenderness, Consistency, Mobility, Temperature
- Size: record in centimetres
- Tenderness: suggests reactive or infective cause
- Consistency: soft (reactive), rubbery (lymphoma), hard (metastatic)
- Mobility: mobile (benign), fixed to surrounding structures (malignant)
- Temperature: warm (infective or inflammatory)
Cervical Lymph Node Groups
Examine from behind with the patient seated:
| Group | Location | Drains |
|---|---|---|
| Submental | Under chin (midline) | Floor of mouth, lower lip, tongue tip |
| Submandibular | Under mandible | Oral cavity, tongue, lips |
| Preauricular | In front of ear | Scalp, conjunctiva |
| Postauricular | Behind ear | Scalp, external auditory canal |
| Anterior triangle | Along anterior border of SCM | Oral cavity, throat, thyroid |
| Posterior triangle | Along posterior border of SCM | Scalp, nasopharynx |
| Supraclavicular | Above clavicle | Right: lung and mediastinum; Left (Virchow's): GI and pelvic |
| Occipital | Back of head | Scalp |
⚠️ Red Flag
A left supraclavicular node (Virchow's node / Troisier's sign) enlarged in the context of unexplained weight loss or GI symptoms strongly suggests metastatic GI or pelvic malignancy (most classically gastric cancer). Always palpate the supraclavicular fossae.
Axillary Lymph Node Groups
Support the patient's arm to relax pectorals, then palpate five groups:
- 1Central (most commonly enlarged)
- 2Anterior (pectoral) — along medial pectoral wall
- 3Posterior (subscapular) — along posterior axillary fold
- 4Lateral (brachial) — along humerus
- 5Apical — at apex of axilla
Causes of axillary lymphadenopathy: breast cancer, melanoma of the arm, arm infections, lymphoma.
Inguinal Lymph Nodes
Two groups along the inguinal ligament:
- Horizontal group — along inguinal ligament: drains lower abdominal wall, buttock, external genitalia
- Vertical group — along femoral vein: drains lower limb
Causes: lower limb infection, STIs, anal or vulval or penile malignancy, lymphoma.
Spleen
Always assess for splenomegaly when lymphadenopathy is found. Percuss from right iliac fossa toward left hypochondrium. Palpate from the right iliac fossa, asking the patient to breathe in deeply.
Differentials for Lymphadenopathy
| Pattern | Causes |
|---|---|
| Localised, tender, soft | Reactive (URTI, dental, scalp infection) |
| Localised, hard, fixed | Metastatic malignancy |
| Generalised, rubbery, non-tender | Lymphoma |
| Generalised, firm | CLL, HIV, EBV (glandular fever) |
| Axillary alone | Breast cancer, melanoma, axillary lymphoma |
B Symptoms (Hodgkin's Lymphoma)
🧠 Mnemonic
Three Bs: Burning sweats (drenching night sweats), Body temperature (fever over 38 degrees C), Bulk loss (more than 10% body weight in 6 months)
The presence of B symptoms indicates Stage B Hodgkin's disease and worsens prognosis.
How to Present
"On examination of the neck I found a 2 cm rubbery, non-tender, mobile lymph node in the left anterior triangle. There were no other palpable cervical, axillary, or inguinal nodes. The spleen was not palpable. The most likely diagnosis is lymphoma, and I would investigate with a full blood count, LDH, and CT neck, chest, abdomen, and pelvis."
"What characteristics help differentiate benign from malignant lymph nodes?"
Benign reactive nodes tend to be soft, mobile, tender, and less than 1 cm. Malignant nodes are typically firm to hard, fixed to surrounding structures, non-tender, and greater than 1 cm. Lymphoma classically produces rubbery, non-tender, mobile nodes, while metastatic carcinoma produces hard, fixed, non-tender nodes.
"What is Virchow's node and what does it signify?"
Virchow's node is an enlarged left supraclavicular lymph node. When found in a patient with unexplained weight loss or GI symptoms, it suggests metastatic spread from an abdominal or pelvic malignancy — most classically gastric cancer — via the thoracic duct. It is also called Troisier's sign and should always prompt urgent investigation.
"What are B symptoms in lymphoma and why do they matter?"
B symptoms are constitutional features indicating systemic disease in Hodgkin's lymphoma: drenching night sweats, unexplained fever above 38 degrees C, and unexplained weight loss of more than 10% body weight in the previous 6 months. Their presence upgrades staging to B and worsens prognosis.
"What is the differential for generalised lymphadenopathy?"
Generalised lymphadenopathy (three or more non-contiguous node groups) is caused by: infections (EBV, CMV, HIV, TB), haematological malignancy (lymphoma, CLL, leukaemia), autoimmune disease (SLE, RA, sarcoidosis), drugs (phenytoin, allopurinol), and rarely hyperthyroidism. Always take a full blood count, blood film, and monospot test, and consider CT staging.
Related guides: [Thyroid Examination OSCE](/blog/thyroid-examination-osce) | [Abdominal Examination OSCE](/blog/abdominal-examination-osce) | [Blood Results Interpretation OSCE](/blog/blood-results-interpretation-osce)