Tutor’s Book

Modul
Clinical Interpretation of Laboratory Tests

Second edition
Desember 2011

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 Module Coordinator

dr. Tri Ratnaningsih, M.Kes., Sp.PK (K)

Department of Clinical Pathology

Faculty of Medicine
Universitas Gadjah Mada

Contributors

dr. Windarwati, Sp.PK(K)

dr. Andaru Dahesih Dewi, M.Kes, Sp.PK (K)
dr Ira Puspitawati, M. Kes,Sp.PK

Department of Clinical Pathology

Faculty of Medicine
Universitas Gadjah Mada

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 CONTENTS

Team
Curriculum Map
Contents
Overview
Schedule of Block
Scenario 1
Scenario 2
Practical session 1: hematology cases
Practical session 2: urinalysis cases
Practical session 3: infectious disease
Module evaluation

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 OVERVIEW

Clinical laboratory test is one of the important supportive approaches for managing
patient in order to accurate diagnosis, treatment evaluation, staging of the disease and
prognosis. There are some aspects should be considered by physicians in making decision on
clinical laboratory tests and interpreting the result, i.e. diagnostic performance, reference
value and proper interpretation of test result. Sensitivity and specificity (analytical and
diagnostic), likelihood ratio, cutoff point, etc are some issues on clinical laboratory test
results which are should be comprehended by general medical practitioner for rational
implementation on patient’s management. Good knowledge and soft skill in interpretation of
routine clinical laboratory area is needed for general physicians to be able to provide the best
practice.

LEARNING OBJECTIVES

GENERAL INSTRUCTIONAL OBJECTIVES

Students understand the principle thinking of making decision on clinical laboratory test
efficiently and how to interpret the results

SPECIFIC INSTRUCTIONAL OBJECTIVES:

1. Students understand the issues on analytical and diagnostic performance of
laboratory test
2. Students understand and are able to perform serial and or parallel appropriate clinical
laboratory test with the intention of the clinical aims
3. Students understand reference values, types of scale results, cutoff points, etc to
facilitate constructing the correct interpretation on the test result
4. Students understand and are able to comprehend clinical laboratory test assignments
efficiently so as to manage patients well

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 SCHEDULE OF BLOCK 4.3

WEEK 1:

TUTORIAL
Scenario Duration
Poor child 4 hours

LECTURE
Topic Department/ Lecturer Duration
Unit
Introduction Clinical dr. Tri Ratnaningsih, 1 hour
Pathology M.Kes, Sp. PK(K)
Procedure of laboratory test and Clinical dr. Usi Sukorini, M.Kes, 2 hours
factors affecting reliability of test Pathology Sp. PK(K)
result
Measurements on clinical Clinical dr. Windarwati, Sp. PK(K) 2 hour
laboratory test Pathology
Diagnostic test Clinical dr. Andaru Dahesihdewi, 2 hours
Pathology M.Kes, Sp. PK(K)
Total 7 hours

LABORATORY PRACTICAL SESSION

Topic Department/ Unit Duration
Clinical interpretation of Hematology tests Clinical Pathology 2 hours
Clinical interpretation of Urinalysis tests Clinical Pathology 2 hours
Total 4 hours

Total: 15 hours

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WEEK 2:

TUTORIAL
Scenario Duration
The Lawyer 4 hours

LECTURE
Topic Department/ Lecturer Duration
Unit
Clinical Interpretation of routine Clinical dr. Tri Ratnaningsih, 2 hours
clinical laboratory test: complete Pathology M.Kes, Sp. PK(K)
blood count
Clinical interpretation of routine Clinical dr. Harjo Mulyono, Sp. 2 hours
clinical laboratory test: urinalysis Pathology PK(K)
and fecal analysis
Clinical interpretation of Clinical dr. Setyawati, Sp. PK(K) 2 hours
hematology test Pathology
Interpretation of clinical chemistry Clinical dr. Siti Muchayat P, M.Si, 2 hours
tests Pathology Sp. PK(K)
Interpretation of clinical Clinical dr. Kismardhani, M. Sc, 2 hours
microbiology tests Pathology Sp. PK(K)
Clinical interpretation of Clinical dr. Umi S Intansari Sp. 2 hours
immunology tests Pathology PK(K)
Point-of-care testing Clinical dr. Ira Puspitawati,MKes, 2 hours
Pathology SpPK
Total 14 hours

LABORATORY PRACTICAL SESSION

Topic Department/ Unit Duration
Clinical interpretation of Hematology tests Clinical Pathology 2 hours
Clinical interpretation of Urinalysis tests Clinical Pathology 2 hours
Clinical interpretation of Infectious Disease Clinical Pathology 2 hours
Total 6 hours

Total: 20 hours

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WEEK 1

SCENARIO 1: Poor Child

Ana is a 7-year-old who lives with her parents in a suburban community. Her parents brought
Adriana to Jogjakarta from their homeland in Wonogiri when she was 1 year old. At the age
of 3, Adriana was in the 10th percentile for height and weight, pale, and her hemoglobin was
5.8 g/dL. Following further diagnostic studies, she was diagnosed with beta-thalassemia
major. Over the course of the next 4 years, Adriana was hospitalized every 1–2 months so she
could be transfused with packed red blood cells. During a routine follow-up visit at the
hematology clinic, Adriana’s laboratory results were as follows:
Hemoglobin: 10 mg/dL
Total serum iron: 150 g/L
The hematologist discusses the planned treatment with Adriana and her parents.

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WEEK 2

SCENARIO 2: The Lawyer

54 year old male lawyer has had high blood glucose for over a year, but only now after a
random reading exceeds 300 mg/dL on an office visit is he willing to admit that he has
diabetes. He has had a previous heart attack and is taking several cardiovascular and
hypertensive medications. His physical exam today is normal. He has a BMI of 28. He
admits to feeling a little tired, recently, and has been getting up at night to urinate at least two
to three times.He has limited activity and rare exercise.

The following is clinical profile:

Age: 54 Lipid Profile Liver Function
Weight: 98 kg. Total: 153 mg/dL ALT: normal
Height: 185 cm LDL: 70 mg/dL AST: normal
BMI: 28 HDL: 41 mg/dL
Triglycerides: 225 mg/dL Blood Pressure
Blood Glucose Normal: 130/90 mmHg
Last A1C: 10.2% Kidney Profile
Creatinine: 0.8 mg/dL Cardiovascular condition
Fructosamine: 429 mmo/L Previous myocardial infarction
(nl <250) Microalbuminuria:
negative Eye Exam
Glucose Random: 358 mg/dL Normal

Foot Exam
Normal pulses and sensation

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 PRACTICAL SESSION I
INTERPRETATION OF HEMATOLOGY CASES

CASE 1

History
23 year old male.
Over the past week noted increasing fatigue, sore throat, earaches, headaches, and episodic
fever and chills.

Physical Exam
Erythematous throat and tonsils.
Swollen cervical lymph nodes.

CBC and blood picture

RBC 5.25 x 1012/L
HGB 15.4 g/dL
HCT 46.1 %
MCV 87.9 fL
MCH 29.3 pg
MCHC 33.4 g/dL
RDW 12.2

WBC 12.9 x 109/L

N 24 %
L (shown) 73
M 0
E 3
B 0

PLT 333 x 109/L

Clinical Course
Three weeks later, the patient's symptoms had abated, and his WBC count was 7.6 x 109/L,
with 56% lymphocytes.

Question:
1. What your interpretation of CBC test result above?
2. What morphologic alterations are seen in this blood smear field?
3. What further laboratory studies, if any, are indicated?
4. What is the most likely diagnosis?

CASE 2

History:
70 year old female.
Symptoms of dyspnea on exertion, easy fatigability, and lassitude for past 2 to 3 months.
Denied hemoptysis, GI, or vaginal bleeding. Claimed diet was good, but appetite varied.

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Physical Exam:
Other than pallor, no significant physical findings were noted. Occult blood was negative.
CBC and blood picture

RBC 3.71 x 1012/L

HGB 5.9 g/dL
HCT 20.9 %
MCV 56.2 fL
MCH 15.9 pg
MCHC 28.3 g/dL
RDW 20.2

WBC 5.9 x 109/L

N 82 %
L 13
M 1
E 4
B 0

PLT 383 x 109/L

Question:
1. What your interpretation of CBC test result above?
2. What morphologic alterations are seen in this blood smear field?
3. What further laboratory studies, if any, are indicated?
4. What is the most likely diagnosis?

CASE 3

History
30 year old male who stated he had always been in good health.
Several years ago at a routine check-up, he was told that he had a mild form of "anemia." He
was recently denied insurance coverage after indicating this condition on an application form.
Now seeking clarification of his anemia and its impact on his insurability.

Physical Exam: Within normal limits: no significant findings.

CBC (with microscopic differential)
RBC 6.22 x 1012/L
HGB 12.1 g/dL
HCT 38.3 %
MCV 61.6 fL
MCH 19.5 pg
MCHC 31.6 g/dL
RDW 15.4

WBC 7.1 x 109/L

N 55 %
L 33
M 10

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 E 1
B 1

PLT 204 x 109/L

Question:
1. What your interpretation of CBC test result above?
2. What morphologic alterations are seen in this blood smear field?
3. What further laboratory studies, if any, are indicated?
4. One of the Further Laboratory Studies is Hemoglobin electrophoresis. The result
is follow: Hemoglobin electrophoresis:
Hemoglobin A 92.7%
Hemoglobin A2 6.6%
Hemoglobin F 0.7%
What is the most likely diagnosis?

Case 4

History
54 year old female.
One year history of fatigue, weight loss, and increasingly severe back pain.

Physical Exam
She appeared pale, but otherwise her physical exam was within normal limits.

CBC(with microscopic differential) blood picture

RBC 2.85 x 1012/L
HGB 7.6 g/dL
HCT 23.9 %
MCV 83.8 fL
MCH 26.7 pg
MCHC 31.8 g/dL
RDW 16.8

WBC 8.4 x 109/L

N 60 %
L 26
M 12
E 1
B 1

PLT 418 x 109/L

Question:
1. What your interpretation of CBC test result above?
2. What morphologic alterations are seen in this blood smear field?
3. What further laboratory studies, if any, are indicated?
4. One of Further Laboratory Studies is Bone marrow biopsy:

Aspirate differential (1000 cells) in Sections: Hypercellular with clusters of

bone marrow specimen: plasma cells.

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 Erythroblasts 19.2%
Myeloblasts 0.4
N promyelocytes 0.8
N and precursors 45.2
L 9.2
M 3.6
E and precursors 3.2
B and precursors 0.0
Plasma cells 18.4

The plasma cells show variable

morphology. Many have a normal
appearance, but immature forms with
prominent nucleoli are also present.
Multinucleated plasma cells and
occasional very large forms are noted
. What is the most likely diagnosis?

Case 5

History
11 year old male.
Presented in emergency room with recent onset of easy bruising, bleeding gums, and
persistent epistaxis.
Previously in excellent health. Mother stated he was "never sick before in his entire life."
No history of recent viral infection, and no family history of bleeding disorders.

Physical Exam
Bleeding from the left nostril. Numerous petechiae and purpura; mostly on the extremities.
No organomegaly.

CBC(with microscopic differential)

RBC 4.52 x 1012/L
HGB 13.4 g/dL
HCT 37.2 %
MCV 82.3 fL
MCH 29.6 pg
MCHC 35.9 g/dL
RDW 12.1
WBC 5.3 x 109/L
N 44 %
L 39
M 14
E 1
B 2
PLT <5 x 109/L
MPV 10.9 fL
Question:
1. What your interpretation of CBC test result above?
2. What morphologic alterations are seen in this blood smear field?

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 3. What further laboratory studies, if any, are indicated?
4. If the result of Bone marrow biopsy as follow:
Aspirate: Erythrocyte and granulocyte maturation within normal limits.
Megakaryocytes appear normal in number and morphology. Sections: Slightly
hypocellular for his age, with abundant megakaryocytes.
What is the most likely diagnosis?

Case 6

History

37 year old male. Lifelong history of a seizure disorder, treated since age two. At a
routine check with his neurologist, he complained of fatigue, exertional dyspnea, and
lightheadedness over the past 2-3 months. He appeared pale, but otherwise his physical
exam was within normal limits. He was found to have a decreased hemoglobin, and was
referred to Hematology Clinic.

CBC (with microscopic differential)

RBC 1.26 x 1012/L
HGB 5.7 g/dL
HCT 16.3 %
MCV 130 fL
MCH 45.2 pg
MCHC 34.9 g/dL
RDW 18.1
WBC 6.2 x 109/L
N 73 %
L 21
M 1
E 4
B 1
PLT 219 x 109/L

QUESTION:
1. What your interpretation of CBC test result above?
2. What morphologic alterations are seen in this blood smear field?
3. What further laboratory studies, if any, are indicated?
4. If the result of chemistry test and BMP as follow:

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Serum folate <1.0 µg/L(RI 3.5-15)
RBC folate 131 µg/L(RI 160-600)
Serum B12 136 ng/L(RI 250-900)

What is the most likely diagnosis?

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 PRACTICAL SESSION II
INTERPRETATION OF URINALYSIS CASES

CASE 1

A 30-year-old-woman is seen by her physician. She has a temperature of 38 0C and complains

of nausea, headache, and flank (below the ribs and above the ileac crest) tenderness and pain.
When asked, she states that urination is sometimes painful, that she must urinate more
frequently than usual, and that she has a sensation of urgency. A random, midstream “clean
catch” urine specimen is collected for a routine UA and culture.

RESULTS
Physical Exam Chemical Exam Microscopic Exam
Color: yellow Glu: neg RBCs: 0 to 2
Clarity: cloudy Bili: neg WBCs: 25 to 50
Odor: NA Ket: neg Casts: 0 to 2 granular
Sp Grav: 1.010 2 to 5 WBC
Blood: trace Bacteria: mod
pH: 6.5 Epith: few SEs
Pro: 30 Crystals: few CaOx
Urob: norm
Nitr: pos
LE: pos
QUESTION:
1. Circle any abnormal or discrepant urinalysis findings
2. What is the probable diagnosis?
3. State two physiologic mechanism that can lead this condition

CASE 2

A 58-year-old male is seen in the emergency room complaining of intermittent severe pain
that radiates from his right side to his abdomen and groin area (renal colic). He has frequent
need to urinate with little or no urine output. Other complaints include a “cold” that he has
been self-treating with over the counter medications and vitamin supplements for more than a
week.

RESULTS
Physical Exam Chemical Exam Microscopic Exam
Color : Pink Glu : neg RBCs : 10 to 25
Clarity : Slt cloudy Bili : neg WBCs : 5 to 10
Odor : NA Ket : >1.030 Casts : 0 to 2 hyaline
Sp Grav : neg Epith : few TEs
Blood neg Bacteria : few
pH : 5.5 Crystals : many CaOx
Pro : trace
Urob : norm

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 Nitr : pos
LE : neg
QUESTION:
1. Circle any abnormal or discrepant urinalysis findings.
2. For each discrepancy noted, list a test the laboratories should perform to confirm or deny
the cause of the test discrepancy.
3. Based on the information provided, which of the following is the most probable cause of
the patient’s condition?
4. State at least three factors that could lead to the development of the patient’s condition.

CASE 3

An obese 58-year-old women is seen by her physician. She complains of perineal itching and
soreness. On pelvic examination, a white vaginal discharge is noted. A sample of the
discharge is collected for culture. A midstream “clean catch” urine specimen is also collected
for culture and routine urinalysis.

RESULTS
Physical Exam Chemical Exam Microscopic Exam
Color : Yellow Glu : 500 RBCs : 0 to 2
Clarity : cloudy Bili : neg WBCs : 10 to 25 ; clumps
Odor : NA Ket : neg Casts : 0 to 2 hyaline
Sp Grav : 1.015 Epith : many SEs
Blood neg Bacteria : neg
pH : 5.0 Yeast : mod
Pro : neg Crystals : few urates
Urob : norm
Nitr : neg
LE : pos

QUESTION:
1. Circle any abnormal or discrepant urinalysis findings.
2. What is the most likely cause of the patient’s vaginitis?
3. Which two microscopic findings suggest that the urine tested is not from a mid stream
“clean catch” specimen?
4. Is the patient showing signs of renal damage or dysfunction?
A. Yes
B. No
5. Explain the physiologic mechanism most likely responsible for the presence of glucose in
the patient’s urine
6. Select the diagnosis that best accounts for the glucosuria observed in this specimen.
A. Normal ; the glucose renal threshold was exceeded
B. Insulin-dependent diabetes mellitus
C. Non-insulin-dependent diabetes mellitus
D. Glucose intolerance

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CASE 4

Yuliana presented to her physician with pains in her lower back following an automobile
accident. The physician suspected renal trauma and ordered a complete urinalysis. The
results from the dipstick were negative for blood. The technologist saw microscopic fields
similar to the field shown below.

QUESTION:

1. What may be a cause for the discrepancy in the results?

2. How would you describe the morphology of the red blood cells seen above?

3. Would you expect the specific gravity of this sample to be high or low?

CASE 5

The medical technologist performing urinalysis on this sample went on her lunch break and
did not refrigerate this sample to preserve it. It was left at room temperature for three hours
before being examined microscopically.

QUESTION:

1. Is the bacteria seen most likely a result of an infection or contamination? Why?

2. What dipstick results would you expect to be abnormal?

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CASE 6

A B
Beni, an eight year old boy, was admitted to the hospital with symptoms of weakness,
anorexia, and oliguria. He recently had a streptococcal throat infection. His urinalysis
revealed:

Physical Appearance Reagent Strip Results

Color- red/amber pH- 6
Clarity- cloudy specific gravity- 1.025
protein- >2000 mg/dL (SSA 4+)
Blood- Large
Nitrite- negative
Leukocytes- negative
Glucose- negative
Ketones- negative
Bilirubin- negative
Urobilinogen- normal

QUESTION:

Which image above is representative of the microscopic examination of this patient? Why?

CASE 7

A B C

Toni presents to his doctor with swelling in his knees and ankles. He was diagnosed with
gouty arthritis.

QUESTION:

Which of the crystals above support the diagnosis?

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Case 8

A B

QUESTION: Which formed element above is associated with the most serious pathological
condition?

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 PRACTICAL SESSION III
CLINICAL INTERPRETATION OF LABORATORY TEST OF
INFECTIOUS DISEASE

CASE 1

A girl with high grade fever and organ enlargement

Chief compliant: 13-year old girl, Fever for 5 days prior to admission

Present illness: 5 days prior to admission she has had high grade fever with chills. She also
developed headache, generalized abdominal pain, and nausea. She has no diarrhea but she has
poor appetite. She went to a private clinic with her parents and the doctor gave her antipyretic
drug but she was not improved. With the continuing high fever she has been getting weaker
and weaker, so the parents brought her to the hospital.

Past history: she did not have any underlying disease, or history of drugs allergy nor a
family history of hematologic disease.

Physical examination

GA: A girl, normal consciousness, looks malaise, Weight 35 kg

V/S: T 39 C, PR 136 /min, RR 24 /min, BP 80/40 mmHg
HEENT: mild pale conjunctiva, no icteric sclera, dry lip, no sunken eyeball, no
injected pharynx
Lymph node: can’t be palpable
Heart: regular, normal S1 S2, no murmur
Lung: clear, no adventitious sound
Abdomen: flat, soft, generalized tenderness, no guarding, liver 7 cm below RCM,
span 13 cm, spleen 4 cm below LCM
Extremities: no edema, no petechiae, no rash, no eschar
Neurological good consciousness, CN : intact, normal muscle tone and power, stiffness
examination: of neck : negative
Lab investigations:

CBC: Hb 9.9 g/dl, Hct 29.7%, WBC 8,800cells/cu.mm. (PMN 63.9%, L 18.4%, Mono 17%,
E 0.6%, Baso 0.1%), Platelet 10,000/cu.mm.
UA: yellow, cloudy, pH 5, specific gravity >1.030, albumin 2+, sugar trace,
RBC -, WBC 0-1, epithelial 3-5, fine granular cast few
Electrolyte: Glucose 112, BUN 53, Creatinin 1.6, Na 135, K 3.9, Cl 105, CO2 17
BGA: pH 7.397, PaO2 99, PaCO2 32, HCO3 19.9, B.E-3.6, O2sat 97.8.
LFT: TP 5.6, Alb 3.2, Glob 2.4, AP 140, Cholesterol 112, AST 77, ALT 24, TB 2.03, DB 0.93
Urine heme: negative

PBS :

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 RBC morphology: Numerous fine ring forms,double chromatin dots, marginal forms and
red cells are not enlarged

QUESTION
1. List the problem (only based on physical examination or before you performed
laboratory investigation). What are differential diagnoses?
2. What is your interpretation of laboratory test result above?
3. What is the most likely diagnosis?
4. How to diagnose malaria?
5. What kind of laboratory test to support diagnosis of severe malaria with
complications?

CASE 2

A 32-year-old nonpregnant woman, G2P2, was seen in the Emergency Department because
of recurrent epigastric pain and colicky pain in the right upper quadrant. The current episode
began four hours after a “heavy” dinner and was characteristic of previous episodes that had
occurred several times a year for the past three years. The pain had become more severe
during the more recent episodes, and the patient developed an intolerance for fatty foods.

Vitals: T37.2°C, P82, BP 124/74, R16

Labs: WBC 8.6x103 cells/µl, Hb 13.1 g/dl, Hct 40%, Na 138 mEq/L, K 4.5 mEq/L, SUN
11 mg/dl, serum creatinine 0.4 mg/dl, total protein 6.1 g/dl, albumin 3.6 g/dl, total bilirubin
2.4 mg/dl, conjugated bilirubin 1.4 mg/dl, AST 80 U/L, ALT 28 U/L, ALP 400 U/L, GGT 120
U/L
Physical exam revealed tenderness without rebound in the right upper quadrant. Bowel
sounds were normal. The urine was slightly dark.

QUESTION

1. Based on her clinical presentation, what is your differential diagnosis?

2. What is the concentration of unconjugated bilirubin? What is the significance of the
elevated total bilirubin and conjugated bilirubin?

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3. Why are the AST and ALT relatively normal? What do the elevation of ALP and GGT
suggest?
4. Why is the urine dark?

CASE 3

A28 year-old previously healthy, non-alcoholic male presented to us with a history of fever
with chills for three days associated with vomiting and dizziness. He had no bleeding
manifestations. On admission, he was plethoric with a temperature of 39 0C and blood
pressure of 110/70 mmHg without a postural drop. His lungs were clear and the abdomen was
soft. The cell count of 3,200/mm (N-43%, L-55%, E-2%), Hb% of 16.9 g/dL with PCV of
48% and a platelet count of 20,000/mmc . The blood picture was suggestive of dengue fever.
On the following day, platelet count dropped to 10,000/mmc and the PCV rose to 50%.

QUESTION
1. How the results of the Complete blood count examination in dengue
infection?
2. What type of laboratory tests are important for diagnosis of dengue fever
infection?
3. How might the results of liver function tests? give an explanation
4. What kind of laboratory tests that important to monitor the course of the
disease in dengue infection? Give a description of its importance!

CASE 4

A six-year-old boy with high-grade fever and abdominal pain in the epigastric region was
examined with ultrasonogram of the abdomen. Hematology-cell analysis, serology (Widal
test), urine analysis, and blood cultures were also performed. The ultrasonogram was helpful
for the identification of multiple organ involvement with Salmonella typhi. The results
revealed mild hepatosplenomegaly, minimal ascitis, and mesenteric lympoadenopathy.
Hematological analysis showed a white blood count of 6,300 cells mL-1; a red blood cell
count of 4.54 million/cu mm. The erythrocyte sedimentation rate (ESR) was 24 mm/1 hr;
hemoglobin level of 11.5 g/dl; and a platelet count of 206,000 cells/mL. The patient’s serum
was agglutinated with lipopolysaccharide (TO), the titre value was 1:320 dilution, and
flagellar antigen (TH) titre was 1:640. The patient was diagnosed with typhoid fever.
Ceftriaxone was given intravenously for five days and the patient fully recovered.

QUESTION
1. What does the character CBC test results on typhoid infection?
2. How to interpret the Widal examinations?
3. What are the limitations of Widal examinations?
4. What is the gold standard examination to diagnose tiphoid? give an
explanation
5. Because of Widal tests have many limitations. whether the types of tests
recommended for diagnosing tiphoid? Explain!

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 MODULE REFERRENCES

1. Harrison's principles of internal medicine (17th ed.). New York: McGraw-Hill

Medical Publishing Division
2. Sheehan K. Clinical Immunology.
3. Hoffbrand, A.V., Pettit,J.E., 1998. Essential Haematology 3rd ed. Blackwell Science
Ltd. Oxford, London.
4. R. Gandasoebrata Penuntun Laboratorium Klinik
5. Ronald A. Sacher, Richard A. McPherson, Tinjauan Klinis Hasil Pemeriksaan
Laboratorium edisi Indonesia, CV EGC.
6. Ganda Subrata. Penuntun Laboratorium Klinik. Dian Rakyat. Cet XI. Jakarta 2004.

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