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Fig. 2C.19: Image depicting profile sign and Schamroth’s sign.

Atypical presentation of clubbing

Acute clubbing Subacute bacterial endocarditis

Lung abscess

Empyema

Unilateral clubbing Hemiplegia

Aneurysm of subclavian artery

Pancoast tumor

Pseudoclubbing Leprosy

Leukemic infiltration

Hyperparathyroidism

Thyroid acropachy

Sclerodactyly

Exposure to vinyl chloride

Subungual tumors or cysts

Painful clubbing Bronchogenic carcinoma

Subacute bacterial endocarditis

Lung abscess

Reversible clubbing Lung abscess

Empyema

Unidigital clubbing Median nerve injury

Trauma

Clubbing with cyanosis Cyanotic congenital heart diseases

ILD

Differential clubbing:

Upper limb (N)

Lower limb (clubbing)

Patent ductus arteriosus (PDA) with reversal of shunt

Reverse differential clubbing:

Upper limb (clubbing)

Lower limb (N)

PDA + transposition of the great arteries (TGA) + reversal of shunt

Phalangeal Depth Ratio (Fig. 2C.20)

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Ratio of distal phalangeal depth (DPD) with interphalangeal depth (IPD).

<1 is normal, >1 is suggestive of clubbing.

Fig. 2C.20: Picture depicting the phalangeal depth at proximal and distal interphalangeal joints.

Digital Index

Sum of phalangeal depth ratios of 10 fingers

A digital index of 10.2 or higher is indicative of clubbing. Although, a phalangeal depth ratio of 1.0 or

greater in any finger is suggestive of clubbing, digital index is more specific for clubbing.

Other Nail Changes

Nail changes Causes

Koilonychia Iron deficiency anemia (IDA)

Hemochromatosis

Beaus lines Measles

Pneumonia

Pulmonary infarction

Plummer nails Seen in hyperthyroidism

Red nails Congestive cardiac failure (CCF)

Blue nails Copper or silver deposit

Black nails Peutz-Jegher’s syndrome

Cushing’s disease

Addison’s disease

White nails Anemia

Hypoalbuminemia

Diabetes mellitus (DM)

CCF

Rheumatoid arthritis

EDEMA

Definition

Abnormal accumulation of fluid in interstitium.

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Sites of Examination of Edema

In mobile patient Legs 2–3 cm above the medial malleolus

In bed ridden supine patient Sacrum

Back over the scapula

To check for abdominal wall edema Pinch the skin over the abdomen

Technique (Fig. 2C.21)

Press the skin and subcutaneous tissue for at least 15–20 seconds against a bony prominence (except

for abdominal wall edema where we pinch the skin and subcutaneous tissue).

Grading of Pitting Edema (Fig. 2C.22)

1+ 2-mm depression, immediate rebound

2+ 4-mm deep pit, a few seconds to rebound

3+ 6-mm deep pit, 10–12 seconds to rebound

4+ 8-mm deep pit, >20 seconds to rebound

Fig. 2C.21: Method of eliciting pedal edema.

Fig. 2C.22: Grading of pitting edema.

Edema

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Pitting Nonpitting (Brawny edema)

Rapid recovery Slow recovery

Recovers in <40 seconds Recovery takes >40 seconds Does not pit or recover in few seconds

Nontender

Skin shows hyperkeratosis

Mechanism: ↓oncotic

pressure

Mechanism: ↑hydrostatic pressure Mechanism: Lymphedema

Low serum protein (N) serum protein Lymphatic obstruction

Causes:

Increased protein loss

Burns

Nephrotic syndrome

Bowel disease

Decreased intake or

synthesis

Kwashiorkor

Malabsorption

Liver disease

Causes:

Systemic venous hypertension (HTN)

Congestive heart failure (CHF) (Fig.

2C.23)

Pericarditis

Tricuspid valve diseases

Local venous HTN

Deep venous thrombosis (DVT)

Inferior vena cava syndrome

Causes:

Myxedema (Fig. 2C.24)—hypothyroidism

Pretibial myxedema—Graves’s disease

Upper limb

Breast cancer

Radiation induced

Lower limb

Aplasia cutis

Congenital (praecox, tarda, milroy’s disease, and Meigs

disease)

Filariasis (Fig. 2C.25)

Recurred streptococcal infection

Malignancies

Facial edema: Trichinosis, hypothyroidism, allergies, nephrotic syndrome, and angioedema (Quincke’s edema)

Neurogenic edema: Secondary to autonomic dysfunction

Drug-induced edema: Nifedipine, corticosteroids, estrogen, nonsteroidal anti-inflammatory drugs (NSAIDs), and insulin

May-Thurner syndrome—chronic, unilateral, pitting edema due to compression of the left iliac vein by the right common iliac

artery against the lumbar spine

Idiopathic edema—chronic, bilateral, and pitting

In females <50 age, more during menstrual cycles.

Fig. 2C.23: Pitting type of pedal edema seen in congestive cardiac failure.

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Fig. 2C.24: Nonpitting type of pedal edema seen in myxedema.

Fig. 2C.25: Nonpitting type of pedal edema seen in filariasis.

LYMPHADENOPATHY

Definitions

Generalized Lymphadenopathy

Generalized lymphadenopathy is defined as involvement of ≥2 noncontiguous lymph node groups and is

typically indicative of systemic disease.

Significant Lymphadenopathy (based on Size, Fixity and Consistency)

Size >2 cm in Inguinal region

Size >1 cm in Extrainguinal region

Any size Supraclavicular

Epitrochlear

Popliteal

Any lymph node with a lesion in the draining area

Based on fixity Fixed to each other (matting)

Fixed to underlying tissues

Fixed to skin

Based on consistency Hard/firm lymph nodes

Persistent Generalized Lymphadenopathy

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It is defined as lymph nodes of more than 1 cm in size, in 2 or more areas persisting for 3 or more

months (mnemonic 1-2-3). Seen in human immunodeficiency virus/acquired immune deficiency

syndrome (HIV/AIDS).

Causes of generalized lymphadenopathy

Infections Bacterial Disseminated TB

Secondary syphilis

Viral HIV

Infectious mononucleosis

Parasitic Toxoplasmosis

Fungal Histoplasmosis

Coccidioidomycosis

Paracoccidioidomycosis

Malignancy Lymphomas

Acute leukemias

Chronic lymphocytic leukemia (CLL)

Chronic myeloid leukemia (CML) (in blast crisis)

Immunological Systemic lupus erythematosus (SLE)

Adult-onset Still’s disease

Juvenile rheumatoid arthritis (JRA)

Sjogren’s syndrome

Kawasaki disease

Serum sickness (postzone phenomenon—excess of antibody)

Granulomatous Sarcoidosis

Amyloidosis

Histiocytosis X

Endocrine Hyperthyroidism

Drugs Phenytoin (pseudolymphoma)

Primidone

Carbamazepine

Allopurinol

Captopril

Cotrimoxazole

Sulindac (NSAIDs)

Hydralazine

Beta-blockers

Syndromic lymphadenopathy Kikuchi-Fujimoto disease

Castleman’s disease

Kimura disease

Rosai–Dorfman syndrome

Familial Mediterranean fever

Miscellaneous Niemann-pick disease

Describing a Lymph Node

Size (significant or not)

Site

Number

Consistency

Overlying skin

Mobility

Tenderness

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Draining area.

Consistency

Soft Normal consistency

Hard Malignancy

Indian rubber Hodgkin’s lymphoma

Shotty lymph node Syphilis

Bubo (large node with central necrosis) Lymphogranuloma venereum

Matted Tuberculosis (due to periadenitis)

Hard lymph nodes in tuberculosis Hyperplastic tuberculosis lymphadenopathy

Different Group of Lymph Nodes (Fig. 2C.26)

Fig. 2C.26: Image showing different groups of lymph nodes.

Cervical Lymph Nodes

Divided into:

Superficial or deep (based on whether above or below deep cervical fascia)

Vertical or horizontal

Superficial Cervical Lymph Nodes

They are superficial to deep cervical fascia

They include:

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External Waldeyer ring

Submental

Submandibular bilateral

Preauricular bilateral

Postauricular bilateral

Occipital lymph nodes.

Pretracheal

Paratracheal

Posterior triangle lymph nodes.

Deep Cervical Lymph Nodes

Horizontal: Supraclavicular lymph nodes

Vertical: Jugulodigastric and jugulo-omohyoid lymph nodes.

Examination of Cervical Lymph Nodes

Examination of anterior group of lymph nodes is done by standing behind the patient→flex the neck

to relax the fascia→first feel for the submental group (using a single finger) (Fig. 2C.27) and

then→bilateral submandibular (Fig. 2C.28) → bilateral preauricular (Fig. 2C.29) → jugulodigastric

(Fig. 2C.30) → juguloomohyoid (Fig. 2C.31) →supraclavicular groups (Fig. 2C.32) (± pre- and

paratracheal).

Examination of posterior group of lymph nodes is done by standing in front of the patient→feel for

the post auricular (Fig. 2C.33) → occipital (Fig. 2C.34) → posterior triangle group of lymph nodes

(Fig. 2C.35).

Fig. 2C.27: Method of examining submental group of lymph node.

Fig. 2C.28: Method of examining submandibular lymph nodes.

Fig. 2C.29: Method of examining preauricular lymph nodes.

Fig. 2C.30: Method of examining jugulodigastric lymph nodes.

Fig. 2C.31: Method of examining jugulo-omohyoid lymph nodes. Fig. 2C.34: Method of examining occipital lymph nodes.

Fig. 2C.32: Method of examining supraclavicular lymph nodes. Fig. 2C.35: Method of examining posterior triangle lymph node

Fig. 2C.33: Method of examining postauricular lymph nodes.

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Supraclavicular Lymph Nodes and Drainage

Right supraclavicular Left supraclavicular

Right lung (all three lobes)

Left lung lower lobe

Left lung upper lobe

4 B’s and Gonads:

Breast

Bronchus

Bowel

Bladder, and

Gonads (testis/ovaries)

Note: mechanism of left supraclavicular lymphadenopathy in GI and other malignancies—reflux of tumor cells from the

thoracic duct into left supraclavicular node at the junction of thoracic duct and left subclavian

Trousseau sign of tetany: Carpopedal spasms

Trousseaus syndrome: Migratory thrombophlebitis in malignancy

Troisier’s sign: Enlarged hard left supraclavicular lymphnode (Virchow’s node).

Other named lymph nodes

Virchow node Left supraclavicular node

Scalene node

(Fig. 2C.36)

Sentinel node of bronchogenic carcinoma

Relax neck

Palpate (deep) between the two heads of SCM

Winterbottom sign Posterior triangle lymph node enlargement

Seen in early phase of African trypanosomiasis

Causes of posterior triangle lymph node

enlargement

Scalp infection

Measles

Rubella

Infectious mononucleosis

Trypanosomiasis.

Node of Woods Jugulodigastric lymph node enlargement seen in TB when spread via

tonsils

Delphian node Pretracheal node

External Waldeyer ring Commonly seen to be enlarged in non-Hodgkin’s lymphoma

Berry’s node Jugulo-omohyoid lymph nodes seen in thyroid malignancy

Axillary Group of Lymph Nodes

There are five axillary lymph node groups

Lymph nodes include:

Lateral (humeral),

Anterior (pectoral),

Posterior (subscapular),

Central and

Apical nodes.

The apical nodes are the final common pathway for all of the axillary lymph nodes.

Note: Examine the right axillary lymph nodes with the left hand except for humeral (lateral) group (which

is examined with right hand).

Examination of Right Axillary Lymph Nodes (Figs. 2C.37 to 2C.46)

Hyperabduct the right arm of patient

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Place the right forearm of patient on your left forearm

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Insinuate your left hand fingertips deep in axilla of patient

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