DAFTAR RIWAYAT HIDUP
Curriculum Vitae
I. Data Pribadi
1. Nama : Raja Arif Kurnia Manik
2. Tempat dan Tanggal Lahir : Sidikalang, 19 September 1994 3. Jenis Kelamin : Laki-Laki
4. Agama : Islam
5. Warga Negara : Indonesia
6. Alamat : Jalan Eka Bakti no.40 Kecamatan Medan Johor
7. Nomor Telephone : 089647745529
8. Riwayat Pendidikan : SD 030281 Sidikalang MTsN Sidikalang MAN Sidikalang
9. Riwayat Organisasi : 1. Pramuka MAN Sidikalang 2. OSIS MAN Sidikalang 3. SCORA FK USU
Demikian CV ini saya buat dengan sebenar benarnya.
LEMBAR PENJELASAN TERHADAP SUBYEK PENELITIAN
Assalamu’alaikum,
Saya adalah mahasiswa semester VII Fakultas Kedokteran Universitas Sumatera Utara yang sedang melakukan penelitian berjudul Gambaran Risiko Trombosis Berdasarkan Caprini Score pada Pasien Kanker di RSUP. Haji
Adam Malik
Trombosis adalah suatu penyakit dimana terdapat gumpalan darah pada saluran pembuluh darah. Penyakit ini merupakan komplikasi yang paling sering terjadi pada pasien kanker. Penyakit ini juga meningkatkan risiko kematian dan kesakitan pada pasien kanker. Maka dari itu, perlu untuk diketahui seberapa besar risiko seorang pasien kanker mengalami penyakit trombosis vena dalam ini.
Tujuan dari penelitian ini adalah untuk mengetahui bagaimana gambaran risiko trrombosis pada pasien kanker di RSUP Haji Adam Malik Medan.
Oleh karena itu, saya meminta kesediaan Ibu/Bapak untuk ikut serta menjadi subyek penelitian ini dengan menjawab pertanyaan yang diajukan saat wawancara dan melalui pengamatan yang dilakukan saat pemeriksaan fisik. Adapun data individu dalam penelitian ini tidak akan dipublikasikan.
LEMBAR PERSETUJUAN UNTUK MENJADI SUBJEK PENELITIAN
Saya yang bertandatangan dibawah ini: Nama :
Umur : Alamat : NO HP :
Setelah membaca semua keterangan dan mendapat penjelasan tentang keuntungan dan hak-hak saya sebagai subjek penelitian yang berjudul Gambaran Resiko Trombosis Berdasarkan Caprini Score pada Pasien Kanker dan saya
telah memahaminya, maka saya dengan sadar dan tanpa paksaan bersedia berpartisipasi dalam penelitian ini untuk diteliti.
Medan, ………2015
Peneliti, Yang membuat pernyataan,
Lembar Scoring
Nama : Jenis Kelamin :
TTL :
Lokasi Kanker :
Add 1 point for each of the following statements ● Age 41-60 years
● Minor surgery less than 45 minutes is planned
● Past Major surgery more than 45 minutes within last month ● Visible varicose vein
● A history of Inflammatory Bowel Disease ● Swoollen legs
● Obese mass index above 25 ● Heart Attack
● Congestive heart failure ● Serious infection ● Lung disease
● On bed rest or restricted mobility less than 72 hours Add 2 point for each of the following statements
● Age 61-74
● Curret or past malignancies
● Planed major surgery lasting longer than 45 minutes
● Non removable paster cast or mold that has kept from moving lesgs within a month
● Tube in blood vessel in neck or chest ● Confined to a bed for 72 hours or more Add 3 point for each of the following statements
● Age 75 or over ● History of blood clots
● Personal or family history of positive blood test indicating an increased risk of blood cloting
Add 5 point for each of the following statements ● Elective hip or knee joint replacement surgery ● Broken hips, pelvis or leg
● Serious trauma
● Spinal cord injury in resulting paralysis ● Experienced a stroke
For women only Add 1 point for each of the following statements ● Current use of birth control or hormone replacement theraphy ● Pregnant or had baby within last month
● History of unexplained stillborn infants, recurrent spontaneous abortion Total skor :
TABULASI SPSS
Jenis Kelamin
Frequency Percent Valid Percent
Cumulative
Frequency Percent Valid Percent
Cumulative
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 29 46.8 46.8 46.8
1 33 53.2 53.2 100.0
Total 62 100.0 100.0
Minor surgery less than 45 minutes planned
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 62 100.0 100.0 100.0
Past major surgery more than 45 minutes within last month
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 59 95.2 95.2 95.2
1 3 4.8 4.8 100.0
Visible varicose vein
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 57 91.9 91.9 91.9
1 5 8.1 8.1 100.0
Total 62 100.0 100.0
Inflammatory bowel syndrome
Frequency Percent Valid Percent
Cumulative
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 56 90.3 90.3 90.3
1 6 9.7 9.7 100.0
Total 62 100.0 100.0
Obese mass index above 25
Frequency Percent Valid Percent
Cumulative
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 59 95.2 95.2 95.2
1 3 4.8 4.8 100.0
Congestive heart failure
Frequency Percent Valid Percent
Cumulative
Frequency Percent Valid Percent
Cumulative
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 58 93.5 93.5 93.5
1 4 6.5 6.5 100.0
Total 62 100.0 100.0
On bed rest or restricted mobility less than 72 hours
Frequency Percent Valid Percent
Cumulative
Frequency Percent Valid Percent
Current or past malignancies
Frequency Percent Valid Percent
Cumulative Percent
Valid 2 62 100.0 100.0 100.0
Planed major surgery lasting longer than 45 minutes
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 62 100.0 100.0 100.0
Non removable paster cast or mold
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 62 100.0 100.0 100.0
Tube in blood vessel in neck or chest
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 62 100.0 100.0 100.0
Confined to a bed for 72 hours
Frequency Percent Valid Percent
Cumulative
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 60 96.8 96.8 96.8
3 2 3.2 3.2 100.0
History of blood clots
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 61 98.4 98.4 98.4
3 1 1.6 1.6 100.0
Total 62 100.0 100.0
Family history of blood clots
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 55 88.7 88.7 88.7
3 7 11.3 11.3 100.0
Total 62 100.0 100.0
personal of positive blood test indicating an increased risk of blood cloting
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 54 87.1 87.1 87.1
3 8 12.9 12.9 100.0
Total 62 100.0 100.0
Elective hip or knee joint replacement surgery
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 61 98.4 98.4 98.4
5 1 1.6 1.6 100.0
Total 62 100.0 100.0
Broken hips pelvis or leg
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 62 100.0 100.0 100.0
Serious trauma
Frequency Percent Valid Percent
Cumulative Percent
Spinal cord injury resulting paralysis
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 60 96.8 96.8 96.8
5 2 3.2 3.2 100.0
Total 62 100.0 100.0
Experienced a stroke
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 61 98.4 98.4 98.4
5 1 1.6 1.6 100.0
Total 62 100.0 100.0
Current use of birth controle
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 62 100.0 100.0 100.0
Pregnant or had baby in last month
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 62 100.0 100.0 100.0
History of unexplained stillborn infants, recurrent spontaneous abortion
Frequency Percent Valid Percent
Cumulative Percent
Valid 0 58 93.5 93.5 93.5
5 4 6.5 6.5 100.0
Total Skor
Frequency Percent Valid Percent
Cumulative Percent
Valid 2.0 4 6.5 6.5 6.5
3.0 11 17.7 17.7 24.2
4.0 15 24.2 24.2 48.4
5.0 14 22.6 22.6 71.0
6.0 3 4.8 4.8 75.8
7.0 5 8.1 8.1 83.9
8.0 2 3.2 3.2 87.1
9.0 3 4.8 4.8 91.9
10.0 2 3.2 3.2 95.2
11.0 1 1.6 1.6 96.8
14.0 2 3.2 3.2 100.0
Total 62 100.0 100.0
Frequency Percent Valid Percent
Valid Moderate 4 6.5 6.5
High 26 42 42
Highest 32 51,5 51,5
