Lymphatic/Hematopoetic System IPM 2

Objectives
Student should be able to …
describe location, size, consistency, and other attributes of lymphadenopathy
identify common clinical scenarios involving lymphadenopathy
identify the signs and symptoms of anemia
define the signs and symptoms of bleeding and coagulation disorders

Overview
This is a short lecture!
A major goal is to synthesize the lymphatic system as a whole…lymph node regions have been discussed individually by specific site…i.e., head, neck, and abdomen, but not put together for systemic illness such as lymphoma.
We will also discuss the signs and symptoms of anemias, leukemias, bleeding disorders, and coagulation disorders

Lymphatic System

Lymph Node Examination
Head/neck
Axillary
Inguinal/femoral

Head and Neck Nodes
Preauricular
Posterior auricular
Occipital
Tonsillar
Submandibular
Submental
Superficial cervical
Posterior cervical
Deep cervical
Supraclavicular

Axillary
A pectoral (anterior)
L lateral
P posterior
C central
Ap apical

Inguinal/ Femoral
Horizontal group
Vertical group

Descriptors of Lymphadenopathy
Location…obvious
Mobility
Size
Texture
Shape
Tender/non-tender
Associated erythema or warmth…signs of inflammation

Spleen
Left upper quadrant
Palpation most specific for detecting enlarged spleen (89-99% specificity)
Spleen palpable to umbilicus is suggestive of hematologic pathology
Percussion is non-sensitive (dullness in Traube’s space) but can be specific in non-obese patients

Case
28 yo man presents with c/o fevers, night sweats and 30 pound weight loss. He develops pruritis when he showers. He also has noted some enlarged “glands” in his neck and armpits. On lymphatic exam he has the following:

Case
painless lymphadenopathy in anterior axilla and anterior cervical as well as supraclavicular areas bilaterally.
Lymph nodes are not tender, freely mobile and no associated inflammation. They are ovoid (grape-shaped) and measure 2 x 3 cm. There is no splenomegaly by palpation or percussion.

Differential Diagnosis
Lymphoma
Infection
Cancer—metastatic
Granulomatous disease

Anemia- Signs/Symptoms
Dyspnea on exertion
Palpitations
Angina pectoris
Intermittent claudication
Headache
Syncope
anorexia
Dizziness/vertigo
Nausea
Cold intolerance
Amenorrhea
Decrease libido/impotence

Anemia
Blood loss
Hemolysis/sequestration
Deficiencies
Decreased production

Symptoms
Symptoms based on acuity of HgB drop
Acute blood loss usually creates rapid onset of symptoms
Slow drop in HgB may lead to fewer symptoms

Anemia of Acute Blood Loss
Trauma or GI tract loss most common
Menstrual/vaginal loss
Urinary tract
Nosebleeds leading to anemia, but not because of it!
Tachycardia and hypotension are common findings
History helps the most for these

Hemolysis and Sequestration
Causes for hemolytic anemias include:
Autoimmune
Drug induced
Cell membrane disorders
Hereditary
Splenomegaly can lead to sequestration of blood cells

Scleral Icterus
Yellow sclera
Can be seen in hemolysis

Deficiencies
Iron deficiency anemia is most common worldwide and in US-spoon nails and pica
Megaloblastic anemias caused by B12 or folate deficiencies-paresthesias and diarrhea
Smooth tongue/glossitis

Koilonychia (spoon nails)

Smooth Tongue/Glossitis

Signs and Symptoms of Coagulation Disorders
Bleeding
Ecchymoses
Petechiae
Hemarthroses
Hematomas

Platelets versus Coags
Petechiae—platelets low or dysfunctional
Ecchymoses, hematomas, hemarthroses—seen more frequently with low clotting factors or dysfunction
Bleeding can be seen with either

Petechiae

Purpura

Hemarthrosis

Hematoma