No. Name : Mr. A Sex : Male

Age : 29 years old No. Reg : 626256

Main complaint : Wound on abdomenCondition : The condition had been apparent for 2 hours due to

suicide before the patient taken to the hospital.

Mechanism of injury

: The patient was trying to kill him self by a knife. Next mechanism was unknown

Sustained Injury : AbdomenSymptom & sign : pain, woundExamination done

: Physical examination

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Primary SurveyPrimary Survey

A: Clear

B: RR: 24x/minutes, spontaneous, symmetric, thoraco abdominal type

C: BP: 120/80 mmHg, PR: 104x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil equal Ø 2,5 mm/2,5 mm, Light Reflex +/+

E: T (ax): 36,5oC

Secondary SurveySecondary SurveyAbdomen:

I : Seen flat. Follow breath motion, , no bowel contour, no bowel motion, seen lacerated wound size 8 x 2 cm

A : Bowel sound (+) normally

P : Tenderness (+), local defans (-)

P : Tympani (+), tapping pain (+)

Laboratory Result-Laboratory Result-WBC : 3,92x 103 / μL

RBC : 5,74x 106 / μL

HGB : 16 g/dL

HCT : 45,5%

PLT : 231x103/ μL

CT / BT : 8‘00” / 2’ 00”

Blood Sugar : 130 mg/dl

Ureum : 43 mg/dl

Creatinin : 1,0 mg/dl

GOT / GPT : 19 / 25 μ/L

WORKING DIAGNOSIS : - Peritonitis generalisata due to Abdominal Trauma due to vulnus ictum penetrans at epigastrium region

MANAGEMENT : • Apply O2• Apply IVFD• Medicaments• Consult to senior digestive surgeon Advice: immediate Laparotomy exploration

OPERATION PROCEDURE

• Lay the patient down onto Supine position under Spinal Anaesthesia

• Proceed thedesinfection and drapping procedure• Perform grid iron incision deepen until peritonium• Identification caecum and appendiks • The appendix located retrocaecal, hiperemis,

edema looked flegmonosa• Perform Appendectomy with tabac sac suture • Control the bleeding and clean the wound with

nacle 0,9%• Close wound layer by layer• Done

POST OP DIAGNOSIS : • general peritonitis ec perforation jejunum + perforation colon transfersum

PROGNOSIS : Fair

FOLLOW UP : Vital SignWound HealingObservation for Acute Abdominal sign