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歲男性，廚房油脂火災，混合二/三度燒傷30% TBSA（前胸、雙臂、部分面部）。PMH: 無. NKDA. 住院第2天（燒傷後48小時）.
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% on 2L NC. UO 0.7 mL/kg/h. 疼痛 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.
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.24小時完成Parkland復甦。維持：D5LR @ 125 mL/h。Morphine 4 mg IV q2h PRN。Cefazolin 1 g IV q8h。KCl 20 mEq IV in NS 於2小時內。Famotidine 20 mg IV BID。每日使用silver sulfadiazine換藥。嚴格記錄輸入/輸出量.
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.燒傷後第2天。利尿期開始；尿量充足。上午實驗室檢查顯示高鉀血症(K+ 5.4)。繼續壓力性潰瘍和感染預防。疼痛控制足夠.