Reasoning GP · Algorithm · 1-page summary
Lymphadenopathy (new or persistent nodes)
For: adults with new, persistent or generalised nodes in primary care. Not for: known lymphoma or CLL (haematology plan); a neck lump that is not a node (neck-lump pathway). Children: NG12 routes in block 2.
Core rule: unexplained, persistent or progressive nodes need investigation and referral now — there is no 6-week rule, and size or tenderness alone never excludes lymphoma.
0Stop — call 999 now — or same-day hospital
- Airway compromise (stridor, hypoxia) from a large neck or mediastinal mass → 999
- SVC obstruction (face, neck or arm swelling, dilated neck veins), cerebral symptoms or rapidly progressive facial/neck swelling → Same-day hospital / acute oncology. Steroids only per the receiving specialist — they may mask lymphoma.
- On lymphoma chemotherapy with temperature ≥38°C → 999 / haematology hotline; IV antibiotics are hospital-led.
- Severe or symptomatic pancytopenia (bruising, bleeding, infection) or blasts on the film → Same-day haematology
1Triage by pattern
| Pattern | Action |
|---|---|
| Clearly reactive | Identifiable infection, well, improving → treat source; no routine bloods; book review. |
| Persistent / unexplained | Or progressive → targeted bloods; NG12 routes (block 2). |
| Hard or fixed | Or B symptoms, or supraclavicular → investigate and refer at the same visit. |
| Generalised | ≥2 non-contiguous groups → systemic exam, medicines, HIV test, FBC + film. |
2Screen — NICE NG12 (consider)
- Unexplained adult nodes → consider Suspected cancer pathway; B symptoms, itch, breathlessness, alcohol node pain inform urgency.
- Adult, generalised nodes or other leukaemia features (pallor, bruising, petechiae, hepatosplenomegaly) → consider Very urgent FBC ≤48 h
- Child / young person: unexplained nodes → consider Very urgent referral ≤48 h; generalised → very urgent FBC; petechiae or hepatosplenomegaly → Immediate
- Supraclavicular or persistent cervical nodes, aged ≥40 → consider Urgent CXR ≤2 weeks.
- Persistent unexplained neck lump → consider head-and-neck pathway (oral at any age; laryngeal if ≥45).
- Unexplained axillary lump, aged ≥30 → consider Breast suspected cancer pathway.
3Assess
☐ All node groups incl. supraclavicular: size (cm), consistency, mobility, tenderness ☐ Drainage area: mouth, throat, scalp, breast, arm, feet, genitals ☐ Liver, spleen, rash, temperature, weight ☐ B symptoms, itch, HIV/STI risk, travel, TB, animals, medicines
If persistent or unexplained: FBC + film, CRP/ESR, U&E, LFTs, LDH if ?lymphoma, HIV; targeted EBV/CMV, syphilis, TB, toxoplasma.
Not in primary care: staging CT before referral; biopsy or FNA (inadequate for lymphoma) outside the specialist pathway.
4Classify
- Reactive (commonest) — tender, soft, mobile; recent URTI, skin or dental infection → treat source, review.
- Systemic infection — EBV/CMV, toxoplasma, syphilis, TB (matted) → targeted tests.
- HIV seroconversion — fever, rash, sore throat, generalised nodes → urgent HIV test and Urgent sexual health
- Suppurative lymphadenitis — hot, red; fluctuant = abscess → drainage.
- Inflammatory / drug — sarcoid (hilar nodes), SLE, phenytoin, carbamazepine, allopurinol.
- Malignant or uncertain — lymphoma (rubbery), metastasis (hard, fixed), CLL; unexplained → block 2.
5Treat today
- EBV: paracetamol, ibuprofen; no amoxicillin or ampicillin; no contact sport or heavy exertion until clinical recovery.
- Bacterial lymphadenitis: antibiotic per local antimicrobial guidance; abscess needs drainage; not responding → hospital assessment; no serial courses.
- Toxoplasma or cat scratch: usually supportive; pregnant with toxoplasma → Urgent obstetrics
- Suspected drug cause: risk-benefit review with the prescriber before stopping. Doses: NICE/SPC, BNF, local formulary.
6Follow up and refer
- Presumed reactive: book a review, measure the node; persistent, enlarging or atypical → investigate, consider suspected cancer pathway.
- Suspected TB: Urgent respiratory / ID; notify UKHSA; no primary-care node procedures.
- Mediastinal mass on CXR → Same-day or urgent haematology; hilar nodes with sarcoid features → urgent respiratory.
- Inguinal + STI risk → sexual health (NAAT, syphilis, HIV); ?LGV → urgent. Known CLL with new nodes or B symptoms → haematology.
7Never reassure by
- Waiting 6 weeks when there is clinical concern.
- A soft, mobile or tender node — lymphoma nodes can be all three.
- A normal FBC or LDH.
- Repeated antibiotic courses or re-reviews of a persistent node.
- Calling a supraclavicular node reactive.
- "Glandular fever" without offering an HIV test when there are risk factors.
8Safety-net — say it, then document it
999 “Call 999 if you struggle to breathe or have noisy breathing, or your face, neck or arm swells quickly. On chemotherapy, a temperature of 38°C or more means 999 or your haematology hotline now.”
Same day “If the lump grows fast or turns hard, you get night sweats, weight loss or fever, unusual bruising or bleeding, or a new headache or other new nerve symptoms — get seen today. If it is still there at your review, we will test or refer, not just wait.”
✓Safe to leave primary care only if — all five, documented
No block 0 feature; no blasts or cytopenias
All node groups, liver and spleen examined
NG12 criteria checked (age, site, B symptoms)
Clear reactive cause, or tests / referral arranged
Review date set; safety-net given
Summary of the full Reasoning GP lymphadenopathy algorithm, which holds the node sites, investigations, treatment and evidence. Sources: NICE NG12 Suspected cancer (updated April 2026); NICE NG33 Tuberculosis; NICE NG60 and BHIVA HIV testing; BASHH LGV guideline; BSH CLL guideline (2025); local TB and sexual-health pathways. Clinical reference — check doses: NICE/SPC, BNF.