History of Presenting Complaint
Overview
With each symptom, always (if relevant) ask about:
- When did it start?
- Did it come on suddenly or gradually?
- Is it continuous or intermittent?
- Has this ever happened before?
Lymphadenopathy
- Site:
- Where are the lumps?
- Are they on both sides?
- Onset:
- When did the lumps start?
- Was there any preceding illness?
- Character:
- Do the lumps hurt?
- Does drinking alcohol elicit pain?
- Are the lumps warm?
- Are the lumps red?
- Do the lumps hurt?
- Associated symptoms:
- See review of systems below
- Timeline:
- Have the lumps changed over time?
- Have they grown?
- Have new ones emerged?
- Lumps lasting >6 weeks are more likely to be malignant
- Have the lumps changed over time?
- Severity:
- How big are the lumps?
Review of systems
- Screen for red flags for haematological malignancy:
- Fever, night sweats, unexplained weight loss
- Unexplained bruising or bleeding
- Bone pain
- Recurrent, severe, persistent, or unusual infections
- Screen for red flags for head and neck cancers:
- Dysphagia, odynophagia, cough, hoarseness, ear pain, epistaxis, blocked nose, haemoptysis, the feeling of a lump in the throat, loose or misaligned teeth
- Screen for infection:
- Sore throat, red eye, ulcers, dysuria, genital discharge, fever
- Recent foreign travel, insect/animal bites
- Are contacts also ill?
- Screen for autoimmune disorders:
- Rheumatological disorders: joint pain, skin rashes, muscle pain, stiffness
- Hypothyroidism and hyperthyroidism
Past Medical History
Questions include:
- Do they have any other medical conditions?
- Have they ever had any previous surgery?
- Do they take any regular medications?
- Do they take any over-the-counter medications, herbal remedies, or supplements?
Family History
- Is there any family history of anything similar?
Allergy History
- Are they allergic to anything?
- What happens during the allergic reaction?
Social History
- Do they smoke?
- If so, how much and how long?
- Do they drink alcohol?
- If so, how much and how long?
- Do they use any illicit drugs?
- If so, how much and how long?
- What is their occupation?
- Who’s at home?
- What support do they have?
- How has this impacted their activities of daily living?
- Has there been any recent foreign travel?
Physical Examinations
Overview
A reticuloendothelial examination is performed. The following properties of lymph nodes should be assessed:
- Size:
- Abnormal lymph nodes are generally >1 cm in diameter
- Persistent lymph nodes >6 weeks may suggest an underlying malignancy
- Shape and consistency:
- In general, hard, firm, and irregular nodes suggest malignancy
- Tender nodes suggest infection or inflammation
- Overlying skin changes (such as ulcers) may suggest malignancy
- Pulsatile lumps suggest a vascular cause
- Mobility:
- Normal lymph nodes are mobile and freely moveable
- Lymph nodes that are fixed or tethered to adjacent or underlying structures suggest malignancy
- Distribution:
- Is the lymphadenopathy localised (in one region) or generalised (in multiple regions)?
- Generalised lymphadenopathy suggests systemic inflammation
- Location:
- Cervical lymphadenopathy – drains the head and neck:
- Causes include infection (e.g. pharyngitis, infectious mononucleosis, and tuberculosis) or malignancy (such as laryngeal cancers or lymphoma)
- Supraclavicular lymphadenopathy – drains the lungs, gastrointestinal tract, and genitourinary tract:
- Supraclavicular lymphadenopathy is much more suggestive of malignancy
- Causes include lymphoma, lung cancer, breast cancer, gastric cancer
- Axillary lymphadenopathy – drains the upper limb, breast, and thorax
- Causes include breast cancer, melanoma, skin infections
- Inguinal lymphadenopathy – drains the lower abdomen, lower limb, external genitalia, and lower extremities:
- Causes include cellulitis, sexually-transmitted infections, lymphoma, melanoma, genitourinary cancer
- Hilar lymphadenopathy:
- Causes include tuberculosis, sarcoidosis, lymphoma
- Other lymphadenopathies:
- Sister Mary Joseph’s nodes – suggest gastric cancer
- Cervical lymphadenopathy – drains the head and neck:
Investigations
Overview
When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations:
- Blood tests:
- Full blood count (FBC) and white cell differential:
- May identify blood dyscrasias
- Throat culture:
- To screen for infection
- Monospot test:
- To screen for infectious mononucleosis
- HIV test:
- To screen for HIV
- Full blood count (FBC) and white cell differential:
- Orifice tests:
- Sputum culture:
- For tuberculosis
- Sputum culture:
- X-rays:
- Chest X-ray:
- To assess hilar lymph nodes and screen for chest pathology (e.g. lung cancer)
- Chest X-ray:
- Special tests:
- Ultrasound scan:
- Malignant lymph nodes may appear differently (e.g. they may have necrosis, calcification etc.)
- Lymph node biopsy:
- Diagnostic for lymphoma
- Bone marrow biopsy:
- For other haematological malignancies
- Ultrasound scan:
Differential Diagnoses: Infective
Infectious mononucleosis
- A history and physical exam may reveal:
- A triad of fever, pharyngitis, and lymphadenopathy
- Splenomegaly may be present
- Lymphadenopathy is in the anterior and posterior triangles of the neck
- Many patients have severe fatigue
- Investigations may reveal:
- Full blood count (FBC):
- May show lymphocytosis
- Monospot:
- Positive
- Full blood count (FBC):
Reactive lymphadenopathy
- A history and physical exam may reveal:
- Fever, malaise, myalgia
- Sore throat, cough
- Coryza, gastroenteritis, rash
- Lymphadenopathy may be tender and warm, which may suggest the development of an abscess
- Investigations depend on the underlying cause
HIV
- A history and physical exam may reveal:
- Flu-like symptoms including fever, malaise, myalgia
- A history of exposure to high-risk material such as needlestick injuries, intravenous drug use, unprotected sexual intercourse
- Investigations may reveal:
- HIV p24 antigen and HIV antibody:
- Positive
- HIV p24 antigen and HIV antibody:
Hepatitis B and C
- A history and physical exam may reveal:
- A history of exposure to high-risk material such as needlestick injuries, intravenous drug use, unprotected sexual intercourse
- Hepatomegaly, jaundice
- Investigations may reveal:
- Hepatitis serology:
- Positive
- Hepatitis serology:
Tuberculosis
- A history may reveal:
- Cough, fever, weight loss, night sweats, haemoptysis
- HIV/immunosuppression
- Travel to an endemic area
- A physical exam may reveal:
- Fever, tachypnoea
- Lymphadenopathy tends to affect the cervical lymph nodes
- Investigations may reveal:
- Chest x-ray:
- May show bilateral hilar lymphadenopathy, may show upper lobe cavitation
- Sputum culture:
- Diagnostic
- Chest x-ray:
Measles
- A history may reveal:
- A prodromal fever followed by conjunctivitis, cough, and a rash starting on the head or trunk, then spreading
- A physical exam may reveal:
- Lymphadenopathy tends to be generalised
- Koplik’s spots
- A maculopapular rash
- Investigations may reveal:
- Measles-specific IgM and/or IgG:
- Positive
- Measles-specific IgM and/or IgG:
Mumps
- A history may reveal:
- Fever, sore throat, and parotitis (enlarged painful salivary glands)
- A physical exam may reveal:
- Parotitis
- Lymphadenopathy tends to be cervical or occipital
- Diagnosis is generally clinical
Rubella
- A history may reveal:
- Prodromal fever followed by a maculopapular rash starting on the face before spreading to the whole body
- A physical exam may reveal:
- Maculopapular rash
- Lymphadenopathy tends to be post-auricular and suboccipital
- Investigations may reveal:
- Anti-rubella IgM and/or IgG:
- Positive
- Anti-rubella IgM and/or IgG:
Cat scratch disease
- A history and physical exam may reveal:
- Exposure to cat scratches
- Cuts and scratches on the skin
- Lymphadenopathy tends to be axillary
- Investigations may reveal:
- Bartonella henselae serology:
- Positive
- Bartonella henselae serology:
Toxoplasmosis
- A history may reveal:
- Exposure to cats, ingestion of undercooked meat, exposure to soil
- Fever, malaise, pharyngitis
- A history of immunosuppression
- A physical exam may reveal:
- Lymphadenopathy tends to be cervical and non-tender
- Investigations may reveal:
- Toxoplasma serology tests:
- Positive
- Toxoplasma serology tests:
Genital herpes
- A history and physical exam may reveal:
- Painful genital ulceration, dysuria, and pruritus
- Unprotected sexual intercourse
- Inguinal lymphadenopathy
- Investigations may reveal:
- Nucleic acid amplification tests (NAAT):
- Positive
- Nucleic acid amplification tests (NAAT):
Lymphogranuloma venereum
- A history and physical exam may reveal:
- Genital ulcers
- Painful inguinal lymphadenopathy
- Unprotected sexual intercourse
- A history of HIV
- Investigations may reveal:
- Nucleic acid amplification tests (NAAT):
- Positive
- Nucleic acid amplification tests (NAAT):
Chancroid
- A history and physical exam may reveal:
- Painful genital ulcers that have ragged borders
- A history of unprotected sexual intercourse
- Unilateral or bilateral inguinal lymphadenopathy
- Investigations may reveal:
- Haemophilus ducreyi serology and polymerase chain reaction:
- Positive
- Haemophilus ducreyi serology and polymerase chain reaction:
Syphilis
- A history and physical exam may reveal:
- A painless ulcer at the site of sexual contact
- Generalised lymphadenopathy – usually seen in secondary syphilis
- Fever, diffuse rash on the palms and soles
- Gummas, Argyll-Robertson pupil
- Investigations may reveal:
- Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR):
- Positive
- Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR):
Differential Diagnoses: Malignant
Lymphoma
- A history may reveal:
- Non-tender supraclavicular/rubbery lymphadenopathy
- Rarely, this can be painful when drinking alcohol in Hodgkin’s lymphoma (HL)
- B-symptoms – fevers, night sweats, weight loss
- Pruritus
- Non-tender supraclavicular/rubbery lymphadenopathy
- A physical exam may reveal:
- Lymphadenopathy
- Splenomegaly/hepatomegaly
- Investigations may reveal:
- Full blood count (FBC) and white cell differential:
- Haemoglobin: may be low due to bone marrow involvement
- White cell count: high or low – depending on bone marrow involvement
- Platelets: low – due to bone marrow involvement
- Erythrocyte sedimentation rate (ESR):
- May be elevated
- Chest x-ray:
- May show mediastinal mass
- Immunophenotyping:
- Can differentiate HL and NHL using flow cytometry– HL is usually CD30 positive and CD15 positive
- Lymph node biopsy:
- Shows Reed-Sternberg cells in Hodgkin’s lymphoma – these are cells that are either nucleated or have a bilobed nucleus with eosinophilic inclusion-like nucleoli. They have an ‘owl’s eye’ appearance
- Full blood count (FBC) and white cell differential:
Metastatic malignancy
- A history may reveal:
- New lymphadenopathy in a patient with cancer should raise suspicion of metastasis
- There may be constitutional symptoms and other features of the specific cancer (e.g. skin lesions, shortness of breath and similar pulmonary symptoms, breast lumps etc.)
Differential Diagnoses: Autoimmune/Inflammatory
Rheumatoid arthritis
- A history and physical exam may reveal:
- Inflammatory pain and stiffness:
- Pain and stiffness improve on exertion
- Morning stiffness >30 minutes – 1 hour
- Joint deformities may be seen:
- Swan neck deformity
- Boutonnière’s deformity
- Bilateral distal polyarthropathy
- Features of systemic upset may be seen
- Joints affected include MCPs and PIPs, but any can be affected
- Lymphadenopathy is often in the axillary region
- Inflammatory pain and stiffness:
- Investigations may reveal:
- Rheumatoid factor (RF):
- Positive
- Anti-cyclic citrullinated peptide (anti-CCP) antibodies:
- Positive
- Rheumatoid factor (RF):
Systemic lupus erythematosus
- A history and physical exam may reveal:
- Classically affects young women
- Photosensitive rash may be present
- Such as the malar ‘butterfly-shaped’ rash on the face sparing the nasolabial folds
- Generalised myalgia
- Mouth ulcers
- Pleurisy
- Hair loss
- Lymphadenopathy may be generalised
- Investigations may reveal:
- Anti-nuclear antibodies (ANA):
- Positive
- Anti-double-stranded DNA (anti-dsDNA):
- Positive
- Anti-nuclear antibodies (ANA):
Sjogren’s syndrome
- A history may reveal:
- Dry eyes, dry mouth, and vaginal dryness are predominant features
- Arthralgia
- Increased risk of lymphoma, lymphadenopathy may suggest its development
- Investigations may reveal:
- Anti-Ro and anti-La antibodies:
- Positive
- These backward spells (ORAL)
- Anti-Ro and anti-La antibodies:
Sarcoidosis
- A history may reveal:
- Fever, arthritis, erythema nodosum, weight loss, malaise
- A physical exam may reveal:
- Wheezing, dry crackles
- Investigations may reveal:
- Chest x-ray:
- Bilateral hilar lymphadenopathy
- Serum ACE:
- Elevated
- Serum calcium:
- Elevated
- Lung biopsy:
- Non-caseating granuloma:
- Chest x-ray:
Kawasaki disease
- A history may reveal:
- Mainly seen in children
- Prolonged fever that is resistant to antipyretics, irritability
- A physical exam may reveal:
- Cervical lymphadenopathy
- Red rash on the palms and soles which may peel
- Bright red and cracked lips
- Conjunctival redness
- Strawberry tongue
- Investigations may reveal:
- Diagnosis is clinical although ESR and CRP may be elevated and echocardiography is performed in all patients to screen for coronary artery aneurysms