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Morning report

Abdominal trauma
Patient’s identity
Name : CS
Age : 40th Y.O
Address : Batu Meja
Sex : L
Hospital admission : 19/05/2017
Primary survey
A : Clear
B : RR: 20x/m  Normal, Chest movement is
symmetric
C : P : 100x/m  Normal
D : GCS E4V5M6, Isokor Pupil (D: 3mm), LR +
E : abdomen, R. epigastric
Secondary survey
• Mechanism of trauma
Patient got stab wounds approximately 4 hours before
admitting to the hospital. He stabbed himself with a
knife, and caused 8 small stab wounds, each measured
3 cm with muscle as the base of wound and the large
wound meassured approximately 10 cm that causes
intraabdominal organ coming out which is a part of
bowel.
According to family, patient has history of
schizophrenia, and will uncontrollably rage when it
attacks. He had 30 times admittion to psychiatric
hospital since 2002.
A : (-)
M: (-)
P : (-)
L : (-)
E : His House
Physical examination
• Blood pressure: 110/70mmHg
• Pulse : 100x/s
• Breathing : 20x/s
• Temperature : 36,5o c
• Head : normocephali, laseration (-), contusion (-) and fracture (-)
• Eyes : anemis conjunctiva (-/-), isokor pupil (D;3cm), hifema (-)
• Ears , Noses, Throat : normal
• Mouth : normal
• Neck : normal
• Chest :
– I: symmetrical chest wall movement , contusio (-),
– P: crepitation (-)
– P: sonor
– A: heart sound I/II reguler, vessiculer,,
• Abdomen :
– I: 8 small stab wounds, each measured 3 cm with muscle as the base
of wound and the large wound meassured approximately 10 cm that
causes intraabdominal organ coming out which is a part of bowel.
– A: normal bowel sound,
– P: tenderness round the wound (+), defans muscular (-)
– P: thympani,
• Extremities : Normal, pitting edema (-), fracture (-), crepitation (-),
deformity (-)
Diagnose
• Vulnus ictum in abdomen R. epigastric
Additional examination
• FAST or DPL
• CT-scan
• Complate blood count
Planning
• IVFD RL 20 dpm
• To clean the wound and Hecting the small wound
• Cetriaxone 2 x 1 g
• Drip metronodazole 3 x 500g
• Ketorolac 3 x 30 mg
• Ranitidin 2 x 50 mg
• ATS
• Omentectomy

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