History
Vitals
Labs
Orders
Notes
35yo male, kitchen grease fire, mixed second/third-degree burns 30% TBSA (anterior chest, both arms, partial face). PMH: none. NKDA. Hospital day 2 (48h post-burn).35歳男性、台所の油火災、混合II度/III度熱傷 30% TBSA（前胸部、両腕、顔面の一部）。既往歴：なし。NKDA。入院2日目（熱傷後48時間）。
BP 110/68, HR 118, RR 22, T 38.1C, SpO2 96% on 2L NC. UO 0.7 mL/kg/h. Pain 7/10.BP 110/68, HR 118, RR 22, T 38.1C, SpO2 96% (2L NC). UO 0.7 mL/kg/h. 痛み7/10.
K+ 5.4 (ref 3.5-5.0), Na 138, Cr 1.3, Hgb 14.5, Hct 47, WBC 16, Glucose 168, Lactate 2.8, Albumin 2.4.K+ 5.4 (基準値3.5-5.0), Na 138, Cr 1.3, Hgb 14.5, Hct 47, WBC 16, Glucose 168, Lactate 2.8, Albumin 2.4.
Parkland resuscitation completed at 24h. Maintenance: D5LR @ 125 mL/h. Morphine 4 mg IV q2h PRN. Cefazolin 1 g IV q8h. KCl 20 mEq IV in NS over 2h. Famotidine 20 mg IV BID. Daily wound care with silver sulfadiazine. Strict I/O.Parkland法蘇生は24時間で完了。維持輸液：D5LR @ 125 mL/h。モルヒネ4 mg IV q2h PRN。Cefazolin 1 g IV q8h。KCl 20 mEq IV NSで2時間かけて。ファモチジン20 mg IV BID。スルファジアジン銀による毎日の創傷処置。厳密なI/O。
Day 2 post-burn. Diuretic phase beginning; UO adequate. Hyperkalemia noted on AM labs (K+ 5.4). Continue stress ulcer and infection prophylaxis. Pain control adequate.熱傷後2日目。利尿期開始；UO適切。高カリウム血症がAM検査で認められた（K+ 5.4）。ストレス潰瘍と感染予防を継続。疼痛管理は適切。