CME Review Article
Pleural Effusions
Sara L. Beers, MD,* and Thomas J. Abramo, MD, FAAP, FACEPy
Abstract: The ability to recognize, understand, and treat pleural
effusions in the pediatric population is important for pediatric health
care providers. The topic of pleural effusions has been extensively
studied in the adult population. In recent years, these studies have
extended into the pediatric population. This review describes pleural
effusions in detail, including the different types and underlying
pathophysiology. We then go on to provide a comprehensive review
of the recent literature regarding the diagnosis and treatment of
pleural effusions in the pediatric population.
Key Words: pleural effusions, transudate, exudate, empyema,
thoracentesis, video-assisted thoracoscopy, thoracotomy
TARGET AUDIENCE
This CME activity is intended for physicians, nurse
practitioners, and physician assistants who care for ill chil-
dren and adults, particularly those with fever and respiratory
complains. Specialists including pediatricians, emergency
physicians, pediatric emergency physicians, family practi-
tioners, internists, surgeons, and pulmonologists will find
this information especially useful.
LEARNING OBJECTIVES
After completion of this article, the reader should be
able to:
1. Distinguish between exudates and transudates and the
pleural space and understand the implications of both
types of effusions.
2. Select antibiotic therapy for patients with pleural effusions
based on an appreciation of the likely bacterial pathogens.
3. Select the appropriate procedure for drainage of pleural
effusions.
*Fellow, Children’s Medical Center Dallas, Pediatric Emergency Medicine,
Dallas, TX and yPhysician-in-Chief, Division of Pediatric Emergency
Medicine, Monroe Carell Jr Children’s Hospital at Vanderbilt, Van-
derbilt University Medical Center, Nashville, TN.
The authors have disclosed that they have no significant relationship with or
financial interest in any commercial companies that pertain to this
educational activity.
Lippincott CME Institute, Inc. has identified and resolved all faculty
conflicts of interest regarding this educational activity.
Address correspondence and reprint requests to Sara L. Beers, MD,
Division of Pediatric Emergency Medicine, UT Southwestern, Children’s
Medical Center Dallas, 1935 Motor St, Dallas, TX 75235. E-mail:
sara.beers@childrens.com.
Copyright n 2007 by Lippincott Williams & Wilkins
ISSN: 0749-5161/07/2305-0330
330
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DEFINITION
A pleural effusion is defined as a collection of fluid
between the visceral and parietal pleurae. A small amount of
lubricating fluid, 0.25 mL/kg, is normally in this space.
When the amount of this fluid increases secondary to
underlying pathology, a pleural effusion is the result.
Pleural effusions are classified as either transudates or
exudates. Transudates are generally of noninfectious etiol-
ogy and result from mechanical factors influencing the rate
of formation or reabsorption of pleural fluid. Exudates are
generally of infectious etiology and result from inflammation
of the pleural surface. Further explanation and discussion on
exudates versus transudates is in the sections of Anatomy
and Physiology and Clinical Presentation and Diagnosis.
HISTORY
Aristotle recognized the entity of empyema, which is
known to be a progression of a pleural effusion. He described
drainage of pus with incision, cautery, and a metal tube.1
Twenty-five centuries later, Dr Evarts A. Graham described
risk of fatal pneumothorax with the drainage of empyemas
during World War I.2
With the advent of sophisticated imaging technologies
and improved surgical strategies, there has been a lot of
progress made in the diagnosis and treatment of pleural
effusions and empyemas since the time of Aristotle in the
300 BC and World War I in the early 1900s.
ANATOMY AND PHYSIOLOGY
The pleura is derived embryologically from the
primitive coelomic cavity. The visceral and parietal pleurae
are continuous with one another at the root of the lung.
Pleural fluid or a pleural effusion is not a disease in and of
itself. However, it does indicate the presence of pulmonary
or systemic pathology. The pleural space is better thought of
as a potential space that becomes a true space in disease
states that cause an accumulation of pleural fluid.
In the case of a transudate, the fluid collection occurs
due to increased pulmonary capillary pressure as seen with
congestive heart failure, a decrease in colloid osmotic
pressure as seen in renal disease, an increase in intrapleural
negative pressure as seen with atelectasis, or a decrease in
lymphatic drainage as seen in surgical trauma to the thoracic
duct. In the case of an exudate, the fluid collection occurs due
to increased capillary permeability as seen with pneumonia.
The most common etiology of a pleural effusion in the
pediatric population is an underlying pneumonia, followed
by congenital heart disease and, less commonly, malignancy.
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Pediatric Emergency Care
Volume 23, Number 5, May 2007
Approximately 40% to 50% of patients with pneumonia will
have associated pleural effusions.3
EPIDEMIOLOGY
Many studies suggest that the prevalence of empyema
complicating childhood pneumonia is increasing in both the
United States and United Kingdom.4 – 7 A recent survey from
Texas suggested that the prevalence may be decreasing.8 This
may be attributable to the introduction of the polyvalent
pneumococcal vaccine in 1991. Empyemas cause significant
morbidity in childhood but rarely cause death, in comparison
with adult empyema, which has an estimated mortality of 20%.9
MICROBIOLOGY
In children younger than 2 years, Staphylococcus
aureus is the most common cause of empyema.10,11 The
following are the most common organisms causing pleural
effusions in children S. aureus, Streptococcus pneumonia,
Haemophilus influenza type B, group A streptococcus,
anaerobes, and gram-negative enterics.12 Staphylococcus
aureus is most commonly seen in the age group of younger
than 12 months but is seen in all ages. Streptococcus
pneumonia is most commonly seen in the age range of 6 to
12 months but can also be seen in all ages. Haemophilus
influenza type B is seen in the 6 to 24 months and is rare after
age 7 years. The overall incidence of Haemophilus influenza
type B is significantly decreasing with the implementation of
Hib vaccine. Group A streptococcus is most commonly seen
in school age children. Anaerobes are most commonly seen
in the age group younger than 2 years. Gram-negative
enterics are seen in all ages.
CLINICAL PRESENTATION AND DIAGNOSIS
In the case of a very small pleural effusion, a child may
be asymptomatic. However, as the effusion increases in size a
child will develop symptoms which may include cough,
dyspnea, retractions, tachypnea, orthopnea, the use of
accessory respiratory muscles, and/or cyanosis. Often, fever
will also be present. Pleuritic chest pain is sharp and often
worse with deep inspiration. Physical findings depend to some
degree on the size of the effusion. Dullness may be elicit with
chest percussion. Breath sounds may be decreased or absent
on the side of the effusion. A dimunition in tactile fremitus
may be appreciated. A friction rub may be heard early in the
development of a pleural effusion. Egophony may be noted
when auscultating the chest in which the examiner hears an
‘‘a’’ sound when the patient is saying ‘‘e’’. As the effusion
increases, a shift of the mediastinum away from the affected
side and occasionally a fullness of the intercostal spaces may
also be appreciated. Hoover’s sign may be present with a large
effusion in which the chest wall motion lags on the effected
side. Of note, the physical findings of a pleural effusion are
often less definite in the infant.
Radiographs are an important tool in diagnosing a
suspected pleural effusion. The first study should be a chest
radiograph, both posteroanterior and lateral. Generally,
blunting of the costophrenic angle requires 200 to 400 mL
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Pleural Effusions
of fluid, with approximately 25 mL of fluid causing slight
elevation of the hemidiaphragm.13,14 Of note, one should not
obtain supine chest radiographs to evaluate a pleural effusion
because this may reveal only diffuse haziness.
It is important to establish if the pleural effusion is
free-flowing or loculated. This aids in both establishing a
diagnosis and treatment plan. Lateral decubitus chest radio-
graphs will allow free-flowing fluid to layer out in a
dependent fashion. The affected side should be placed down.
The amount of free-flowing fluid needed to allow layering
noted on a lateral decubitus film is 5 to 10 mL.14
Ultrasonography is useful in identifying solid versus
liquid lesions with a 92% accuracy and is be useful in
evaluating for the presence of loculations.13 Ultrasound can
also be quite useful with facilitating a thoracentesis, allowing
fluid to be obtained with decreased risk. Computed tomography
is also used in evaluating pleural effusions. Computed
tomography clearly visualizes the underlying lung parenchyma.
Loculations are also visualized with computed tomography but
not with the degree of certainty that is seen with ultrasound.15
In diagnosing a pleural effusion, the differentiation
between a transudate and an effusion is important. This is done
by analyzing the fluid. Transudates generally consist of a
serous, pale yellow fluid, whereas exudates may be cloudy or
contain frank pus. Specifically, an exudate has a protein
concentration that is greater than 50% compared with the
serum protein concentration, an lactate dehydrogenase (LDH)
concentration that is greater than 60% compared with the
serum LDH concentration and an absolute LDH concentration
of greater than 200 IU/mL. A transudate has a protein
concentration that is less than 50% compared with the serum
protein concentration, an LDH concentration that is less than
60% compared with the serum LDH and an absolute LDH
concentration of less than 200 IU/mL. A milky fluid suggests a
chylothorax. When this is seen, triglycerides and cholesterol
level of the fluid should be measured, and a fat stain such as
Sudan black or red ‘‘O’’ stain may be done on the fluid.
TREATMENT
Treatment of pleural effusions generally depends on
the severity of disease on presentation and on the underlying
etiology of the effusion. Effective therapy requires control of
any infection, resolution of the effusion, and reexpansion of
the lung. Treatment will likely include antibiotic therapy.
When the underlying effusion is thought to be noninfectious
in nature as in congestive heart failure or renal failure,
empirical antibiotics can be started pending fluid analysis.
Antibiotic choice should include a third generation
cephalosporin and an antistaphylococcal b-lactamase –
resistant penicillin.16 Vancomycin should be considered if
methicillin – resistant Staphylococcus aureus is suspected.
Antibiotics can later be adjusted if a particular organism is
identified. Most antibiotics have good penetration into the
pleural space to achieve bactericidal levels. Although there are
no evidenced-based guidelines for the duration of antibiotic
therapy, antibiotics should be intravenous until the child
is afebrile and then continued orally for an additional 2 to
3 weeks.17
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Beers and Abramo
Not all pleural effusions require drainage. The decision
to perform a thoracentesis depends on the size of the effusion
and the patients’ symptoms. If the child is symptomatic then
drainage should occur. If the effusion is estimated to be
greater than 10 mL on a lateral decubitus film, a
thoracentesis should be performed. The decision to then
place a chest tube will depend on the results of the fluid
obtained by thoracentesis. If the fluid obtained reveals an
empyema, then a chest tube is required. The controversy
exists with the pleural effusions that are not clearly identified
as an empyema or pus. These are classified as complicated
and uncomplicated pleural effusions.
The complicated pleural effusion has a pH less than
7.2, a glucose less than 40 mg/dL, and an LDH greater than
1000 IU/L. The uncomplicated pleural effusion has a pH
greater than 7.3, a glucose greater than 60 mg/dL, and an
LDH less than 1000 IU/L. The gram stain and culture may or
may not be positive with the complicated pleural effusion but
are negative in the uncomplicated pleural effusion.
Measuring the pH properly and interpreting it properly
are very important. One must keep in mind that if the patient
is acidemic, then the pH of the pleural effusion fluid must be
0.15 to 0.3 pH units less than the serum pH to truly reflect a
pleural fluid acidosis. Furthermore, the pleural fluid sample
needs to be handled properly and be heparinized and kept on
ice until it is analyzed.
In a recent study by Utine et al,18 interleukin (IL) 8,
nitric oxide, and tumor necrosis factor a concentrations were
measured in pediatric pleural effusions. It was observed that
all 3 markers increased progressively as the stage of the
disease progressed. However, only IL-8 concentration was
statistically significant. Utine et al18 concluded that IL-8 may
be used as an alternative marker for the complication of a
pleural effusion.
The uncomplicated pleural effusion may not require a
chest tube but rather can be monitored. Antibiotics should be
started and a repeat thoracentesis should be done about 12
hours later. If the effusion remains uncomplicated, then a
chest tube is not necessary. However, if the effusion has
become a complicated effusion, then a chest tube should be
placed for drainage. Without the placement of a chest tube,
the effusion is likely to loculate and cause further tissue
damage. In the adult literature, there is some controversy
around this point. Some authors suggest that complicated
pleural effusions can be treated with antibiotic therapy
alone.19 Further studies need to be done on this topic, in
particular in the pediatric population.
In the past, large bore chest tubes were used to drain
pleural effusions. More recently, the use of percutaneous
pigtail catheters have been used in the pediatric population.
They are smaller and thus require less force with insertion.
As well, they are flexible and thus thought to be less
painful. Percutaneous pigtail catheters are recommended for
the drainage of pleural effusions in place of large bore chest
tubes in the pediatric population.20,21 However, the limita-
tion with these smaller catheters compared with larger bore
chest tubes may be with draining the thicker pleural fluid of
complicated pleural effusions and empyemas. Fuhrman
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Pediatric Emergency Care
Volume 23, Number 5, May 2007
TABLE 1. Chest Tube Size by Age
Age Size (F)
Newborn 10 – 12
6 mo 10 – 12
1 yr 16 – 20
4 yrs 20 – 28
10 yrs 28 – 32
>14 yrs 28 – 32
et al21 describes successful drainage of 2 of 2 empyemas in
pediatric patients, whereas another author Roberts et al20
reports unsuccessful drainage of 5 of 5 empyemas in pediatric
patients with pigtail catheters.
The proper technique for placing a chest tube begins
with selecting the correct chest tube size (Table 1). Next,
the position of the patient must be chosen. In general, the
older child may be placed in a sitting position, whereas an
infant should be placed supine. The preferred site for chest
tube placement is between the anterior axillary and
midaxillary lines at the level of the nipple (fifth intercostal
space). Clean the site with povidone-iodine solution. Next,
infiltrate the skin, subcutaneous tissue, and periosteum with
1% lidocaine. Make the skin incision at least 1 intercostal
space below the rib over which the catheter will pass. This
helps with maintaining an airtight seal with the chest tube
in place and after its removal. Using a curved hemostat or
Kelly clamp, bluntly dissect through the muscle and fascial
layers to the upper surface of the chosen rib. Next, slide the tip
of the instrument over the superior rib margin puncturing
through the intercostal muscles and pleura. A large ‘‘pop’’
will be felt. Do not enter more than 1 cm into the thoracic
cavity. Spread the tips of the instrument. Fluid under pressure
in the pleural space may surge out. Next, grasp the tip of the
chest tube with the hemostat or clamp and advance it through
the incision and up the previously dissected tract into the
pleural space. Once the tip of the chest tube is in the pleural
space, open the hemostat and advance the tube until it meets
some resistance. The tip will likely be at the apex of the
hemithorax. Last, approximate the incision with several nylon
sutures, some of which should encircle the tube to secure it in
place. A sterile occlusive dressing should be placed. A chest
radiograph must be obtained immediately to evaluate the
location of the chest tube as well as to ensure that a
pneumothorax has not occurred.
When performing a thoracentesis, place the child in a
sitting position leaning forward with their head supported
on a pillow. Elevate the arm on the involved side. In this
position, the preferred site for performing the thoracentesis
is readily located. The lower tip of the scapula lies just
above the seventh intercostal space in the posterior axillary
line (a site where sufficient amounts of free fluid are
usually present). When performing a thoracentesis on an
infant the position should be lateral decubitus with the
affected side down. As with placement of a chest tube
described above, the site is cleaned, and local anesthetic is
used. A needle thoracentesis catheter connected to a
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Pediatric Emergency Care
Volume 23, Number 5, May 2007
syringe is advanced through the skin just over the top
surface of the rib. Maintain continuous suction on the
syringe while entering the pleural cavity. A decrease in
resistance and return of fluid indicate entry of the needle
into the pleural space. Remove the syringe and needle.
Quickly attach another syringe (20 –50 mL), stopcock, and
T-connector. Remove some pleural fluid. At the end of the
procedure, remove the catheter, and apply pressure.
Afterwards, always obtain a chest radiograph to rule out
a pneumothorax.
An alternative to chest tubes or percutaneous pigtail
catheters for ongoing drainage of complicated pleural
effusions or empyemas may be repeated ultrasound-guided
thoracocentesis. Shoseyov et al22 compared repeat ultrasound-
guided thoracocentesis with chest tube drainage in the
treatment of pediatric empyema and found both treatments to
be equally efficacious.
The timing of drainage of complicated pleural effusions
and empyemas has been studied in adults. Currently, there
have been no published pediatric studies, but several adult
studies conclude early chest tube placement upon diagnosis of
an empyema offers improved outcomes.23,24
The use of fibrinolytic agents in loculated pleural
effusions has been shown to be effective therapy in the
pediatric population since the early 1990s.23,25,26 Their
mechanism of action is to decrease fibrinous strands and
reopen pleural pores blocked by fibrinous debris, thereby
helping the resorption of pleural fluid. Streptokinase, a
bacterially derived protein, and urokinase, a protein derived
from human urine, carry risk of anaphylactic and hypersen-
sitivity reactions.27 – 31 Urokinase is no longer available in
the United States. Tissue plasminogen activator is a
recombinant fibrinolytic agent that is being used by many
physicians to facilitate the drainage of loculated pleural
effusions in children. Feola et al26 showed effective therapy
using tissue plasminogen activator in pediatric patients with
complicated pleural effusions.
In general, uncomplicated pleural effusions can be
managed conservatively without the need for surgical
intervention. However, when the pleural effusion is compli-
cated or has progressed to an empyema, there may be a need
for surgical intervention beyond a chest tube. An empyema is
believed to originate as a pleural effusion that subsequently
becomes infected by an adjacent lung infection. About 5%
of patients with pleural effusions will develop into an
empyema.32
Empyemas are classified by stages of progression.
During stage I or the exudative phase, fluid accumulates.
During stage II or the fibrinopurulent phase, pus accumu-
lates, and fibrin deposits produce a pleural peel and
loculations of the fluid. During stage III or the organizing
phase, fibroblasts proliferate and scar formation results in
lung entrapment.15,25
Numerous recent studies in both adults and more
recently in pediatrics evaluated the role of video-assisted
thoracoscopy verses full thoracotomy with decortication in
the treatment of empyemas. Consensus is that the video-
assisted thoracoscopy procedure is the treatment of choice
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Pleural Effusions
for early organizing empyemas (fibrinopurulent phase)
because it has significant success and is less invasive than
a thoracotomy.15,33 – 38 However, decortication by standard
thoracotomy remains the treatment of choice for more
advanced organizing empyemas, when the lung is entrapped
by a thick fibrous peel.15
COMPLICATIONS AND SEQUELAE
With appropriate treatment, children with pleural
effusions should do well without long-term complications.
Although there are no published studies that evaluate long-
term outcomes specifically with pleural effusions, Sarihan
et al39 showed that most children returning for follow-up,
several months after treatment of empyemas, had normal
chest radiographs. Only a small percentage of these children
showed persistent pleural thickening. Of the children who
were old enough to perform pulmonary function tests, the
majority had normal function, with only 5 of 15 patients
showing mild restrictive dysfunction.
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12. Panitch H, Pastamelos C, Schidlow D. Abnormalities of the pleural
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13. Bryant R, Salmon S. Pleural empyema. Clin Infect Dis. 1996;22:
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14. Moskowitz H, Platt R, Schachar R, et al. Roentgen visualization of
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18. Utine G, Ozcelik U, Yalcin E, et al. Childhood parapneumonic
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19. Berger H, Morganroth M. Immediate drainage is not required for all
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20. Roberts J, Bratton S, Brogan T. Efficacy and complications of
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30. Perri JA, Stahfeld KR, Villella ER, et al. The management of
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Pediatric Emergency Care
Volume 23, Number 5, May 2007 Pleural Effusions

CME EXAM
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CME EXAMINATION
May 2007

Please mark your answers on the ANSWER SHEET.

Pleural Effusions, Beers and Abramo

1. The father of a 3-year-old boy brings his son to the
emergency department with persistence of chest pain, cough,
and upper abdominal pain for 1 week, not improving after
treatment with amoxicillin for 3 days. Chest radiograph
shows a small pleural effusion on the left and possible
blunting of the right costophrenic angle. Via thoracentesis on
the left side, you obtain 10 mL of clear, mildly straw-colored
fluid with a lactate dehydrogenase level of 1200 IU/L and
pH of 7.1. The most likely cause of this effusion is:
a) Pneumonia due to Staphylococcus aureus
b) Infection with Mycoplasma pneumoniae
c) Pulmonary tuberculosis
d) Congestive failure from myocarditis
e) Subdiaphragmatic abscess
2. A 12-year-old boy complains of fever and right-sided
chest pain for 5 days. His examination reveals decreased
breath sounds on the right, and a chest radiograph
confirms a small pleural effusion that is barely visible
as blunting of the right costophrenic angle. The amount of
fluid in his pleural space is likely to be approximately:
a) 2 mL
b) 10 mL
c) 50 mL
d) 250 mL
e) 1250 mL
3. A 4-year-old boy is diagnosed with a right-sided
pneumonia and pleural effusion. Analysis of the fluid-
shows: 15,000 white blood cells/mm3, lactate dehydro-
genase 140, and pH 7.3. After inserting a pigtail catheter,
you might begin treatment with:
a) Cefotaxime
b) Penicillin
c) Ampicillin
d) Ciprofloxacin
e) Azithromycin
4. A 7-year-old girl complains of fever and cough for 1 week.
She has been taking penicillin for a presumed streptococ-
cal pharyngitis for 2 days without improvement. Chest
radiograph shows a left-sided pneumonia with a large
pleural effusion that layers out in lateral decubitus view.
You decide to place a pigtail catheter using a guidewire in
the following location on the left side.
a) 2nd intercostals space, anterior axillary line
b) 2nd intercostals space, mild axillary line
c) 4th intercostals space, mid clavicular line
d) 5th intercostals space, mid axillary line
e) 6th intercostals space, mid scapular line
5. A 14-year-old girl with pneumonia and an uncomplicated
pleural effusion, based on analysis of the fluid obtained by
thoracentesis, seems mildly short of breath 2 hours after
the procedure. A repeat chest radiograph shows an effusion
that has increased slightly in size and the absence of any
pneumothorax. Her oxygen saturation is 97%. You decide
to drain the effusion and ask a colleague to assist you, as

n 2007 Lippincott Williams & Wilkins 335

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Beers and Abramo Pediatric Emergency Care
Volume 23, Number 5, May 2007

you will be sedating the patient. Your colleague sees you a) Is inserted in the posterior axillary line
open up a kit with a pigtail catheter and suggests a large b) Leaves a smaller scar at the insertion site
bore chest tube instead. You reply that you prefer a c) Becomes obstructed less frequently
pigtail catheter because, as compared with a large bore d) Drains thick fluid more effectively
chest tube, a pigtail catheter: e) Can remain in place longer

336 n 2007 Lippincott Williams & Wilkins

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Pediatric Emergency Care
Volume 23, Number 5, May 2007 Pleural Effusions

ANSWER SHEET FOR THE PEDIATRIC EMERGENCY CARE

CME PROGRAM EXAM
May 2007
Please answer the questions on pages 335 and 336 by filling in the appropriate circles on the answer sheet below. Please
mark the one best answer and fill in the circle until the letter is no longer visible. To process your exam, you must also provide
the following information:

Name (please print): ______________________________________________________________________________________

Street Address ___________________________________________________________________________________________

City/State/Zip ___________________________________________________________________________________________

Daytime Phone __________________________________________________________________________________________

Specialty _______________________________________________________________________________________________

1. A B C D E
2. A B C D E
3. A B C D E
4. A B C D E
5. A B C D E
Your evaluation of this CME activity will help guide future planning. Please respond to the following questions.
1. Did the content of the article(s) meet the stated learning objectives?
[ ] Yes [ ] No
2. On a scale of 1 to 5, with 5 being the highest, how do you rank the overall quality of this educational activity as it pertains to
your practice?
[]5 []4 []3 []2 []1
3. As a result of meeting the learning objectives of this educational activity, will you be changing your practice behavior in
a manner that improves your patient care? If yes, please explain.
[ ] Yes [ ] No
________________________________________________________________________________________________________
________________________________________________________________________________________________________
4. Did you perceive any evidence of bias for or against any comercial products? If so, please explain.
[ ] Yes [ ] No
________________________________________________________________________________________________________
________________________________________________________________________________________________________
5. Please state one or two topics that you would like to see addressed in future issues.
________________________________________________________________________________________________________
6. How long did it take you to complete this CME activity?
__________hour(s) __________minutes

Mail by July 15, 2007 to

Lippincott CME Institute, Inc.
770 Township Line Road, Suite 300
Yardley, PA 19067

n 2007 Lippincott Williams & Wilkins 337

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Beers and Abramo Pediatric Emergency Care
Volume 23, Number 5, May 2007

CME EXAM ANSWERS

Answers for the Pediatric Emergency Care CME Program Exam

Below you will find the answers to the examination covering the review article in the February 2007 issue. All participants whose
examinations were postmarked by April 15, 2007 and who achieved a score of 80% or greater will receive a certificate from
Lippincott CME Institute, Inc.

EXAM ANSWERS
February 2007

1. D
2. C
3. B
4. B
5. D

338 n 2007 Lippincott Williams & Wilkins

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