Z/M/43yo

77.54.28
Chief Complaint : stab wound on the abdomen, waist,
thigh
It has been suffered by the patient since 14 hour before
admitted to Adam Malik Hospital. The patient was stabbed
3 times from the front by his brother who has the same
height with him. The type of weapon used was folding knife.
History of unconsciousness (-), shortness of breath (-),
nausea (-), vomiting (–)
Defecation and micturition (+) normal.
Patient was reffered from district hospital.
Primary Survey:
A: Clear
B: Spontaneous, RR :20x/i with nasal canule 5 lpm
C: warm acral, HR : 89 bpm, BP 120/80 mmHg
D: GCS 15 (E4V5M6)
E: logroll and undressed  stab wound on the
umbilical area , (L) waist, (L) thigh.
VAS : 5
 Secondary Survey
» A : no history of alergic
» M : no history of medication
» P : no history of past illness
» L : 4 hours before accident
» E : in the house
Secondary Survey
Head : No abnormalities was found
Neck : No abnormalities was found
Chest : No abnormalities was found
Abdomen : in localized state
Genitalia : male, no abnormalities was found
Extremities: in localized state
Secondary Survey:
Abdomen :
L : Symmetric, distension (-)
-Sutured wound o/t infraumbilical,
transverse, size 8 cm, active bleeding (-),
sutured interuptedly
-Sutured wound o/t (L) illiac region, size 4
cm, active bleeding (-), sutured interuptedly

L : Peristaltic (+) N
F : Soepel, tenderness (-), muscular
rigidity (-)
Secondary survey

Extremities :
(L)Thigh
L: Sutured wound on the anterior of
(L) thigh, size 2 cm,active bleeding
(-), sutured interuptedly
F: NVD (+) N
M : DOF (-), ROM (+) N
DRE : Perineum was usual, tight anal
sphincter tone, smooth mucosa,
ampulla was filled with feces, pain (-),
gloves : stool (+), blood (-) mucous (-)
CXR
USG FAST
Laboratory finding

•Hb / Hct / WBC / PLT : 14,6/ 42 / 12.000/ 300.000

•Na / K / Cl : 132/ 4.3 / 105
•Ureum / Creatinin : 11 / 0.79
•Glucose ad random : 100
Working diagnosis :

Susp. Penetrating Abdominal Stab Wound with

Stable Hemodinamic
Treatment at the ER :
• O2 5 LPM nasal canule
• IVFD Crystalloid ringer solution 20 gtt/i
• Antibiotic injection Ceftriaxon 1g IV
• Analgesic injection  Ketorolac 30 mg IV
• TT 0,5 cc IM
• ATS Injection 3000 Iu

Plan:
• LWE (Local Wound Exploration)
At the operating theatre :
» Patient in supine position, aseptic and antiseptic procedure was performed.
» Infiltration of lidocain 2% subcutaneously
» The previous sutures was removed, identified of stab wound o/t
infraumbillical area ,transverse, size 8x2x2 cm, iregular edge,subcutis base,
minimal contamination, active bleeding (-).
» Identified of stab wound o/t (L) illiac region, size 4x2x2 cm, iregular edge,
subcutis base, minimal contamination, active bleeding (-).
» Identified of stab wound o/t anterior of the (L) thigh, size 2x2x1 cm, iregular
edge, subcutis base, minimal contamination, active bleeding (-).
» The wound was washed thoroughly with NaCl 0,9% until clean, refreshing of
the wound edge.
» Surgical wound was closed layer by layer.
» Operation was done.
Cranial
Cranial