PANCE Blueprint Pulmonary (10%)

Pleural Diseases (PEARLS)

The NCCPA™ PANCE  Pulmonary Content Blueprint includes two pleural diseases.

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IM_NUR_LungSoundsPleuralFrictionRub_v1.2_ A pleural friction rub occurs near the anterior lateral lung and develops due to rubbing of the pleural surfaces. The sensation of a pleural friction rub is often uncomfortable. This lung sound is prominent during both inspiration and expiration and does not resolve with coughing.  Pleural rubs are common in pneumonia, pulmonary embolism, and pleurisy (pleuritis).

Lung Sounds - Pleural Friction Rub

Pleural effusion (ReelDx) Dyspnea, and a vague discomfort or sharp pain that worsens during inspiration

  • Differentiate exudate and transudate with pleurocentesis and Light’s Criteria
    • Exudate: (local pleural disease) - protein ratio ↑, LDH ↑, infection, malignancy, trauma
    • Transudate: Congestive heart failure, atelectasis, cirrhosis
  • Decreased tactile fremitusdullness to percussion and and diminished breath sounds over the effusion
  • Lateral decubitus x-ray and upright films: Blunting of costophrenic angle. Mediastinal shift away from effusion
  • Thoracentesis is the gold standard
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IM_MED_Lightscriteria_V1.3_ Light's Criteria is a diagnostic tool used to determine of the cause of a pulmonary effusion; transudate versus exudate. This relies on a comparison of the chemistries in the pleural fluid to those in the blood. According to Light's criteria, a pleural effusion is likely exudative if at least one of the following exists: The ratio of pleural fluid protein to serum protein is greater than 0.5, the ratio of pleural fluid LDH and serum LDH is greater than 0.6, or the pleural fluid LDH is greater than 0.6 or 2⁄3 times the normal upper limit for serum.

Light's Criteria Picmonic

Pneumothorax (ReelDx) Absence of breath sounds and hyperresonance to percussion with tracheal deviation


  • Primary spontaneous pneumothorax occurs in the absence of underlying disease - tall, thin males between 10 and 30 years of age are at the greatest risk of primary pneumothorax
  • Secondary spontaneous pneumothorax occurs in the presence of underlying disease - asthma, COPD, cystic fibrosis, interstitial lung disease


  • Etiology: Penetrating injury
  • Physical exam: Hyperresonance to percussion and tracheal shift to the contralateral side

Small pneumothoraces <15% of the diameter of the hemithorax will resolve spontaneously without the need for chest tube placement

  • For large, > 15% of the diameter of hemithorax, and symptomatic pneumothoraces, chest tube placement is performed
  • Patients should be followed with serial CXR every 24 hours until resolved
Pulmonary nodules (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: Pleural and Restrictive Pulmonary Diseases
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