1. Reticuloendothelial and Immune System History and Examination Dr. Lanice Jones Vientiane 2008

2. Definition Phagocytic cells of the body, including the lymphatic system, spleen and bone marrow, tonsils, and thymus gland Responsible for immune defence in the body

3. History Localized symptoms Pain from swelling, pressure (swollen lymph nodes or ‘glands’ Fullness (abdominal fullness ie enlarged spleen) Generalized symptoms: Fatigue, tiredness, lack of energy Weight loss Night sweats Associated symptoms: ie joint pain, rash,

4. Lymphatic System Function: 1. Defence System: Filtration and phagocytosis, production of antibodies 2. Hematopoiesis: lymph nodes are the site of final stages of maturation for some lymphocytes and monocytes that have migrated from the bone marrow 3. Fluid Balance: return fluid filtered out of capillaries back to the venous circulation system

5. Lymph Node Examination Lymph node Groups 1. Head: occipital, preauricular, ostauricular, subental, subandibular 2. Cervical: anterior, posterior, deep 3. Clavicular: supraclavicular, infraclavicular 4. Axillary: anterior, lateral, posterior, apical, medial 5. Epitroclear 6. Inguinal

6. Lymph nodes of the Head 1. Submental lymph nodes 2. Submandibular 3. Parotid 4. Preauricular 5. Postauricular 6. Occipital 7. Anterior cervical 8. Supracalvicular 9. Posterior cervical

7. Examination of Lymph Nodes Often not palpable Enlarge with infection, or inflammation (enlarged submandibular node, which drains the tonsils, in acute tonsillitis

8. Axillary Lymph Nodes Lateral Medial Apical Anterior Posterior Nodes

9. Lymph Node distribution

10. Examination of the Lymphatic System Inspection: Lymphedema Surgical scars Obvious masses Palpation: Move fingers in a circular motion over the area of lymph node distribution Small nodes are common

11. Lymphatic System Palpation: Note Location of nodes Size of nodes Discrete or matted node Mobile or fixed Consistency (soft, firm, hard) Tenderness

12. Matted lymph nodes – stuck together

13. Spleen Function: To remove material from the blood stream, such as removing old and deformed red blood cells Control quality and function of red blood cells Supplies 25% of the mass of lymphoid tissue Can react and enlarge quickly to fight infection and inflammation

14. History Pain or discomfortLeft Upper Quadrant Feeling of fullness in the abdomen Pain in left shoulder area (irritation to diaphragm and phrenic nerve) Early saity (fullness after eating a small amount, from pressure on the abdomen)

15. Examination Inspection: Pallor or erythema, conjunctiva, mucous membranes, palms Percussion: Traube’s space Palpation:

16. Percussion of Traube’s Space Location: Draw line through 6 th rib midclavicular line Draw line through 9 th rib midaxillary line Draw a line curving upwards from 9 th to sixth rib Draw line along costal margin The space between costal margin and curving upwards between 9 th to 6 th rib is Traube’s Space

17. Traube’s Space Percussion Air in the stomach produces a tympanic sound with percussion over Traube’s space Dullness over Traube’s space on inspiration suggests possible Splenomegly

18. Splenic Palpation Reach over and around the patient to support and press forward the lower rib cage and adjacent tissue Palpate below the left costal margin with your right hand Ask the patient to take a deep breath, and try to feel the edge of the spleen as it comes down on deep inspiration. A normal sized spleen can be palpated with a low flat diaphragm ie COPD or with very deep inspiration

19. Examination of the Tonsils History: pain, swelling, difficulty swallowing, vocal change, bad breath Physical Exam: inspection: symmetry, color, size, coating, pus, Palpation: lymph nodes