A 55-year-old patient with a headache explains to the advanced practice registered nurse (APRN) that they have had headaches before, but this one is unusual because of some new symptoms. Which of the following symptoms would prompt an immediate investigation?

A. Submandibular is incorrect because these lymph nodes are located beneath the mandible along the jawline. They typically drain the tongue, lips, and oral cavity, and are palpated in the submandibular region, not behind the sternocleidomastoid muscle.

B. Tonsillar is incorrect because tonsillar (or jugulodigastric) nodes are located just below the angle of the mandible and drain the tonsils and pharynx. While they can be enlarged with tonsillitis, the nodes described in this case are posterior and along the neck, which does not match the tonsillar node location.

C. Occipital is incorrect because occipital lymph nodes are located at the base of the skull, posteriorly, and primarily drain the posterior scalp. They are not along the sternocleidomastoid muscles.

D. Posterior cervical is correct because posterior cervical lymph nodes are located along the anterior edge of the trapezius muscle and just behind the sternocleidomastoid. These nodes drain the posterior scalp and neck, and may become small, mobile, and tender during upper respiratory infections, such as viral pharyngitis or tonsillitis. Their location along the posterior border of the sternocleidomastoid matches the description in this patient.

A. Spleen is incorrect because the spleen is assessed using bimanual palpation, beginning in the right lower quadrant and progressing diagonally toward the left upper quadrant. The spleen must enlarge significantly before it becomes palpable, and the hooking technique is not appropriate for detecting splenomegaly.

B. Liver is correct because the hooking technique is a specialized method used to palpate the liver edge, particularly in patients who are overweight, obese, or have increased abdominal muscle tone, where standard palpation may be difficult. In this technique, the examiner stands to the patient’s right, hooks their fingers under the right costal margin, and asks the patient to take a deep breath. As the patient inhales, the diaphragm descends and pushes the liver downward, allowing the examiner to feel the liver edge as it meets the fingertips. This method helps assess the size, consistency, and tenderness of the liver, which can indicate conditions such as hepatomegaly, cirrhosis, or liver congestion.

C. Kidney is incorrect because the kidneys are evaluated using deep bimanual palpation, with one hand placed under the flank and the other on the abdomen. The examiner attempts to “capture” the kidney between the hands during inspiration. The hooking technique is not used for kidney assessment.

D. Gallbladder is incorrect because the gallbladder is typically not palpable unless enlarged or inflamed. Instead, it is assessed using Murphy’s sign, where the patient experiences pain and inspiratory arrest during palpation of the right upper quadrant. The hooking technique does not apply to gallbladder evaluation.