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Chief Complaint: Abdomen painful sensation, distension, multiple abrasion wound of abdomen and Lt. forearm past car accident for two days. Present Illness: According to this patient's statement, he was robust in the past. Unfortunately, he suffered from car accident and collided by a car over abdomen region... 顯示更多 Chief Complaint:
Abdomen painful sensation, distension, multiple abrasion wound of abdomen and Lt. forearm past car accident for two days.

Present Illness:
According to this patient's statement, he was robust in the past. Unfortunately, he suffered from car accident and collided by a car over abdomen region on Oct 3 95'. then he was sent to XX醫院 and received conservative treatment. Today, those symptons became deteriorated and he was transfered to our ER and admitted for further evaluation and managements.

Past, Personal and Family History:Nothing particular.

Physical Examination:
General Appearance:Ill-looking. Development:MD.
Nourishment:MN.
Mentality:Clear. Skin:Multiple abrasion wound of abdomen.
Head and its organs: and Lt. forearm.
Conjuntiva:No anemia. Sclera:No icteric scleric change.
Neck:Supple. Lymph Nodes:No Lymphadenopathy.
Chest:Symmetrical expansion with free movements.
Heart:Regular heart beat.
No murmur or thrill.
Lungs:Clear breathing sounds. Bil.
No rales or wheezing sounds.
Abdimen:Abdomen painful sensation with rebounding pain and distension.
Liver:No hepatomegaly.
Others:Abrasion wound of abeomen.
Extremities:No pitting edema.
Reflexes:No pathological reflexs.
Others:X-ray revealed subphrenic free air.
BP:100/60 mmHg.

Impression:Blunt abdomen injury with
perforation of hollow organs.
Signature:Dr. 陳XX
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