PhysDi - Heme/Lymph Disorders Flashcards
Facts about lymphatic system
- 3% of total body weight
- every tissue supplied by blood has lymph vessels except placenta and brain
Role of lymphatics in human body
- movement of lymph fluid
- production of lymphocytes
- production of Abs
- phagocytosis
- absorption of fat
- 2nd line manufacturing of blood
lymph fluid
- Clear, sometimes yellow-tinged fluid
- Contains variety of WBCs, rarely RBC
lymph ducts
- intimately related to cardiovascular system
- closed circuit
- no built in pumping mechanism, sluggish movement
lymphocytes
- formed by lymph nodes, tonsils, adenoids, spleen, but primarily bone marrow
- differentiation takes place in thymus
lymph nodes
- occur in groups
- over 600 nodes in body
superficial nodes
- subQ conntective tissues
- gateway to assessing health
- readily accessible
- provide early clues to infection or malignancy
deeper nodes
beneath the fascia of muscles and w/i body cavities
Disorders cause what 3 physical signs in the lymphatics?
- palpable lymph nodes (lymphadenopathy)
- red streaks in the skin from superficial lymphangitis
- lymphedema
bubos
lymphadenopathy caused by the black plague
spleen
- LUQ
- highly vascular
- stores RBCs
- important site for blood filtering w/ macrophages
- forms blood early in life
What is the spleen made of?
- white pulp: lymph nodules and tissue
- red pulp: venous sinusoids
tonsils
- organized as follicles and crypts covered by mucous membrane
- small, diamond shaped
- lie b/w the palatine arches
- made of lymphoid tissue
adenoids
- “pharyngeal tonsils”
- located in the nasopharyngeal border
- can obstruct nasopharyngeal passageway when enlarged
thymus
- located in superior mediastinum
- vital in early childhood while immune system is developing
- site for T cell production
- no function in adulthood
peyer patches
- small, raised areas of lymph tissue on mucosa of the small intestine
- made of clusters of lymphoid nodules
- aka GALT: gut associated lymphoid tissue
acute lymphangitis
- inflammation/infection of lymphatic channels or vessels
- occurs when viruses or bacteria invade the vessels of your lymph system
- typically through infected cut or wound
- usually strep or staph
- rarely non infectious cause like malignancy
sx of acute lymphangitis
- chills
- moderate lymph nodes swelling and pain
- +/- fever
- +/- red streaking from wound to nearest lymph
diagnosis of acute lymphangitis
- physical exam
- can biopsy wound
- blood cultures
Tx of acute lymphangitis
- abx (IV or oral)
- pain meds
- anit-inflammatories
- surgery or debridement
complications of acute lymphangitis
- cellulitis
- bacteremia
- sepsis
- abscess
acute suppurative lymphadenitis
-bacterial infection of the lymph nodes w/ pus formation
most common causative organism and more rare causes of acute suppurative lymphadenitis
- most common: group A strep
- others: cat scratch disease, TB
Sx of acute suppurative lymphadenitis
- fever
- moderate lymph node swelling and pain
- overlying skin erythema and tenderness
- lymph node feels rubbery if abscess has formed
aquired lymphadema
- trauma to ducts of regional nodes OR sometimes infection
- axillary, inguinal
- from surgery or metastases
- does NOT pit
congenital lymphadema
- hypoplasia/maldevelopment
- at birth
- legs/feet
S/S of lymphadema
- Swelling
- Feeling of heaviness/tightness
- Restricted ROM
- Aching or discomfort
- Recurring infections
- Hardening or thickening of skin (fibrosis)
diagnosis of lymphadema
-if not obvious reasons like surgery, may order MRI, CT, or doppler US
Tx of lymphadema
- no cure
- exercises
- wrapping of limb
- massage
- compression garments
elephantiasis
- massive accumulation of lymphadema throughout the body
- caused by filarial worm infection that obsructs the lymphatics and prevents drainage
hematologic and lymphatic patient history
- all symptoms that a patient could present with overlap with other systems
- ex: bleeding, fatigue, malaise, fever, blood in stool, etc. etc.
heme/lymph PMH
- autoimmune disease
- transfusions
- thyroid disease
- chronic kidney disease
- celiacs
- cirrhosis
- splenomegaly
- cancer
- chronic pancreatitis
heme/lymph past surgical hx
- gastric bypass
- gastrectomy
- mechanical heart valve
- small bowel resection
heme/lymph social hx
- diet restrictions
- vegan
- drug use
- alcohol use
- exposure to toxic substances
heme/lymph family hx
- anemia
- celiacs
- pernicious anemia
- autoimmune disease
- ethnicity
neck ROS
- swelling
- lumps
- goiter
- pain
- limitation of movement
hematologic ROS
- anemia
- petechiae
- purpura
- easy bruising/bleeding
- epistaxis
- past transfusions and any reactions
- lymphadenopathy
physical exam for hematologic patient
- skin: pallor
- HEENOT: smooth tongue, pale conjunctiva
- Neck/lymph exam
- musculoskeletal: TTP at sternum, anterior tibia
- abdomen: hepatosplenomegaly, rectal exam for occult blood
- neuro: peripheral neuropathy, decreased sensation
dematologic exam for hematologic patient
- petechiae
- purpura
- pallor: mucous membranes, nail beds, conjunctiva, palmar skin creases
- jaundice
- nails - koilonychias
- mouth: angular chelitis
- lower extremity ulcers
HEENOT exam for hematologic patient
- skin: pale
- eyes: pallor of conjunctiva
- Mouth: smooth and beefy red tongue, atrophic tongue, adequate teeth
cardio exam for the hematologic patient
- forceful heartbeat
- strong peripheral pulses
- tachycardia
- systolic flow murmur
- high output heart failure (severe anemia)
- 4th heart sounds
exam of lymph nodes in the extremities
- axillary: feel up, down, front and back (box method)
- epitrochlear: just above funny bone
- inguinal: groin
- popliteal: behind knee
general tips for exam of lymph nodes
- can use inspection and palpation
- use pads of fingers 2, 3, 4
- dorsum of hand for temp
- measuring device
- gloves if needed
- gown and cover patient
- room at comfortable temp
appearance of normal lymph nodes
- round/oval and smooth
- easily palpable not generally found in healthy adults
abnormal lymph nodes indications
- more tender = more likely d/t inflammation
- cancerous nodes usually NOT tender
- harder the node and more discreet, more likely a malignancy
- palpable subraclavicular node on left = BAD
What to not if nodes are palpable
- number
- consistency
- discrete or matted
- location
- mobility
- tenderness
- size
- warmth
- color of overlying skin
Nine S’s of a “lump”
- size
- shape
- surface characteristics
- site
- symptoms
- squeezability
- spread
- sensations
- symmetry
exam for supraclavicular nodes
- probe deeply in angle formed by clavicle and sternocleidomastoid
- NEVER a normal finding
- Virchow’s node
anterior (pectoral) group of axillary nodes
- at lower part of pec minor
- receive lymph fluid from breasts and upper abdomen
posterior (subscapular) group of axillary nodes
-located at lower region of armpits rear wall
lateral (brachial) group of axillary nodes
- situated medially and horizontally to the side of the posterior group
- receive lymph from the arms
central group of axillary nodes
- b/w lateral and posterior group
- receives lymph from anterior, posterior, and lateral groups and passes it to the apical group
apical group of axillary nodes
- found at upper part of pec minor
- collects lymph from all other axillary nodes
general tips for exam of axillary lymph nodes
- more firm deliberate touch (less ticklish)
- support the patient’s forearm w/ your contralateral arm
- touch bare skin
- gown pt
- warm hands and room
how to examine the axillary lymph nodes
- pt is seated
- palpate w/ contralateral hand
- support pts wrist and elevate their arm
- place hand in axilla w/ fingers together and palm toward chest wall
- firmly rake fingers along thoracic cage to feel for nodes
epitrochlear node exam
support elbow in one hand as you explore w/ the other
inguinal node exam
- have pt lie supine w/ knee slightly flexed
- palate at and just below inguinal ligament then distally along course of greater saphenous vein
- drainage from scrotum/penis (not testes) and vulva/lower third of vagina
popliteal node exam
- palpate posterior knee
- rare to find abnormalities
