Examination of the axilla is a routine part of the general examination of the lymphatic system. It is of particular importance in examination of the female breast, as much of the lymphatic drainage from the organ is to this group of nodes (figure 11). For the left axilla, take the weight of the subject’s left arm in your left hand. Now use your right hand to examine the axilla.

Cup your fingers and press them upwards and inwards into the apex of the axilla. Lower the subject’s arm onto your hand, and draw your fingers downwards over the medial wall, to palpate the apical and medial nodes (figure 12a–c). During this manoeuvre explain what you are doing and that pressure is being applied. Watch the subject’s face to ensure that it does not cause any marked discomfort.

1. Lateral
2. Apical
3. Anterior
4. Posterior
5. Medial
6. Anterior axillary fold (pectoralis major)
7. Posterior axillary fold (teres major and tendon of latissimus dorsi)

Examine the anterior group (figure 13) of lymph nodes against the muscles and the fascia of the anterior wall of the axilla, and between the pectoralis major and minor muscles.

The posterior and lateral groups of axillary lymph nodes are more easily palpated from behind; apply pressure respectively to the posterior wall of the axilla, and the medial aspects of the humeral neck and shaft (figure 14a,b).

In examination of the right axilla the procedure is repeated, using your right hand to support the subject’s right arm and palpating with your left hand. It is common to find small palpable axillary nodes in the normal subject and these are often termed ‘shotty nodes’. They can be found on self-examination. Note any swelling of the arm that could be indicative of lymphatic obstruction.

On completion of examination of the axilla on each side, palpate the infraclavicular and supraclavicular fossae for their respective groups of nodes (figure 15a,b). In the latter, look particularly for the scalene node behind the lower attachment of the sternomastoid muscle.

Enlarged scalene nodes should be specifically looked for, not only in breast, but also lung and abdominal malignancies. Ask the subject to turn their head to the other side, against your hand, to define the sternal head and the relationship of any lump to the muscle (figure 16a,b).

Complete the examination of the breast by examining for hepatomegaly (figure 17), and tenderness along the length of the spine. Spinal tenderness is first explored by digital pressure and, if no tenderness is found, progress to more vigorous percussion of a fist on the back of the other hand (figure 18a,b).

Patients should also be instructed in self-examination, observing for symmetry in front of a mirror with arms at their sides, raised and pressed on hips. They should then lie with their hand behind their head and the shoulder supported on a pillow, as already described, palpating with the opposite hand.

Explain the technique of examination of the breast described, and cupping the fingers into the axilla. Medical advice should be sought for new symptoms or changing signs.

a,b. Palpating for spinal tenderness. Figure 18 a,b. Palpating for spinal tenderness