M/M/53yo

78.10.68
 Chief Complaint : Shortness of breath

It has been suffered by patient 1 day before

admitted to Adam Malik Hospital. Initially, patient
has attempted suicide by stabbing his own belly,
he stabbed with machete one time, from the
front straight to the belly about 2 cm. He
complaint shortness of breath after he stabbed
his own belly. Pain (+), History of unconciousness
(-), Nausea and vomitting (-), defecation (+),
micturition (+) normal, bloody cough (-). History
of mentally ill (-).
 Primary Survey:
A : Clear
B : Spontaneous, RR : 30 x/min
C : Warm acral, HR : 88 x /min, BP: 120/70mmHg
D : GCS 15
E : Logroll & undressed, bruise (-), Stab wound
on the upper abdomen , active bleeding (-)
VAS: 4
 AMPLE History
• A : No history of allergy
• M : No history of medication
• P : No history of past illness
• L : 6 hours before accident
• E : at home
 Secondary Survey
Head : No abnormality was found
Neck : No abnormality was found
Thorax : In localized state
Abdomen : In localized state
Extremity : No abnormality was found
 Localized State
Thorax:
• Look: Symmetrical on both sides.
Bulging (-). Lag of chest wall
movement (+). Sucking chest
wound (-). Active bleeding (-)
• Listen: Decreased sound of
breath (+) on the (L) hemithorax.
• Feel: Crepitation (-). Tenderness
around the wound. Hipersonor
o/t (L) hemithorax.
 Localized State
Abdomen:
• I : Symmetrical, Distention (-),
lacerated wound of right upper
abdomen sized 7x1x0,3 cm (2,5 cm
to arcus costae, 3 cm to processus
xyphoideus), irregular edge,
subcutaneous-based, deformity (-),
haematom (-), active bleeding (-)
• A : decrease of peristaltic (-)
• P : Tymphani, liver dullness (+)
• P : tenderness, suppel (+),
peristaltik normal (+)
• DRE : Perineum was normal, anal sphincter
tone was tight, tenderness (-), ampula was
filled with stool.
Gloves : stool (+), mucus (-), blood (+)
 Laboratory Findings
Hb/Hct/WBC/Plt : 11.9/34/3.440/193.000
KGD : 119
Na/K/Cl : 131/4.0/101
Ur/Cr : 92/3.08
 Working Diagnosis:
Non Penetrating Abdominal Stab Wound +
(L) Haematopenumothorax
USG FAST
Chest X-Ray
 Treatment at the ER:
• Inj. Antitetanus Serum 3000 IU IM
• Inj. Tetanus Toxoid 0,5 cc IM
• Inj. Analgetic Ketorolac 30 mg IV
• Plan :
Chest Tube Insertion + WSD
Wound Exploration
 At the operating theatre :
− In supine position, left hand being elevated, aseptic and
antiseptic procedure was performed.
− Infiltration of lidocain 2% rhomboidly at ICS 5th just
anterior of the midaxillary line.
− The transverse incision was made, cutis and
subcutaneous were opened sharply. Muscle and parietal
pleura were opened bluntly.
− Chest tube No. 24 Fr was inserted cranioposterolaterally.
− Came out serohaemorrhagic fluid for about 50 cc, sample
was taken for laboratory examination, undulation (+),
initial bubble (-), expiratory bubble (-).
− Chest tube was fixated with silk material 2/0 cutting slip
knot.
− Operation was done.
Post Operation
 At the operating theatre
• In supine position, under GA-ETT, aseptic, antiseptic and drapping procedure were performed.
• The incision was expanded from the wound, skin, subcutaneous, linea alba, peritoneum were
opened.
• Identification of diaphragm, no rupture was found.
• Identification of solid organ. Liver was intact. No lacerated was found.
• Identification of hollow organ. Gaster was intact.
• Identification of small bowel, from Treitz ligament until ileocaecal junction, there is no
perforation.
• Bleeding was controlled
• Abdominal cavity was rinsed until clean using normal saline.
• Surgical wound closed layer by layer.
• Operation was done.
Durante Operation
Post Operation
Laporan operasi