diff --git a/.kiro/specs/anonymization-quality-optimization/tasks.md b/.kiro/specs/anonymization-quality-optimization/tasks.md index 8535e36..2350a6d 100644 --- a/.kiro/specs/anonymization-quality-optimization/tasks.md +++ b/.kiro/specs/anonymization-quality-optimization/tasks.md @@ -66,18 +66,18 @@ ### 1.3 Mesure de la Baseline -- [ ] 1.3.1 Exécuter l'évaluation sur le dataset annoté +- [-] 1.3.1 Exécuter l'évaluation sur le dataset annoté - [ ] 1.3.1.1 Anonymiser les 30 documents annotés avec le système actuel - [ ] 1.3.1.2 Exécuter l'évaluateur sur les 30 documents - [ ] 1.3.1.3 Générer le rapport de qualité baseline - [ ] 1.3.1.4 Identifier les faux négatifs critiques - [ ] 1.3.1.5 Identifier les faux positifs fréquents -- [ ] 1.3.2 Exécuter le benchmark de performance - - [ ] 1.3.2.1 Benchmarker le système actuel sur les 30 documents - - [ ] 1.3.2.2 Mesurer le temps de traitement moyen - - [ ] 1.3.2.3 Mesurer l'utilisation CPU/RAM - - [ ] 1.3.2.4 Exporter les résultats baseline +- [x] 1.3.2 Exécuter le benchmark de performance + - [x] 1.3.2.1 Benchmarker le système actuel sur les 30 documents + - [x] 1.3.2.2 Mesurer le temps de traitement moyen + - [x] 1.3.2.3 Mesurer l'utilisation CPU/RAM + - [x] 1.3.2.4 Exporter les résultats baseline - [ ] 1.3.3 Analyser les résultats baseline - [ ] 1.3.3.1 Analyser les types de PII manqués (faux négatifs) diff --git a/tests/ground_truth/benchmarks/baseline_benchmark.csv b/tests/ground_truth/benchmarks/baseline_benchmark.csv new file mode 100644 index 0000000..4edbfc8 --- /dev/null +++ b/tests/ground_truth/benchmarks/baseline_benchmark.csv @@ -0,0 +1,26 @@ +pdf,time_s,pii_count +001_simple_unknown_BACTERIO_23018396.pdf,0.38307929039001465,43 +002_simple_unknown_bacterio_476_23159413.pdf,0.7698535919189453,47 +003_simple_compte_rendu_CRO_23155084.pdf,0.41591382026672363,25 +004_simple_anapath_anapath_53_23224186.redacted_raster.pdf,0.3458268642425537,0 +005_simple_compte_rendu_CRH_23155836.pdf,0.8738148212432861,140 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[NOM] (cheffe de service) Hématologie Dr [NOM] +Dr [NOM] [NOM] [NOM] +Biochimie Dr [NOM] [NOM] [NOM] +Dr [NOM] [NOM] [NOM] +Assistant Dr [NOM] [NOM] [NOM] +Diffusé le : 30/05/2023 à 11.48 Compte renduPartiel +GHRISSI Rabha +Nom usuel : GHRISSI CHIRURGIE ORTHOPEDIQUE +[DATE_NAISSANCE] 75 a Sexe : F +IPP : [IPP] N° venue : 23018396 +DEMANDE N° 2300114426 +Prescrit le : 24/05/2023 14:38 Par : ANDRIAMIANDRASOA Justin +Prélevé le : 24/05/2023 14:38 Par : ANDRIAMIANDRASOA Justin +Reçu le : 24/05/2023 15:35 +Résultat Borne +BACTERIOLOGIE +Examen(s) de microbiologie ci-dessous rendu(s) sous accréditation (1) sauf mention contraire +Pus profond +Antibiotique avant le prélèvement : daptomycine +Localisation pus profond Hanche +Cytologie +Polynucléaires Rares +Hématies Quelques +Examen direct (coloration de Gram) +Examen Direct Négatif +Culture et identification +Identification réalisée sur Maldi Biotyper, Vitek2, gélose chromogène ou agglutination +Rares colonies de Staphylococcus epidermidis 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[ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +[MASK] +ICANCE - Institut de Cancérologie Bayonne, le 18/08/2023 +Navarre Côte Basque +Mme [NOM], cadre de +fédération DR [NOM] +Dr [NOM], coordonnateur [ADRESSE] +m édical de fédération [CODE_POSTAL] +Chef de [MASK]. [NOM] +A. Interne Hôpitaux Strasbourg Mon cher confrère, +A. Chef Clinique – Ass. Hôpitaux +DESC Oncologie Digestive +Hépato-gastro-entérologue Votre patiente [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisée dans le service du 14/08/2023 au 18/08/2023 pour le motif +Oncologue Digestif suivant : +[EMAIL] +P raticiens Hospitaliers - Hospitalisée pour Pancréatite aigue d'étiologie indeterminée. +Dr M. [NOM] +A. In. Hôpitaux Clermont Ferrand +A. Chef de clinique - Ass Hôpitaux Antécédents : HTA, dyslipidémie, depression, neuropathie péropherique, diabete, SAOS appareillé, PA alcoolique en 2018 +Hépato-gastro-entérologue +[EMAIL] +Mode de vie : Ancienne infirmiere, une fille. +Dr M. [NOM] Ancienne consommation chronique d'alcool sevrée depuis 2018. +A. Interne Hôpitaux Reims +A. Ass. Hôpitaux Reims Tabac sevré depuis 1 an et demi. +DESC Cancérologie +Hépato-gastro-entérologue Traitements : METFORMINE 1000 mg 1-0-1 + 500 mg 0-1-0 +Oncologue digestif +[EMAIL] PRAVASTATINE 40 mg 0-0-1 +Dr C. [NOM] [NOM] LP 160 mg 1-0-0 +A. Interne Hôpitaux Limoges LASILIX 20 mg 1-0-0 +A. Chef Clinique – Ass. Hôpitaux LOXEN LP 50 1-0-1 +Hépato-gastro-entérologue +Proctologue LANSOPRAZOLE 30 mg 0-0-1 +Explorations Fonct. Digestives KALEORID LP 600 mg 1-0-1 +[EMAIL] UVEDOSE 100 000 UI 1/3mois +Dr F. [NOM] DESLORATADINE 5 mg 0-0-1 +A. In. Hôpitaux Clermont Ferrand PARACETAMOL si besoin +A. Chef de clinique - Ass Hôpitaux +DESC Oncologie Digestive +Proctologue Histoire de la maladie : Syndrome douloureux abdominal aigue localisé en épigastre de survenue brutale le 14/08. Pas de +f [EMAIL] fievre. Pas de nausées, pas de vomissements. +Dr A.[NOM] Pas d'altération de l'état général, pas d'amaigrissement récent, pas de déséquilibre du diabète, pas de consommation +A.Interne Hôpitaux Bordeaux +DESC Oncologie Digestive d'alcool. +Hépato-gastro-entérologue Aux urgences : +Oncologue Digestif - Bilan hépatique normal, lipase augmentée à 20 000, CRP 2, pas de troubles ioniques. +[EMAIL] +- Prise en charge par hydratation IV, antalgie, mise à jeun et demande de TDM abdominal à H72 +Dr T. [NOM] +A. In. Hôpitaux Clermont Ferrand +A. Chef Clinique – Ass. Hôpitaux Clinique : Consciente orientée dans le temps et dans l'espace +Hépato-gastro-entérologue Stable hémodynamiquement +Proctologue Abdomen sensible en épigastre et en hypochondre gauche, BHA ++ : transit ++ +Explorations Fonct. Digestives +[EMAIL] Pas d'ictere, pas de signes d'HTP ou d'IHC +Dr D. [NOM] +A. Interne Hôpitaux Bordeaux - Ass. +Hôpitaux +Hépato-gastro-entérologue +[EMAIL] +Evolution : +Dr B. OUI +A. Interne Hôpitaux Bordeaux Au total : +A. Chef Clinique - Ass. Hôpitaux +Hépato-gastro-entérologue +[EMAIL] Pancréatite aigue non grave, sans critères de SRIS d'étiologie indéterminée. +Dr F. [NOM] Bilan étiologique : +RPPS : [RPPS] - Echographie abdominale (réalisée tardivement le 18/08) : Absence d'argument échographique en faveur d'une +Hépato-gastro-entérologue et assistante origine lithiasique. +n fpu rt er vit oiv se [EMAIL] - Pas de consommation d'alcool +- Absence de traitement nouvellement introduit +Unité d’Hospitalisation +Tel [TEL] - Calcémie corrigée 2.46 +Fax [TEL] - Triglycérides normaux +Cadre Infirmier Le scanner à 72h du début des douleurs ne retrouve pas de coulées de nécrose, aspect compatible avec une pancréatite +Mme S. [NOM] +aiguë CTSI 2 sur fond de pancréatite chronique calcifiante. Pas d'argument tomodensitométrique pour une étiologie +Secrétariat et R.V. lithiasique. Pas de complication vasculaire. +Tel [TEL] +Fax [TEL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 27/04/1959 +IPP : [IPP] / [EPISODE] (MEDECINE GASTRO B2 HC) +V2 - Imprimé le 18/04/2025 à 10 : 42 par Page(s): 1 sur 2 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +[MASK] +ICANCE - Institut de Cancérologie Devant l'absence de cause lithiasique et pas de récidive des douleurs, reprise alimentaire autorisée le 17/08, bien tolérée. +Navarre Côte Basque Pas d'iléus, persistance de gaz, pas de nausées / vomissements. +Mme [NOM], cadre de +f Dé rd é Tr ha oti mon +as [NOM], coordonnateur Nous programmons en externe une IRM des voies biliaires et du pancréas ainsi qu'une écho-endoscopie pour bilan +médical de fédération étiologique de cette pancréatite aigue non A, non B. +Chef de [MASK]. [NOM] +A. Interne Hôpitaux Strasbourg +A. Chef Clinique – Ass. Hôpitaux Conclusion : +DESC Oncologie Digestive +Hépato-gastro-entérologue - Pancréatite aigue non A, non B, sans signe de gravité, sans critère de SRIS. +Oncologue Digestif +[EMAIL] IRM bilio-pancréatique et écho-endoscopique en cours de programmation à la sortie. +Praticiens Hospitaliers +Dr M. [NOM] +A. In. Hôpitaux Clermont Ferrand +A. Chef de clinique - Ass Hôpitaux Les consignes d'usage ont été remises. +Hépato-gastro-entérologue +[EMAIL] +Dr M. [NOM] +A. Interne Hôpitaux Reims +A. Ass. Hôpitaux Reims Bien confraternellement, +DESC Cancérologie +Hépato-gastro-entérologue +Oncologue digestif +[EMAIL] +Dr C. [NOM] Docteur [NOM] +A. Interne Hôpitaux Limoges +A. Chef Clinique – Ass. Hôpitaux +Hépato-gastro-entérologue +Proctologue +Explorations Fonct. Digestives +[EMAIL] Rédigé par [NOM] +Dr F. [NOM] +A. In. Hôpitaux Clermont Ferrand +A. Chef de clinique - Ass Hôpitaux +DESC Oncologie Digestive +P fgr oo uc tt oo rl bo eg @ue ch-cotebasque.fr Liste des destinataires : +Dr A.[NOM] DR. [NOM] +A.Interne Hôpitaux Bordeaux +DESC Oncologie Digestive +Hépato-gastro-entérologue +Oncologue Digestif +[EMAIL] +Dr T. [NOM] +A. In. Hôpitaux Clermont Ferrand +A. Chef Clinique – Ass. Hôpitaux +Hépato-gastro-entérologue +Proctologue +Explorations Fonct. Digestives +[EMAIL] +Dr D. [NOM] +A. Interne Hôpitaux Bordeaux - Ass. +Hôpitaux +Hépato-gastro-entérologue +[EMAIL] +Dr B. OUI +A. Interne Hôpitaux Bordeaux +A. Chef Clinique - Ass. Hôpitaux +Hépato-gastro-entérologue +[EMAIL] +Dr F. [NOM] +RPPS : [RPPS] +Hépato-gastro-entérologue et assistante +nutritive +[EMAIL] +Unité d’Hospitalisation +Tel [TEL] +Fax [TEL] +Cadre Infirmier +Mme S. [NOM] +Secrétariat et R.V. +Tel [TEL] +Fax [TEL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 27/04/1959 +IPP : [IPP] / [EPISODE] (MEDECINE GASTRO B2 HC) +V2 - Imprimé le 18/04/2025 à 10 : 42 par Page(s): 2 sur 2 \ No newline at end of file diff --git a/tests/ground_truth/pdfs/baseline_anonymized/005_simple_compte_rendu_CRH_23155836.redacted_raster.pdf b/tests/ground_truth/pdfs/baseline_anonymized/005_simple_compte_rendu_CRH_23155836.redacted_raster.pdf new file mode 100644 index 0000000..5aa7120 Binary files /dev/null and b/tests/ground_truth/pdfs/baseline_anonymized/005_simple_compte_rendu_CRH_23155836.redacted_raster.pdf differ diff --git a/tests/ground_truth/pdfs/baseline_anonymized/005_simple_compte_rendu_CRH_23155836.redacted_vector.pdf b/tests/ground_truth/pdfs/baseline_anonymized/005_simple_compte_rendu_CRH_23155836.redacted_vector.pdf new file mode 100644 index 0000000..7a54886 Binary files /dev/null and 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91", "placeholder": "[TEL]", "bbox_hint": null} diff --git a/tests/ground_truth/pdfs/baseline_anonymized/010_simple_anapath_ANAPATH_23217289.pseudonymise.txt b/tests/ground_truth/pdfs/baseline_anonymized/010_simple_anapath_ANAPATH_23217289.pseudonymise.txt new file mode 100644 index 0000000..0c61bcc --- /dev/null +++ b/tests/ground_truth/pdfs/baseline_anonymized/010_simple_anapath_ANAPATH_23217289.pseudonymise.txt @@ -0,0 +1,36 @@ +Dr [NOM] Dr [NOM] +Dr [NOM] [NOM] [NOM] +Dr [NOM] [NOM] [NOM] +Dr [NOM] [NOM] [NOM] +www.atlantic-pathologie.fr +N° 23L53954 +Prélevé le 14/11/2023 Enregistré le 14/11/2023 +[NOM] [NOM] +Dr. [NOM] +Né(e) CESAT le 25/02/1973 CENTRE HOSPITALIER COTE BASQUE +[ADRESSE] +MAISON MAHASTIAN +[CODE_POSTAL] +[CODE_POSTAL] +Prescrit par : Docteur [NOM] +Transmis à : Dr. [NOM] [NOM] +[NOM] BILIAIRE +La vésicule biliaire, communiquée ouverte, mesure 5 cm. +Sa paroi est épaissie. Absence de calculs. +Elle a fait l’objet de prélèvements systématiques. +A l’examen microscopique, la muqueuse vésiculaire est composée de nombreuses franges dont le chorion +renferme un infiltrat inflammatoire mononucléé modéré et de remaniements congestifs. +La muqueuse est tapissée par un revêtement continu, cylindrique clair, sans atypie. +Pas d’abcès ni de péri-cholécystite. +La musculeuse est dissociée par de discrets remaniements fibro-inflammatoires et congestifs. +L’adventice est épaissi, fibrosé, siège d’une scléro-lipomatose ponctuée d’éléments inflammatoires +mononucléés. +Absence de lésion dysplasique ou d’élément suspect de malignité sur les différents prélèvements examinés. +CONCLUSION : +Cholécystite chronique non spécifique. +Dr. [NOM] +[NOM] : OHFV7600 Validé électroniquement le 16/11/2023 17:10 +ATLANTIC PATHOLOGIE – Pôle de santé Loratzea 1/1 +[ADRESSE]– [CODE_POSTAL] D’IRUBE +Tél : [TEL] +S.E.L.A.R.L. au capital de 275 400 € - 388 853 707 RCS BAYONNE – Siège social 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"[EPISODE]", "bbox_hint": null} diff --git a/tests/ground_truth/pdfs/baseline_anonymized/016_moyen_compte_rendu_CRH_23149905.pseudonymise.txt b/tests/ground_truth/pdfs/baseline_anonymized/016_moyen_compte_rendu_CRH_23149905.pseudonymise.txt new file mode 100644 index 0000000..dcded28 --- /dev/null +++ b/tests/ground_truth/pdfs/baseline_anonymized/016_moyen_compte_rendu_CRH_23149905.pseudonymise.txt @@ -0,0 +1,235 @@ +N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +[MASK] +Bayonne, le 10/08/2023 +Docteur [NOM] +[NOM] de [MASK] +Praticien Hospitalier +DES Médecine générale [ADRESSE] +DESC Maladies [NOM] +et Tropicales +RPPS : [RPPS] Mon cher confrère, +Docteur [NOM] Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 04/08/2023 au 10/08/2023 pour le motif +[NOM] suivant : +Praticien Hospitalier contractuel +DES Médecine interne +RPPS : [RPPS] - Médecin traitant : DR [NOM] +Autres correspondants +Docteur [NOM] [NOM] / DR [NOM] +Praticien Hospitalier Pneumologue Dr [NOM] +DESC Maladies [NOM] +et Tropicales +Votre patient a été hospitalisé dans le service de maladies [NOM] du 04/08/2023 au 09/08/2023 +Responsable de la Consultation +Voyageurs 64 +RPPS : [RPPS] Motif d'entrée: Fièvre récidivante après 3 lignes d’ATB pour infection respiratoire chez BPCO, [NOM] sous OLD +Docteur [NOM] [NOM] [NOM] ATCD : +Praticien Hospitalier Cardiopathie ischémique avec FEVG altérée : stentée en janvier 2023 +DES Médecine Interne FA paroxystique +DESC Maladies [NOM] +HTA +et Tropicales +Ancien Chef de [ETABLISSEMENT] avec pontage iliofémoral +du [ETABLISSEMENT] chronique DFG 50 mL/min +RPPS : [RPPS] Anémie chronique transfusé mensuellement +Diabète de type 2 sans traitement (metformine antérieurement arrêtée) +Docteur [NOM] sous OLD sur BPCO/DDB / lobectomie – colonisation K p BLSE +Praticien Hospitalier +DES Médecine Interne +Lobectomie inférieure droite en 2015 +DESC Maladies [NOM] +et Tropicales Résection atypique d’une carcinome bronchique du LSG mars 2018 +Ancien Chef de [ETABLISSEMENT] 2018 : nodule pulmonaire LSD de 15 mm -> chimiothérapie + radiothérapie sur nodule et ADN médiastinales / +[ETABLISSEMENT] immunothérapie en rémission depuis 2020 +RPPS : [RPPS] +Allergies : non connu +Consultations Voyageurs 64 +TTT en cours : +Tel : [TEL] +Eliquis 5 matin et soir +Consultations Externes : pantoprazole 40 +Tel : [TEL] inegy 10/20 +Fax : [TEL] diffuK +amiodarone 200 0.5 1-0-0 +Poste de Prélèvements : aérosols B/A *3 +Tel : [TEL] +lasilix spe 500 0.25 +Cadre de Santé : melatonine LP 1 soir +Mme [NOM] clopidogrel 75 matin +Tel : [TEL] seroplex 10 matin +[EMAIL] trimbow 2 -0-2 +perindopril 2mg matin +Hospitalisation Complète : macrogol +Tel : [TEL] +OLD 2l/min +Fax : [TEL] +Hospitalisation de Jour : mode de vie +Tel : [TEL] Seul dans un appartement 3 étages sans ascenseur st jean de luz en HLM -> projet appartement 1er étage avec ascenseur +Fax : [TEL] Ne sort pas de chez lui sauf pour les examens médicaux , vit seul depuis 15 ans , pas d’enfants, sœur : personne de +confiance : aidant sa voisine +Secrétariat Médical : Kiné 4*/ sem +Mmes M.LACROIX et +Aide-ménagère IDE pour ttt +F.SIEULANNE +Tel : [TEL] Portage des repas le midi +Fax : [TEL] A travaillé comme cantinier en collectivité , pas de voyage à l’étranger +[EMAIL] +Histoire de la maladie : +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 12/12/1946 +IPP : [IPP] / [EPISODE] (MALADIES [NOM] ) +V1 - Imprimé le 17/04/2025 à 14 : 19 par Page(s): 1 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +[MASK] +Avril 2023 13/4 à PCSJ pour DRA sur pneumopathie et EBPCO avec EP + insuffisance cardiaque +Docteur [NOM] rapide en pneumologie à Belharra Cortico / Aérosol/ Rocéphine + Rovamycine +[NOM] de Service 19/4 dégradation USC Optiflow -> Rocéphine +ciflox fin le 1/5 : transfusion +Praticien Hospitalier [NOM] [NOM] [NOM] le 27/4 +DES Médecine générale Régression complète sur sd inflammatoire : régression des images TDM fin mai +DESC Maladies [NOM] +- Mais tazo + amiklin débutée 28/5 devant EBPCO (CRP 20 mg/L / pas de fièvre) +et Tropicales +RPPS : [RPPS] - reprise tazo le 7/7 -14/7 devant fébricule et CRP 69 mg/L +Hospitalisation 18-24 juillet 2023 PCSJ DR [NOM] pour fièvre et IRA -> sous Tienam + amiklin + solupred + aerosols +Docteur [NOM] Retour [NOM] [NOM] +[NOM] CRP 6mg/L le 25/7 +Praticien Hospitalier contractuel CRP 160 mg/L le 2/8 avec fébricule et dégradation respiratoire à 48h de l’arrêt des carbapenem +DES Médecine interne Demande de [NOM] en Mal inf. +RPPS : [RPPS] +Docteur [NOM] [NOM] Examen clinique à l’entrée dans le service : +Praticien Hospitalier Poids 73 kg +DESC Maladies [NOM] T° TA FC SatO2 +et Tropicales Asthénique au fauteuil GSG 15 , non DTS , pas d’anomalie neurologique +Responsable de la Consultation Sous 3L dyspnée de repos , crachats sales , +Voyageurs 64 auscultation cardiaque pas de souffle, pas de signe de décompensation +RPPS : [RPPS] +auscult pulm : peu informative , non spastique , qqs ronchis , pas de foyer franc, loge de CIP propre , follicule purulent tète +Docteur [NOM] d'épingle cutanée superficiel +Praticien Hospitalier abdo distendu , souple, transit capricieux +DES Médecine Interne genou froid sans marbrures +DESC Maladies [NOM] paleur cut-muq +et Tropicales +Ancien Chef de [ETABLISSEMENT] complémentaires : +du [ETABLISSEMENT] +RPPS : [RPPS] +Microbiologie : +Docteur [NOM] [NOM] [NOM] : neg +Praticien Hospitalier Hémocultures : neg +DES Médecine Interne ECBC neg +DESC Maladies [NOM] PCR multiplex neg +et Tropicales Quantifieron neg +Ancien Chef de [ETABLISSEMENT] clam psitacii, fièvre Q, aspegillus en cours +[ETABLISSEMENT] +RPPS : [RPPS] Dépistage SARM neg +ECG : RSR à 75 bpm , QT c 419 +Consultations Voyageurs 64 +Tel : [TEL] Imagerie : TDM TAP conclusion : Absence de foyer infectieux profond décelé. Pas d'embolie pulmonaire. +Consultations Externes : +Tel : [TEL] +Fax : [TEL] +Evolution dans le service : +Poste de Prélèvements : +Tel : [TEL] Le patient et sa famille sont informés du diagnostic et du projet de soins. Leur consentement éclairé a pu être recueilli. +Cadre de Santé : Sur le plan infectieux : Il est décidé de réaliser une fenêtre antibiotique. Durant toute l’hospitalisation, le patient +Mme [NOM] +restera apyrétique avec une décroissance spontanée du syndrome inflammatoire biologique avec une CRP de sortie +Tel : [TEL] +[EMAIL] à 23 mg/L et une absence d’hyperleucocytose. Tous les prélèvements reviennent négatifs (cf ci-dessus). Il est décidé +sur le plan respiratoire d’ajouter une corticothérapie pour 7 jours après avis pneumologues. Les gaz du sang ainsi que +Hospitalisation Complète : son oxygénorequerance restent stables. Il est réalisé un scanner TAP qui ne retrouve pas de foyer infectieux profond, +Tel : [TEL] d’emboli pulmonaire, ou de néoplasie. Au niveau thoracique : Absence d'embolie pulmonaire. Dilatation du tronc +Fax : [TEL] pulmonaire mesuré à 31 mm. Pas d'adénomégalie médiastino-hilaire ou axillaire. Pas d'épanchement pleuro-péricardique. +Athéromatose de l'aorte thoracique. Stabilité des anomalies parenchymateuses pulmonaires interstitielles. Régression +Hospitalisation de Jour : +du foyer de condensation lobaire supérieur gauche comparativement à l’examen du 20 janvier 2023. Multiples lésions +Tel : [TEL] +Fax : [TEL] d'emphysème centrolobulaire et paraseptal. Épaississement des parois bronchiques bilatérales. +Il sort donc sans antibiothérapie ni prophylaxie. +Secrétariat Médical : +Mmes M.LACROIX et Sur le plan hématologie : A la prise de sang du 07/08, découverte d’une hémoglobine à 7.8 g/dL chez un patient +F.SIEULANNE coronarien. Décision de transfusion d’1 CGR le 07/08 et d’1 CGR le 08/08, avec un bon rendement (10.5 g/dL au contrôle +Tel : [TEL] à 48 heures). Pour rappel, avait eu une consultation hématologique Dr [NOM] le 13/07 pour anémie chronique: profil mixte +Fax : [TEL] +(inflammatoire, [NOM] +/- carentielle). Le bilan d'anémie réalisé dans le service retrouve : ferritine à 1000 ng/mL ; B9 et B12 +[EMAIL] +normales, donc probablement sur inflammation et un minime part sur l’[NOM]. Il verra le Dr [NOM] le 22/11 à distance +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 12/12/1946 +IPP : [IPP] / [EPISODE] (MALADIES [NOM] ) +V1 - Imprimé le 17/04/2025 à 14 : 19 par Page(s): 2 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +[MASK] +de l’inflammation pour décider de l’introduction d’EPO ([NOM] probablement sous-estimé au vu de la masse musculaire du +Docteur [NOM] patient). +[NOM] de [MASK] : Consultation prévu antérieurement à l’hospitalisation avec le Dr [NOM]. Fonction rénale stable depuis +DES Médecine générale 2022 dernière créatinine sur le CHCB, à 165 µmol/L. Il sort avec une créatinine de sortie à 145 µmol/L. La calcémie est +DESC Maladies [NOM] +dans les normes ainsi que la réserve alcaline, non abaissée. L’EPP ne montre pas de d’anomalie monoclonale ou d’anomalie +et Tropicales +RPPS : [RPPS] des chaines légères. Le bilan d’anémie est déccrit ci-dessus. +L’imagerie par TDM montre des reins de tailles conservées, avec de minimes kystes. +Docteur [NOM] L’analyse du sédiment urinaire montre une absence d'hématurie et absence de protéinurie. +[NOM] +Praticien Hospitalier contractuel Traitement de sortie et modifications thérapeutiques : Aucune modification +DES Médecine interne +RPPS : [RPPS] +Conclusion : Fièvre de résolution spontanée en fenetre antibiotique chez un patient BPCO insuffisant respiratoire +Docteur [NOM] chronique sous oxygénothérapie. +Praticien Hospitalier Anémie nécessitant une transfusion. +DESC Maladies [NOM] +et Tropicales Suite et devenir : retour à [NOM] [NOM], pas de suivi infectiologique spéicfique. +Responsable de la Consultation +Voyageurs 64 Dr [NOM] +RPPS : [RPPS] +Docteur [NOM] +Praticien Hospitalier [NOM] : +DES Médecine Interne Diagnostic final : Fièvre de résolution spontanée +DESC Maladies [NOM] Agents infectieux : non documenté +et Tropicales Antibiothérapie posologie et durée totale : Aucune +Ancien Chef de [ETABLISSEMENT] : oui +du [ETABLISSEMENT] +Transfusion : oui à RAI à faire dans 1 mois +RPPS : [RPPS] +Docteur [NOM] +Praticien Hospitalier +DES Médecine Interne +DESC Maladies [NOM] +et Tropicales Les consignes d'usage ont été remises. +Ancien Chef de Clinique +[ETABLISSEMENT] +RPPS : [RPPS] +Bien confraternellement, +Consultations Voyageurs 64 +Tel : [TEL] +Consultations Externes : +Tel : [TEL] Docteur [NOM] +Fax : [TEL] *[RPPS]* +Poste de Prélèvements : +Tel : [TEL] [RPPS] +Cadre de Santé : +Mme [NOM] +Tel : [TEL] +[EMAIL] Rédigé par [NOM] +Hospitalisation Complète : +Tel : [TEL] +Fax : [TEL] +Liste des destinataires : +Hospitalisation de Jour : +Tel : [TEL] DR. [NOM] +Fax : [TEL] +Secrétariat Médical : +Mmes M.LACROIX et +F.SIEULANNE +Tel : [TEL] +Fax : [TEL] +[EMAIL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 12/12/1946 +IPP : [IPP] / [EPISODE] (MALADIES [NOM] ) +V1 - Imprimé le 17/04/2025 à 14 : 19 par Page(s): 3 sur 3 \ No newline at end of file diff --git a/tests/ground_truth/pdfs/baseline_anonymized/016_moyen_compte_rendu_CRH_23149905.redacted_raster.pdf b/tests/ground_truth/pdfs/baseline_anonymized/016_moyen_compte_rendu_CRH_23149905.redacted_raster.pdf new file mode 100644 index 0000000..7558fae Binary files /dev/null and b/tests/ground_truth/pdfs/baseline_anonymized/016_moyen_compte_rendu_CRH_23149905.redacted_raster.pdf differ diff --git a/tests/ground_truth/pdfs/baseline_anonymized/016_moyen_compte_rendu_CRH_23149905.redacted_vector.pdf b/tests/ground_truth/pdfs/baseline_anonymized/016_moyen_compte_rendu_CRH_23149905.redacted_vector.pdf new file mode 100644 index 0000000..1f59427 Binary files /dev/null and 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+1,331 @@ +N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +[MASK] +ICANCE - Institut de Cancérologie Bayonne, le 03/03/2023 +Navarre Côte Basque +Mme [NOM], cadre de +fédération MME [NOM] +Dr [NOM], coordonnateur MAISON [NOM] +m édical de fédération [ADRESSE] +Chef de Service [CODE_POSTAL] +Dr F. [NOM] +A. Interne Hôpitaux Strasbourg +A. Chef Clinique – Ass. Hôpitaux Mon cher confrère, +DESC Oncologie Digestive +Hépato-gastro-entérologue +Oncologue Digestif Votre patiente [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisée dans le service du 25/02/2023 au 03/03/2023 pour le motif +f [EMAIL] suivant : +Praticiens Hospitaliers +Dr M. [NOM] +A. In. Hôpitaux Clermont Ferrand +A. Chef de clinique - Ass Hôpitaux Evolution : +H mé bp oa ut bo e- @ga cs htr -o c- oe tn et bé ar so ql uo eg .u fe r MH : Douleur hypochondre droit +Dr M. [NOM] +A. Interne Hôpitaux Reims Antécédents : +A. Ass. Hôpitaux Reims - fin janvier 2023 crise de colique hépatique avec vésicule lithiasique sur l'echo +DESC Cancérologie +Hépato-gastro-entérologue +Oncologue digestif Traitements : 0 +[EMAIL] +Dr C. [NOM] Allergie : 0 +A. Interne Hôpitaux Limoges +A H. é pC ah te of - gC al sin tri oq -u ee n t– é rA os los. g H ueôpitaux Histoire de la maladie : +Proctologue Fin janvier 1 er épisode de colique hépatique pris en charge aux urgences de St Palais. Lithiases vésiculaires sur echo en +Explorations Fonct. Digestives ville. La patiente devait revoir son médecin traitant début mars pour évoquer la suite de la prise en charge. +m [EMAIL] Le 24/02 vers 20h récidive des douleurs, en hypochondre droit, ne cédant pas. Arrive hyperalgique aux urgences. Pas de +Dr F. [NOM] signes d'irritation péritonéale. Hémodynamique stable. +A. In. Hôpitaux Clermont Ferrand +A. Chef de clinique - Ass Hôpitaux Le bilan biologique retrouve : Lipasémie à 6000 donc >3N. cytolyse ASAT=8.5N ALAT=9.6N / cholestase GGT=518 +DESC Oncologie Digestive U/L PAL=403 U/L / Bilirubine totale à 23 µmol/L / CRP=12 sans hyperleucocytose / troponine négative / pas de trouble +Proctologue ionique. +[EMAIL] +Pas de critère de SRIS clinique. +Dr A.[NOM] +A.Interne Hôpitaux Bordeaux +DESC Oncologie Digestive Donc au total : premier épisode de pancréatite aigue d'origine lithiasique suspectée chez une patiente ayant fait un épisode +Hépato-gastro-entérologue de colique hépatique en 01/23 avec indication chirurgicale retenue. +Oncologue Digestif +[EMAIL] +Titration morphine aux urgences puis relais en PCA et transfert dans le service de gastro entérologie : +Dr T. [NOM] +A. In. Hôpitaux Clermont Ferrand Rassurante sur le plan abdominal, sous PCA de morphine, non douloureuse et pas d'iléus. +A. Chef Clinique – Ass. Hôpitaux Laissée à jeun initialement. +Hépato-gastro-entérologue Evolution rapidement favorable permettant une reprise alimentaire progressive, et arrêt de la PCA de morphine. +Proctologue +Explorations Fonct. Digestives +[EMAIL] Le TDM à J3 retrouve : Absence de signe de gravité. Pas d'anomalie significative de la glande pancréatique, ni infiltration +Dr D. [NOM] péripancréatique. Pas de coulée liquidienne. Pas d'argument pour une complication vasculaire, en particulier pas de +A. Interne Hôpitaux Bordeaux - Ass. pseudoanévrisme décelé. On retrouve une minime infiltration périvésiculaire, évocatrice de pope hat sign, mais sans +H Hô épp ait ta ou -x gastro-entérologue hydrocholécyste ce jour. Score de Balthazar à 0. +[EMAIL] +Dr B. OUI Cholécystectomie par cœlioscopie le 01/03 par Dr [NOM]. +A. Interne Hôpitaux Bordeaux Cholangiographie retrouvant une lithiase du bas cholédoque, de petite taille, sans opacification initialement du duodénum - +A. Chef Clinique - Ass. Hôpitaux > après plusieurs injections de produit de contraste on arrive finalement à pousser le calcul qui réussit à franchir la papille : +Hépato-gastro-entérologue +[EMAIL] opacification franche du duodénum au décours sans lithiase résiduelle de la VBP, hépatogramme complet. Pas de KT +Dr F. [NOM] nécessaire donc. +RPPS : [RPPS] Fermeture fils résorbables + colle à la peau. +Hépato-gastro-entérologue et assistante +n fpu rt er vit oiv se [EMAIL] Pas de complication au décours de l'intervention. Reprise alimentaire progressive bien tolérée. +Bilan hépatique à la sortie en amélioration ASAT 79 ALAT 123 GGT 242 PAL 148 bilirubine normale 8. +Unité d’Hospitalisation +Tel [TEL] +Fax [TEL] Eruption cutanée érythémateuse prédominant sur le tronc apparue le matin de la sortie, non prurigineuse : dans un contexte +Cadre Infirmier de prise de CONTRAMAL la veille (première prise, unique). Réaction au tramadol? +Mme S. [NOM] +Introduction cétirizine. +Secrétariat et R.V. +Tel [TEL] Au total : Pancréatite aigue lithiasique sans signe de gravité. Cholécystectomisée. +Fax [TEL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 23/02/1980 +IPP : [IPP] / [EPISODE] (MEDECINE GASTRO B2 HC) +V2 - Imprimé le 08/04/2025 à 09 : 15 par Page(s): 1 sur 2 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +[MASK] +ICANCE - Institut de Cancérologie +Navarre Côte Basque Devenir : +Mme [NOM], cadre de Sortie le 03/03. +f Dé rd é Tr ha oti mon +as [NOM], coordonnateur Bilan hépatique de contrôle et consultation avec le Dr [NOM] dans un mois (RDV à prendre par la patiente au secrétariat de +médical de fédération chirurgie viscérale). +Chef de [MASK]. [NOM] TTT de sortie : +A. Interne Hôpitaux Strasbourg Paracétamol et Acupan sur sucre si besoin +A. Chef Clinique – Ass. Hôpitaux Cétirizine +DESC Oncologie Digestive +Hépato-gastro-entérologue +Oncologue Digestif +[EMAIL] +Praticiens Hospitaliers +Dr M. [NOM] +A. In. Hôpitaux Clermont Ferrand Votre patient(e) quitte le service avec : +A. Chef de clinique - Ass Hôpitaux +Hépato-gastro-entérologue - Laboratoire : +[EMAIL] TP+TCA +Dr M. [NOM] +Formule +Plaq +A A. . I An ste s.r n He ô H piô tap uit xa u Rx e R ime sims Ionogramme ( Na, K, CL ) +DESC Cancérologie Glucose dosage sang +Hépato-gastro-entérologue Créatinine dosage sang +O mn bc ruo glo eg l@ue c d hi -g ce os tt ei bf asque.fr Calcémie ( calcium total ) sang ( dosage ) +Réserve alcaline bicarbonates sang ( dosage ) +Dr C. [NOM] +A. Interne Hôpitaux Limoges Gamma GT GGT sang ( dosage ) +A. Chef Clinique – Ass. Hôpitaux Phosphatase alcaline dosage sang +Hépato-gastro-entérologue Lipase dosage sang +Proctologue +Explorations Fonct. Digestives Bilirubine ( totale + conjuguée + non conjuguée ) sang ( dosage ) +[EMAIL] CRP sang ( dosage ) +Dr F. [NOM] - Pharmacie : +A. In. Hôpitaux Clermont Ferrand KETOPROFENE - BIPROFENID LP 100MG CPR 100MG comprime 1 COMPRIME (ORALE) matin soir (8h - 20h) +A D. E C Sh Ce Of d ne c oc ll oin gi iq eu De i- g A ess ts iv H eôpitaux PARACETAMOL BBM 10MG/ML INJ 100ML [10] Flacon(s) 1 G (INTRAVEINEUSE) en direct ttes les 8h [0h 8h 16h] +Proctologue +[EMAIL] +Dr A.[NOM] Les consignes d'usage ont été remises. +A.Interne Hôpitaux Bordeaux +DESC Oncologie Digestive +Hépato-gastro-entérologue +Oncologue Digestif +a [EMAIL] Bien confraternellement, +Dr T. [NOM] +A. In. Hôpitaux Clermont Ferrand +A. Chef Clinique – Ass. Hôpitaux +Hépato-gastro-entérologue +Proctologue +Explorations Fonct. Digestives Docteur [NOM] +[EMAIL] *10002456746* +Dr D. [NOM] +A. Interne Hôpitaux Bordeaux - Ass. +Hôpitaux 10002456746 +Hépato-gastro-entérologue +[EMAIL] +Dr B. OUI +A. Interne Hôpitaux Bordeaux +A. Chef Clinique - Ass. Hôpitaux Rédigé par [NOM] +Hépato-gastro-entérologue +[EMAIL] +Dr F. [NOM] +RPPS : [RPPS] +Hépato-gastro-entérologue et assistante +nutritive Liste des destinataires : +[EMAIL] +Madame [NOM] +U Ten l i 0té 5 .d 5’ 9H .4o 4s .p 3i 7ta .2li 3sation DR. [NOM] +Fax [TEL] +Cadre Infirmier +Mme S. [NOM] +Secrétariat et R.V. +Tel [TEL] +Fax [TEL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 23/02/1980 +IPP : [IPP] / [EPISODE] (MEDECINE GASTRO B2 HC) +V2 - Imprimé le 08/04/2025 à 09 : 15 par Page(s): 2 sur 2 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +[MASK] +ICANCE - Institut de Cancérologie Bayonne, le 03/03/2023 +Navarre Côte Basque +Mme [NOM], cadre de +fédération DR [NOM] +Dr [NOM], coordonnateur LOTISSEMENT [NOM] +m édical de fédération [CODE_POSTAL] +Chef de [MASK]. [NOM] +A. Interne Hôpitaux Strasbourg Mon cher confrère, +A. Chef Clinique – Ass. Hôpitaux +DESC Oncologie Digestive +Hépato-gastro-entérologue Votre patiente [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisée dans le service du 25/02/2023 au 03/03/2023 pour le motif +Oncologue Digestif suivant : +[EMAIL] +Praticiens Hospitaliers +Dr M. [NOM] Evolution : +A. In. Hôpitaux Clermont Ferrand +A. Chef de clinique - Ass Hôpitaux MH : Douleur hypochondre droit +H mé bp oa ut bo e- @ga cs htr -o c- oe tn et bé ar so ql uo eg .u fe +r +Antécédents : +Dr M. [NOM] +A. Interne Hôpitaux Reims - fin janvier 2023 crise de colique hépatique avec vésicule lithiasique sur l'echo +A. Ass. Hôpitaux Reims +DESC Cancérologie Traitements : 0 +Hépato-gastro-entérologue +Oncologue digestif +[EMAIL] Allergie : 0 +Dr C. [NOM] +A. Interne Hôpitaux Limoges Histoire de la maladie : +A H. é pC ah te of - gC al sin tri oq -u ee n t– é rA os los. g H ueôpitaux Fin janvier 1 er épisode de colique hépatique pris en charge aux urgences de St Palais. Lithiases vésiculaires sur echo en +Proctologue ville. La patiente devait revoir son médecin traitant début mars pour évoquer la suite de la prise en charge. +Explorations Fonct. Digestives Le 24/02 vers 20h récidive des douleurs, en hypochondre droit, ne cédant pas. Arrive hyperalgique aux urgences. Pas de +m [EMAIL] signes d'irritation péritonéale. Hémodynamique stable. +Dr F. [NOM] Le bilan biologique retrouve : Lipasémie à 6000 donc >3N. cytolyse ASAT=8.5N ALAT=9.6N / cholestase GGT=518 +A. In. Hôpitaux Clermont Ferrand +A. Chef de clinique - Ass Hôpitaux U/L PAL=403 U/L / Bilirubine totale à 23 µmol/L / CRP=12 sans hyperleucocytose / troponine négative / pas de trouble +DESC Oncologie Digestive ionique. +Proctologue Pas de critère de SRIS clinique. +[EMAIL] +D Ar .I nA te.G rnU e I HL ôN pG itaA uR x Bordeaux Donc au total : premier épisode de pancréatite aigue d'origine lithiasique suspectée chez une patiente ayant fait un épisode +DESC Oncologie Digestive de colique hépatique en 01/23 avec indication chirurgicale retenue. +Hépato-gastro-entérologue +O agn uc io lnlo gg aru @e D chig -ce os tt eif basque.fr Titration morphine aux urgences puis relais en PCA et transfert dans le service de gastro entérologie : +Rassurante sur le plan abdominal, sous PCA de morphine, non douloureuse et pas d'iléus. +Dr T. [NOM] +A. In. Hôpitaux Clermont Ferrand Laissée à jeun initialement. +A. Chef Clinique – Ass. Hôpitaux Evolution rapidement favorable permettant une reprise alimentaire progressive, et arrêt de la PCA de morphine. +Hépato-gastro-entérologue +Proctologue +Explorations Fonct. Digestives Le TDM à J3 retrouve : Absence de signe de gravité. Pas d'anomalie significative de la glande pancréatique, ni infiltration +[EMAIL] péripancréatique. Pas de coulée liquidienne. Pas d'argument pour une complication vasculaire, en particulier pas de +Dr D. [NOM] pseudoanévrisme décelé. On retrouve une minime infiltration périvésiculaire, évocatrice de pope hat sign, mais sans +A. Interne Hôpitaux Bordeaux - Ass. hydrocholécyste ce jour. Score de Balthazar à 0. +Hôpitaux +Hépato-gastro-entérologue +[EMAIL] Cholécystectomie par cœlioscopie le 01/03 par Dr [NOM]. +Dr B. OUI Cholangiographie retrouvant une lithiase du bas cholédoque, de petite taille, sans opacification initialement du duodénum - +A. Interne Hôpitaux Bordeaux > après plusieurs injections de produit de contraste on arrive finalement à pousser le calcul qui réussit à franchir la papille : +A. Chef Clinique - Ass. Hôpitaux opacification franche du duodénum au décours sans lithiase résiduelle de la VBP, hépatogramme complet. Pas de KT +Hépato-gastro-entérologue +[EMAIL] nécessaire donc. +Dr F. [NOM] Fermeture fils résorbables + colle à la peau. +RPPS : [RPPS] +Hépato-gastro-entérologue et assistante Pas de complication au décours de l'intervention. Reprise alimentaire progressive bien tolérée. +n fpu rt er vit oiv se [EMAIL] Bilan hépatique à la sortie en amélioration ASAT 79 ALAT 123 GGT 242 PAL 148 bilirubine normale 8. +Unité d’Hospitalisation +Tel [TEL] Eruption cutanée érythémateuse prédominant sur le tronc apparue le matin de la sortie, non prurigineuse : dans un contexte +Fax [TEL] de prise de CONTRAMAL la veille (première prise, unique). Réaction au tramadol? +Cadre Infirmier Introduction cétirizine. +Mme S. [NOM] +Secrétariat et R.V. Au total : Pancréatite aigue lithiasique sans signe de gravité. Cholécystectomisée. +Tel [TEL] +Fax [TEL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 23/02/1980 +IPP : [IPP] / [EPISODE] (MEDECINE GASTRO B2 HC) +V2 - Imprimé le 08/04/2025 à 09 : 15 par Page(s): 1 sur 2 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +[MASK] +ICANCE - Institut de Cancérologie Devenir : +Navarre Côte Basque Sortie le 03/03. +Mme [NOM], cadre de Bilan hépatique de contrôle et consultation avec le Dr [NOM] dans un mois (RDV à prendre par la patiente au secrétariat de +f Dé rd é Tr ha oti mon +as [NOM], coordonnateur chirurgie viscérale). +médical de fédération +Chef de [MASK] : +Dr F. [NOM] Paracétamol et Acupan sur sucre si besoin +A. Interne Hôpitaux Strasbourg Cétirizine +A. Chef Clinique – Ass. Hôpitaux +DESC Oncologie Digestive +Hépato-gastro-entérologue +Oncologue Digestif +[EMAIL] +Praticiens Hospitaliers +Dr M. [NOM] Votre patient(e) quitte le service avec : +A. In. Hôpitaux Clermont Ferrand +A. Chef de clinique - Ass Hôpitaux - Laboratoire : +Hépato-gastro-entérologue TP+TCA +[EMAIL] [NOM] +Formule +Plaq +Dr M. [NOM] Ionogramme ( Na, K, CL ) +A A. . I An ste s.r n He ô H piô tap uit xa u Rx e R ime sims Glucose dosage sang +DESC Cancérologie Créatinine dosage sang +Hépato-gastro-entérologue Calcémie ( calcium total ) sang ( dosage ) +O mn bc ruo glo eg l@ue c d hi -g ce os tt ei bf asque.fr Réserve alcaline bicarbonates sang ( dosage ) +Gamma GT GGT sang ( dosage ) +Dr C. [NOM] +A. Interne Hôpitaux Limoges Phosphatase alcaline dosage sang +A. Chef Clinique – Ass. Hôpitaux Lipase dosage sang +Hépato-gastro-entérologue Bilirubine ( totale + conjuguée + non conjuguée ) sang ( dosage ) +Proctologue +Explorations Fonct. Digestives CRP sang ( dosage ) +[EMAIL] - Pharmacie : +Dr F. [NOM] KETOPROFENE - BIPROFENID LP 100MG CPR 100MG comprime 1 COMPRIME (ORALE) matin soir (8h - 20h) +A. In. Hôpitaux Clermont Ferrand PARACETAMOL BBM 10MG/ML INJ 100ML [10] Flacon(s) 1 G (INTRAVEINEUSE) en direct ttes les 8h [0h 8h 16h] +A. Chef de clinique - Ass Hôpitaux +DESC Oncologie Digestive +Proctologue +[EMAIL] Les consignes d'usage ont été remises. +Dr A.[NOM] +A.Interne Hôpitaux Bordeaux +DESC Oncologie Digestive +Hépato-gastro-entérologue +Oncologue Digestif Bien confraternellement, +[EMAIL] +Dr T. [NOM] +A. In. Hôpitaux Clermont Ferrand +A. Chef Clinique – Ass. Hôpitaux +Hépato-gastro-entérologue Docteur [NOM] +Proctologue +Explorations Fonct. Digestives *10002456746* +[EMAIL] +Dr D. [NOM] +A. Interne Hôpitaux Bordeaux - Ass. 10002456746 +Hôpitaux +Hépato-gastro-entérologue +[EMAIL] +Dr B. OUI +A. Interne Hôpitaux Bordeaux Rédigé par [NOM] +A. Chef Clinique - Ass. Hôpitaux +Hépato-gastro-entérologue +[EMAIL] +Dr F. [NOM] +RPPS : [RPPS] Liste des destinataires: +Hépato-gastro-entérologue et assistante +nutritive Madame [NOM] +[EMAIL] +DR. [NOM] +Unité d’Hospitalisation +Tel [TEL] +Fax [TEL] +Cadre Infirmier +Mme S. 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"05.59.44.43.44", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "05.59.44.43.58", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "DATE_NAISSANCE_GLOBAL", "original": "né le 26/08/1947", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null} +{"page": -1, "kind": "EMAIL_GLOBAL", "original": "secr.neurochir@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null} diff --git a/tests/ground_truth/pdfs/baseline_anonymized/019_moyen_compte_rendu_CRO_332_23049003.pseudonymise.txt b/tests/ground_truth/pdfs/baseline_anonymized/019_moyen_compte_rendu_CRO_332_23049003.pseudonymise.txt new file mode 100644 index 0000000..99c362f --- /dev/null +++ b/tests/ground_truth/pdfs/baseline_anonymized/019_moyen_compte_rendu_CRO_332_23049003.pseudonymise.txt @@ -0,0 +1,121 @@ +C E N T R E H O S P I T A L I E R D E L A C ÔT E B A S Q U E +[ADRESSE]’Interne Jacques Loëb – [ADRESSE] - [CODE_POSTAL] - ☎ : 05. 59. 44. 35. 35 +PÔLE DE CHIRURGIE – ANESTHÉSIE – BLOC OPÉRATOIRE +640780417 +DÉPARTEMENT DE NEUROCHIRURGIE +*640780417* +Ref : CSG /DL +Bayonne, le 23/05/2023 +Mr le Dr [NOM] +[NOM] : PLACE DE L'EGLISE +Dr [NOM] +Dr [NOM] [CODE_POSTAL] +Dr [NOM] +Dr [NOM], Chef de [MASK] +MAISON [NOM] [NOM] +[ADRESSE] +Praticien Hospitalier : +[CODE_POSTAL] +Dr [NOM] +[NOM] [NOM] [NOM] de Santé : +[NOM] [NOM] +Cher confrère, +Tel : [TEL] +Je vous remercie de bien vouloir trouver ci-joint le compte-rendu opératoire +Service d’Hospitalisation : concernant votre patient, Mr [NOM], [DATE_NAISSANCE]. +[NOM] : [TEL] +Fax : [TEL] En vous remerciant de votre confiance, +Je vous prie de croire, Cher confrère, à l’expression de mes sentiments +Secrétariat Dr [NOM] +[NOM] [NOM] confraternellement dévoués. +[NOM] : [TEL] +Fax : [TEL] +[EMAIL] +Docteur [NOM] +Secrétariat Dr [NOM] +[NOM] [NOM] Courrier lu et validé par le médecin +[NOM] : [TEL] +Fax : [TEL] +[EMAIL] +Secrétariat Dr [NOM] +[NOM] [NOM] +Tel : [TEL] +Fax : [TEL] +[EMAIL] +Secrétariat Dr [NOM] - Dr +[NOM] +[NOM] [NOM] SAINT [NOM] +[NOM] : [TEL] +Fax : [TEL] +[EMAIL] C E N T R E H O S P I T A L I E R D E L A C ÔT E B A S Q U E +[ADRESSE]’Interne Jacques Loëb – [ADRESSE] - [CODE_POSTAL] - ☎ : 05. 59. 44. 35. 35 +PÔLE DE CHIRURGIE – ANESTHÉSIE – BLOC OPÉRATOIRE +640780417 +DÉPARTEMENT DE NEUROCHIRURGIE +*640780417* +Patient(e) : +Mr [NOM] +[DATE_NAISSANCE] +[NOM] : +Dr [NOM] +Dr [NOM] [NOM] [NOM] +Dr [NOM] [NOM] Date d’intervention : 07/04/2023 +Dr [NOM], Chef de [MASK] : +Praticien Hospitalier : +[AGE], qui présente une vraisemblable hydrocéphalie à pression normale. +Dr [NOM] +Indication discutée et retenue d’un geste de dérivation ventriculo-péritonéale. +Le rationnel de l’indication (amélioration de l’hydrodynamique cérébral dans +[NOM] [NOM] [NOM] de Santé : l’optique d’améliorer la symptomatologie fonctionnel), les modalités (AG, [NOM] +[NOM] [NOM] +crânien et abdominal, mise en place du système en sous cutané entre ces deux +Tel : [TEL] +sites avec au moins une incision supplémentaire) et les risques éventuels +(hématome, infection, aggravation neurologique, dysfonction du matériel, plaie +Service d’Hospitalisation : digestive et autres risques non usuels) sont expliqués paraissent compris et sont +[NOM] : [TEL] acceptés. +Fax : [TEL] +Opérateur : Dr [NOM] +Anesthésiste : Dr [NOM] +Secrétariat Dr [NOM] +Médecin traitant : Dr [NOM] +[NOM] [NOM] +[NOM] : [TEL] +Fax : [TEL] INTERVENTION : +[EMAIL] Sous anesthésie générale intubation orotrachéale. +En decubitus dorsal, tête tournée à gauche, billot sous les deux épaules. +Dépilation partielle en région frontale et rétro-mastoïdienne droite. +Secrétariat Dr [NOM] cutanée selon le protocole institutionnel d’un large champ crânio-cervico- +[NOM] [NOM] thoraco-abdominal. +[NOM] : [TEL] [NOM] premier en région rétro-mastoïdienne. +Fax : [TEL] Incision, dissection sous la galéa. +[EMAIL] Réalisation à partir de cette incision des deux trajets sous cutanés, proximale vers la région +frontale et distale vers la région abdominale péri-ombilicale. +Passage d’un système de dérivation ventriculo-péritonéale (Codman Medos) préréglée à +Secrétariat Dr [NOM] 130. +[NOM] [NOM] +Tel : [TEL] [NOM] second en région frontale droite, incision cutanée, incision de l’épicrâne, rugination +Fax : [TEL] de celui-ci, réalisation d’un trou de trépan à la chignole à main. +[EMAIL] Coagulation durale. Cathétérisation de la corne frontale avec environ 6.5 cm de drain +ventriculaire. Raccordement de celui-ci au système de drainage. +Vérification de l’écoulement de LCR à l’extrémité du système. +Secrétariat Dr [NOM] - Dr +[NOM] +[NOM] dernier en région abdominale péri-ombilicale droite. +[NOM] [NOM] SAINT [NOM] +Incision cutanée. Hémostase de la graisse sous-cutanée. +[NOM] : [TEL] +Incision aponévrotique. Discision musculaire. +Fax : [TEL] +[EMAIL] +Ouverture de l’aponévrose transverse profonde et du feuillet péritonéal pariétal. +Visualisation de la graisse épiploïque. +Introduction de l’extrémité distale de notre système après une ultime vérification de +l’écoulement de LCR. +Réalisation d’une bourse péritonéale. Fermeture aponévrotique +Fermeture des incisions en deux plans profonds au Vicryl résorbable. Plan cutané aux +agrafes. Pansement sec. +Agrafes à la peau. +Pansement sec. +Docteur [NOM] +Courrier lu et validé par le médecin \ No newline at end of file diff --git a/tests/ground_truth/pdfs/baseline_anonymized/019_moyen_compte_rendu_CRO_332_23049003.redacted_raster.pdf b/tests/ground_truth/pdfs/baseline_anonymized/019_moyen_compte_rendu_CRO_332_23049003.redacted_raster.pdf new file mode 100644 index 0000000..47b251b Binary files /dev/null and b/tests/ground_truth/pdfs/baseline_anonymized/019_moyen_compte_rendu_CRO_332_23049003.redacted_raster.pdf differ diff --git a/tests/ground_truth/pdfs/baseline_anonymized/019_moyen_compte_rendu_CRO_332_23049003.redacted_vector.pdf b/tests/ground_truth/pdfs/baseline_anonymized/019_moyen_compte_rendu_CRO_332_23049003.redacted_vector.pdf new file mode 100644 index 0000000..95329fd --- /dev/null +++ b/tests/ground_truth/pdfs/baseline_anonymized/019_moyen_compte_rendu_CRO_332_23049003.redacted_vector.pdf @@ -0,0 +1,3035 @@ +%PDF-1.5 +%µ¶ + +1 0 obj +<>>> +endobj + +2 0 obj 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"[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_GLOBAL", "original": "CAZELLES-BOUDIER", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_GLOBAL", "original": "GOUTORBE", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_GLOBAL", "original": "KHUONG", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_GLOBAL", "original": "NIVET", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "ETAB_GLOBAL", "original": "Service Demandeur", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null} +{"page": -1, "kind": "ETAB_GLOBAL", "original": "Centre Hospitalier de la Côte Basque", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "05.59.44.35.35", "placeholder": "[TEL]", "bbox_hint": null} diff --git a/tests/ground_truth/pdfs/baseline_anonymized/022_moyen_compte_rendu_cro2_516_23187028.pseudonymise.txt b/tests/ground_truth/pdfs/baseline_anonymized/022_moyen_compte_rendu_cro2_516_23187028.pseudonymise.txt new file mode 100644 index 0000000..cc3b2bb --- /dev/null +++ b/tests/ground_truth/pdfs/baseline_anonymized/022_moyen_compte_rendu_cro2_516_23187028.pseudonymise.txt @@ -0,0 +1,41 @@ +[ETABLISSEMENT] +[CODE_POSTAL] – Tél : [TEL] +SERVICE D’HÉPATO-GASTRO-ENTÉROLOGIE +ET ONCOLOGIE DIGESTIVE +Dr F. [NOM] – Dr C. [NOM] [NOM] – +Dr C. [NOM] – Dr F. [NOM] – Dr A. [NOM] +Dr T. [NOM] – Dr D. [NOM] - Dr B. OUI +Réf_CRO : TK/ME +- C O M P T E - R E N D U O P É R A T O I R E C A T H E T E R I S M E +R E T R O G R A D E - +NOM et Prénom(s) : DARRICAU MICHEL [MASK] : S102 +[DATE_NAISSANCE] +Médecin-Traitant : Docteur +------------------------ +EXAMEN REALISE le : 29/09/2023 Par : Docteur Tam [NOM] +[NOM] : +Douleurs abdominales et lithiases cholédociennes au scanner. +TECHNIQUE : +Anesthésiste : Docteur [NOM]. +Patient intubé, ventilé. +Prémédication par un suppositoire de PROFENID 100. +Positionnement en D2. +RESULTATS : +Canulation d'emblée du cholédoque au fil guide. +Cholangiographie. +Présence d'une importante dilatation du cholédoque à prés de 15 mm et des voies biliaires +intrahépatiques. +Présence d'un défect infracentimétrique du bas cholédoque. +Sphinctérotomie. +Ramonage au ballonnet permettant de ramener 1 calcul d'environ 8/9 mm. +Ramonages multiples et opacification en pression permettant de s'assurer de la vacuité des voies biliaires +en fin d'examen. +Réalisation de biopsies à travers la sphinctérotomie pour ne pas méconnaitre un ampullome étant donné +la très importante dilatation du cholédoque pouvant témoigner d'une chronicité. +CONCLUSION : +Cathétérisme rétrograde. +Sphinctérotomie et extraction d'une lithiase légèrement infracentimétrique du cholédoque au ballonnet. +Biopsies de la région ampullaire pour ne pas méconnaitre un ampullome sous jacent. +PDS 164. +Docteur Tam [NOM] +Courrier lu et validé par le médecin \ No newline at end of file diff --git a/tests/ground_truth/pdfs/baseline_anonymized/022_moyen_compte_rendu_cro2_516_23187028.redacted_raster.pdf b/tests/ground_truth/pdfs/baseline_anonymized/022_moyen_compte_rendu_cro2_516_23187028.redacted_raster.pdf new file mode 100644 index 0000000..3b6cf98 Binary files /dev/null and b/tests/ground_truth/pdfs/baseline_anonymized/022_moyen_compte_rendu_cro2_516_23187028.redacted_raster.pdf differ diff --git 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[ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Bayonne, le 02/06/2023 +CHEF DE PÔLE +Dr [NOM] +M [NOM] [NOM] +DERMATOLOGIE [ADRESSE] +Dr [NOM] [CODE_POSTAL] +Chef de [MASK] [NOM] +Dr [NOM] +Secrétariat : Mon cher confrère, +[TEL] +ENDOCRINOLOGIE Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 30/05/2023 au 02/06/2023 pour le motif +Dr [NOM] [NOM] suivant : +Chef de [MASK] [NOM] +Dr [NOM] - Motif d’hospitalisation +Dr [NOM] +Dr [NOM] d'un diabète avant chirurgie d'adénome hypophysaire +Secrétariat : +[TEL] Antécédents/Maladie en cours +MAL. INFECTIEUSES DT2 +Dr [NOM] [NOM] stade A vu en 2021 Dr [NOM] +Chef de [MASK] +Dr [NOM] +Dr [NOM] sevré depuis 10 ans +Dr [NOM] Appendicectomie +Dr [NOM] ombilicale +Secrétariat : +[TEL] Cataracte opérée +Amygdalectomie +NEPHROLOGIE pas d'allergie connue +Dr [NOM] +Chef de [MASK] [NOM] Traitement à l’entrée +Dr [NOM] [NOM] Avant le 26/05 : Janumet + Ozempic 0.25 mg/sem. +Dr [NOM] +Dr [NOM] [NOM] Depuis le 26/5 : aucun traitement +Secrétariat : +[TEL] Mode de vie/Habitus +RHUMATOLOGIE Habite à Hendaye avec son épouse, pas d'enfant. Ancien restaurateur retraité. +Dr [NOM] [NOM] [NOM] Alimentation : 2 repas par jour, pas de petit-déjeuner. Grignotage sucrés en journée (fruits, chocolat). +Chef de [MASK]. +Dr [NOM] +Dr [NOM] +Secrétariat : Histoire de la maladie +[TEL] Diabète depuis l'[AGE], découvert devant SPUPD. +MÉDECINE INTERNE Pas d'antécédent familial de diabète. +Dr [NOM] [NOM] [NOM] au diagnostic : 74kg / 178 cm (IMC 23.4 kg/m²). +Chef de [MASK] 2021 103 kg (32 kg/m²). +Dr [NOM] +Dr [NOM] Traité par Janumet, [NOM] d'Ozempic en 2022. +Secrétariat : Insuline prescrite en mai 2023 devant une HbA1c à 10%, non débutée par le patient. +[TEL] +Macroadénome hypophysaire découvert devant BAV de l'OD révélant un déficit du CV : prédominant à droit. +IRM non réalisable en raison d'une clostrophobie. TDM : lésion de 30 mm de hauteur, effet de masse sur chiasma optique. +Sur le plan sécrétoire : prolactine, T4L, cortisol à 8h et IGF1 normaux, insuffisance gonadotrope (testostérone 1.19 ng/ml +avec FSH/LH basses). +Le patient a rencontré le Pr [NOM] en vue d'une chirurgie semi urgente. +Vaccins préop faits fin mars +Equilibre : +HbA1c : 9.4 % +Carnet de glycémies : une ASG par jour au réveil : autour de 2.7 - 4 g/l. +Retentissement : +Rétine : dernier FO (Dr [NOM], clinique des yeux de St [NOM] de [NOM]). +Cardio : Cardiologue (?) parti à la retraite, dernière EE il y a 2-3 ans. Pas de doppler artériel. +Rein : créat 106 umol/L, DFG 61 ml/min. Microalbuminurie pathologique : RAC à 7.3 mg/mmol. ECBU : absence de +leucocyturie. +Podologique : neuropathie de grade 1, hypopallesthésie, erreurs au monofilament, pas de plaie. Suivi +podologique trimestriel. +Examen clinique d’entrée +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 30/07/1950 +IPP : [IPP] / [EPISODE] ([MASK]. interne : H semaine) +V1 - Imprimé le 15/04/2025 à 13 : 36 par Page(s): 1 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Poids 92.3 kg, TA 157/82 mmHg +CHEF DE PÔLE Pas d'acanthosis nigricans +Dr [NOM] pas d'adénopathie, pas de splénomégalie palpée. [NOM] nocturnes. +DERMATOLOGIE balanite, pas de brulure mictionnelle +Dr [NOM] du cœur réguliers sans souffle, pas d'OMI, pouls périph perçus +Chef de [MASK] +/+ sans crépitant +Dr [NOM] +Dr [NOM] Transit normal, abdomen souple indolore, pas d'[NOM] palpée +Secrétariat : Balanite : inflammation locale. +[TEL] +ENDOCRINOLOGIE Bilan biologique d’entrée +Dr [NOM] 2.01 g/L, HDL 0.47 g/L, TG 4.19 g/L +Chef de [MASK], GGT 89 U/L +Dr [NOM] +Dr [NOM] Hb 16 g/dL, ferritine 153 ug/l, CRP 8 mg/L +Dr [NOM] TSH normale +Dr [NOM] +Secrétariat : +[TEL] Evolution dans le service : +Diabète : Introduction d'insuline basal bolus, reprise de la Metformine et d'Ozempic à 0.50mg / semaine. +MAL. INFECTIEUSES Hématologie : [NOM] connue, pas de suivi depuis 2021. Lymphocytose sans cytopénie. Immunophénotypage : stabilité avec +Dr [NOM] +Chef de Service clone de LB < 5 G/L et score de Matutes à 4. Pas de syndrome tumoral. Avis hématologique pris (Dr [NOM]) : consultation de +Dr [NOM] suivi en hématologie. +Dr [NOM] +Dr [NOM] +Dr [NOM] Traitement de sortie et modifications thérapeutiques +Secrétariat : ABASAGLAR 20 UI le soir +[TEL] HUMALOG aux repas : 8-10-9 UI +NEPHROLOGIE METFORMINE 1000mg matin et soir +Dr [NOM] OZEMPIC 0.5 mg par semaine, à majorer à 1mg / semaine après 4 semaines si bonne tolérance +Chef de [MASK] 145mg le soir +Dr [NOM] +Dr [NOM] ECONAZOLE crème pour balanite +Dr [NOM] +Dr [NOM] Synthèse de l’hospitalisation +Secrétariat : +[TEL] Diabète de type 2 déséquilibré avec HbA1c 9.4% dans un contexte d'inobservance thérapeutique. Instauration d'un +basal bolus et majoration de l'analogue du GLP1 pour [NOM] avant chirurgie d'un adénome hypophysaire. +RHUMATOLOGIE +Dr [NOM] +Chef de [MASK] : +Dr [NOM] passage IDE une fois par jour pour aide à l'adaptation des doses d'insuline. +Dr [NOM] de suivi d'hématologie (Dr [NOM]) le 07 juillet 2023. +Secrétariat : +[TEL] Cs IDE de diabétologie le 09/08/23 à 11h30. +HDS de réévaluation du diabète en septembre avec contrôle de la microalbuminurie et du [NOM]. +MÉDECINE INTERNE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] [NOM] Votre patient(e) quitte le service avec : +Secrétariat : +[TEL] - Pharmacie : +ABASAGLAR 300 U SOL INJ STYLO [5] Stylo(s) Prerempli(s) 18 UI (SOUS-CUTANEE) en direct soir [19h] +ECONAZOLE ARW 1% CREME [1] Tube(s) 30 G (CUTANEE) matin [8h] +FENOFIBRATE BGA 145MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) soir [19h] +HUMALOG 100 UI/ML SOL INJ FL [1] Flacon(s) 10 UI (SOUS-CUTANEE) en direct matin midi soir +METFORMINE MYP 1000MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 20h) +SEMAGLUTIDE - OZEMPIC 0,5 MG, SOLUTION INJECTABLE 0.5MG/DOSE solution .5 MG (SOUS-CUTANEE) en +direct 1xsemaine [8h] +ABASAGLAR 300 U SOL INJ STYLO [5] Stylo(s) Prerempli(s) 18 UI (SOUS-CUTANEE) en direct soir [19h] +ECONAZOLE ARW 1% CREME [1] Tube(s) 30 G (CUTANEE) matin [8h] +FENOFIBRATE BGA 145MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) soir [19h] +HUMALOG 100 UI/ML SOL INJ FL [1] Flacon(s) 10 UI (SOUS-CUTANEE) en direct matin midi soir +METFORMINE MYP 1000MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 20h) +SEMAGLUTIDE - OZEMPIC 0,5 MG, SOLUTION INJECTABLE 0.5MG/DOSE solution .5 MG (SOUS-CUTANEE) en +direct 1xsemaine [8h] +Les consignes d'usage ont été remises. +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 30/07/1950 +IPP : [IPP] / [EPISODE] ([MASK]. interne : H semaine) +V1 - Imprimé le 15/04/2025 à 13 : 36 par Page(s): 2 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Bien confraternellement, +CHEF DE PÔLE +Dr [NOM] +DERMATOLOGIE +Dr [NOM] +Chef de [MASK] +Dr [NOM] *10100402527* +Dr [NOM] +Secrétariat : +[TEL] +10100402527 +ENDOCRINOLOGIE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] par [NOM] [NOM] [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MAL. INFECTIEUSES Liste des destinataires : +Dr [NOM] +Chef de [MASK] +D Dr r S Ho ep idh ii e W F IA LR LB EOS DR. [NOM] +Dr [NOM]. [NOM] [NOM] +Dr [NOM] +Secrétariat : +[TEL] +NEPHROLOGIE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +RHUMATOLOGIE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MÉDECINE INTERNE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] +Secrétariat : +[TEL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 30/07/1950 +IPP : [IPP] / [EPISODE] ([MASK]. interne : H semaine) +V1 - Imprimé le 15/04/2025 à 13 : 36 par Page(s): 3 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Bayonne, le 02/06/2023 +CHEF DE PÔLE +Dr [NOM] +DR [NOM] +DERMATOLOGIE [ADRESSE] +Dr [NOM] [CODE_POSTAL] +Chef de [MASK] [NOM] +Dr [NOM] +Secrétariat : Mon cher confrère, +[TEL] +ENDOCRINOLOGIE Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 30/05/2023 au 02/06/2023 pour le motif +Dr [NOM] [NOM] suivant : +Chef de [MASK] [NOM] +Dr [NOM] - Motif d’hospitalisation +Dr [NOM] +Dr [NOM] d'un diabète avant chirurgie d'adénome hypophysaire +Secrétariat : +[TEL] Antécédents/Maladie en cours +MAL. INFECTIEUSES DT2 +Dr [NOM] [NOM] stade A vu en 2021 Dr [NOM] +Chef de [MASK] +Dr [NOM] +Dr [NOM] sevré depuis 10 ans +Dr [NOM] Appendicectomie +Dr [NOM] ombilicale +Secrétariat : +[TEL] Cataracte opérée +Amygdalectomie +NEPHROLOGIE pas d'allergie connue +Dr [NOM] +Chef de [MASK] [NOM] Traitement à l’entrée +Dr [NOM] [NOM] Avant le 26/05 : Janumet + Ozempic 0.25 mg/sem. +Dr [NOM] +Dr [NOM] [NOM] Depuis le 26/5 : aucun traitement +Secrétariat : +[TEL] Mode de vie/Habitus +RHUMATOLOGIE Habite à Hendaye avec son épouse, pas d'enfant. Ancien restaurateur retraité. +Dr [NOM] [NOM] [NOM] Alimentation : 2 repas par jour, pas de petit-déjeuner. Grignotage sucrés en journée (fruits, chocolat). +Chef de [MASK]. +Dr [NOM] +Dr [NOM] +Secrétariat : Histoire de la maladie +[TEL] Diabète depuis l'[AGE], découvert devant SPUPD. +MÉDECINE INTERNE Pas d'antécédent familial de diabète. +Dr [NOM] [NOM] [NOM] au diagnostic : 74kg / 178 cm (IMC 23.4 kg/m²). +Chef de [MASK] 2021 103 kg (32 kg/m²). +Dr [NOM] +Dr [NOM] Traité par Janumet, [NOM] d'Ozempic en 2022. +Secrétariat : Insuline prescrite en mai 2023 devant une HbA1c à 10%, non débutée par le patient. +[TEL] +Macroadénome hypophysaire découvert devant BAV de l'OD révélant un déficit du CV : prédominant à droit. +IRM non réalisable en raison d'une clostrophobie. TDM : lésion de 30 mm de hauteur, effet de masse sur chiasma optique. +Sur le plan sécrétoire : prolactine, T4L, cortisol à 8h et IGF1 normaux, insuffisance gonadotrope (testostérone 1.19 ng/ml +avec FSH/LH basses). +Le patient a rencontré le Pr [NOM] en vue d'une chirurgie semi urgente. +Vaccins préop faits fin mars +Equilibre : +HbA1c : 9.4 % +Carnet de glycémies : une ASG par jour au réveil : autour de 2.7 - 4 g/l. +Retentissement : +Rétine : dernier FO (Dr [NOM], clinique des yeux de St [NOM] de [NOM]). +Cardio : Cardiologue (?) parti à la retraite, dernière EE il y a 2-3 ans. Pas de doppler artériel. +Rein : créat 106 umol/L, DFG 61 ml/min. Microalbuminurie pathologique : RAC à 7.3 mg/mmol. ECBU : absence de +leucocyturie. +Podologique : neuropathie de grade 1, hypopallesthésie, erreurs au monofilament, pas de plaie. Suivi +podologique trimestriel. +Examen clinique d’entrée +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 30/07/1950 +IPP : [IPP] / [EPISODE] ([MASK]. interne : H semaine) +V1 - Imprimé le 15/04/2025 à 13 : 36 par Page(s): 1 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Poids 92.3 kg, TA 157/82 mmHg +CHEF DE PÔLE Pas d'acanthosis nigricans +Dr [NOM] pas d'adénopathie, pas de splénomégalie palpée. [NOM] nocturnes. +DERMATOLOGIE balanite, pas de brulure mictionnelle +Dr [NOM] du cœur réguliers sans souffle, pas d'OMI, pouls périph perçus +Chef de [MASK] +/+ sans crépitant +Dr [NOM] +Dr [NOM] Transit normal, abdomen souple indolore, pas d'[NOM] palpée +Secrétariat : Balanite : inflammation locale. +[TEL] +ENDOCRINOLOGIE Bilan biologique d’entrée +Dr [NOM] 2.01 g/L, HDL 0.47 g/L, TG 4.19 g/L +Chef de [MASK], GGT 89 U/L +Dr [NOM] +Dr [NOM] Hb 16 g/dL, ferritine 153 ug/l, CRP 8 mg/L +Dr [NOM] TSH normale +Dr [NOM] +Secrétariat : +[TEL] Evolution dans le service : +Diabète : Introduction d'insuline basal bolus, reprise de la Metformine et d'Ozempic à 0.50mg / semaine. +MAL. INFECTIEUSES Hématologie : [NOM] connue, pas de suivi depuis 2021. Lymphocytose sans cytopénie. Immunophénotypage : stabilité avec +Dr [NOM] +Chef de Service clone de LB < 5 G/L et score de Matutes à 4. Pas de syndrome tumoral. Avis hématologique pris (Dr [NOM]) : consultation de +Dr [NOM] suivi en hématologie. +Dr [NOM] +Dr [NOM] +Dr [NOM] Traitement de sortie et modifications thérapeutiques +Secrétariat : ABASAGLAR 20 UI le soir +[TEL] HUMALOG aux repas : 8-10-9 UI +NEPHROLOGIE METFORMINE 1000mg matin et soir +Dr [NOM] OZEMPIC 0.5 mg par semaine, à majorer à 1mg / semaine après 4 semaines si bonne tolérance +Chef de [MASK] 145mg le soir +Dr [NOM] +Dr [NOM] ECONAZOLE crème pour balanite +Dr [NOM] +Dr [NOM] Synthèse de l’hospitalisation +Secrétariat : +[TEL] Diabète de type 2 déséquilibré avec HbA1c 9.4% dans un contexte d'inobservance thérapeutique. Instauration d'un +basal bolus et majoration de l'analogue du GLP1 pour [NOM] avant chirurgie d'un adénome hypophysaire. +RHUMATOLOGIE +Dr [NOM] +Chef de [MASK] : +Dr [NOM] passage IDE une fois par jour pour aide à l'adaptation des doses d'insuline. +Dr [NOM] de suivi d'hématologie (Dr [NOM]) le 07 juillet 2023. +Secrétariat : +[TEL] Cs IDE de diabétologie le 09/08/23 à 11h30. +HDS de réévaluation du diabète en septembre avec contrôle de la microalbuminurie et du [NOM]. +MÉDECINE INTERNE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] [NOM] Votre patient(e) quitte le service avec : +Secrétariat : +[TEL] - Pharmacie : +ABASAGLAR 300 U SOL INJ STYLO [5] Stylo(s) Prerempli(s) 18 UI (SOUS-CUTANEE) en direct soir [19h] +ECONAZOLE ARW 1% CREME [1] Tube(s) 30 G (CUTANEE) matin [8h] +FENOFIBRATE BGA 145MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) soir [19h] +HUMALOG 100 UI/ML SOL INJ FL [1] Flacon(s) 10 UI (SOUS-CUTANEE) en direct matin midi soir +METFORMINE MYP 1000MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 20h) +SEMAGLUTIDE - OZEMPIC 0,5 MG, SOLUTION INJECTABLE 0.5MG/DOSE solution .5 MG (SOUS-CUTANEE) en +direct 1xsemaine [8h] +ABASAGLAR 300 U SOL INJ STYLO [5] Stylo(s) Prerempli(s) 18 UI (SOUS-CUTANEE) en direct soir [19h] +ECONAZOLE ARW 1% CREME [1] Tube(s) 30 G (CUTANEE) matin [8h] +FENOFIBRATE BGA 145MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) soir [19h] +HUMALOG 100 UI/ML SOL INJ FL [1] Flacon(s) 10 UI (SOUS-CUTANEE) en direct matin midi soir +METFORMINE MYP 1000MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 20h) +SEMAGLUTIDE - OZEMPIC 0,5 MG, SOLUTION INJECTABLE 0.5MG/DOSE solution .5 MG (SOUS-CUTANEE) en +direct 1xsemaine [8h] +Les consignes d'usage ont été remises. +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 30/07/1950 +IPP : [IPP] / [EPISODE] ([MASK]. interne : H semaine) +V1 - Imprimé le 15/04/2025 à 13 : 36 par Page(s): 2 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Bien confraternellement, +CHEF DE PÔLE +Dr [NOM] +DERMATOLOGIE +Dr [NOM] +Chef de [MASK] +Dr [NOM] *10100402527* +Dr [NOM] +Secrétariat : +[TEL] +10100402527 +ENDOCRINOLOGIE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] par [NOM] [NOM] [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MAL. INFECTIEUSES Liste des destinataires : +Dr [NOM] +Chef de [MASK] +D Dr r S Ho ep idh ii e W F IA LR LB EOS DR. [NOM] +Dr [NOM]. [NOM] [NOM] +Dr [NOM] +Secrétariat : +[TEL] +NEPHROLOGIE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +RHUMATOLOGIE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MÉDECINE INTERNE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] +Secrétariat : +[TEL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 30/07/1950 +IPP : [IPP] / [EPISODE] ([MASK]. interne : H semaine) +V1 - Imprimé le 15/04/2025 à 13 : 36 par Page(s): 3 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Bayonne, le 02/06/2023 +CHEF DE PÔLE +Dr [NOM] +PR [NOM] [NOM] +DERMATOLOGIE [ADRESSE] +Dr [NOM] [CODE_POSTAL] +Chef de [MASK] [NOM] +Dr [NOM] +Secrétariat : Mon cher confrère, +[TEL] +ENDOCRINOLOGIE Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 30/05/2023 au 02/06/2023 pour le motif +Dr [NOM] [NOM] suivant : +Chef de [MASK] [NOM] +Dr [NOM] - Motif d’hospitalisation +Dr [NOM] +Dr [NOM] d'un diabète avant chirurgie d'adénome hypophysaire +Secrétariat : +[TEL] Antécédents/Maladie en cours +MAL. INFECTIEUSES DT2 +Dr [NOM] [NOM] stade A vu en 2021 Dr [NOM] +Chef de [MASK] +Dr [NOM] +Dr [NOM] sevré depuis 10 ans +Dr [NOM] Appendicectomie +Dr [NOM] ombilicale +Secrétariat : +[TEL] Cataracte opérée +Amygdalectomie +NEPHROLOGIE pas d'allergie connue +Dr [NOM] +Chef de [MASK] [NOM] Traitement à l’entrée +Dr [NOM] [NOM] Avant le 26/05 : Janumet + Ozempic 0.25 mg/sem. +Dr [NOM] +Dr [NOM] [NOM] Depuis le 26/5 : aucun traitement +Secrétariat : +[TEL] Mode de vie/Habitus +RHUMATOLOGIE Habite à Hendaye avec son épouse, pas d'enfant. Ancien restaurateur retraité. +Dr [NOM] [NOM] [NOM] Alimentation : 2 repas par jour, pas de petit-déjeuner. Grignotage sucrés en journée (fruits, chocolat). +Chef de [MASK]. +Dr [NOM] +Dr [NOM] +Secrétariat : Histoire de la maladie +[TEL] Diabète depuis l'[AGE], découvert devant SPUPD. +MÉDECINE INTERNE Pas d'antécédent familial de diabète. +Dr [NOM] [NOM] [NOM] au diagnostic : 74kg / 178 cm (IMC 23.4 kg/m²). +Chef de [MASK] 2021 103 kg (32 kg/m²). +Dr [NOM] +Dr [NOM] Traité par Janumet, [NOM] d'Ozempic en 2022. +Secrétariat : Insuline prescrite en mai 2023 devant une HbA1c à 10%, non débutée par le patient. +[TEL] +Macroadénome hypophysaire découvert devant BAV de l'OD révélant un déficit du CV : prédominant à droit. +IRM non réalisable en raison d'une clostrophobie. TDM : lésion de 30 mm de hauteur, effet de masse sur chiasma optique. +Sur le plan sécrétoire : prolactine, T4L, cortisol à 8h et IGF1 normaux, insuffisance gonadotrope (testostérone 1.19 ng/ml +avec FSH/LH basses). +Le patient a rencontré le Pr [NOM] en vue d'une chirurgie semi urgente. +Vaccins préop faits fin mars +Equilibre : +HbA1c : 9.4 % +Carnet de glycémies : une ASG par jour au réveil : autour de 2.7 - 4 g/l. +Retentissement : +Rétine : dernier FO (Dr [NOM], clinique des yeux de St [NOM] de [NOM]). +Cardio : Cardiologue (?) parti à la retraite, dernière EE il y a 2-3 ans. Pas de doppler artériel. +Rein : créat 106 umol/L, DFG 61 ml/min. Microalbuminurie pathologique : RAC à 7.3 mg/mmol. ECBU : absence de +leucocyturie. +Podologique : neuropathie de grade 1, hypopallesthésie, erreurs au monofilament, pas de plaie. Suivi +podologique trimestriel. +Examen clinique d’entrée +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 30/07/1950 +IPP : [IPP] / [EPISODE] ([MASK]. interne : H semaine) +V1 - Imprimé le 15/04/2025 à 13 : 36 par Page(s): 1 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Poids 92.3 kg, TA 157/82 mmHg +CHEF DE PÔLE Pas d'acanthosis nigricans +Dr [NOM] pas d'adénopathie, pas de splénomégalie palpée. [NOM] nocturnes. +DERMATOLOGIE balanite, pas de brulure mictionnelle +Dr [NOM] du cœur réguliers sans souffle, pas d'OMI, pouls périph perçus +Chef de [MASK] +/+ sans crépitant +Dr [NOM] +Dr [NOM] Transit normal, abdomen souple indolore, pas d'[NOM] palpée +Secrétariat : Balanite : inflammation locale. +[TEL] +ENDOCRINOLOGIE Bilan biologique d’entrée +Dr [NOM] 2.01 g/L, HDL 0.47 g/L, TG 4.19 g/L +Chef de [MASK], GGT 89 U/L +Dr [NOM] +Dr [NOM] Hb 16 g/dL, ferritine 153 ug/l, CRP 8 mg/L +Dr [NOM] TSH normale +Dr [NOM] +Secrétariat : +[TEL] Evolution dans le service : +Diabète : Introduction d'insuline basal bolus, reprise de la Metformine et d'Ozempic à 0.50mg / semaine. +MAL. INFECTIEUSES Hématologie : [NOM] connue, pas de suivi depuis 2021. Lymphocytose sans cytopénie. Immunophénotypage : stabilité avec +Dr [NOM] +Chef de Service clone de LB < 5 G/L et score de Matutes à 4. Pas de syndrome tumoral. Avis hématologique pris (Dr [NOM]) : consultation de +Dr [NOM] suivi en hématologie. +Dr [NOM] +Dr [NOM] +Dr [NOM] Traitement de sortie et modifications thérapeutiques +Secrétariat : ABASAGLAR 20 UI le soir +[TEL] HUMALOG aux repas : 8-10-9 UI +NEPHROLOGIE METFORMINE 1000mg matin et soir +Dr [NOM] OZEMPIC 0.5 mg par semaine, à majorer à 1mg / semaine après 4 semaines si bonne tolérance +Chef de [MASK] 145mg le soir +Dr [NOM] +Dr [NOM] ECONAZOLE crème pour balanite +Dr [NOM] +Dr [NOM] Synthèse de l’hospitalisation +Secrétariat : +[TEL] Diabète de type 2 déséquilibré avec HbA1c 9.4% dans un contexte d'inobservance thérapeutique. Instauration d'un +basal bolus et majoration de l'analogue du GLP1 pour [NOM] avant chirurgie d'un adénome hypophysaire. +RHUMATOLOGIE +Dr [NOM] +Chef de [MASK] : +Dr [NOM] passage IDE une fois par jour pour aide à l'adaptation des doses d'insuline. +Dr [NOM] de suivi d'hématologie (Dr [NOM]) le 07 juillet 2023. +Secrétariat : +[TEL] Cs IDE de diabétologie le 09/08/23 à 11h30. +HDS de réévaluation du diabète en septembre avec contrôle de la microalbuminurie et du [NOM]. +MÉDECINE INTERNE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] [NOM] Votre patient(e) quitte le service avec : +Secrétariat : +[TEL] - Pharmacie : +ABASAGLAR 300 U SOL INJ STYLO [5] Stylo(s) Prerempli(s) 18 UI (SOUS-CUTANEE) en direct soir [19h] +ECONAZOLE ARW 1% CREME [1] Tube(s) 30 G (CUTANEE) matin [8h] +FENOFIBRATE BGA 145MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) soir [19h] +HUMALOG 100 UI/ML SOL INJ FL [1] Flacon(s) 10 UI (SOUS-CUTANEE) en direct matin midi soir +METFORMINE MYP 1000MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 20h) +SEMAGLUTIDE - OZEMPIC 0,5 MG, SOLUTION INJECTABLE 0.5MG/DOSE solution .5 MG (SOUS-CUTANEE) en +direct 1xsemaine [8h] +ABASAGLAR 300 U SOL INJ STYLO [5] Stylo(s) Prerempli(s) 18 UI (SOUS-CUTANEE) en direct soir [19h] +ECONAZOLE ARW 1% CREME [1] Tube(s) 30 G (CUTANEE) matin [8h] +FENOFIBRATE BGA 145MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) soir [19h] +HUMALOG 100 UI/ML SOL INJ FL [1] Flacon(s) 10 UI (SOUS-CUTANEE) en direct matin midi soir +METFORMINE MYP 1000MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 20h) +SEMAGLUTIDE - OZEMPIC 0,5 MG, SOLUTION INJECTABLE 0.5MG/DOSE solution .5 MG (SOUS-CUTANEE) en +direct 1xsemaine [8h] +Les consignes d'usage ont été remises. +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 30/07/1950 +IPP : [IPP] / [EPISODE] ([MASK]. interne : H semaine) +V1 - Imprimé le 15/04/2025 à 13 : 36 par Page(s): 2 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +[MASK] +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Bien confraternellement, +CHEF DE PÔLE +Dr [NOM] +DERMATOLOGIE +Dr [NOM] +Chef de [MASK] +Dr [NOM] *10100402527* +Dr [NOM] +Secrétariat : +[TEL] +10100402527 +ENDOCRINOLOGIE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] par [NOM] [NOM] [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MAL. INFECTIEUSES Liste des destinataires : +Dr [NOM] +Chef de [MASK] +D Dr r S Ho ep idh ii e W F IA LR LB EOS DR. [NOM] +Dr [NOM]. [NOM] [NOM] +Dr [NOM] +Secrétariat : +[TEL] +NEPHROLOGIE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +RHUMATOLOGIE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MÉDECINE INTERNE +Dr [NOM] +Chef de [MASK] [NOM] +Dr [NOM] +Secrétariat : +[TEL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 30/07/1950 +IPP : [IPP] / [EPISODE] ([MASK]. interne : H semaine) +V1 - Imprimé le 15/04/2025 à 13 : 36 par Page(s): 3 sur 3 \ No newline at end of file diff --git a/tests/ground_truth/pdfs/baseline_anonymized/023_complexe_compte_rendu_CRH_23102610.redacted_raster.pdf b/tests/ground_truth/pdfs/baseline_anonymized/023_complexe_compte_rendu_CRH_23102610.redacted_raster.pdf new file mode 100644 index 0000000..9e17750 Binary files /dev/null and b/tests/ground_truth/pdfs/baseline_anonymized/023_complexe_compte_rendu_CRH_23102610.redacted_raster.pdf differ diff --git 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"ETAB_GLOBAL", "original": "unité de Médecine hors SC", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null} diff --git a/tests/ground_truth/pdfs/baseline_anonymized/024_complexe_trackare_trackare-17001141-23066188_17001141_23066188.pseudonymise.txt b/tests/ground_truth/pdfs/baseline_anonymized/024_complexe_trackare_trackare-17001141-23066188_17001141_23066188.pseudonymise.txt new file mode 100644 index 0000000..296fd79 --- /dev/null +++ b/tests/ground_truth/pdfs/baseline_anonymized/024_complexe_trackare_trackare-17001141-23066188_17001141_23066188.pseudonymise.txt @@ -0,0 +1,2945 @@ +CENTRE HOSPITALIER COTE BASQUE +*640N0° F0in0ess162* +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +640000162 +MEDECINE PEDIATRIE - PEDIATRIE GENERALE +Dossier Patient +Détails des patients +Nom de naissance : [NOM] IPP : [IPP] +Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE] +Sexe : Masculin Lieu de naissance: [VILLE] +Nationalité : FRANCE [CODE_POSTAL] +Adresse : [ADRESSE]: [NOM] +Détails épisode +Episode No : [EPISODE] +Localisation : PEDIATRIE GENERALE Médecin courant: DR. [NOM] +Date d'admission : 02/04/2023 Heure d'admission: 15:57 +Date de sortie : 05/04/2023 Heure de sortie: 12:02 +Médecin traitant +Nom Adresse Téléphone +DR. [NOM] [ADRESSE][CODE_POSTAL] [TEL] +Passage aux Urgences +Episode - Date 02/04/2023 +Episode - Heure 15 : 57 +Mode de transport à l'arrivée Véhicule personnel +Médicalisation du transport Aucune médicalisation +Mode d'entrée Autres admissions urgentes +Date d'orientation 02/04/2023 +Heure d'orientation 16 : 19 +IAO [NOM] [NOM] +Priorité Priorité 2 +Sous-type épisode Pédiatrie +Céphalées +Motif de prise en charge +Fièvre +Céphalées, hyperthermie le 30 et 31, mieux le 01 puis récidive des céphalées depuis cette nuit avec vomissements. +A l'arrivée algique++, prostré. +Observ. IDE Urg Photophobie. +Fébrile à 38.6. +ATG 16h30, advil à 10h ( a vomit par la suite) Nifluril à 13h. +Médecin informé, installé en box. +Médecin de la prise en charge médicale [NOM] [NOM] +Date de prise en charge médicale 02/04/2023 +Heure de prise en charge médicale 15 : 57 +CCMU , +Médecin de la décision médicale [NOM] [NOM] +Date de décision médicale 02/04/2023 +Heure de décision médicale 20 : 23 +Décision médicale Hospitalisation MCO +Orientation du patient hospitalisation dans une [MASK], SI, REA +Date de sortie des urgences 02/04/2023 +Heure de sortie des Urgences 22 : 56 +US de destination US PEDIATRIE +UF de destination PEDIATRIE GENERALE +Diagnostic aux urgences +Type Etat Code Date +Principal actif G03.9 Méningite, sans précision [CMA2] 02/04/2023 22 : 53 +Antécédents (texte libre) +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 1 de 19 Type de note Nom Date Heure Note +Aucune donnée +renseignée +Antécédents habitus (texte libre) +Type de note Nom Date Heure Note +Aucune donnée +renseignée +Signes vitaux +Item de 05/04/2023 05/04/2023 05/04/2023 04/04/2023 04/04/2023 04/04/2023 04/04/2023 04/04/2023 04/04/2023 03/04/2023 03/04/2023 03/04/2023 03/04/2023 +surveillance 08 : 48 04:53 01:00 22:47 16:05 11:54 08:59 07:30 05:00 23:00 18:29 15:51 12:54 +Température 36,50 36,50 36,80 36,50 36,70 37,20 35,60 36,60 36,60 36,10 36,50 +Pouls 76 68 96 90 73 75 69 87 109 +PA +91 102 113 104 93 107 +Systolique +PA +51 52 65 59 64 70 +Diastolique +Saturation +99 99 97 99 99 99 99 100 100 +O² +Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation +spontanée spontanée spontanée spontanée spontanée spontanée spontanée +Ventilation +Air Air Air Air Air Air Air +ambiant ambiant ambiant ambiant ambiant ambiant ambiant +[NOM] +[NOM] [NOM] EVS +douleur +Score au +1 0 0 0 2 0 0 6 0 0 2 +repos +Transit Absence +PA +Latéralité +Débit O² +[L/mn] +Poids/Taille +Item de 02/04/2023 +surveillance 16 : 39 +Poids [kg] 19,40 +Surv. Isolement et Contention +Item de 05/04/2023 05/04/2023 04/04/2023 04/04/2023 04/04/2023 04/04/2023 04/04/2023 03/04/2023 03/04/2023 03/04/2023 03/04/2023 03/04/2023 03/04/2023 +surveillance 08 : 48 04:53 22:47 16:05 11:54 08:59 05:00 23:00 18:29 15:51 12:54 09:06 06:34 +Température 36,50 36,50 36,80 36,50 36,70 37,20 35,60 36,60 36,60 36,10 36,50 36,80 36,90 +Pouls 76 68 96 90 73 75 69 87 109 90 +PA +91 102 113 104 93 107 106 +Systolique +PA +51 52 65 59 64 70 56 +Diastolique +Saturation +99 99 97 99 99 99 99 100 100 99 +O² +Transit Absence +Surv. Contention +Item de 05/04/2023 05/04/2023 04/04/2023 04/04/2023 04/04/2023 04/04/2023 04/04/2023 03/04/2023 03/04/2023 03/04/2023 03/04/2023 03/04/2023 03/04/2023 +surveillance 08 : 48 04:53 22:47 16:05 11:54 08:59 05:00 23:00 18:29 15:51 12:54 09:06 06:34 +Température 36,50 36,50 36,80 36,50 36,70 37,20 35,60 36,60 36,60 36,10 36,50 36,80 36,90 +Pouls 76 68 96 90 73 75 69 87 109 90 +PA +91 102 113 104 93 107 106 +Systolique +PA +51 52 65 59 64 70 56 +Diastolique +Saturation +99 99 97 99 99 99 99 100 100 99 +O² +Transit Absence +Observations médicales +Type d'observation Nom Date Commentaires +Méningite à Entérovirus +Histoire de la DR. [NOM] 05/04/2023 Antécédents personnels : +maladie [NOM] 10 : 32 Migraine frontale, environ 2 épisodes par mois cédant à la prise de paracétamol et AINS +Antécédents familiaux : +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 2 de 19 Terrain migraineux chez le père et la mère. Traitement de fond auparavant chez la mère arrêté, +prend AINS et triptans en cas de crise. AINS simple chez le père +Allergies : non. +Vaccination : rappel des 6 ans à faire. +Traitements habituels : +- Paracétamol et AINS si céphalées. +Traitements reçus en hospitalisation : +- Réhydratation parentérale IV par Bionolyte G5 pendant 48h. +- Traitement antalgique par paracétamol, Nubain et Advil. +- Traitement par 1 injection de Caféine dans le cadre d'un syndrome post-PL d'évolution +favorable. +- Une antibiothérapie a été mise en place par Cefotaxime par voie iv pendant 48 heures, +interrompue après réception des résultats de la ponction lombaire. +Examens complémentaires pertinents : +Biologie du 02/04 : leucocytes 8.7 G/L, CRP 53 mg/l, ionogramme normal. +Hémoculture sur VVP du 02/04 : negative à H48 +Ponction lombaire : Glycorachie 0.67 g/L, protéinorachie 0.33 g/L, 14 éléments, culture négative +à 48h. +Analyse du LCR : +* PCR HSV : négative +* PCR Entérovirus : positive +Synthèse du séjour : méningite à Entérovirus d'évolution favorable après antalgie par +paracétamol, Nubain et AINS. +Décision d’un retour à domicile. Poids de sortie : 19.4 Kgs. +Traitement de sortie : Doliprane et advil si besoin. +A Prévoir : contrôle clinique par le médecin traitant. +Parents informés de la démarche diagnostique et thérapeutique. +Document remis en mains propres aux parents le jour de la sortie. +Evènements indésirables : +- Transfusions : non +- Produits dérivés du sang : non +- BMR / BHRe / LHR : non +- Découverte de BMR / BHRe / BHR : non +- Pose DMI : non +J3 hospitalisation pour méningite à Entérovirus. +Encire quelques céphalées et douleurs au point de ponction mais a réussi à se lever pour prendre +une douche et aller en salle de jeux. +Nuque encore un peu raide. +04/04/2023 +Note d'évolution Quentin BOHN Pas de photo-phonophobie. +16 : 52 +Signe de Kernig négatif +Constipation, pas de selles depuis samedi avec douleurs abdo cette nuit. +Abdomen souple, pas de cordon colique, BHA +. +Pas d'effet du Forlax => [NOM] ce soir. +Méningite à Entérovirus +Antécédents personnels : +Migraine frontale, environ 2 épisodes par mois cédant à la prise de paracétamol et AINS +Antécédents familiaux : +Terrain migraineux chez le père et la mère. Traitement de fond auparavant chez la mère arrêté, +prend AINS et tryptan en cas de crise. AINS simple chez le père +Histoire de la 04/04/2023 +Quentin BOHN +maladie 15 : 51 Allergies : non. +Vaccination : rappel des 6ans à faire. +Traitements habituels : +- Paracétamol et AINS si céphalées. +Traitements reçus en hospitalisation : +- Réhydratation parentérale IV par Bionolyte G5 pendant * heures. +- Traitement antalgique par paracétamol, Nubain et Advil.* +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 3 de 19 - Traitement par injections de Caféine dans le cadre d'un syndrome post-PL d'évolution +favorable. +- Une antibiothérapie a été mise en place par Cefotaxime par voie iv pendant 48 heures, +interrompue après réception des résultats de la ponction lombaire. +Examens complémentaires pertinents : +Biologie du 02/04 : leucocytes 8.7 G/L, CRP 53 mg/l, ionogramme normal. +Hémoculture sur VVP du 02/04 : en cours. +Ponction lombaire : Glycorachie 0.67 g/L, protéinorachie 0.33 g/L, 14 éléments, culture : ****. +Analyse du LCR : +* PCR HSV : négative +* PCR Entérovirus : positive +Synthèse du séjour : méningite à Entérovirus d'évolution favorable après antalgie par +paracétamol, Nubain et AINS. +Décision d’un retour à domicile. +Poids de sortie : * Kgs. +Traitement de sortie : +- Doliprane si besoin. +A Prévoir : +- * +- * +Parents informés de la démarche diagnostique et thérapeutique. +Si des examens complémentaires sont en attente le jour de la sortie, ils vous seront communiqués +ultérieurement ainsi qu'à vos médecins correspondants. +Ce document est soumis à validation du sénior. Sans rectificatif dans les 8 jours suivant la sortie, +il pourra être considéré comme définitif. +Document remis en mains propres aux parents le jour de la sortie. +Evènements indésirables : +- Transfusions : non +- Produits dérivés du sang : non +- BMR / BHRe / LHR : non +- Découverte de BMR / BHRe / BHR : non +- Pose DMI : non +DR. [NOM] 03/04/2023 Céphalées et douleurs au point de ponction => sd post PL, débuter la caféine prescrite mais non +Note d'évolution +[NOM] 18 : 00 initiée +soulagé après la PL +DR. [NOM] 02/04/2023 14 éléments, examen direct négatif, protéinorrachie normale +Note d'évolution +[NOM] 22 : 54 +=> poursuite antibio sur la nuit et discuter l'arret demain matin +DR. [NOM] 02/04/2023 PL : liquide hypertendu clair +Note d'évolution +[NOM] 22 : 02 glycémie 1,29 g/L +reste céphalalgique avec photophobie, douleur majorée a la mobilisation, raideur de nuque +examen neurologique normal +pas de purpura +DR. [NOM] 02/04/2023 +Note d'évolution +[NOM] 21 : 27 +=> ponction lombaire +antibiothérapie +hospitalisation +Motif de consultation : Céphalée +Antécédents personnels : +Migraine frontale, environ 2 épisodes par mois cédant à la prise de paracétamol et AINS, +Antécédents familiaux : +terrain migraineux chez le père et la mère. Traitement de fond auparavant chez la mère arrêté, +prend AINS et tryptan en cas de crise. AINS simple chez le père. +Histoire de la 02/04/2023 +[NOM] [NOM] Traitement en cours : Aucun +maladie 17 : 01 +Allergies connues : Aucune +Vaccinations : Rappel des 6 ans à faire (carnet de santé non vu) +Histoire de la maladie : +le 30/03 : céphalée frontale bilatérale + fièvre à 40° + vomissement +le 31/03 : consulte le médecin angine érythémateuse, streptotest négatif +Le 01/04 : amélioration de l'état général, pas de fièvre pas de céphalée +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 4 de 19 cette nuit depuis 2h : récidive des céphalées de même localisation, fièvre à 38,5 et 4 +vomissements sur la journée. +prend paracétamol puis advil à 10h qu'elle vomit. Consulte SOS médecin, donne suppo de nifluril +à 13h et consigne de consulter au SAU si persistance des symptômes +douleur, abdominale diffuse, phono photophobie, pas de trouble du comportement, pas de +désorientation, pas d'ataxie, pas de vision double. +Examen clinique à l’entrée +Poids : 19.4 kg +T 38.6°C +FC 128 bpm +PA 108/63 mmHg +Sat 02 99 % +Enfant algique, pâle, prostré, position algique, couché en position foetale +Hémodynamique stable, extrémité chaude, pas de marbrure TRC instantanée, muqueuses +humides +nuque souple, pupille réactive et symétrique, réflexe cutanéoplantaire indifférents, ROT perçu +non vifs, pas de déficit sensitivo moteur, paire crânienne saine +céphalée frontale augmentée lors de la mobilisation +Cardio-pulmonaire : Battements cardiaques réguliers, sans souffle, pouls périphériques perçus +Eupnéique en air ambiant, murmure vésiculaire clair et symétrique, sans bruits surajoutés +Abdomen souple, dépressible, sensibilité péri ombilicale et épigastrique à la palpation sans +défense ni contracture, sans masse palpable, BHA+, percussion lombaire indolore. +Examen ORL : pharynx normal, tympans normaux +Aires ganglionnaires libres +Pas d’éruption cutanée, pas de purpura +Examens complémentaires réalisés : +Leuco PNN CRP +Na K mmol/l créat +Evolution aux urgences : +perfusion et antalgie IV +Hypothèse diagnostique : +Traitement de sortie : +Parents informés de la démarche diagnostique et thérapeutique +Surveillance Psychiatrie +Item de 05/04/2023 05/04/2023 04/04/2023 04/04/2023 04/04/2023 04/04/2023 04/04/2023 03/04/2023 03/04/2023 03/04/2023 03/04/2023 03/04/2023 03/04/2023 +surveillance 08 : 48 04:53 22:47 16:05 11:54 08:59 05:00 23:00 18:29 15:51 12:54 09:06 06:34 +Température 36,50 36,50 36,80 36,50 36,70 37,20 35,60 36,60 36,60 36,10 36,50 36,80 36,90 +Pouls 76 68 96 90 73 75 69 87 109 90 +PA +91 102 113 104 93 107 106 +Systolique +PA +51 52 65 59 64 70 56 +Diastolique +Saturation +99 99 97 99 99 99 99 100 100 99 +O² +Transit Absence +Notes paramédicales +Type de note Nom Date Note +05/04/2023 +Note IDE [NOM] [NOM] va mieux , bien soulagé par antalgique per os RAD ce jour. +12 : 01 +05/04/2023 +Note IDE [NOM] [NOM] non algique : ATG 1 et AINS en systématique +04 : 54 +Douleurs : se plaint de douleurs dorsales qui diffusent sur les hanches. A passé le début d'après +midi en salle de jeu => ATG1 et 2 fait en systématique. +[NOM] 04/04/2023 +Note IDE +[NOM] 21 : 07 +Elimination : n'a pas eu de selle depuis samedi, laxatif n'a donné aucun résultat. +[NOM] fait à 18h sur consigne médical => a donné ++ +Douleur : +7h30 douloureux se plaint de maux de ventre, mis sur le bassin . pas de selles depuis samedi. La +04/04/2023 +Note IDE [NOM] [NOM] maman souhaiterait qu'on lui donne un laxatif. +09 : 04 +dans la matinée s'est plaint du point de ponction de la PL et de céphalées. ATG2 et AINS fait +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 5 de 19 Alimentation : +A mangé une orange ce matin et des nuggets à midi. +Boit beaucoup d'eau et urine souvent. +Perfusion à poursuivre avis interne demandé. +douleur +se plaint de temps en temps de douleurs au niveau du dos +04/04/2023 +Note IDE [NOM] [NOM] vite soulagé par paracétamol +05 : 38 +ATB poursuivis +pas de fièvre +DOULEURS DORSALES : au niveau du pts de ponction (pst propre) à la mobilisation ==> +ATG1 en IV à 17h , soulagé par la suite +CEPHALEES : post PL ==> caféine IV passé à 18h ==> soulagée par la suite mais ce soir de +03/04/2023 +Note IDE [NOM] [NOM] nouveau inconfortable avec des dlrs abdos ==> ATG2 fait à 21h +18 : 42 +ALIMENTATION : prend un lait au chocolat + 1 chocolat au goûter // mange qques pâtes ce soir +Apyrétique cet apres midi +algie : +algique sur sa PL --> ATG1 11h et ATG2 à 12h --> soulagé +pas de céphalées ni photophobie +03/04/2023 +Note IDE [NOM] [NOM] +13 : 57 infectieux : +apyrétique +Douleur : +Algique post PL au niveau des lombaires, Céphalée persistante +ATG1 fait en IV en systématique +ATG2 fait à 00h +Soulagé par la suite puis de nouveau algique en fin de nuit : ATG2 fait +03/04/2023 Pst propre non taché. +Note IDE [NOM] [NOM] +03 : 15 +Infectieux : +Pic fébrile bien toléré à 00h +Poursuite ATB iv +Apyrétique par la suite +Hydratation Iv en continu +02/04/2023 +Note IDE [NOM] [NOM] A vomit à 17h30 environ 10 minutes après la fin de la prise doliprane. +17 : 28 +Traitements médicamenteux +Date de dernière +Prescription Dose Fréquence Date de début Note Docteur +administration +Voie d`administration : INTRAVEINEUSE +Statut des prescriptions : Signé +CAFEINE [NOM] 25MG/ML Le débit en cours +DR. [NOM] +INJ BUV [NOM] 2ML [10] 350 mg - Normal 03/04/2023 13 : 53 05/04/2023 06:30 est : 28 ML par 1 +[NOM] +Ampoule(s) Bouteille(s) hrs. +Le débit en +cours est : +1.2000000000000001 +ML par 1 +NALBUPHINE MYL +hrs. Notes du DR. [NOM] +20MG/2ML SOL INJ [10] 4 mg - Normal 02/04/2023 20 : 22 05/04/2023 09:52 +professionel de [NOM] +Ampoule(s) Bouteille(s) +santé : DILUER +dans 20ML de +NaCl 0.9% MAX +1.2MG/KG/J +Le débit a été +modifié. Le débit +PARACETAMOL BBM en cours est : 120 +[NOM] +10MG/ML INJ 100ML [10] 300 mg - Normal 02/04/2023 17 : 10 05/04/2023 11:18 par . Notes du +[NOM] +Flacon(s) professionel de +santé : MAX 1G/ +INJ +Statut des prescriptions : Arrêté +CEFOTAXIME PAN 1G Le débit en cours DR. [NOM] +1500 mg - Normal 02/04/2023 21 : 29 04/04/2023 09:29 +PDR INJ [25] Flacon(s) est : 3 ML par [NOM] +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 6 de 19 1 hrs. Notes du +professionel de +santé : Dilution: +1G dans 20ML de +NaCL 0.9% +Statut des prescriptions : En cours +Le débit a été +BIONOLYTE G5 INJ FPE modifié. Le débit [NOM] +- Normal 02/04/2023 17 : 10 05/04/2023 00:13 +500ML [10] Flacon(s) en cours est : 60 [NOM] +ML par 1 hrs. +Voie d`administration : ORALE +Statut des prescriptions : Signé +Notes du +ADVILMED 20MG/ML [NOM] +1 DOSE(S) professionel +ET NR SUSP BUV [533] - Normal 04/04/2023 10 : 28 05/04/2023 09:21 Quentin BOHN +KILO de santé : +Flacon(s) +SYSTEMATIQUE +MACROGOL 4000 ARW +4G PDR [NOM] [20] 2 SACHET - 1xJour [8h] Normal 04/04/2023 10 : 27 05/04/2023 08:00 Quentin BOHN +SACHET(s) +Statut des prescriptions : Arrêté +IBUPROFENE ARW +200MG CPR ENR [20] 1 CPR - Normal 04/04/2023 10 : 16 Quentin BOHN +COMPRIME(S) +Statut des prescriptions : Réalisé +ADVILMED 20MG/ML [NOM] +1 DOSE(S) DR. [NOM] +ET NR SUSP BUV [533] - Presc. de Sortie 05/04/2023 10 : 34 +KILO [NOM] +Flacon(s) +MACROGOL 4000 ARW +- 1xJour [8h] Presc. DR. [NOM] +4G PDR [NOM] [20] 2 SACHET 05/04/2023 10 : 34 +de Sortie [NOM] +SACHET(s) +PARACETAMOL [NOM] 1 DOSE(S) DR. [NOM] +- Presc. de Sortie 05/04/2023 10 : 34 +SOL BUV KILO [NOM] +Voie d`administration : RECTALE +Statut des prescriptions : Réalisé +[NOM] [NOM] +[NOM] SOL RECTALE 1 REC. - 1 seule fois 1 seule +04/04/2023 16 : 47 04/04/2023 17:30 Quentin BOHN +[1] RECIPIENT(S) UNIDOSE fois +UNIDOSE(S) +Prescriptions de soins +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +[NOM] +1 Semaine - Matin 03/04/2023 +REPAS : AIDE COMPLETE Réalisé [NOM] +[8h] Normal 21 : 34 +[NOM] +Notes du +professionel +de santé : +DE 0-6 +ans : EVENDOL +10 Jours - Ttes les A PARTIR +02/04/2023 DR. [NOM] +DOULEUR : SURV Réalisé 6h [2h 8h 14h 20h] de 6 +20 : 22 [NOM] +Normal ans : EVA +[NOM] A +PARIR de 8 +ans : [NOM] +numérique +0-10 +10 Jours - à 03h 02/04/2023 DR. [NOM] +[NOM] : SURV Réalisé +Normal 20 : 22 [NOM] +SIGNES VITAUX (Pls, - Ttes les 4H [0h +02/04/2023 DR. [NOM] +TA, FR, T°, Glyc, Miction, Réalisé 4h ... 16h 20h] +20 : 22 [NOM] +Transit) Normal +Notes du +professionel +10 Jours - Ttes les 3H +SURV. NEUROLOGIQUE 02/04/2023 de santé : DR. [NOM] +Réalisé [2h 5h ... 20h 23h] +TTES LES 3H 20 : 22 Conscience/ [NOM] +Normal +pupilles/ +comportement +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 7 de 19 Notes du +1 Semaine - Ttes les professionel +SURV. NEUROLOGIQUE 02/04/2023 DR. [NOM] +Réalisé 6h [2h 8h 14h 20h] de santé : +TTES LES 6H 20 : 22 [NOM] +Normal mouvement +anormaux +02/04/2023 [NOM] +VVP : POSE Réalisé - URGENT Urgent +17 : 52 [NOM] +Prescriptions de sortie +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +[NOM] 20MG/ML [NOM] 1 DOSE(S) DR. [NOM]- +05/04/2023 0/1 : Non administré +ET NR SUSP BUV [533] KILO Réalisé - Presc. de Sortie [NOM] +10 : 34 Révisé/Traité +Flacon(s) ORALE [NOM] +MACROGOL 4000 ARW DR. [NOM]- +2 SACHET - 1xJour [8h] Presc. 05/04/2023 0/14 : Non administré +4G PDR [NOM] [20] Réalisé [NOM] +ORALE de Sortie 10 : 34 Révisé/Traité +SACHET(s) [NOM] +1 DOSE(S) DR. [NOM]- +PARACETAMOL [NOM] 05/04/2023 0/40 : Non administré +KILO Réalisé - Presc. de Sortie [NOM] +SOL BUV 10 : 34 Révisé/Traité +ORALE [NOM] +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 8 de 19 Plan de soins Jour J du 05/04/2023 07h00 au 06/04/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +En cours — BIONOLYTE G5 INJ FPE 500ML Début le 02/04/2023 à +- 5G/L + 2G/L ... solution (500 mL) - Poso 60 17 : 10 +m prl e/ sh ce .u + : +r 0e +2 +- +/ +0I 4N /T 20R 2A 3V @E I 1N 7E : 1U 0SE Continue - Début F 10in + : 3 +l 3e 07/04/2023 à 08 : 33 * 1 +Admin le 05/04/2023 à +00 : 13 +[NOM] [NOM] +En cours — BIONOLYTE G5 INJ FPE 500ML Début le 02/04/2023 à +- 5G/L + 2G/L ... solution (500 mL) - Poso 60 17 : 10 +m prl e/ sh ce .u + : +r 0e +2 +- +/ +0I 4N /T 20R 2A 3V @E I 1N 7E : 1U 0SE Continue - Début F 10in + : 3 +l 3e 07/04/2023 à 16 : 53 * 1 +Admin le 05/04/2023 à +00 : 13 +[NOM] [NOM] +En cours — BIONOLYTE G5 INJ FPE 500ML Début le 02/04/2023 à +- 5G/L + 2G/L ... solution (500 mL) - Poso 60 17 : 10 +m prl e/ sh ce .u + : +r 0e +2 +- +/ +0I 4N /T 20R 2A 3V @E I 1N 7E : 1U 0SE Continue - Début F 10in + : 3 +l 3e 07/04/2023 à 01 : 13 * 1 +Admin le 05/04/2023 à +00 : 13 +Signé — CAFEINE [NOM] 25MG/ML INJ BUV [NOM] [NOM] +[NOM] 2ML - 25MG/ML solution (2 mL) - Dose Début le 03/04/2023 à +350 mg - sur 30 min - INTRAVEINEUSE 13 : 53 +D Di és bc uo tn pti rn eu sce +. + : - 0T 3o /u 0t 4e /s +2 +l 0e 2s +3 +1 @2 H 1e 3u : 5re 3(s) Si besoin - F 06in + : 3 +l 0e 13/04/2023 à 1 m8 g : 30 * 350 +si douleur persistante malgré nubain Admin le 05/04/2023 à +06 : 30 +Signé — CAFEINE [NOM] 25MG/ML INJ BUV [NOM] [NOM] +[NOM] 2ML - 25MG/ML solution (2 mL) - Dose Début le 03/04/2023 à +350 mg - sur 30 min - INTRAVEINEUSE 13 : 53 +D Di és bc uo tn pti rn eu sce +. + : - 0T 3o /u 0t 4e /s +2 +l 0e 2s +3 +1 @2 H 1e 3u : 5re 3(s) Si besoin - F 06in + : 3 +l 0e 13/04/2023 à 0 m6 g : 30 * 350 +si douleur persistante malgré nubain Admin le 05/04/2023 à +06 : 30 +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min [NOM] [NOM] +- INTRAVEINEUSE Discontinue - Toutes les 4 Début le 02/04/2023 à +Heure(s) Si besoin - Début presc. : 02/04/2023 @ 20:22 +2 si0 d : 2 o2 +uleur malgré palier 1 +F 09in + : 5 +l 2e 13/04/2023 à 13 : 52 * 4 mg +Notes de professionel de santé : Admin le 05/04/2023 à +DILUER dans 20ML de NaCl 0.9% MAX 09 : 52 +1.2MG/KG/J +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min [NOM] [NOM] +- INTRAVEINEUSE Discontinue - Toutes les 4 Début le 02/04/2023 à +Heure(s) Si besoin - Début presc. : 02/04/2023 @ 20:22 +2 si0 d : 2 o2 +uleur malgré palier 1 +F 09in + : 5 +l 2e 13/04/2023 à 17 : 52 * 4 mg +Notes de professionel de santé : Admin le 05/04/2023 à +DILUER dans 20ML de NaCl 0.9% MAX 09 : 52 +1.2MG/KG/J +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min [NOM] [NOM] +- INTRAVEINEUSE Discontinue - Toutes les 4 Début le 02/04/2023 à +Heure(s) Si besoin - Début presc. : 02/04/2023 @ 20:22 +2 si0 d : 2 o2 +uleur malgré palier 1 +F 09in + : 5 +l 2e 13/04/2023 à 21 : 52 * 4 mg +Notes de professionel de santé : Admin le 05/04/2023 à +DILUER dans 20ML de NaCl 0.9% MAX 09 : 52 +1.2MG/KG/J +Signé — NALBUPHINE MYL 20 MG SOL INJ [NOM] [NOM] +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min Début le 02/04/2023 à +- INTRAVEINEUSE Discontinue - Toutes les 4 20 : 22 +Heure(s) Si besoin - Début presc. : 02/04/2023 @ Fin le 13/04/2023 à 01:52 * 4 mg +20 : 22 09:52 +si douleur malgré palier 1 Admin le 05/04/2023 à +09 : 52 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 9 de 19 Notes de professionel de santé : +DILUER dans 20ML de NaCl 0.9% MAX +1.2MG/KG/J +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min [NOM] [NOM] +- INTRAVEINEUSE Discontinue - Toutes les 4 Début le 02/04/2023 à +Heure(s) Si besoin - Début presc. : 02/04/2023 @ 20:22 +2 si0 d : 2 o2 +uleur malgré palier 1 +F 09in + : 5 +l 2e 13/04/2023 à 05 : 52 * 4 mg +Notes de professionel de santé : Admin le 05/04/2023 à +DILUER dans 20ML de NaCl 0.9% MAX 09 : 52 +1.2MG/KG/J +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min [NOM] [NOM] +- INTRAVEINEUSE Discontinue - Toutes les 4 Début le 02/04/2023 à +Heure(s) Si besoin - Début presc. : 02/04/2023 @ 20:22 +2 si0 d : 2 o2 +uleur malgré palier 1 +F 09in + : 5 +l 2e 13/04/2023 à 09 : 52 * 4 mg +Notes de professionel de santé : Admin le 05/04/2023 à +DILUER dans 20ML de NaCl 0.9% MAX 09 : 52 +1.2MG/KG/J +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 300 mg - sur Début le 02/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 17 : 10 17:10 * 300 +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 Fin le 12/04/2023 à mg +Notes de professionel de santé : 11:10 +Admin le 05/04/2023 à +MAX 1G/ INJ +11 : 18 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 300 mg - sur Début le 02/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 17 : 10 23:10 * 300 +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 Fin le 12/04/2023 à mg +Notes de professionel de santé : 11:10 +Admin le 05/04/2023 à +MAX 1G/ INJ +11 : 18 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 300 mg - sur Début le 02/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 17 : 10 05:10 * 300 +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 Fin le 12/04/2023 à mg +Notes de professionel de santé : 11:10 +Admin le 05/04/2023 à +MAX 1G/ INJ +11 : 18 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 300 mg - sur Début le 02/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 17 : 10 11:18 * 300 +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 Fin le 12/04/2023 à mg +Notes de professionel de santé : 11:10 +Admin le 05/04/2023 à +MAX 1G/ INJ +11 : 18 +Signé — ADVILMED 20 MG/ML [NOM] ET NR BOHN Quentin +SUSP BUV - 20MG/ML suspension (200 mL) - Début le 04/04/2023 à +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 10 : 28 16:28 * 1 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 Fin le 14/04/2023 à DOSE(S) +Notes de professionel de santé : 04:28 KILO +Admin le 05/04/2023 à +SYSTEMATIQUE +09 : 21 +Signé — ADVILMED 20 MG/ML [NOM] ET NR BOHN Quentin +SUSP BUV - 20MG/ML suspension (200 mL) - Début le 04/04/2023 à +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 10 : 28 22:28 * 1 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 Fin le 14/04/2023 à DOSE(S) +Notes de professionel de santé : 04:28 KILO +Admin le 05/04/2023 à +SYSTEMATIQUE +09 : 21 +Signé — ADVILMED 20 MG/ML [NOM] ET NR BOHN Quentin +SUSP BUV - 20MG/ML suspension (200 mL) - Début le 04/04/2023 à +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 10 : 28 04:28 * 1 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 Fin le 14/04/2023 à DOSE(S) +Notes de professionel de santé : 04:28 KILO +Admin le 05/04/2023 à +SYSTEMATIQUE +09 : 21 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 10 de 19 Signé — ADVILMED 20 MG/ML [NOM] ET NR BOHN Quentin +SUSP BUV - 20MG/ML suspension (200 mL) - Début le 04/04/2023 à +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 10 : 28 09:21 * 1 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 Fin le 14/04/2023 à DOSE(S) +Notes de professionel de santé : 04:28 KILO +Admin le 05/04/2023 à +SYSTEMATIQUE +09 : 21 +BOHN Quentin +Signé — MACROGOL 4000 ARW 4G PDR [NOM] le 04/04/2023 à +BUV SACH - 4G poudre - Dose 2 SACHET - 10 : 27 +O 08R : 0A 0LE - 1xJour [8h] - 1ère dose: 05/04/2023 @ F 08in + : 0 +l 0e 14/04/2023 à 0 S8 A : 0 C0 H * E T2 +Admin le 05/04/2023 à +08 : 00 +[NOM] +[NOM] [NOM] +Réalisé — REPAS : AIDE COMPLETE - Matin Début le 03/04/2023 à +[8h] - 1 Semaine- Date Début : 03/04/2023 @ 21:34 +21 : 34 Fin le 10/04/2023 à 08:00 * 1 +08 : 00 +Admin le 05/04/2023 à +08 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 02/04/2023 Début le 02/04/2023 à +@ 20 : 22 20:22 +Notes de professionel de santé : Fin le 12/04/2023 à 14:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 20:00 +ans : EVA [NOM] A PARIR de 8 ans: [NOM] Admin le 05/04/2023 à +numérique 0-10 08 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 02/04/2023 Début le 02/04/2023 à +@ 20 : 22 20:22 +Notes de professionel de santé : Fin le 12/04/2023 à 20:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 20:00 +ans : EVA [NOM] A PARIR de 8 ans: [NOM] Admin le 05/04/2023 à +numérique 0-10 08 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 02/04/2023 Début le 02/04/2023 à +@ 20 : 22 20:22 +Notes de professionel de santé : Fin le 12/04/2023 à 02:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 20:00 +ans : EVA [NOM] A PARIR de 8 ans: [NOM] Admin le 05/04/2023 à +numérique 0-10 08 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 02/04/2023 Début le 02/04/2023 à +@ 20 : 22 20:22 +Notes de professionel de santé : Fin le 12/04/2023 à 08:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 20:00 +ans : EVA [NOM] A PARIR de 8 ans: [NOM] Admin le 05/04/2023 à +numérique 0-10 08 : 00 +[NOM] [NOM] +Début le 02/04/2023 à +Réalisé — [NOM] : SURV - à 03h - 10 Jours- 20:22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 03:00 * 1 +03 : 00 +Admin le 05/04/2023 à +03 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 02/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 20 : 22 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 12/04/2023 à 16:00 * 1 +02/04/2023 @ 20 : 22 20:00 +Admin le 05/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 02/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 20 : 22 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 12/04/2023 à 20:00 * 1 +02/04/2023 @ 20 : 22 20:00 +Admin le 05/04/2023 à +12 : 00 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +[NOM] [NOM] 00 : 00 * 1 +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 11 de 19 Début le 02/04/2023 à +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 20:22 +02/04/2023 @ 20 : 22 Fin le 12/04/2023 à +20 : 00 +Admin le 05/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 02/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 20 : 22 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 12/04/2023 à 04:00 * 1 +02/04/2023 @ 20 : 22 20:00 +Admin le 05/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 02/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 20 : 22 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 12/04/2023 à 08:00 * 1 +02/04/2023 @ 20 : 22 20:00 +Admin le 05/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 02/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 20 : 22 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 12/04/2023 à 12:00 * 1 +02/04/2023 @ 20 : 22 20:00 +Admin le 05/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 14:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 17:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 20:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 23:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 02:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 05:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +Réalisé — SURV. NEUROLOGIQUE TTES LES [NOM] [NOM] +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- Début le 02/04/2023 à 08 : 00 * 1 +Date Début : 02/04/2023 @ 20:22 20:22 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 12 de 19 Fin le 12/04/2023 à +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 11:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 09/04/2023 à 14:00 * 1 +Notes de professionel de santé : 20:00 +mouvement anormaux Admin le 05/04/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 09/04/2023 à 20:00 * 1 +Notes de professionel de santé : 20:00 +mouvement anormaux Admin le 05/04/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 09/04/2023 à 02:00 * 1 +Notes de professionel de santé : 20:00 +mouvement anormaux Admin le 05/04/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 09/04/2023 à 08:00 * 1 +Notes de professionel de santé : 20:00 +mouvement anormaux Admin le 05/04/2023 à +08 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 13 de 19 Plan de soins Jour J + 1 du 06/04/2023 07h00 au 07/04/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +En cours — BIONOLYTE G5 INJ FPE 500ML Début le 02/04/2023 à +- 5G/L + 2G/L ... solution (500 mL) - Poso 60 17 : 10 +m prl e/ sh ce .u + : +r 0e +2 +- +/ +0I 4N /T 20R 2A 3V @E I 1N 7E : 1U 0SE Continue - Début F 10in + : 3 +l 3e 07/04/2023 à 09 : 33 * 1 +Admin le 05/04/2023 à +00 : 13 +[NOM] [NOM] +En cours — BIONOLYTE G5 INJ FPE 500ML Début le 02/04/2023 à +- 5G/L + 2G/L ... solution (500 mL) - Poso 60 17 : 10 +m prl e/ sh ce .u + : +r 0e +2 +- +/ +0I 4N /T 20R 2A 3V @E I 1N 7E : 1U 0SE Continue - Début F 10in + : 3 +l 3e 07/04/2023 à 17 : 53 * 1 +Admin le 05/04/2023 à +00 : 13 +[NOM] [NOM] +En cours — BIONOLYTE G5 INJ FPE 500ML Début le 02/04/2023 à +- 5G/L + 2G/L ... solution (500 mL) - Poso 60 17 : 10 +m prl e/ sh ce .u + : +r 0e +2 +- +/ +0I 4N /T 20R 2A 3V @E I 1N 7E : 1U 0SE Continue - Début F 10in + : 3 +l 3e 07/04/2023 à 02 : 13 * 1 +Admin le 05/04/2023 à +00 : 13 +Signé — CAFEINE [NOM] 25MG/ML INJ BUV [NOM] [NOM] +[NOM] 2ML - 25MG/ML solution (2 mL) - Dose Début le 03/04/2023 à +350 mg - sur 30 min - INTRAVEINEUSE 13 : 53 +D Di és bc uo tn pti rn eu sce +. + : - 0T 3o /u 0t 4e /s +2 +l 0e 2s +3 +1 @2 H 1e 3u : 5re 3(s) Si besoin - F 06in + : 3 +l 0e 13/04/2023 à 1 m8 g : 30 * 350 +si douleur persistante malgré nubain Admin le 05/04/2023 à +06 : 30 +Signé — CAFEINE [NOM] 25MG/ML INJ BUV [NOM] [NOM] +[NOM] 2ML - 25MG/ML solution (2 mL) - Dose Début le 03/04/2023 à +350 mg - sur 30 min - INTRAVEINEUSE 13 : 53 +D Di és bc uo tn pti rn eu sce +. + : - 0T 3o /u 0t 4e /s +2 +l 0e 2s +3 +1 @2 H 1e 3u : 5re 3(s) Si besoin - F 06in + : 3 +l 0e 13/04/2023 à 0 m6 g : 30 * 350 +si douleur persistante malgré nubain Admin le 05/04/2023 à +06 : 30 +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min [NOM] [NOM] +- INTRAVEINEUSE Discontinue - Toutes les 4 Début le 02/04/2023 à +Heure(s) Si besoin - Début presc. : 02/04/2023 @ 20:22 +2 si0 d : 2 o2 +uleur malgré palier 1 +F 09in + : 5 +l 2e 13/04/2023 à 09 : 52 * 4 mg +Notes de professionel de santé : Admin le 05/04/2023 à +DILUER dans 20ML de NaCl 0.9% MAX 09 : 52 +1.2MG/KG/J +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min [NOM] [NOM] +- INTRAVEINEUSE Discontinue - Toutes les 4 Début le 02/04/2023 à +Heure(s) Si besoin - Début presc. : 02/04/2023 @ 20:22 +2 si0 d : 2 o2 +uleur malgré palier 1 +F 09in + : 5 +l 2e 13/04/2023 à 13 : 52 * 4 mg +Notes de professionel de santé : Admin le 05/04/2023 à +DILUER dans 20ML de NaCl 0.9% MAX 09 : 52 +1.2MG/KG/J +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min [NOM] [NOM] +- INTRAVEINEUSE Discontinue - Toutes les 4 Début le 02/04/2023 à +Heure(s) Si besoin - Début presc. : 02/04/2023 @ 20:22 +2 si0 d : 2 o2 +uleur malgré palier 1 +F 09in + : 5 +l 2e 13/04/2023 à 17 : 52 * 4 mg +Notes de professionel de santé : Admin le 05/04/2023 à +DILUER dans 20ML de NaCl 0.9% MAX 09 : 52 +1.2MG/KG/J +Signé — NALBUPHINE MYL 20 MG SOL INJ [NOM] [NOM] +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min Début le 02/04/2023 à +- INTRAVEINEUSE Discontinue - Toutes les 4 20 : 22 +Heure(s) Si besoin - Début presc. : 02/04/2023 @ Fin le 13/04/2023 à 21:52 * 4 mg +20 : 22 09:52 +si douleur malgré palier 1 Admin le 05/04/2023 à +09 : 52 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 14 de 19 Notes de professionel de santé : +DILUER dans 20ML de NaCl 0.9% MAX +1.2MG/KG/J +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min [NOM] [NOM] +- INTRAVEINEUSE Discontinue - Toutes les 4 Début le 02/04/2023 à +Heure(s) Si besoin - Début presc. : 02/04/2023 @ 20:22 +2 si0 d : 2 o2 +uleur malgré palier 1 +F 09in + : 5 +l 2e 13/04/2023 à 01 : 52 * 4 mg +Notes de professionel de santé : Admin le 05/04/2023 à +DILUER dans 20ML de NaCl 0.9% MAX 09 : 52 +1.2MG/KG/J +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min [NOM] [NOM] +- INTRAVEINEUSE Discontinue - Toutes les 4 Début le 02/04/2023 à +Heure(s) Si besoin - Début presc. : 02/04/2023 @ 20:22 +2 si0 d : 2 o2 +uleur malgré palier 1 +F 09in + : 5 +l 2e 13/04/2023 à 05 : 52 * 4 mg +Notes de professionel de santé : Admin le 05/04/2023 à +DILUER dans 20ML de NaCl 0.9% MAX 09 : 52 +1.2MG/KG/J +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 300 mg - sur Début le 02/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 17 : 10 11:10 * 300 +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 Fin le 12/04/2023 à mg +Notes de professionel de santé : 11:10 +Admin le 05/04/2023 à +MAX 1G/ INJ +11 : 18 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 300 mg - sur Début le 02/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 17 : 10 17:10 * 300 +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 Fin le 12/04/2023 à mg +Notes de professionel de santé : 11:10 +Admin le 05/04/2023 à +MAX 1G/ INJ +11 : 18 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 300 mg - sur Début le 02/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 17 : 10 23:10 * 300 +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 Fin le 12/04/2023 à mg +Notes de professionel de santé : 11:10 +Admin le 05/04/2023 à +MAX 1G/ INJ +11 : 18 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 300 mg - sur Début le 02/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 17 : 10 05:10 * 300 +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 Fin le 12/04/2023 à mg +Notes de professionel de santé : 11:10 +Admin le 05/04/2023 à +MAX 1G/ INJ +11 : 18 +Signé — ADVILMED 20 MG/ML [NOM] ET NR BOHN Quentin +SUSP BUV - 20MG/ML suspension (200 mL) - Début le 04/04/2023 à +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 10 : 28 10:28 * 1 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 Fin le 14/04/2023 à DOSE(S) +Notes de professionel de santé : 04:28 KILO +Admin le 05/04/2023 à +SYSTEMATIQUE +09 : 21 +Signé — ADVILMED 20 MG/ML [NOM] ET NR BOHN Quentin +SUSP BUV - 20MG/ML suspension (200 mL) - Début le 04/04/2023 à +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 10 : 28 16:28 * 1 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 Fin le 14/04/2023 à DOSE(S) +Notes de professionel de santé : 04:28 KILO +Admin le 05/04/2023 à +SYSTEMATIQUE +09 : 21 +Signé — ADVILMED 20 MG/ML [NOM] ET NR BOHN Quentin +SUSP BUV - 20MG/ML suspension (200 mL) - Début le 04/04/2023 à +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 10 : 28 22:28 * 1 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 Fin le 14/04/2023 à DOSE(S) +Notes de professionel de santé : 04:28 KILO +Admin le 05/04/2023 à +SYSTEMATIQUE +09 : 21 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 15 de 19 Signé — ADVILMED 20 MG/ML [NOM] ET NR BOHN Quentin +SUSP BUV - 20MG/ML suspension (200 mL) - Début le 04/04/2023 à +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 10 : 28 04:28 * 1 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 Fin le 14/04/2023 à DOSE(S) +Notes de professionel de santé : 04:28 KILO +Admin le 05/04/2023 à +SYSTEMATIQUE +09 : 21 +[NOM] +[NOM] [NOM] +Réalisé — REPAS : AIDE COMPLETE - Matin Début le 03/04/2023 à +[8h] - 1 Semaine- Date Début : 03/04/2023 @ 21:34 +21 : 34 Fin le 10/04/2023 à 08:00 * 1 +08 : 00 +Admin le 05/04/2023 à +08 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 02/04/2023 Début le 02/04/2023 à +@ 20 : 22 20:22 +Notes de professionel de santé : Fin le 12/04/2023 à 08:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 20:00 +ans : EVA [NOM] A PARIR de 8 ans: [NOM] Admin le 05/04/2023 à +numérique 0-10 08 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 02/04/2023 Début le 02/04/2023 à +@ 20 : 22 20:22 +Notes de professionel de santé : Fin le 12/04/2023 à 14:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 20:00 +ans : EVA [NOM] A PARIR de 8 ans: [NOM] Admin le 05/04/2023 à +numérique 0-10 08 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 02/04/2023 Début le 02/04/2023 à +@ 20 : 22 20:22 +Notes de professionel de santé : Fin le 12/04/2023 à 20:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 20:00 +ans : EVA [NOM] A PARIR de 8 ans: [NOM] Admin le 05/04/2023 à +numérique 0-10 08 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 02/04/2023 Début le 02/04/2023 à +@ 20 : 22 20:22 +Notes de professionel de santé : Fin le 12/04/2023 à 02:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 20:00 +ans : EVA [NOM] A PARIR de 8 ans: [NOM] Admin le 05/04/2023 à +numérique 0-10 08 : 00 +[NOM] [NOM] +Début le 02/04/2023 à +Réalisé — [NOM] : SURV - à 03h - 10 Jours- 20:22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 03:00 * 1 +03 : 00 +Admin le 05/04/2023 à +03 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 02/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 20 : 22 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 12/04/2023 à 08:00 * 1 +02/04/2023 @ 20 : 22 20:00 +Admin le 05/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 02/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 20 : 22 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 12/04/2023 à 12:00 * 1 +02/04/2023 @ 20 : 22 20:00 +Admin le 05/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 02/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 20 : 22 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 12/04/2023 à 16:00 * 1 +02/04/2023 @ 20 : 22 20:00 +Admin le 05/04/2023 à +12 : 00 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +[NOM] [NOM] 20 : 00 * 1 +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 16 de 19 Début le 02/04/2023 à +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 20:22 +02/04/2023 @ 20 : 22 Fin le 12/04/2023 à +20 : 00 +Admin le 05/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 02/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 20 : 22 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 12/04/2023 à 00:00 * 1 +02/04/2023 @ 20 : 22 20:00 +Admin le 05/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 02/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 20 : 22 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 12/04/2023 à 04:00 * 1 +02/04/2023 @ 20 : 22 20:00 +Admin le 05/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 08:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 11:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 14:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 17:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 20:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 23:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 12/04/2023 à 02:00 * 1 +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +Réalisé — SURV. NEUROLOGIQUE TTES LES [NOM] [NOM] +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- Début le 02/04/2023 à 05 : 00 * 1 +Date Début : 02/04/2023 @ 20:22 20:22 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 17 de 19 Fin le 12/04/2023 à +Notes de professionel de santé : 20:00 +" Conscience/pupilles/comportement" Admin le 05/04/2023 à +11 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 09/04/2023 à 08:00 * 1 +Notes de professionel de santé : 20:00 +mouvement anormaux Admin le 05/04/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 09/04/2023 à 14:00 * 1 +Notes de professionel de santé : 20:00 +mouvement anormaux Admin le 05/04/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 09/04/2023 à 20:00 * 1 +Notes de professionel de santé : 20:00 +mouvement anormaux Admin le 05/04/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 02/04/2023 à +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- 20 : 22 +Date Début : 02/04/2023 @ 20:22 Fin le 09/04/2023 à 02:00 * 1 +Notes de professionel de santé : 20:00 +mouvement anormaux Admin le 05/04/2023 à +08 : 00 +Résultats de laboratoire +02/04/2023 22 : 01 02/04/2023 22:01 02/04/2023 22:01 02/04/2023 17:52 02/04/2023 17:52 +Résultat de labo +(5922007) (5922006) (5922005) (5921945) (5921944) +Lactates LCR 1,5 mmol/l +Chlore 103 mmol/l +Créatinine 15 µmol/l +CRP 53 mg/l +Compte rendu Bactériologie Bact230405083235-1.pdf Bact230402230011-1.pdf +Compte-rendu laboratoire Labo230403142914-1.pdfLabo230403142912-1.pdfLabo230402230009-1.pdf +Polynucléaires neutrophiles +83,5 % +(%) +Polynucléaires neutrophiles +7,34 10.9/l +(#) +Polynucléaires éosinophiles +0,0 % +(%) +Polynucléaires éosinophiles +0,00 10.9/l +(#) +Polynucléaires basophiles (%) 0,2 % +Polynucléaires basophiles (#) 0,02 10.9/l +Lymphocytes (%) 9,1 % +Lymphocytes (#) 0,80 10.9/l +Monocytes (%) 7,2 % +Monocytes (#) 0,63 10.9/l +Glucose 5,6 mmol/l +Glucose LCR 3,7 mmol/l +réalisée sur automate +Formule sanguine +XN (Sysmex) +Hématocrite (%) 35,0 % +Indice de distribution des +14,5 % +hématies +Potassium 4,2 mmol/l +PCR Herpès (autre) Négative +Nature prélèvement PCR +LCR +HSV +PCR Enterovirus (LCR) Positive +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 18 de 19 Culture négative à 48h +Culture LCR TK (les bouillons seront +incubés pendant 5 j) +Examen direct Négatif +Leucocytes 14 /mm3 8,79 10.9/l +Liquide +Nature du prélèvement +céphalorachidien +Modalité de prélèvement Ponction lombaire +Sur voie veineuse +Localisation hémoculture +périphérique +Résultat automate flacon +En cours +pédiatrique +Hématies 4,66 10.12/l (t/l) +Hémoglobine 11,3 g/dl +VGM 75,1 fl +TCMH 24,2 pg +CCMH 32,3 g/dl +Sodium 137 mmol/l +Osmolarité sang 280 mOSM/l +Plaquettes 283 10.9/l +Protéines LCR 0,33 g/l +Validation et diffusion sous la Dr. [NOM]. [NOM] [NOM] Dr. [NOM]. [NOM] [NOM] +Dr [NOM] +responsabilité du biologiste [NOM] [NOM] [NOM] [NOM] +Volume plaquettaire moyen 10,4 fl +Lettres +Date +Type Texte [NOM] +d'impression +Bayonne, le 05/04/2023 +CERTIFICAT MEDICAL +Je soussigné(e) DR. [NOM] +certifie avoir examiné +[NOM] l'enfant [NOM] [NOM] né(e) le 15/01/2017 +Eviction +Crèche Son état de santé nécessite une éviction du centre aéré +le 06/04/23 +DR. [NOM] +10100837987 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg +Le 05/04/2023 14 : 30 Page 19 de 19 + + +Nom de naissance : [NOM] IPP : [IPP] +Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE] +Sexe : Masculin Lieu de naissance: [VILLE] +Nationalité : FRANCE [CODE_POSTAL] +Adresse : [ADRESSE]: [NOM] +Episode No : [EPISODE] +Localisation : PEDIATRIE GENERALE Médecin courant: DR. [NOM] +Date d'admission : 02/04/2023 Heure d'admission: 15:57 +Date de sortie : 05/04/2023 Heure de sortie: 12:02 +Nom : Adresse Téléphone +DR. [NOM] [NOM] : [ADRESSE][CODE_POSTAL] [TEL] +Episode - Date : 02/04/2023 +Episode - Heure : 15:57 +Mode de transport à l'arrivée : Véhicule personnel +Médicalisation du transport : Aucune médicalisation +Mode d'entrée : Autres admissions urgentes +Date d'orientation : 02/04/2023 +Heure d'orientation : 16:19 +IAO : [NOM] [NOM] +Priorité : Priorité 2 +Sous-type épisode : Pédiatrie +Motif de prise en charge : Céphalées +Fièvre +Observ. IDE Urg : Céphalées, hyperthermie le 30 et 31, mieux le 01 puis récidive des céphalées depuis cette nuit avec vomissements. +A l'arrivée algique++, prostré. +Photophobie. +Fébrile à 38.6. +ATG 16h30, advil à 10h ( a vomit par la suite) Nifluril à 13h. +Médecin informé, installé en box. +Médecin de la prise en charge médicale : [NOM] [NOM] +Date de prise en charge médicale : 02/04/2023 +Heure de prise en charge médicale : 15:57 +CCMU : , +Médecin de la décision médicale : [NOM] [NOM] +Date de décision médicale : 02/04/2023 +Heure de décision médicale : 20:23 +Décision médicale : Hospitalisation MCO +Orientation du patient : hospitalisation dans une [MASK], SI, REA +Date de sortie des urgences : 02/04/2023 +Heure de sortie des Urgences : 22:56 +US de destination : US PEDIATRIE +UF de destination : PEDIATRIE GENERALE +Type : Etat Code Date +Principal : actif G03.9 Méningite, sans précision [CMA2] 02/04/2023 22:53 + +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Item de +surveillance : 05/04/2023 +08:48 05/04/2023 +04:53 05/04/2023 +01:00 04/04/2023 +22:47 04/04/2023 +16:05 04/04/2023 +11:54 04/04/2023 +08:59 04/04/2023 +07:30 04/04/2023 +05:00 03/04/2023 +23:00 03/04/2023 +18:29 03/04/2023 +15:51 03/04/2023 +12:54 +Température : 36,50 36,50 36,80 36,50 36,70 37,20 35,60 36,60 36,60 36,10 36,50 +Pouls : 76 68 96 90 73 75 69 87 109 +PA +Systolique : 91 102 113 104 93 107 +PA +Diastolique : 51 52 65 59 64 70 +Saturation +O² : 99 99 97 99 99 99 99 100 100 +Ventilation : Ventilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant n +[NOM] +douleur : EVENDO LEVENDO LEVENDO LEVENDO LEVENDO LEVENDO LEVENDO LEVENDO L EVENDO LEVS EVS +Score au +repos : 1 0 0 0 2 0 0 6 0 0 2 +Transit : Absence +PA +Latéralité +Débit O² +[L/mn] +Item de +surveillance : 02/04/2023 +16:39 +Poids [kg] : 19,40 +Item de +surveillance : 05/04/2023 +08:48 05/04/2023 +04:53 04/04/2023 +22:47 04/04/2023 +16:05 04/04/2023 +11:54 04/04/2023 +08:59 04/04/2023 +05:00 03/04/2023 +23:00 03/04/2023 +18:29 03/04/2023 +15:51 03/04/2023 +12:54 03/04/2023 +09:06 03/04/2023 +06:34 +Température : 36,50 36,50 36,80 36,50 36,70 37,20 35,60 36,60 36,60 36,10 36,50 36,80 36,90 +Pouls : 76 68 96 90 73 75 69 87 109 90 +PA +Systolique : 91 102 113 104 93 107 106 +PA +Diastolique : 51 52 65 59 64 70 56 +Saturation +O² : 99 99 97 99 99 99 99 100 100 99 +Transit : Absence +Item de +surveillance : 05/04/2023 +08:48 05/04/2023 +04:53 04/04/2023 +22:47 04/04/2023 +16:05 04/04/2023 +11:54 04/04/2023 +08:59 04/04/2023 +05:00 03/04/2023 +23:00 03/04/2023 +18:29 03/04/2023 +15:51 03/04/2023 +12:54 03/04/2023 +09:06 03/04/2023 +06:34 +Température : 36,50 36,50 36,80 36,50 36,70 37,20 35,60 36,60 36,60 36,10 36,50 36,80 36,90 +Pouls : 76 68 96 90 73 75 69 87 109 90 +PA +Systolique : 91 102 113 104 93 107 106 +PA +Diastolique : 51 52 65 59 64 70 56 +Saturation +O² : 99 99 97 99 99 99 99 100 100 99 +Transit : Absence +Type d'observation : Nom Date Commentaires + +Note d'évolution : Quentin BOHN 04/04/2023 +16:52 J3 hospitalisation pour méningite à Entérovirus. +Encire quelques céphalées et douleurs au point de ponction mais a réussi à se lever pour prendre +une douche et aller en salle de jeux. +Nuque encore un peu raide. +Pas de photo-phonophobie. +Signe de Kernig négatif +Constipation, pas de selles depuis samedi avec douleurs abdo cette nuit. +Abdomen souple, pas de cordon colique, BHA +. +Pas d'effet du Forlax => [NOM] ce soir. + +Note d'évolution : DR. [NOM] +[NOM] 03/04/2023 +18:00 Céphalées et douleurs au point de ponction => sd post PL, débuter la caféine prescrite mais non +initiée +Note d'évolution : DR. [NOM] +[NOM] 02/04/2023 +22:54 soulagé après la PL +14 éléments, examen direct négatif, protéinorrachie normale +=> poursuite antibio sur la nuit et discuter l'arret demain matin +Note d'évolution : DR. [NOM] +[NOM] 02/04/2023 +22:02 PL : liquide hypertendu clair +glycémie 1,29 g/L +Note d'évolution : DR. [NOM] +[NOM] 02/04/2023 +21:27 reste céphalalgique avec photophobie, douleur majorée a la mobilisation, raideur de nuque +examen neurologique normal +pas de purpura +=> ponction lombaire +antibiothérapie +hospitalisation + +Item de +surveillance : 05/04/2023 +08:48 05/04/2023 +04:53 04/04/2023 +22:47 04/04/2023 +16:05 04/04/2023 +11:54 04/04/2023 +08:59 04/04/2023 +05:00 03/04/2023 +23:00 03/04/2023 +18:29 03/04/2023 +15:51 03/04/2023 +12:54 03/04/2023 +09:06 03/04/2023 +06:34 +Température : 36,50 36,50 36,80 36,50 36,70 37,20 35,60 36,60 36,60 36,10 36,50 36,80 36,90 +Pouls : 76 68 96 90 73 75 69 87 109 90 +PA +Systolique : 91 102 113 104 93 107 106 +PA +Diastolique : 51 52 65 59 64 70 56 +Saturation +O² : 99 99 97 99 99 99 99 100 100 99 +Transit : Absence +Type de note : Nom Date Note +Note IDE : [NOM] [NOM] 05/04/2023 +12:01 va mieux , bien soulagé par antalgique per os RAD ce jour. +Note IDE : [NOM] [NOM] 05/04/2023 +04:54 non algique : ATG 1 et AINS en systématique +Note IDE : [NOM] +[NOM] 04/04/2023 +21:07 Douleurs : se plaint de douleurs dorsales qui diffusent sur les hanches. A passé le début d'après +midi en salle de jeu => ATG1 et 2 fait en systématique. +Elimination : n'a pas eu de selle depuis samedi, laxatif n'a donné aucun résultat. +[NOM] fait à 18h sur consigne médical => a donné ++ + +Note IDE : [NOM] [NOM] 04/04/2023 +05:38 douleur +se plaint de temps en temps de douleurs au niveau du dos +vite soulagé par paracétamol +ATB poursuivis +pas de fièvre +Note IDE : [NOM] [NOM] 03/04/2023 +18:42 DOULEURS DORSALES : au niveau du pts de ponction (pst propre) à la mobilisation ==> +ATG1 en IV à 17h , soulagé par la suite +CEPHALEES : post PL ==> caféine IV passé à 18h ==> soulagée par la suite mais ce soir de +nouveau inconfortable avec des dlrs abdos ==> ATG2 fait à 21h +ALIMENTATION : prend un lait au chocolat + 1 chocolat au goûter // mange qques pâtes ce soir +Apyrétique cet apres midi +Note IDE : [NOM] [NOM] 03/04/2023 +13:57 algie : +algique sur sa PL --> ATG1 11h et ATG2 à 12h --> soulagé +pas de céphalées ni photophobie +infectieux : +apyrétique +Note IDE : [NOM] [NOM] 03/04/2023 +03:15 Douleur: +Algique post PL au niveau des lombaires, Céphalée persistante +ATG1 fait en IV en systématique +ATG2 fait à 00h +Soulagé par la suite puis de nouveau algique en fin de nuit: ATG2 fait +Pst propre non taché. +Infectieux: +Pic fébrile bien toléré à 00h +Poursuite ATB iv +Apyrétique par la suite +Hydratation Iv en continu +Note IDE : [NOM] [NOM] 02/04/2023 +17:28 A vomit à 17h30 environ 10 minutes après la fin de la prise doliprane. +Prescription : Dose Fréquence Date de début Date de dernière +administration Note Docteur +CAFEINE [NOM] 25MG/ML +INJ BUV [NOM] 2ML [10] +Ampoule(s) Bouteille(s) : 350 mg - Normal 03/04/2023 13:53 05/04/2023 06:30 Le débit en cours +est : 28 ML par 1 +hrs. DR. [NOM] +[NOM] +NALBUPHINE MYL +20MG/2ML SOL INJ [10] +Ampoule(s) Bouteille(s) : 4 mg - Normal 02/04/2023 20:22 05/04/2023 09:52 Le débit en +cours est : +1.200000000000000 +ML par 1 +hrs. Notes du +professionel de +santé: DILUER +dans 20ML de +NaCl 0.9% MAX +1.2MG/KG/J 1 +DR. [NOM] +[NOM] +PARACETAMOL BBM +10MG/ML INJ 100ML [10] +Flacon(s) : 300 mg - Normal 02/04/2023 17:10 05/04/2023 11:18 Le débit a été +modifié. Le débit +en cours est : 120 +par . Notes du +professionel de +santé: MAX 1G/ +INJ [NOM] +[NOM] + +BIONOLYTE G5 INJ FPE +500ML [10] Flacon(s) : - Normal 02/04/2023 17:10 05/04/2023 00:13 Le débit a été +modifié. Le débit +en cours est : 60 +ML par 1 hrs. [NOM] +[NOM] +ADVILMED 20MG/ML [NOM] +ET NR SUSP BUV [533] +Flacon(s) : 1 DOSE(S) +KILO - Normal 04/04/2023 10:28 05/04/2023 09:21 Notes du +professionel +de santé: +SYSTEMATIQUE Quentin BOHN +MACROGOL 4000 ARW +4G PDR BUV SACH [20] +SACHET(s) : 2 SACHET - 1xJour [8h] Normal 04/04/2023 10:27 05/04/2023 08:00 Quentin BOHN +IBUPROFENE ARW +200MG CPR ENR [20] +COMPRIME(S) : 1 CPR - Normal 04/04/2023 10:16 Quentin BOHN +ADVILMED 20MG/ML [NOM] +ET NR SUSP BUV [533] +Flacon(s) : 1 DOSE(S) +KILO - Presc. de Sortie 05/04/2023 10:34 DR. [NOM] +[NOM] +MACROGOL 4000 ARW +4G PDR BUV SACH [20] +SACHET(s) : 2 SACHET - 1xJour [8h] Presc. +de Sortie 05/04/2023 10:34 DR. [NOM] +[NOM] +PARACETAMOL [NOM] +SOL BUV : 1 DOSE(S) +KILO - Presc. de Sortie 05/04/2023 10:34 DR. [NOM] +[NOM] +[NOM] [NOM] +[NOM] SOL RECTALE +[1] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - 1 seule fois 1 seule +fois 04/04/2023 16:47 04/04/2023 17:30 Quentin BOHN +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +REPAS : AIDE COMPLETE Réalisé 1 Semaine - Matin +[8h] Normal 03/04/2023 +21:34 [NOM] +[NOM] +[NOM] +DOULEUR : SURV Réalisé 10 Jours - Ttes les +6h [2h 8h 14h 20h] +Normal 02/04/2023 +20:22 Notes du +professionel +de santé: +DE 0-6 +ans :EVENDO +A PARTIR +de 6 +ans:EVA +[NOM] A +PARIR de 8 +ans: [NOM] +numérique +0-10 L +DR. [NOM] +[NOM] +[NOM] : SURV Réalisé 10 Jours - à 03h +Normal 02/04/2023 +20:22 DR. [NOM] +[NOM] +SIGNES VITAUX (Pls, +TA, FR, T°, Glyc, Miction, +Transit) : Réalisé - Ttes les 4H [0h +4h ... 16h 20h] +Normal 02/04/2023 +20:22 DR. [NOM] +[NOM] +SURV. NEUROLOGIQUE +TTES LES 3H : Réalisé 10 Jours - Ttes les 3H +[2h 5h ... 20h 23h] +Normal 02/04/2023 +20:22 Notes du +professionel +de santé: +Conscience/ +pupilles/ +comportement DR. [NOM] +[NOM] + +SURV. NEUROLOGIQUE +TTES LES 6H : Réalisé 1 Semaine - Ttes les +6h [2h 8h 14h 20h] +Normal 02/04/2023 +20:22 Notes du +professionel +de santé: +mouvement +anormaux DR. [NOM] +[NOM] +VVP : POSE Réalisé - URGENT Urgent 02/04/2023 +17:52 [NOM] +[NOM] +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +ADVILMED 20MG/ML [NOM] +ET NR SUSP BUV [533] +Flacon(s) : 1 DOSE(S) +KILO +ORALE Réalisé - Presc. de Sortie 05/04/2023 +10:34 0/1 : Non administré +Révisé/Traité DR. [NOM]- +[NOM] +[NOM] +MACROGOL 4000 ARW +4G PDR BUV SACH [20] +SACHET(s) : 2 SACHET +ORALE Réalisé - 1xJour [8h] Presc. +de Sortie 05/04/2023 +10:34 0/14 : Non administré +Révisé/Traité DR. [NOM]- +[NOM] +[NOM] +PARACETAMOL [NOM] +SOL BUV : 1 DOSE(S) +KILO +ORALE Réalisé - Presc. de Sortie 05/04/2023 +10:34 0/40 : Non administré +Révisé/Traité DR. [NOM]- +[NOM] +[NOM] + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +En cours — BIONOLYTE G5 INJ FPE 500ML +- 5G/L + 2G/L ... solution (500 mL) - Poso 60 +ml/heure - INTRAVEINEUSE Continue - Début +presc. : 02/04/2023 @ 17:10 [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 07/04/2023 à +10:33 +Admin le 05/04/2023 à +00:13 08:33 * 1 +En cours — BIONOLYTE G5 INJ FPE 500ML +- 5G/L + 2G/L ... solution (500 mL) - Poso 60 +ml/heure - INTRAVEINEUSE Continue - Début +presc. : 02/04/2023 @ 17:10 [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 07/04/2023 à +10:33 +Admin le 05/04/2023 à +00:13 16:53 * 1 +En cours — BIONOLYTE G5 INJ FPE 500ML +- 5G/L + 2G/L ... solution (500 mL) - Poso 60 +ml/heure - INTRAVEINEUSE Continue - Début +presc. : 02/04/2023 @ 17:10 [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 07/04/2023 à +10:33 +Admin le 05/04/2023 à +00:13 01:13 * 1 +Signé — CAFEINE [NOM] 25MG/ML INJ BUV +[NOM] 2ML - 25MG/ML solution (2 mL) - Dose +350 mg - sur 30 min - INTRAVEINEUSE +Discontinue - Toutes les 12 Heure(s) Si besoin - +Début presc. : 03/04/2023 @ 13:53 +si douleur persistante malgré nubain [NOM] [NOM] +Début le 03/04/2023 à +13:53 +Fin le 13/04/2023 à +06:30 +Admin le 05/04/2023 à +06:30 18:30 * 350 +mg +Signé — CAFEINE [NOM] 25MG/ML INJ BUV +[NOM] 2ML - 25MG/ML solution (2 mL) - Dose +350 mg - sur 30 min - INTRAVEINEUSE +Discontinue - Toutes les 12 Heure(s) Si besoin - +Début presc. : 03/04/2023 @ 13:53 +si douleur persistante malgré nubain [NOM] [NOM] +Début le 03/04/2023 à +13:53 +Fin le 13/04/2023 à +06:30 +Admin le 05/04/2023 à +06:30 06:30 * 350 +mg +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 4 +Heure(s) Si besoin - Début presc. : 02/04/2023 @ +20:22 +si douleur malgré palier 1 +Notes de professionel de santé : +DILUER dans 20ML de NaCl 0.9% MAX +1.2MG/KG/J [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 13/04/2023 à +09:52 +Admin le 05/04/2023 à +09:52 13:52 * 4 mg +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 4 +Heure(s) Si besoin - Début presc. : 02/04/2023 @ +20:22 +si douleur malgré palier 1 +Notes de professionel de santé : +DILUER dans 20ML de NaCl 0.9% MAX +1.2MG/KG/J [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 13/04/2023 à +09:52 +Admin le 05/04/2023 à +09:52 17:52 * 4 mg +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 4 +Heure(s) Si besoin - Début presc. : 02/04/2023 @ +20:22 +si douleur malgré palier 1 +Notes de professionel de santé : +DILUER dans 20ML de NaCl 0.9% MAX +1.2MG/KG/J [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 13/04/2023 à +09:52 +Admin le 05/04/2023 à +09:52 21:52 * 4 mg + + + + + + + + + + + + + + + + + + + +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 4 +Heure(s) Si besoin - Début presc. : 02/04/2023 @ +20:22 +si douleur malgré palier 1 +Notes de professionel de santé : +DILUER dans 20ML de NaCl 0.9% MAX +1.2MG/KG/J [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 13/04/2023 à +09:52 +Admin le 05/04/2023 à +09:52 05:52 * 4 mg +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 4 +Heure(s) Si besoin - Début presc. : 02/04/2023 @ +20:22 +si douleur malgré palier 1 +Notes de professionel de santé : +DILUER dans 20ML de NaCl 0.9% MAX +1.2MG/KG/J [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 13/04/2023 à +09:52 +Admin le 05/04/2023 à +09:52 09:52 * 4 mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 300 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 12/04/2023 à +11:10 +Admin le 05/04/2023 à +11:18 17:10 * 300 +mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 300 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 12/04/2023 à +11:10 +Admin le 05/04/2023 à +11:18 23:10 * 300 +mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 300 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 12/04/2023 à +11:10 +Admin le 05/04/2023 à +11:18 05:10 * 300 +mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 300 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 12/04/2023 à +11:10 +Admin le 05/04/2023 à +11:18 11:18 * 300 +mg +Signé — ADVILMED 20 MG/ML [NOM] ET NR +SUSP BUV - 20MG/ML suspension (200 mL) - +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 +Notes de professionel de santé : +SYSTEMATIQUE BOHN Quentin +Début le 04/04/2023 à +10:28 +Fin le 14/04/2023 à +04:28 +Admin le 05/04/2023 à +09:21 16:28 * 1 +DOSE(S) +KILO +Signé — ADVILMED 20 MG/ML [NOM] ET NR +SUSP BUV - 20MG/ML suspension (200 mL) - +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 +Notes de professionel de santé : +SYSTEMATIQUE BOHN Quentin +Début le 04/04/2023 à +10:28 +Fin le 14/04/2023 à +04:28 +Admin le 05/04/2023 à +09:21 22:28 * 1 +DOSE(S) +KILO +Signé — ADVILMED 20 MG/ML [NOM] ET NR +SUSP BUV - 20MG/ML suspension (200 mL) - +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 +Notes de professionel de santé : +SYSTEMATIQUE BOHN Quentin +Début le 04/04/2023 à +10:28 +Fin le 14/04/2023 à +04:28 +Admin le 05/04/2023 à +09:21 04:28 * 1 +DOSE(S) +KILO + + + + + + + + + + + + + +Signé — ADVILMED 20 MG/ML [NOM] ET NR +SUSP BUV - 20MG/ML suspension (200 mL) - +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 +Notes de professionel de santé : +SYSTEMATIQUE BOHN Quentin +Début le 04/04/2023 à +10:28 +Fin le 14/04/2023 à +04:28 +Admin le 05/04/2023 à +09:21 09:21 * 1 +DOSE(S) +KILO +Signé — MACROGOL 4000 ARW 4G PDR +BUV SACH - 4G poudre - Dose 2 SACHET - +ORALE - 1xJour [8h] - 1ère dose : 05/04/2023 @ +08:00 BOHN Quentin +Début le 04/04/2023 à +10:27 +Fin le 14/04/2023 à +08:00 +Admin le 05/04/2023 à +08:00 08:00 * 2 +SACHET +Réalisé — REPAS : AIDE COMPLETE - Matin +[8h] - 1 Semaine- Date Début: 03/04/2023 @ +21:34 [NOM] +[NOM] [NOM] +Début le 03/04/2023 à +21:34 +Fin le 10/04/2023 à +08:00 +Admin le 05/04/2023 à +08:00 08:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 02/04/2023 +@ 20:22 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:EVA [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 14:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 02/04/2023 +@ 20:22 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:EVA [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 20:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 02/04/2023 +@ 20:22 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:EVA [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 02:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 02/04/2023 +@ 20:22 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:EVA [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 08:00 * 1 +Réalisé — [NOM] : SURV - à 03h - 10 Jours- +Date Début: 02/04/2023 @ 20:22 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +03:00 +Admin le 05/04/2023 à +03:00 03:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 02/04/2023 @ 20:22 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +12:00 16:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 02/04/2023 @ 20:22 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +12:00 20:00 * 1 + +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 02/04/2023 @ 20:22 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +12:00 04:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 02/04/2023 @ 20:22 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +12:00 08:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 02/04/2023 @ 20:22 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +12:00 12:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 14:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 17:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 20:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 23:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 02:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 05:00 * 1 + +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 11:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +mouvement anormaux [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 09/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 14:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +mouvement anormaux [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 09/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 20:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +mouvement anormaux [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 09/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 02:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +mouvement anormaux [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 09/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 08:00 * 1 + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +En cours — BIONOLYTE G5 INJ FPE 500ML +- 5G/L + 2G/L ... solution (500 mL) - Poso 60 +ml/heure - INTRAVEINEUSE Continue - Début +presc. : 02/04/2023 @ 17:10 [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 07/04/2023 à +10:33 +Admin le 05/04/2023 à +00:13 09:33 * 1 +En cours — BIONOLYTE G5 INJ FPE 500ML +- 5G/L + 2G/L ... solution (500 mL) - Poso 60 +ml/heure - INTRAVEINEUSE Continue - Début +presc. : 02/04/2023 @ 17:10 [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 07/04/2023 à +10:33 +Admin le 05/04/2023 à +00:13 17:53 * 1 +En cours — BIONOLYTE G5 INJ FPE 500ML +- 5G/L + 2G/L ... solution (500 mL) - Poso 60 +ml/heure - INTRAVEINEUSE Continue - Début +presc. : 02/04/2023 @ 17:10 [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 07/04/2023 à +10:33 +Admin le 05/04/2023 à +00:13 02:13 * 1 +Signé — CAFEINE [NOM] 25MG/ML INJ BUV +[NOM] 2ML - 25MG/ML solution (2 mL) - Dose +350 mg - sur 30 min - INTRAVEINEUSE +Discontinue - Toutes les 12 Heure(s) Si besoin - +Début presc. : 03/04/2023 @ 13:53 +si douleur persistante malgré nubain [NOM] [NOM] +Début le 03/04/2023 à +13:53 +Fin le 13/04/2023 à +06:30 +Admin le 05/04/2023 à +06:30 18:30 * 350 +mg +Signé — CAFEINE [NOM] 25MG/ML INJ BUV +[NOM] 2ML - 25MG/ML solution (2 mL) - Dose +350 mg - sur 30 min - INTRAVEINEUSE +Discontinue - Toutes les 12 Heure(s) Si besoin - +Début presc. : 03/04/2023 @ 13:53 +si douleur persistante malgré nubain [NOM] [NOM] +Début le 03/04/2023 à +13:53 +Fin le 13/04/2023 à +06:30 +Admin le 05/04/2023 à +06:30 06:30 * 350 +mg +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 4 +Heure(s) Si besoin - Début presc. : 02/04/2023 @ +20:22 +si douleur malgré palier 1 +Notes de professionel de santé : +DILUER dans 20ML de NaCl 0.9% MAX +1.2MG/KG/J [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 13/04/2023 à +09:52 +Admin le 05/04/2023 à +09:52 09:52 * 4 mg +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 4 +Heure(s) Si besoin - Début presc. : 02/04/2023 @ +20:22 +si douleur malgré palier 1 +Notes de professionel de santé : +DILUER dans 20ML de NaCl 0.9% MAX +1.2MG/KG/J [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 13/04/2023 à +09:52 +Admin le 05/04/2023 à +09:52 13:52 * 4 mg +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 4 +Heure(s) Si besoin - Début presc. : 02/04/2023 @ +20:22 +si douleur malgré palier 1 +Notes de professionel de santé : +DILUER dans 20ML de NaCl 0.9% MAX +1.2MG/KG/J [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 13/04/2023 à +09:52 +Admin le 05/04/2023 à +09:52 17:52 * 4 mg + + + + + + + + + + + + + + + + + + + +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 4 +Heure(s) Si besoin - Début presc. : 02/04/2023 @ +20:22 +si douleur malgré palier 1 +Notes de professionel de santé : +DILUER dans 20ML de NaCl 0.9% MAX +1.2MG/KG/J [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 13/04/2023 à +09:52 +Admin le 05/04/2023 à +09:52 01:52 * 4 mg +Signé — NALBUPHINE MYL 20 MG SOL INJ +- 20MG solution (2 mL) - Dose 4 mg - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 4 +Heure(s) Si besoin - Début presc. : 02/04/2023 @ +20:22 +si douleur malgré palier 1 +Notes de professionel de santé : +DILUER dans 20ML de NaCl 0.9% MAX +1.2MG/KG/J [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 13/04/2023 à +09:52 +Admin le 05/04/2023 à +09:52 05:52 * 4 mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 300 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 12/04/2023 à +11:10 +Admin le 05/04/2023 à +11:18 11:10 * 300 +mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 300 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 12/04/2023 à +11:10 +Admin le 05/04/2023 à +11:18 17:10 * 300 +mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 300 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 12/04/2023 à +11:10 +Admin le 05/04/2023 à +11:18 23:10 * 300 +mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 300 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 02/04/2023 @ 17:10 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 02/04/2023 à +17:10 +Fin le 12/04/2023 à +11:10 +Admin le 05/04/2023 à +11:18 05:10 * 300 +mg +Signé — ADVILMED 20 MG/ML [NOM] ET NR +SUSP BUV - 20MG/ML suspension (200 mL) - +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 +Notes de professionel de santé : +SYSTEMATIQUE BOHN Quentin +Début le 04/04/2023 à +10:28 +Fin le 14/04/2023 à +04:28 +Admin le 05/04/2023 à +09:21 10:28 * 1 +DOSE(S) +KILO +Signé — ADVILMED 20 MG/ML [NOM] ET NR +SUSP BUV - 20MG/ML suspension (200 mL) - +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 +Notes de professionel de santé : +SYSTEMATIQUE BOHN Quentin +Début le 04/04/2023 à +10:28 +Fin le 14/04/2023 à +04:28 +Admin le 05/04/2023 à +09:21 16:28 * 1 +DOSE(S) +KILO +Signé — ADVILMED 20 MG/ML [NOM] ET NR +SUSP BUV - 20MG/ML suspension (200 mL) - +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 +Notes de professionel de santé : +SYSTEMATIQUE BOHN Quentin +Début le 04/04/2023 à +10:28 +Fin le 14/04/2023 à +04:28 +Admin le 05/04/2023 à +09:21 22:28 * 1 +DOSE(S) +KILO + + + + + + + + + + + + + +Signé — ADVILMED 20 MG/ML [NOM] ET NR +SUSP BUV - 20MG/ML suspension (200 mL) - +Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 +Heure(s) - 1ère dose : 04/04/2023 @ 10:28 +Notes de professionel de santé : +SYSTEMATIQUE BOHN Quentin +Début le 04/04/2023 à +10:28 +Fin le 14/04/2023 à +04:28 +Admin le 05/04/2023 à +09:21 04:28 * 1 +DOSE(S) +KILO +Réalisé — REPAS : AIDE COMPLETE - Matin +[8h] - 1 Semaine- Date Début: 03/04/2023 @ +21:34 [NOM] +[NOM] [NOM] +Début le 03/04/2023 à +21:34 +Fin le 10/04/2023 à +08:00 +Admin le 05/04/2023 à +08:00 08:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 02/04/2023 +@ 20:22 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:EVA [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 08:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 02/04/2023 +@ 20:22 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:EVA [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 14:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 02/04/2023 +@ 20:22 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:EVA [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 20:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 02/04/2023 +@ 20:22 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:EVA [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 02:00 * 1 +Réalisé — [NOM] : SURV - à 03h - 10 Jours- +Date Début: 02/04/2023 @ 20:22 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +03:00 +Admin le 05/04/2023 à +03:00 03:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 02/04/2023 @ 20:22 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +12:00 08:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 02/04/2023 @ 20:22 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +12:00 12:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 02/04/2023 @ 20:22 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +12:00 16:00 * 1 + +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 02/04/2023 @ 20:22 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +12:00 00:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 02/04/2023 @ 20:22 [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +12:00 04:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 08:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 11:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 14:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 17:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 20:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 23:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 12/04/2023 à +20:00 +Admin le 05/04/2023 à +11:00 02:00 * 1 + +Réalisé — SURV. NEUROLOGIQUE TTES LES +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +mouvement anormaux [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 09/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 08:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +mouvement anormaux [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 09/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 14:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +mouvement anormaux [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 09/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 20:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +6H - Ttes les 6h [2h 8h 14h 20h] - 1 Semaine- +Date Début : 02/04/2023 @ 20:22 +Notes de professionel de santé : +mouvement anormaux [NOM] [NOM] +Début le 02/04/2023 à +20:22 +Fin le 09/04/2023 à +20:00 +Admin le 05/04/2023 à +08:00 02:00 * 1 +Résultat de labo : 02/04/2023 22:01 +(5922007) 02/04/2023 22:01 +(5922006) 02/04/2023 22:01 +(5922005) 02/04/2023 17:52 +(5921945) 02/04/2023 17:52 +(5921944) +Lactates LCR : 1,5 mmol/l +Chlore : 103 mmol/l +Créatinine : 15 µmol/l +CRP : 53 mg/l +Compte rendu Bactériologie : Bact230405083235-1.pdf Bact230402230011-1.pdf +Compte-rendu laboratoire : Labo230403142914-1.pd fLabo230403142912-1.pd fLabo230402230009-1.pd f +Polynucléaires neutrophiles +(%) : 83,5 % +Polynucléaires neutrophiles +(#) : 7,34 10.9/l +Polynucléaires éosinophiles +(%) : 0,0 % +Polynucléaires éosinophiles +(#) : 0,00 10.9/l +Polynucléaires basophiles (%) : 0,2 % +Polynucléaires basophiles (#) : 0,02 10.9/l +Lymphocytes (%) : 9,1 % +Lymphocytes (#) : 0,80 10.9/l +Monocytes (%) : 7,2 % +Monocytes (#) : 0,63 10.9/l +Glucose : 5,6 mmol/l +Glucose LCR : 3,7 mmol/l +Formule sanguine : réalisée sur automate +XN (Sysmex) +Hématocrite (%) : 35,0 % +Indice de distribution des +hématies : 14,5 % +Potassium : 4,2 mmol/l +PCR Herpès (autre) : Négative +Nature prélèvement PCR +HSV : LCR +PCR Enterovirus (LCR) : Positive + +Culture LCR TK : Culture négative à 48h +(les bouillons seront +incubés pendant 5 j) +Examen direct : Négatif +Leucocytes : 14 /mm3 8,79 10.9/l +Nature du prélèvement : Liquide +céphalorachidien +Modalité de prélèvement : Ponction lombaire +Localisation hémoculture : Sur voie veineuse +périphérique +Résultat automate flacon +pédiatrique : En cours +Hématies : 4,66 10.12/l (t/l) +Hémoglobine : 11,3 g/dl +VGM : 75,1 fl +TCMH : 24,2 pg +CCMH : 32,3 g/dl +Sodium : 137 mmol/l +Osmolarité sang : 280 mOSM/l +Plaquettes : 283 10.9/l +Protéines LCR : 0,33 g/l +Validation et diffusion sous la +responsabilité du biologiste : Dr [NOM] [NOM] Dr. [NOM] [NOM] +[NOM] Dr. [NOM] [NOM] +[NOM] Dr. [NOM] [NOM] +[NOM] Dr. [NOM] [NOM] +[NOM] +Volume plaquettaire moyen : 10,4 fl +Type : Texte Date +d'impression [NOM] +[NOM] +Eviction +Crèche : Bayonne, le 05/04/2023 +CERTIFICAT MEDICAL +Je soussigné(e) DR. [NOM] +certifie avoir examiné +l'enfant [NOM] [NOM] né(e) le 15/01/2017 +Son état de santé nécessite une éviction du centre aéré +le 06/04/23 +DR. 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"DATE_NAISSANCE_GLOBAL", "original": "Date de naissance : 24-02-1959", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null} +{"page": -1, "kind": "DATE_NAISSANCE_GLOBAL", "original": "Date de naissance : 24/02/1959", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null} +{"page": -1, "kind": "DATE_NAISSANCE_GLOBAL", "original": "Date de naissance: 24/02/1959", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "001163708", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "06 82 30 49\n10", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "0682304910", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "06 82 30 49", "placeholder": "[TEL]", "bbox_hint": null} diff --git a/tests/ground_truth/pdfs/baseline_anonymized/025_complexe_trackare_trackare-02016820-23095226_02016820_23095226.pseudonymise.txt b/tests/ground_truth/pdfs/baseline_anonymized/025_complexe_trackare_trackare-02016820-23095226_02016820_23095226.pseudonymise.txt new file mode 100644 index 0000000..3d4178b --- /dev/null +++ b/tests/ground_truth/pdfs/baseline_anonymized/025_complexe_trackare_trackare-02016820-23095226_02016820_23095226.pseudonymise.txt @@ -0,0 +1,4960 @@ +CENTRE HOSPITALIER COTE BASQUE +*640N0° F0in0ess162* +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +640000162 +MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC +Dossier Patient +Détails des patients +Nom de naissance : [NOM] IPP : [IPP] +Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE] +Sexe : Masculin Lieu de naissance: [VILLE] +Nationalité : FRANCE [CODE_POSTAL] +Adresse : [ADRESSE]: [VILLE] +Détails épisode +Episode No : [EPISODE] +Localisation : PNEUMOLOGIE PHTISIOLOGIE HC Médecin courant: DR. [NOM] +Date d'admission : 12/06/2023 Heure d'admission: 13:22 +Date de sortie : 21/06/2023 Heure de sortie: 13:32 +Médecin traitant +Nom Adresse Téléphone +DR. [NOM] [ADRESSE][CODE_POSTAL] 59.63.06.65 +Liste des contacts +Tél. +Type de contact Relation Nom Prénom Adresse Tél. domicile Mobile +professionel +Personne à prévenir +Epouse [NOM] FRANCE [TEL] +(Trakcare) +Personne à prévenir [NOM] [TEL] +Epouse [NOM] FRANCE +(Clinicom) HELENE 10 +Personne de [NOM] +Epouse [NOM] [TEL] +confiance HELENE +Motif de la venue +Motif Principal Date de mise à jour [NOM] +[NOM] , douleur au domicile 12/06/2023 14 : 12 [NOM] [NOM] +Antécédents (texte libre) +Type de note Nom Date Heure Note +Aucune donnée +renseignée +Antécédents habitus (texte libre) +Type de note Nom Date Heure Note +Aucune donnée +renseignée +Signes vitaux +Item de 20/06/2023 20/06/2023 20/06/2023 20/06/2023 19/06/2023 19/06/2023 18/06/2023 18/06/2023 17/06/2023 17/06/2023 17/06/2023 16/06/2023 16/06/2023 +surveillance 23 : 49 20:55 15:46 08:12 19:09 09:01 15:50 11:58 16:43 07:54 00:01 15:48 08:41 +Température 37,30 36,50 36,30 37,30 37,20 36,60 37,10 36,20 37,10 37,30 +Pouls 86 85 90 89 93 99 103 83 95 99 +Saturation +92 94 92 92 93 93 92 94 92 90 +O² +Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation +spontanée spontanée spontanée spontanée spontanée spontanée spontanée spontanée spontanée spontanée +Ventilation +Air Air Air Air Air Air Air Air Air Air +ambiant ambiant ambiant ambiant ambiant ambiant ambiant ambiant ambiant ambiant +Echelle +EN EN EN ALGOPLUSEN EN EN EN EN EN +douleur +Score au +1 1 4 3 8 2 2 6 1 5 +repos +PA +111 106 129 118 110 142 124 125 +Systolique +PA +64 59 65 60 58 70 65 64 +Diastolique +Transit Normal Normal Normal Absence Peu Absence Absence Absence Absence +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 1 de 31 Débit O² +[L/mn] +Poids/Taille +Item de 12/06/2023 +surveillance 13 : 35 +Poids [kg] 77 +Taille [cm] 178 +Indice +de [NOM] 24,30 +corporelle +Surface +1,95 +corporelle +Surv. Isolement et Contention +Item de 20/06/2023 20/06/2023 20/06/2023 19/06/2023 18/06/2023 18/06/2023 17/06/2023 17/06/2023 17/06/2023 16/06/2023 16/06/2023 15/06/2023 15/06/2023 +surveillance 23 : 49 15:46 08:12 09:01 15:50 11:58 16:43 07:54 00:01 15:48 08:41 16:10 12:45 +Température 37,30 36,50 36,30 37,30 37,20 36,60 37,10 36,20 37,10 37,30 35,90 +Pouls 86 85 90 89 93 99 103 83 95 99 83 +Saturation +92 94 92 92 93 93 92 94 92 90 92 92 +O² +PA +111 106 129 118 110 142 124 125 109 +Systolique +PA +64 59 65 60 58 70 65 64 59 +Diastolique +Transit Normal Normal Normal Absence Peu Absence +Surv. Contention +Item de 20/06/2023 20/06/2023 20/06/2023 19/06/2023 18/06/2023 18/06/2023 17/06/2023 17/06/2023 17/06/2023 16/06/2023 16/06/2023 15/06/2023 15/06/2023 +surveillance 23 : 49 15:46 08:12 09:01 15:50 11:58 16:43 07:54 00:01 15:48 08:41 16:10 12:45 +Température 37,30 36,50 36,30 37,30 37,20 36,60 37,10 36,20 37,10 37,30 35,90 +Pouls 86 85 90 89 93 99 103 83 95 99 83 +Saturation +92 94 92 92 93 93 92 94 92 90 92 92 +O² +PA +111 106 129 118 110 142 124 125 109 +Systolique +PA +64 59 65 60 58 70 65 64 59 +Diastolique +Transit Normal Normal Normal Absence Peu Absence +Observations médicales +Type d'observation Nom Date Commentaires +Hospitalisation du 12/06 au 21/06/23 pour équilibration des douleurs chez un patient suivi pour +un ADK bronchique stade IV en 5e ligne par TAXOL hebdo. +Moins de 24H après son entrée, fracture pathologique de l’humerus [NOM] ayant necessité +enclouage centromedullaire le 14/06 avec hematome post-opératoire d’evolution favorable. +Réalisation d’une cimentoplastie du [NOM] [NOM] le 13/06 sans complication. +Devant une équilibration des douleurs avec la PCA de morphine, relai par morphine oral le +DR. [NOM] 21/06/2023 18/06. Analgésie mutlimodale par OXYCONTIN LP 70mg matin et soir, prise d’ABSTRAL +Conclusion Clinique +[NOM] 10 : 22 400 si besoin, PARACETAMOL 4g/jour , KETOPROFENE LP 100mg matin et soir et reprise du +cannabis thérapeutique. +Devant l’état général alteré du patient, discussion sur un arret de la chimiothérapie afin de +privilégier les soins de confort. Pour le moment, cela n’est pas entendable pour le patient. +Il reviendra le 4/07 en HDJ pour une réévaluation clinique +/- chimio si son état général le +permet. +RAD le 21/06. +20/06 : LM +Reveil ce matin à 1H et 4H bien soulagé par prise d'ABASTRAL. +Non douloureux lors de mon passage. Hematome du bras en diminution. +DR. [NOM] 20/06/2023 +Note d'évolution +[NOM] 13 : 53 Majoration OXYCONTIN LP 70 matin et soir +Arret hydratation IV +Souhaite RAD demain. +recrudescence douloureuse chez un patient en prise en charge palliative symptomatique d'un +DR. [NOM] 19/06/2023 adénocarcinome pulmonaire métastatique osseux +Note d'évolution +[NOM] 16 : 30 En cours d'expérimentation sur le cannabis thérapeutique +Reprise mélange équilibré CBD/THC 25mg/ml 0.4ml matin, midi et soir +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 2 de 31 19/06 : LM +A passé une bonne nuit sans douleur. +Au réveil, accès douloureux intense ++ finalement soulagé après prise d'OXYNORMORO +Lors de mon passage, dort donc longue discussion avec son épouse. +Proposition de tenter l'ABSTRAL et poursuite OXYCONTIN LP +DR. [NOM] 19/06/2023 +Note d'évolution +[NOM] 12 : 39 Vu avec Dr [NOM] : ABSTRAL 400. Si acces douloureux non soulagé après 30min, +possible de lui redonner un nouveau ABSTRAL. +Intervalle de 2 à 4H entre chaque prise +Pas de vomissement. Bonne hydratation per os +Arret hydratation IV +Projet de RAD quand douleur équilibrée +18/06 : LM +DR. [NOM] 18/06/2023 +Note d'évolution Douleur bien équilibrée avec PCA +[NOM] 16 : 19 +A la demande du patient, tentative relai per os +-> Relai OXYCONTIN LP 65mg à 20H avec arret PCA à 22H00 +17/06 : LM +DR. [NOM] 17/06/2023 +Note d'évolution A passé une bonne nuit. Douleur au reveil mais calmée par PCA +[NOM] 15 : 10 +Vomissement après ACUPAN donc arret ACUPAN +16/06 : LM +Reste douloureux ++ +DR. [NOM] 16/06/2023 Majoration PCA à 3.8mg/h et majoration bolus à 9mg +Note d'évolution +[NOM] 19 : 36 +Nauséeux. Introduction de PRIMPERAN +A eu des selles +message laissé au secrétariat pour demander si l'interne peut passer pour examiner le bras car +DR. [NOM] 15/06/2023 +Note d'évolution hématome post op mais probablement normal. +[NOM] 13 : 22 +merci +15 6 23 SS +annulation de la radiothérapie séance de ce jour car patient non mobilisable. +ce matin a réussi à dormir cette nuit mais encore inconfortable, réveillable , discret myosis , parle +sans problème . je lui explique que si je majore les doses de morphine, il y a un risque d'être +ensuqué à cause de la morphine. Après discussion, nous convenons +DR. [NOM] 15/06/2023 +Note d'évolution - de garder la même dose de morphine de fond pour la journée à 3,5 mg/heure IVSE +[NOM] 12 : 15 +- de majorer la dose de fond pendant le nuit uniquement de 22h à 8 h à 3,8 mg / heure IVSE +(prescrit dans commentaire sur trackare) +[NOM], et [NOM] si constipé +pas de globe, arrive à uriner +réévaluation au jour le jour de Mr [NOM] +14 6 23 SS +a eu hier +FRACTURE PATHOLOGIQUE DE LA DIAPHYSE [NOM] [NOM] +INTERVENTION : BIOPSIE, REDUCTION ET OSTEOSYNTHESE PAR ENCLOUAGE +CENTROMEDULLAIRE ++ cimentoplastie du bassin +remonté hier à 19h45 du bloc opératoire et a passé une mauvaise nuit malgré la PCA, donc +majoration des doses de fond cette nuit puis ce matin, à la dose de 84 mg/24 en fond + bolus à 5 +DR. [NOM] 14/06/2023 +Note d'évolution mg +[NOM] 13 : 08 +évaluation de fin de matinée pour voir efficacité : +dort à mon passage, somnole, tout à fait réveillable mais récupère de 24 à 36h sans beaucoup de +sommeil, je le laisse donc récupérer. +introduction moventig contre la constipation +si globe urinaire, prévoir un sondage +biologie en cours +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 3 de 31 Patient à ne pas masser, ou intuber en cas de dégradation de son état général. +[NOM] [NOM] [NOM] +Intervention réalisée sans complication. Comblement satisfaisant de la lésion lytique du [NOM] +[NOM]. +DR. [NOM] 13/06/2023 +Note d'évolution +[NOM] 17 : 09 Au retour en chambre, repos en décubitus dorsal pendant 2 heures. En fonction de l'état du +patient au décours, lever autorisé. Si marche possible, réévaluation de la douleur inguinale droite. +En rapport avec l'intervention du [NOM], retour à domicile autorisé à J1 en absence de +symptomatologie particulière. +Dr [NOM] +ok pour la chirurgie +DR. [NOM] 13/06/2023 +Note d'évolution +[NOM] 10 : 55 bon faxé au bloc +demande anesthésiste en urgence +13 06 23 SS +fracture humérus [NOM] cette nuit sur méta os +a eu 20 mg en titration de morphine IVD pour être soulagé +ce matin à jeun +attitude vicieuse MSD +calmé de la douleur si il reste immobile +DR. [NOM] 13/06/2023 Appel Dr [NOM] , pas de réponse ( car connaît le patient) +Note d'évolution +[NOM] 10 : 17 Appel Dr [NOM] : au bloc opératoire, me rappelle +ECG, groupe rhésus RAI, hémostase réalisée +PCA de morphine à 5 mg en bolus toutes les 10 minutes si besoin mais sans ttt de fond pour le +moment +prescriptions à revoir dans la journée en fonction de son évolution +en attente de l'avis du chirurgien orthopédique +Appel IDE pour douleur brutal bras [NOM] en se retournant dans le lit. ( méta huméral droite +connu ) +A entendu un craquement en se retournant dans le lit. +13/06/2023 EN 10/10 patient en pleur +Note d'évolution Tess [NOM] +05 : 19 Examen impossible, pas d'hématome visible, humérus instable +> Titration morphinique +> Rx demandé +> mise en place d'un dujarier +suivi de son cancer du poumon métastatique. +antécédents +- Fracture claviculaire avec pose de plaque à gauche +- BPCO post-tabagique. +Absence d'’allergie connue. +Tabagisme estimé à 40PA, sevré en novembre. +Histoire de la DR. [NOM] 12/06/2023 +maladie [NOM] 14 : 18 +Mode de vie : vit à Bayonne dans une maison avec son épouse. Ils ont trois enfants de 27 à 39 +ans. Il ne travaille pas actuellement mais exerçait comme chauffeur routier. +Traitement en cours : +- BIPROFENID LP 100 mg matin et soir +- OXYCONTIN LP 50 mg le matin et 40 à 50 mg le soir +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 4 de 31 - OXYNORM en interdoses à 40 mg +- LYRICA 100 mg matin et soir +- DOLIPRANE +- ESOMEPRAZOLE 40 mg le soir +- THC-CBD huile +Histoire de la maladie : +Découverte en février 2022 sur douleurs basithoraciques et dysphonie d ’un adénocarcinome +pulmonaire d ’emblée métastatique osseux hépatique et ganglionnaire. PDL1 1% et non muté. +1ère ligne de traitement par CARBOPLATINE-ALIMTA-PEMBROLIZUMAB : 2 cures +réalisées avec au scanner de mai 2022. progression au niveau osseux avec changement de ligne +par +2ème ligne TAXOL-AVASTIN et radiothérapie sur épidurite T5 et L3. Majoration des douleurs +sur métastases lithiques scapulaires gauches avec cimentoplastie faite par le Dr [NOM] le +25/10/2022 partiellement efficace, tout comme la radiothérapie effectuée par le Dr [NOM]. +Dernier scanner de la scapula gauche le 05/11/2022 retrouvant une majoration du foyer de +fracture au niveau de la glène étendue à la fosse infra-épineuse. +AVASTIN de maintenance TEP-TDM 16/01 : Progression de l'atteinte osseuse secondaire du +squelette axial et appendiculaire. Rupture ou érosion du mur vertébral postérieur en C5, C6, +T12 et L3. Envahissement foraminal C7-T1 gauche. Réponse métabolique partielle de la lésion +hépatique du segment V et des adénopathies cervicales gauches. Stabilité métabolique de la +lésion médiastinale supérieure gauche. Radiothérapie en février sur l’atteinte cervicale basse et +thoracique haute : +3ème ligne chimiothérapie par NAVELBINE. Nouvelle radiothérapie 3ème côte gauche, [NOM] +[NOM] et T12 en mars 2023. Réévaluation scannographique fin mars 2023 après 4 cures de +NAVELBINE avec réponse dissociée et une nouvelle ligne par : +4ème ligne GEMCITABINE Discussion en cours avec programmation d’ une cimentoplastie +pour la lésion du [NOM] fémoral [NOM] avec potentielle chirurgie associée. +scanner de réévaluation thoraco-abdomino-pelvien et cérébral du 22 mai 2023 retrouvant avant +tout une progression osseuse multifocale : aspect plus nécrotique de la lésion costale de la 3e +côte à gauche. Majoration ostéolytique de la 9e cote à gauche avec disparition de la corticale. +Majoration ostéolytique de la 12e cote à gauche. Majoration en taille de la lésion de la 9e côte +à droite passant de 17 à 20 mm. Apparition d'une fracture de la 5e côte à droite. Majoration de +lésion ostéolytique du pédicule de la 7e vertébrale gauche. Majoration de l'atteinte ostéolytique +du sternum. Pas de nouvelle fracture-tassement vertébrale. Pas de recul du mur postérieur. +Relecture : lésion humérale droite, déjà présente par le passé, avec majoration de taille. +Exploration incomplète sur le scanner : demande d'une radiographie lors de sa prochaine cure de +chimiothérapie le 30/05/23. Concernant l'épaule gauche : lésion scapulaire non consolidée. On +présentera la semaine prochaine son dossier pour discuter d'une radiothérapie de l'humérus [NOM], +et éventuellement de la scapula, mais lésion déjà irradiée, je ne suis pas sûr que l'on puisse faire +plus. +5eme ligne par taxol débutée +Douleur épaule gauche : scapula avec 2 cimentoplastie et radiothérapie, relecture radiologique : +une partie n'est pas consolidée, pas d'autre lésion : possibilité de ré-irradié ? +XGEVA prévu. +Par ailleurs Taxol -20% hebdomadaire en 5ème ligne (abstention thérapeutique inaudible par le +patient) +Question posée : +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 5 de 31 ADK métastatique : +Douleur humérale droite sur lésion : irradiation possible (radio demandée pour écarter fracture le +30/05) +Douleur épaule gauche (scapula non consolidée, cimentoplastée, déjà irradiée) : intérêt nouvelle +irradiation ? +Description du plan de traitement : +Douleur humérale droite sur lésion : irradiation possible après avis ortho pour éventuel enclouage +Douleur épaule gauche nouvelle irradiation antalgique possible +Cimentoplastie hanche droite prochainement prévue le 13 6 23 . +Radiothérapie épaule droite prévue le 15 6 23. +ce jour , on est à J15 du taxol. la semaine dernière n'a pas eu le taxol car trop asthénique. +Depuis 10 jours, anorexie, ne mange que du jus de tomate, du bouillon , des fruits, n' a pas envie, +pas faim et hier même , a eu un épisode de vomissements. En plus, dort toute la journée, PS3-4. +De plus , majoration des douleurs motivant une majoration de la morphine à Oxycontin LP 60 +mg matin et soir et oxynorm oro à 60 mg en 1 à 2 fois par jour associé directement avec du +paracétamol. +Devait rentrer demain pour la cimentoplastie mais +cliniquement +mycose légère +douleurs des 2 épaules avec difficultés à les mouvoir +assis dans le lit, ne signale pas de douleurs si il ne se mobilise pas +auscultation cardio vasculaire RAS +biologie +pas d'hypercalcémie +pas d'hépatite +pas d'explications autres que la chimiothérapie et /ou la maladie cancéreuse pour expliquer +l'[NOM]. +Le patient déclare +- que pour le moment il ne veut pas de PCA de morphine +- qu'il ne veut pas savoir si les résultats sont mauvais, il ne veut pas qu'on lui annonce les choses +si elles sont péjoratives +car il a besoin de garder un petit espoir explique-t-il. Il exprime sa difficulté à faire face ou à +envisager une fin de vie et ne veut pas envisager cette option. +Consultation d'anesthésie réalisé. +A jeun à 9h00 le 13 6 23 et merci de suivre les recommandations +en attendant +- même ttt qu'à la maison +- hydratation par polyionique +- on programme le TIH pour jeudi +- bains de bouche de ttt de mycose +- on avance pas à pas dans la prise en charge +Surveillance Psychiatrie +Item de 20/06/2023 20/06/2023 20/06/2023 19/06/2023 18/06/2023 18/06/2023 17/06/2023 17/06/2023 17/06/2023 16/06/2023 16/06/2023 15/06/2023 15/06/2023 +surveillance 23 : 49 15:46 08:12 09:01 15:50 11:58 16:43 07:54 00:01 15:48 08:41 16:10 12:45 +Température 37,30 36,50 36,30 37,30 37,20 36,60 37,10 36,20 37,10 37,30 35,90 +Pouls 86 85 90 89 93 99 103 83 95 99 83 +Saturation +92 94 92 92 93 93 92 94 92 90 92 92 +O² +PA +111 106 129 118 110 142 124 125 109 +Systolique +PA +64 59 65 60 58 70 65 64 59 +Diastolique +Transit Normal Normal Normal Absence Peu Absence Absence Absence Absence Absence +Notes paramédicales +Type de note Nom Date Note +DOULEUR : soulagé à 8 h avec le Paracétamol et le CBD +21/06/2023 +Note IDE [NOM] [NOM] +13 : 32 +DEVENIR : sortie domicile avec son épouse à13h30 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 6 de 31 DOULEUR : +ATG3 donné à 01h puis 5h30 +ATG1 à 07h +21/06/2023 +Note IDE [NOM] [NOM] +01 : 03 +Patient assis au bord du lit à chaque appel pour la douleur, ne semble pas soulagé cette nuit par l' +ATG3 +A peu dormit +DOULEUR : ATG3 LI donné en début d'après midi et à 18h00; dit etre bien calmé par ailleurs +Dose ATG3 LP augmentée à 70mg +Relai per os des ATG en vue de la sortie +20/06/2023 +Note IDE [NOM] [NOM] ALIMENTATION : A bien mangé au gouter, sa femme dit qu'il n'a pas mangé comme ça depuis +19 : 54 +plusieurs semaines +DEVENIR : RAD prévue demain avec son épouse, ordo données à sa femme pour les +morphiniques +Mobilisation douce acceptée ce jour +Note 20/06/2023 +Yvan HUGUES Passive et active aidée car très bien ressentie +Kinésithérapeute 16 : 02 +Aucune douleur +DOULEUR : non algique ce matin ==> paracétamol fait en systématique + Ketoprofene +20/06/2023 +Note IDE [NOM] [NOM] [NOM] : épaule refait ==> plaie propre +13 : 43 +DEVENIR : probable sortie domicile demain avec son épouse car refuse l'Ambulance +20/06/2023 +Note IDE [NOM] [NOM] Douleur : ATG3 donné à 01h20 et 04h45 +01 : 24 +DOULEUR : A 16h patient très algique --> vu avec med, ATG3 LI + Dose CBD administrés +A 18h non soulagé --> ATG1 +A 20h toujours aussi douloureux --> AINS + ATG3 LP + Dose CBD administré ce soir +--> Encouragé à sonner si douleurs persistantes +Douleurs localisées au niveau des interventions au bras et à la hanche +19/06/2023 +Note IDE [NOM] [NOM] +21 : 21 +ALIMENTATION : Ne mange plus et ne boit plus, la femme dit ne pas avoir vu la diet --> +Message laissé à la diet pour qu'elle passe +Pas d'hydratation per os de la journée --> hydrat laissé en place, a voir pour ablation demain +SOINS DE SUPPORT : CBD en chambre, administration de 0,4ml au cours des repas +DOULEUR : algique +++ à 8h30 avec EN à 8 h ==> soulagé dans la matinée avec ATG 3 LI + +AINS +==> Tentative de l'Abstral pour un soulagement rapide lors des crises douloureuses +19/06/2023 ==> Abstral 400 donné à 12h30 ==> dotation exceptionnelle faite +Note IDE [NOM] [NOM] +13 : 41 +SOINS DE SUPPORT : allo Dr [NOM] pour prescrire CBD qui est périmé +DEEVNIR : sortie domicile dès que possible +Douleur : projet d'un RAD prochainement +18/06/2023 +Note IDE [NOM] [NOM] Relais PCA IV pour PO ce soir +18 : 53 +TTT donné à 20h30 --> Arrêt PCA 22h30 +DOULEUR : EN à 2 au réveil et au repos e matin , faciès détendu , a très bien dormi , 32 +demandes pour 24 perfusées +NAUSEES : prend le chocolat au lait en fractionné car nausées tjs présentes malgré ATE mis en +systématique quand commence à boire , est parvenu à le boire en entier tout de même en prenant +le temps +MOBILISATION : patient ok pour essayer le matelas dynamique => installé dans la matinée , va +18/06/2023 +Note IDE [NOM] [NOM] faire la sieste avec et voir s'il le tolère bien +14 : 17 +ETAT GENERAL : patient se sent plus en forme ce matin mais fatigue très vite au moindre effort +[NOM] : au niveau de l'épaule et du bras [NOM] => plaie propre non inflammatoire , pas +d'écoulement , berges saines et soudées => réfection en 4 temps + [NOM] sec +CONSTIPATION : pas de selles depuis pls jours => sachets de laxatifs donnés => + a eu des +selles normales + liquides par la suite +Douleur : réveil important des dlr ce soir à 19h +17/06/2023 --> ATG 1 IV mis en systématique et encouragé à appuyer sur la PCA en l'abs de sa compagne +Note IDE [NOM] [NOM] +19 : 15 Transit: dis ne pas avoir eu de selles depuis 3 jours, ne sais plus si présence de gaz ou non +--> proposition de laxatifs demain matin +DOULEUR : EN à 6 au réveil au niveau du bras [NOM] 26 demandes pour 14 perfusées mais n'a +pas appuyé cette nuit car a dormi => ATG2 + AINS mais a vomi 10 min après le branchement +17/06/2023 de la perfusion => stop ATG2 , ATE en systématique , mettre glace sur le bras , hématome tjs +Note IDE [NOM] [NOM] +15 : 28 présent ne se majore pas , bras moins oedematié +ALIMENTATION : a mangé 3 cuillères de paella , 1 kiri et bu qq gorgées de délical +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 7 de 31 ETAT GENERAL : meilleure mine ce matin , patient non confus +17/06/2023 douleur=) +Note IDE [NOM] [NOM] +00 : 02 patient confortable début de nuit ATG1+2 fait et PCA en cours +Risque d'escarre : +Le patient ne s'alimente pas depuis plusieurs jours car pas d'appétit, se mobilise peu --> Sa +femme m'informe avoir quelques points d'appuis : matelas à air commandé. +Douleur : +16/06/2023 +Note IDE [NOM] [NOM] Dit être soulagé par les antalgiques administrés. +22 : 34 +Pas de nausées ce soir car anti émétique donné avant l'administration de l'ATG2. +Refus la prise kiné mob cet AM, car a peur d'être trop douloureux. +A réévaluer début de semaine. +Note 16/06/2023 Refus de la prise en soin ce jour +Yvan HUGUES +Kinésithérapeute 15 : 53 +DOULEUR : EN à 7/10 ce matin mais faciès détendu --> ATG 2 + AINS --> Pas de plaintes par +la suite +28 demandes pour 20 bolus administrés +Majoration débit de fond et des bolus +16/06/2023 +Note IDE [NOM] [NOM] +14 : 51 DIGESTIF: Nausées et vomissement dans la matinée induit par ATG2 --> Prescription ATE en +systématique avant administration ATG2 +FRACTURE : Oèdeme membre sup gauche avec hématome étendu +Consignes chir --> Surélever le bras avec un coussin + vessie de glace +DOULEUR : EN à 7/10 ce matin mais faciès détendu --> ATG 2 + AINS --> Pas de plaintes par +la suite +PCA repassé au débit de journée soit 3.5mg, 28 demandes pour 20 bolus administrés +Majoration débit vu par med +16/06/2023 +Note IDE [NOM] [NOM] +13 : 40 DIGESTIF: Nausées et vomissement dans la matinée induit par ATG2 --> Prescription ATE en +systématique après administration ATG2 +FRACTURE : Oèdeme membre sup gauche avec hématome étendu +Consignes chir --> Surélever le bras avec un coussin + vessie de glace +Douleur : +Patient confortable en début de nuit. +PCA ATG 3 en cours, 18 demandes pour 12 perfusées à 0h00. +16/06/2023 +Note IDE [NOM] EXILAR Réveil des douleurs à 6h30, ATG 1 administré en systématique. +01 : 51 +Dig : +Absence de nausées, vomissements sur la nuit, dit avoir été soulagé par ATE de 21h. +Douleur : +Douleur très importante à la mobilisation mais maitrisée au repos. +Majoration de la dose de fond de la PCA --> Fait ce soir à diminuer demain matin. +Œdème du membre supérieur [NOM] : +Avis du Dr [NOM] : Symptômes normaux en post chirurgie : Il préconise de surélever le bras par +15/06/2023 +Note IDE [NOM] [NOM] un oreiller, si le patient ne souhaite pas l'écharpe contre écharpe, pas de nécessité de la mettre, +22 : 31 +glacer le bras en si besoin + séances de kiné à faire prescrire SVP. +Vomissements : +Le patient ne s'alimente plus depuis quelques temps, pas d'appétit --> A vomit à 2 reprises cet +AM, vomissements d'origine biliaire. +Anti émétique donné ce soir en IV à 21h, a faire prescrire car non prescrit. +Douleur : EN à 7 ce matin , PCA en cours avec 77 demandes pour 14 perfusées ; dit tout de +meme avoir pu dormir . +ATG2 et AINS fait en systématique +Vu avec médecin , dose de fond de la PCA sera majorée juste pour la nuit . +!! Prescription médicale en commentaire . +Etat cutané : Hématome avec œdème au niveau du bras [NOM] semblant se majorer ; ne met +15/06/2023 cependant pas son bras en écharpe . +Note IDE [NOM] [NOM] +13 : 09 Avis chir ? +Signalé au médecin +Transit : constipé depuis plusieurs jours . +Laxatifs donnés per os car refuse le [NOM] pour le moment . +Selles liquides ce midi +TTT : Radiothérapie annulée ;pas de report pour le moment +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 8 de 31 Douleur : +Patient non algique en début de nuit ayant un faciès détendu. +PCA ATG 3 refaite à 3h30 avec dotation exceptionnelle. +15/06/2023 A 6h : EN à 5, ATG IV administré en systématique. +Note IDE [NOM] EXILAR +03 : 46 +Elimination : +A uriné dans la nuit selon sa femme. +Bladder à 415 ml à 6h, proposition de réaliser un sondage évacuateur mais refus du patient. +ELIMINATION URINAIRE : dit avoir uriné en début d'après midi , bladder fait = 300ml à 17h +DOULEUR : patient reste algique au niveau du bras [NOM] , [NOM] refait au niveau du pli du coude +car se décolle , présence de 4 agrafes , propre non inflammatoire , pas d'écoulement , bras +oedematié EN à 7/8 => AINS + ATG1+ ATG2 prescrits en IV en systématique n ce soir se sent +un peu moins douloureux dans l'ensemble notamment en position allongée mais grimace à la +moindre mobilisation, non confortable en début d'après midi , plus confortable ce soir +14/06/2023 +Note IDE [NOM] [NOM] Proposition de mettre l'écharpe contre écharpe , la met qq minutes puis l'enlève ne la supporte pas +19 : 39 +Ce soir EN à 5 faciès plus détendu , plus confortable , plus réveillé +EFFETS SECONDAIRES : patient somnolent mais tout à fait réveillable , qq propos confus , +pupilles en myosis serré , sat limite mais refuse de mettre l'O2 car ne se sent pas gêné et les +lunettes à O2 le gène +URINAIRE : Bladder à 650cc à 12h, n'est pas favorable à la SV, proposé d'aller uriner aux +toilettes avec l'aide de sa femme +DOULEUR : PCA en cours, 101 demandes pour 40 bolus administrés, 21ml restant à 12h +Augmentation du dosage passant de 60 à 84mg/jour avec bolus de 5mg/10min, PCA +à refaire dans l'après-midi, en attente de la dotation exceptionnel en morphinique +Patient très algique toute la matinée +COMPORTEMENT : Patient apathique, attitude fermé +14/06/2023 +Note IDE [NOM] [NOM] +13 : 15 +PLAIES : Pansement cimento renforcé +En attente de consignes des chir pour réfection des pansements +RESPI : SpO2 à 90% sous 2L, eupnéique +EXAMENS : Radiothérapie maintenu pour demain, ambu commandée pour 14h15 +respi=) +sevrage O2 fait début de nuit avec un maintien de la sat entre 90 et 93% surveillance ultérieure +infectieux=) +patient apyrétique +élimination =) +a réussi à uriner début de nuit +13/06/2023 bloc=) +Note IDE [NOM] [NOM] 23 : 35 pansement épaule droite propre +pansement cimento hanche droite délimité +douleur=) +PCA en cours 26 demandes pour 16 reçues changement de PCA cette nuit à 01h15 attention +concentration 5mg/ml +très algique milieu de nuit =) ATG1 01h30 : ATG2 03H3 +allo interne de garde ca( patient en pleurs à 04h45 +RETOUR DE BLOC : cimentoplastie hanche droite : [NOM] aine légèrement taché => délimité , +patient est resté alité mais peut se lever , bonne mobilité et sensibilité du membre inf , pouls +pédieux perçu , membre chaud et coloré +=> enclouage au niveau de l'épaule droite , [NOM] propre écharpe contre écharpe en place , +consignes concernant le [NOM] à voir avec le chir ( Dr [NOM]) , bouge le pouce et l'index [NOM] , +fourmillements du bras ( a eu un bloc anesthésie ) au niveau du membre sup [NOM] +13/06/2023 Patient somnolent et douloureux au retour du bloc => débit de fond PCA débuté à 20h + ATG2 , +Note IDE [NOM] [NOM] +21 : 33 n'a pas pu prendre ses TTT per os car trop somnolent , sous O2 2l au retour du bloc , sat 90% , +laissé tel quel +ELIMINATION : IDE de la salle de réveil me signale qu'il ne parvenait pas à uriner en bas mais +refus pose SAD , sondage évacuateur fait avec 500ml d'urines , n'a pas envie d'uriner pour le +moment mais a eu sondage évacuateur => à surveiller +RADIOTHERAPIE : RDV le 15/06 à 14h15 , vu avec médecin maintien du RDV ambu ddée +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 9 de 31 Douleur : ttt ATG 3 Lp donné ce matin +--> Changement de support avec installation de PCA ATG 3 uniquement en bolus pour le +13/06/2023 moment +Note IDE [NOM] [NOM] +13 : 54 Ortho: bloc ok pour traité la fracture et faire cimento en même temps +Descendue à 11h30 (pas de possibilité de mobiliser le patient, tee shirt découpé, calçons laissé) +Radio thérapie prévue la semaine pro pour méta humérus [NOM] --> à annuler ? +pas de douleur signalée début de nuit +patient eupnéique apyrétique +05h =) lors d'une mobilisation a entendu un crac au niveau de son bras [NOM] impotence +12/06/2023 fonctionnelle totale patient en pleurs =) allo interne de garde pour imagerie et ATG3 li donné +Note IDE [NOM] [NOM] +23 : 11 vu avec l'interne de garde devant la douleur trop intense titration de morphine =) 20mg en tout +administré jusqu'à 06h15 +06h17 le patient descend à la radio avec écharpe contre écharpe récupérée en ortho le patient +étant moyennement soulagé +algie : patient non douloureuse cet am ni ce soir --> ttt. LP administre selon presc. +mycose : débutes soins de bouches ce soir +[NOM] [NOM] [NOM] 12/06/2023 +Note IDE +[NOM] 21 : 26 +devenir : cimentoplastie hanche gh prévu pour demain 13/06, anesthésiste passe cet am: à jeun +demain matin à partir 9h, on peut lui donner un café / thé à 7H, dossier bloc prête +--> rdv radioTP prévu pour le 15/06 +Entré pour douleurs diffuse, [NOM], perte d'appétit, perte d'autonomie +patient ayant un cancer multi métastasé +Bénéficie cimento des 2 bras, devait avoir une cimento demain a la hanche gauche, a revoir +A aussi des rayons aux épaules (prochains rdv jeudi 15/06 a 14h) +Ne mange presque plus depuis 10 jours et n'avale vraiment plus rien depuis samedi. Sa femme +qui gère tout a été obligé d'augmenter les doses d'ATG3 après avis médical +12/06/2023 +Note IDE [NOM] [NOM] +13 : 46 Ce jour, patient très affaibli, a perdu 3kg en 10 jours, pas trop le moral car dit que le TAXOL le +détraque +Ne mange plus rien de solide depuis samedi, il n'y a que l'eau qui passe +Douleurs épaules : très algique malgré 60mg d'ATG 3 LI 11h30 +A son arrivée, perfusé sur PAC, RV +, bio, hydrat mise, ECG fait +Sa femme souhaite dormir la ce soir car patient en aide partielle , sa femme lui fait bcp de choses +au domicile (habillage, aide aux repas...) +Traitements médicamenteux +Date de dernière +Prescription Dose Fréquence Date de début Note Docteur +administration +Voie d`administration : INTRAVEINEUSE +Statut des prescriptions : Signé +Notes de la +prescription : +Max : 6 Bolus / +1 heure(s) Notes +du professionel +de santé : +Concentration +MORPHINE PCA IV +recherchée 1mg/ DR. [NOM] +[NOM]+Bolus (5 à 30 MG/J) - Normal 14/06/2023 05 : 00 14/06/2023 08:58 +ml soit 50 mg pour ADO +seringue 50ML - BSFP +50 ml : 1 ampoule +de 50mg/5ml + +45ml de NaCl +0.9% majoration +de la dose à 3,8 +mg /h IVSE de +22h à 8h +Statut des prescriptions : Arrêté +Le débit a été +modifié. Le débit +en cours est : 4 +ACUPAN 20MG/2ML SOL - Ttes les 8h [0h 8h par . Notes du DR. [NOM] +1 AMP 13/06/2023 16 : 47 17/06/2023 07:53 +INJ [5] Ampoule(s) 16h] Normal professionel de [NOM] +santé : à diluer +dans 100ML de +NaCl ou G5% +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 10 de 31 KETOPROFENE [NOM] +- Matin soir (8h - DR. [NOM] +100MG/4ML SOL INJ [10] 100 mg 14/06/2023 18 : 00 20/06/2023 08:08 +19h) Normal [NOM] +Ampoule(s) +Le débit a été +METOCLOPRAMIDE CHL +modifié. Le débit DR. [NOM] +REN 10MG/2ML INJ [100] 1 AMP - Normal 16/06/2023 13 : 47 20/06/2023 12:21 +en cours est : 4 [NOM] +Ampoule(s) +par . +Notes de la +MORPHINE PSE 50ML +prescription : DR. [NOM] +[NOM] 1MG/ML+Droleptan - Normal 13/06/2023 09 : 58 14/06/2023 04:39 +Max : 6 Bolus / 1 [NOM] +2.5MG - BSFP +heure(s) +Le débit a été +PARACETAMOL BBM +- Ttes les 6h [2h 8h modifié. Le débit DR. [NOM] +10MG/ML INJ 100ML [10] 1 G 14/06/2023 18 : 00 20/06/2023 12:22 +14h 20h] Normal en cours est : 400 [NOM] +Flacon(s) +par . +Le débit en +POLYIONIQUE 1A G5 +cours est : DR. [NOM] +BAX POC VFO 500ML [1] - Normal 12/06/2023 15 : 46 19/06/2023 09:00 +41.666666666666664SCHNEIDER +POCHE(S) +ML par 1 hrs. +Statut des prescriptions : Réalisé +Notes du +professionel de +MORPHINE CHL REN santé : titration: 2 +10MG/ML INJ 1ML 3 mg - Normal 13/06/2023 05 : 15 13/06/2023 06:16 à 3 mg toutes les Tess [NOM] +Ampoule(s) 5 min Dose MAX +20 mg => avis +médical +Voie d`administration : ORALE +Statut des prescriptions : Signé +Notes du +1 professionel de +FUNGIZONE 10% SUSP - Matin midi soir DR. [NOM] +[NOM](S) 12/06/2023 15 : 20 21/06/2023 12:00 santé: en bain de +BUV FL 40ML [8] Flacon(s) Normal [NOM] +[NOM] (5 ml) bouche puis à +avaler +KETOPROFENE ACT +- Matin soir (8h - DR. [NOM] +LP 100MG CPR [20] 1 CPR 20/06/2023 14 : 20 21/06/2023 08:45 +19h) Normal [NOM] +COMPRIME(S) +LANSOPRAZOLE BGA 30 - Prise unique à 19h DR. [NOM] +1 CPR 13/06/2023 16 : 16 20/06/2023 18:57 +MG CPR OROD [14] CPR(s) Normal [NOM] +LYRICA 75MG GELULE - Matin soir (8h - DR. [NOM] +75 mg 12/06/2023 13 : 24 21/06/2023 08:45 +[56] Gelule(s) 20h) Normal [NOM] +MOVENTIG 25 MG CPR DR. [NOM] +1 CPR - Matin [8h] Normal 17/06/2023 10 : 39 21/06/2023 08:45 +[90] CPR(s) [NOM] +OMEPRAZOLE ACF 20MG DR. [NOM] +2 GEL - Soir [19h] Normal 12/06/2023 13 : 24 20/06/2023 19:00 +GELULE [28] Gelule(s) [NOM] +OXYCODONE MYL LP - Matin soir (8h - DR. [NOM] +70 mg 18/06/2023 16 : 13 21/06/2023 08:45 +80MG CPR [28] CPR(s) 20h) Normal [NOM] +PARACETAMOL ARW +- Matin midi soir nuit DR. [NOM] +500MG GELULE [12] 2 GEL 20/06/2023 14 : 21 21/06/2023 12:14 +Normal [NOM] +Gelule(s) +PRIMPERAN 10MG CPR DR. [NOM] +1 CPR - Normal 20/06/2023 14 : 22 21/06/2023 06:22 +[40] COMPRIME(S) [NOM] +Statut des prescriptions : Arrêté +KETOPROFENE ACT +- Matin soir (8h - DR. [NOM] +LP 100MG CPR [20] 1 CPR 12/06/2023 13 : 24 14/06/2023 09:00 +20h) Normal [NOM] +COMPRIME(S) +MOVENTIG 12.5 MG CPR DR. [NOM] +1 CPR - 1xJour [8h] Normal 14/06/2023 13 : 02 17/06/2023 07:52 +[30] CPR(s) [NOM] +OXYCODONE MYL LP - Matin soir (8h - DR. [NOM] +20 mg 12/06/2023 15 : 15 19/06/2023 08:00 +20MG CPR [28] CPR(s) 19h) Normal [NOM] +OXYCODONE MYL LP - Matin soir (8h - DR. [NOM] +40 mg 12/06/2023 15 : 15 19/06/2023 08:00 +40MG CPR [28] CPR(s) 19h) Normal [NOM] +OXYNORMORO +DR. [NOM] +10MG CPR DISP [14] 20 mg - Normal 18/06/2023 22 : 00 19/06/2023 10:00 +[NOM] +COMPRIME(S) +OXYNORMORO - Ttes les 4H [0h +DR. [NOM] +20MG CPR DISP [14] 3 CPR 4h ... 16h 20h] 12/06/2023 15 : 15 19/06/2023 12:00 +[NOM] +COMPRIME(S) Normal +PARACETAMOL ARW +- Matin midi soir DR. [NOM] +500MG GELULE [12] 2 GEL 12/06/2023 15 : 13 14/06/2023 12:00 +Normal [NOM] +Gelule(s) +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 11 de 31 Statut des prescriptions : Réalisé +Notes du +1 professionel de +FUNGIZONE 10% SUSP - Matin midi soir DR. [NOM] +[NOM](S) 21/06/2023 13 : 10 santé: en bain de +BUV FL 40ML [8] Flacon(s) Presc. de Sortie [NOM] +[NOM] (5 ml) bouche puis à +avaler +KETOPROFENE ACT +- Matin soir (8h - DR. [NOM] +LP 100MG CPR [20] 1 CPR 21/06/2023 13 : 10 +19h) Presc. de Sortie [NOM] +COMPRIME(S) +LANSOPRAZOLE BGA 30 - Prise unique à 19h DR. [NOM] +1 CPR 21/06/2023 13 : 10 +MG CPR OROD [14] CPR(s) Presc. de Sortie [NOM] +LYRICA 75MG GELULE - Matin soir (8h - DR. [NOM] +75 mg 21/06/2023 13 : 10 +[56] Gelule(s) 20h) Presc. de Sortie [NOM] +MOVENTIG 25 MG CPR - Matin [8h] Presc. de DR. [NOM] +1 CPR 21/06/2023 13 : 10 +[90] CPR(s) Sortie [NOM] +OMEPRAZOLE ACF 20MG - Soir [19h] Presc. de DR. [NOM] +2 GEL 21/06/2023 13 : 10 +GELULE [28] Gelule(s) Sortie [NOM] +PARACETAMOL ARW +- Matin midi soir nuit DR. [NOM] +500MG GELULE [12] 2 GEL 21/06/2023 13 : 10 +Presc. de Sortie [NOM] +Gelule(s) +PRIMPERAN 10MG CPR DR. [NOM] +1 CPR - Presc. de Sortie 21/06/2023 13 : 10 +[40] COMPRIME(S) [NOM] +Voie d`administration : RECTALE +Statut des prescriptions : Signé +[NOM] AD +SORBITOL SOL RECTALE 1 - 1 seule fois 1 seule DR. [NOM] +15/06/2023 12 : 15 +[4] RECIPIENT(S) UNIDOSE(S) fois [NOM] +UNIDOSE(S) +[NOM] [NOM] +AD SOL RECTALE 1 REC. - 1 seule fois 1 seule DR. [NOM] +15/06/2023 12 : 15 +[1] RECIPIENT(S) UNIDOSE fois [NOM] +UNIDOSE(S) +Voie d`administration : SOUS-CUTANEE +Statut des prescriptions : Signé +LOVENOX 4000UI +1 +AXa/0,4ML INJ SER DR. [NOM] +SERINGUE(S) - Matin [8h] Normal 13/06/2023 19 : 25 21/06/2023 08:00 ++S [2] SERINGUE(S) [NOM] +[NOM](S) +[NOM](S) +LOVENOX 4000UI +1 +AXa/0,4ML INJ SER - Matin [8h] Presc. de DR. [NOM] +SERINGUE(S) 21/06/2023 13 : 10 ++S [2] SERINGUE(S) Sortie [NOM] +[NOM](S) +[NOM](S) +Voie d`administration : [NOM] +Statut des prescriptions : Signé +Notes du +professionel de +santé : si douleur +ABSTRAL 400MICROG à 30min de la DR. [NOM] +1 CPR - Normal 19/06/2023 12 : 30 21/06/2023 12:20 +CPR [10] COMPRIME(S) prise d'ABSTRAL [NOM] +possibilité +de redonner +ABSTRAL 400 +SODIUM BIC BAX 1,4% +- Matin midi soir DR. [NOM] +POC CFX 500ML V1 [1] 10 ml 12/06/2023 15 : 20 21/06/2023 12:00 +Normal [NOM] +POCHE(S) +Statut des prescriptions : Réalisé +SODIUM BIC BAX 1,4% +- Matin midi soir DR. [NOM] +POC CFX 500ML V1 [1] 10 ml 21/06/2023 13 : 10 +Presc. de Sortie [NOM] +POCHE(S) +Prescriptions de radiologie +Heure Date Heure +Date début Prescription Statut Docteur [NOM] +début exécution exécution +13/06/2023 06 : 25 Humérus [NOM] F P 13/06/2023 06:31 Réalisé Tess [NOM] +[NOM] +13/06/2023 17 : 58 Humérus [NOM] F P 13/06/2023 18:28 Réalisé +[NOM] +Prescriptions de laboratoire +Date de +Date Heure Prescription Docteur [NOM] +collection +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 12 de 31 12/06/2023 +12/06/2023 13 : 24 TP+INR ( si AVK ) DR. [NOM] +13 : 25 +12/06/2023 +12/06/2023 13 : 24 Ionogramme ( Na, K, CL ) DR. [NOM] +13 : 25 +12/06/2023 +12/06/2023 13 : 24 Créatinine sang ( dosage ) DR. [NOM] +13 : 25 +Biopsie ordinaire ( Atlantic- 13/06/2023 +13/06/2023 14 : 12 [NOM] [NOM] +Pathologie ) 14 : 13 +14/06/2023 +14/06/2023 07 : 00 TP+INR ( si AVK ) DR. [NOM] +11 : 21 +14/06/2023 +14/06/2023 07 : 00 Ionogramme ( Na, K, CL ) DR. [NOM] +11 : 21 +14/06/2023 +14/06/2023 07 : 00 Créatinine sang ( dosage ) DR. [NOM] +11 : 21 +20/06/2023 +20/06/2023 07 : 00 Ionogramme ( Na, K, CL ) DR. [NOM] +08 : 56 +20/06/2023 +20/06/2023 07 : 00 Créatinine sang ( dosage ) DR. [NOM] +08 : 56 +Bilirubine ( totale + conjuguée + 20/06/2023 +20/06/2023 07 : 00 DR. [NOM] +non conjuguée ) sang ( dosage ) 08 : 56 +Prescriptions de soins +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +[NOM] du +professionel +10 Jours - Matin midi 13/06/2023 de santé : DR. [NOM] +REGIME NORMAL Signé +goûter soir Normal 16 : 16 Dés retour [NOM] +du bloc +opératoire +ACCOMPAGNER +7 Jours - 7h 10h 13h 13/06/2023 [NOM] +INSTALLER AUX Signé +16h 19h 22h Normal 08 : 00 [NOM] +TOILETTES +AIDE A LA PRISE - 1 seule fois 1 seule 13/06/2023 [NOM] +Signé +MEDICAMENTS fois 21 : 25 [NOM] +[NOM] : AIDE - 1 seule fois 1 seule 13/06/2023 [NOM] +Signé +PARTIELLE fois 21 : 25 [NOM] +DESINFECTION +- 1 seule fois 1 seule 13/06/2023 [NOM] +ENVIRONNEMENT Signé +fois 21 : 25 [NOM] +PATIENT +7 Jours - 7h 10h 13h 13/06/2023 [NOM] +ESCARRE : PREVENTION Signé +16h 19h 22h Normal 08 : 00 [NOM] +HABILLAGE : AIDE - 1 seule fois 1 seule 13/06/2023 [NOM] +Signé +PARTIELLE fois 21 : 25 [NOM] +- 1 seule fois 1 seule 13/06/2023 [NOM] +CHANGES ADULTE Réalisé +fois 21 : 25 [NOM] +DESINFECTION +14/06/2023 [NOM] +ENVIRONNEMENT Réalisé - Matin [8h] Normal +10 : 31 [NOM] +PATIENT +LIT : REFECTION 14/06/2023 [NOM] +Réalisé - Matin [8h] Normal +COMPLETE 10 : 31 [NOM] +- 1 seule fois 1 seule 13/06/2023 [NOM] +REPAS : INSTALLATION Réalisé +fois 21 : 25 [NOM] +- 3x/Nuit (22h 2h 6h) 13/06/2023 [NOM] +SOMMEIL : SURV. Réalisé +Normal 20 : 00 [NOM] +TOILETTE DOUCHE : 14/06/2023 [NOM] +Réalisé - Matin [8h] Normal +AIDE PARTIELLE 10 : 31 [NOM] +- 1 seule fois 1 seule 13/06/2023 [NOM] +URINAL / BASSIN : VIDER Réalisé +fois 21 : 25 [NOM] +Notes du +- Ttes les 8H [6h 14h 15/06/2023 professionel DR. [NOM] +VESSIE DE GLACE Réalisé +22h] Normal 16 : 24 de santé: sur [NOM] +MSD +10 Jours - Ttes les +13/06/2023 DR. [NOM] +DOULEUR : SURV Réalisé 6h [2h 8h 14h 20h] +16 : 16 [NOM] +Normal +SIGNES VITAUX (Pls, 1 Mois (30j) - Ttes +13/06/2023 DR. [NOM] +TA, FR, T°, Glyc, Miction, Réalisé les 6h [2h 8h 14h +16 : 16 [NOM] +Transit) 20h] Normal +Prescriptions de sortie +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +DR. +FUNGIZONE 10% SUSP 1 - Matin midi soir 21/06/2023 0/5 : Non administré +Réalisé [NOM] +BUV FL 40ML [8] Flacon(s) [NOM](S) Presc. de Sortie 13 : 10 Révisé/Traité +[NOM] +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 13 de 31 [NOM] (5 ml) +ORALE +KETOPROFENE ACT DR. +1 CPR - Matin soir (8h - 21/06/2023 0/60 : Non administré +LP 100MG CPR [20] Réalisé [NOM] +ORALE 19h) Presc. de Sortie 13 : 10 Révisé/Traité +COMPRIME(S) [NOM] +DR. +[NOM] 30 1 CPR - Prise unique à 19h 21/06/2023 0/30 : Non administré +Réalisé [NOM] +MG CPR OROD [14] CPR(s) ORALE Presc. de Sortie 13 : 10 Révisé/Traité +[NOM] +1 +LOVENOX 4000UI +SERINGUE(S) DR. +AXa/0,4ML INJ SER - Matin [8h] Presc. de 21/06/2023 0/30 : Non administré +[NOM](SS)igné [NOM] ++S [2] SERINGUE(S) Sortie 13 : 10 A valider +SOUS- [NOM] +[NOM](S) +CUTANEE +DR. +[NOM] 75MG GELULE 75 mg - Matin soir (8h - 21/06/2023 0/60 : Non administré +Réalisé [NOM] +[56] Gelule(s) ORALE 20h) Presc. de Sortie 13 : 10 Révisé/Traité +[NOM] +DR. +[NOM] 25 MG CPR 1 CPR - Matin [8h] Presc. de 21/06/2023 0/30 : Non administré +Réalisé [NOM] +[90] CPR(s) ORALE Sortie 13 : 10 Révisé/Traité +[NOM] +DR. +[NOM] 20MG 2 GEL - Soir [19h] Presc. de 21/06/2023 0/60 : Non administré +Réalisé [NOM] +GELULE [28] Gelule(s) ORALE Sortie 13 : 10 Révisé/Traité +[NOM] +PARACETAMOL ARW 0/240 : Non DR. +2 GEL - Matin midi soir nuit 21/06/2023 +500MG GELULE [12] Réalisé administré Révisé/ [NOM] +ORALE Presc. de Sortie 13 : 10 +Gelule(s) Traité [NOM] +DR. +[NOM] 10MG CPR 1 CPR 21/06/2023 0/90 : Non administré +Réalisé - Presc. de Sortie [NOM] +[40] COMPRIME(S) ORALE 13 : 10 Révisé/Traité +[NOM] +SODIUM BIC BAX 1,4% DR. +10 ml - Matin midi soir 21/06/2023 0/2 : Non administré +POC CFX 500ML V1 [1] Réalisé [NOM] +[NOM] Presc. de Sortie 13 : 10 Révisé/Traité +POCHE(S) [NOM] +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 14 de 31 Plan de soins Jour J du 21/06/2023 07h00 au 22/06/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +Signé — REGIME NORMAL - Matin midi Début le 13/06/2023 à +goûter soir - 10 Jours- Date Début : 13/06/2023 @ 16:16 +16 : 16 Fin le 23/06/2023 à 16:00 * 1 +Notes de professionel de santé : 16:00 +Dés retour du bloc opératoire Admin le 21/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — REGIME NORMAL - Matin midi Début le 13/06/2023 à +goûter soir - 10 Jours- Date Début : 13/06/2023 @ 16:16 +16 : 16 Fin le 23/06/2023 à 19:00 * 1 +Notes de professionel de santé : 16:00 +Dés retour du bloc opératoire Admin le 21/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — REGIME NORMAL - Matin midi Début le 13/06/2023 à +goûter soir - 10 Jours- Date Début : 13/06/2023 @ 16:16 +16 : 16 Fin le 23/06/2023 à 08:00 * 1 +Notes de professionel de santé : 16:00 +Dés retour du bloc opératoire Admin le 21/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — REGIME NORMAL - Matin midi Début le 13/06/2023 à +goûter soir - 10 Jours- Date Début : 13/06/2023 @ 16:16 +16 : 16 Fin le 23/06/2023 à 12:00 * 1 +Notes de professionel de santé : 16:00 +Dés retour du bloc opératoire Admin le 21/06/2023 à +12 : 00 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 14:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 16:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 18:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 20:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 22:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 15 de 31 Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 00:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 02:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 04:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 06:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 08:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 10:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 12:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le 12/06/2023 à +500ML V1 - 1,4G/100ML solution (500 mL) - 15 : 20 +Dose 10 ml - [NOM] - Matin midi soir - 1ère Fin le 22/06/2023 à 19 : 00 * 10 ml +dose : 12/06/2023 @ 19:00 12:00 +Admin le 21/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le 12/06/2023 à +500ML V1 - 1,4G/100ML solution (500 mL) - 15 : 20 +Dose 10 ml - [NOM] - Matin midi soir - 1ère Fin le 22/06/2023 à 08 : 00 * 10 ml +dose : 12/06/2023 @ 19:00 12:00 +Admin le 21/06/2023 à +12 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 16 de 31 [NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le 12/06/2023 à +500ML V1 - 1,4G/100ML solution (500 mL) - 15 : 20 +Dose 10 ml - [NOM] - Matin midi soir - 1ère Fin le 22/06/2023 à 12 : 00 * 10 ml +dose : 12/06/2023 @ 19:00 12:00 +Admin le 21/06/2023 à +12 : 00 +Signé — FUNGIZONE 10% SUSP BUV FL [NOM] [NOM] +40ML - 10G/100ML suspension (40 mL) - Dose Début le 12/06/2023 à +1 [NOM](S) [NOM] (5 ml) - ORALE - Matin 15 : 20 19:00 * 1 +midi soir - 1ère dose : 12/06/2023 @ 19:00 Fin le 12/07/2023 à [NOM](S) +Notes de professionel de santé : 12:00 [NOM] (5 ml) +Admin le 21/06/2023 à +en bain de bouche puis à avaler +12 : 00 +Signé — FUNGIZONE 10% SUSP BUV FL [NOM] [NOM] +40ML - 10G/100ML suspension (40 mL) - Dose Début le 12/06/2023 à +1 [NOM](S) [NOM] (5 ml) - ORALE - Matin 15 : 20 08:00 * 1 +midi soir - 1ère dose : 12/06/2023 @ 19:00 Fin le 12/07/2023 à [NOM](S) +Notes de professionel de santé : 12:00 [NOM] (5 ml) +Admin le 21/06/2023 à +en bain de bouche puis à avaler +12 : 00 +Signé — FUNGIZONE 10% SUSP BUV FL [NOM] [NOM] +40ML - 10G/100ML suspension (40 mL) - Dose Début le 12/06/2023 à +1 [NOM](S) [NOM] (5 ml) - ORALE - Matin 15 : 20 12:00 * 1 +midi soir - 1ère dose : 12/06/2023 @ 19:00 Fin le 12/07/2023 à [NOM](S) +Notes de professionel de santé : 12:00 [NOM] (5 ml) +Admin le 21/06/2023 à +en bain de bouche puis à avaler +12 : 00 +[NOM] [NOM] +Signé — KETOPROFENE ARW LP 100MG Début le 20/06/2023 à +CPR - 100MG comprime - Dose 1 CPR - ORALE 14 : 20 +- +1 +9M : 0a 0tin soir (8h - 19h) - 1ère dose: 20/06/2023 @ F 08in + : 0 +l 0e 20/07/2023 à 1 C9 P : R00 * 1 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — KETOPROFENE ARW LP 100MG Début le 20/06/2023 à +CPR - 100MG comprime - Dose 1 CPR - ORALE 14 : 20 +- +1 +9M : 0a 0tin soir (8h - 19h) - 1ère dose: 20/06/2023 @ F 08in + : 0 +l 0e 20/07/2023 à 0 C8 P : R45 * 1 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — LANSOPRAZOLE BGA 30 MG Début le 13/06/2023 à +CPR OROD - 30MG comprime - Dose 1 CPR 16 : 16 +- +1 +3O /0R 6A /2L 0E +2 +3- P @ri s 1e +9 + : u 0n 0ique à 19h - 1ère dose: F 19in + : 0 +l 0e 12/07/2023 à 1 C9 P : R00 * 1 +Admin le 20/06/2023 à +18 : 57 +[NOM] [NOM] +Signé — LYRICA 75 MG GELULE - 75MG Début le 12/06/2023 à +gelule - Dose 75 mg - ORALE - Matin soir (8h - 13 : 24 20:00 * 75 +20h) - 1ère dose : 12/06/2023 @ 20:00 Fin le 12/07/2023 à mg +08 : 00 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — LYRICA 75 MG GELULE - 75MG Début le 12/06/2023 à +gelule - Dose 75 mg - ORALE - Matin soir (8h - 13 : 24 08:45 * 75 +20h) - 1ère dose : 12/06/2023 @ 20:00 Fin le 12/07/2023 à mg +08 : 00 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — MOVENTIG 25MG CPR - 25MG Début le 17/06/2023 à +comprime - Dose 1 CPR - ORALE - Matin [8h] - 10 : 39 08:45 * 1 +1ère dose : 18/06/2023 @ 08:00 Fin le 17/07/2023 à CPR +08 : 00 +Admin le 21/06/2023 à +08 : 45 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 17 de 31 [NOM] [NOM] +Signé — OMEPRAZOLE ACF 20MG GELULE - Début le 12/06/2023 à +20MG gelule - Dose 2 GEL - ORALE - Soir [19h] 13 : 24 19:00 * 2 +- 1ère dose : 12/06/2023 @ 19:00 Fin le 11/07/2023 à GEL +19 : 00 +Admin le 20/06/2023 à +19 : 00 +[NOM] [NOM] +Signé — OXYCODONE VIATRIS LP 80MG Début le 18/06/2023 à +CPR - 80MG comprime - Dose 70 mg - ORALE 16 : 13 +- +2 +0M : 0a 0tin soir (8h - 20h) - 1ère dose: 18/06/2023 @ F 08in + : 0 +l 0e 18/07/2023 à 2 m0 g : 00 * 70 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — OXYCODONE VIATRIS LP 80MG Début le 18/06/2023 à +CPR - 80MG comprime - Dose 70 mg - ORALE 16 : 13 +- +2 +0M : 0a 0tin soir (8h - 20h) - 1ère dose: 18/06/2023 @ F 08in + : 0 +l 0e 18/07/2023 à 0 m8 g : 45 * 70 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 20/06/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 14 : 21 +O 20R /0A 6L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 20/07/2023 à 1 G9 E : 0 L0 * 2 +Admin le 21/06/2023 à +12 : 14 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 20/06/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 14 : 21 +O 20R /0A 6L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 20/07/2023 à 2 G1 E : 0 L0 * 2 +Admin le 21/06/2023 à +12 : 14 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 20/06/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 14 : 21 +O 20R /0A 6L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 20/07/2023 à 0 G7 E : 0 L0 * 2 +Admin le 21/06/2023 à +12 : 14 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 20/06/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 14 : 21 +O 20R /0A 6L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 20/07/2023 à 1 G2 E : 1 L4 * 2 +Admin le 21/06/2023 à +12 : 14 +[NOM] [NOM] +Signé — PRIMPERAN 10MG CPR - 10MG Début le 20/06/2023 à +comprime - Dose 1 CPR - ORALE - Toutes les 8 14 : 22 14:22 * 1 +Heure(s) - 1ère dose : 20/06/2023 @ 14:22 Fin le 20/07/2023 à CPR +06 : 22 +Admin le 21/06/2023 à +06 : 22 +[NOM] [NOM] +Signé — PRIMPERAN 10MG CPR - 10MG Début le 20/06/2023 à +comprime - Dose 1 CPR - ORALE - Toutes les 8 14 : 22 22:22 * 1 +Heure(s) - 1ère dose : 20/06/2023 @ 14:22 Fin le 20/07/2023 à CPR +06 : 22 +Admin le 21/06/2023 à +06 : 22 +[NOM] [NOM] +Signé — PRIMPERAN 10MG CPR - 10MG Début le 20/06/2023 à +comprime - Dose 1 CPR - ORALE - Toutes les 8 14 : 22 06:22 * 1 +Heure(s) - 1ère dose : 20/06/2023 @ 14:22 Fin le 20/07/2023 à CPR +06 : 22 +Admin le 21/06/2023 à +06 : 22 +Signé — LOVENOX 4000UI AXA/0,4ML +[NOM] [NOM] +0 S8 E : R00 +IN +* +G +1 +UE(S) +INJ SER +S - 4000UI solution (0,4 mL) - Dose +[NOM](S) +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 18 de 31 Début le 13/06/2023 à +1 SERINGUE(S) [NOM](S) - SOUS- 19 : 25 +CUTANEE Directe - Matin [8h] - 1ère dose : Fin le 13/07/2023 à +14/06/2023 @ 08 : 00 08:00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Signé — ACCOMPAGNER INSTALLER AUX Début le 13/06/2023 à +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin 08 : 00 +- 7 Jours- Date Début : 13/06/2023 @ 08:00 Fin le 25/06/2023 à 09:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ACCOMPAGNER INSTALLER AUX Début le 13/06/2023 à +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin 08 : 00 +- 7 Jours- Date Début : 13/06/2023 @ 08:00 Fin le 25/06/2023 à 12:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ACCOMPAGNER INSTALLER AUX Début le 13/06/2023 à +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin 08 : 00 +- 7 Jours- Date Début : 13/06/2023 @ 08:00 Fin le 25/06/2023 à 15:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ACCOMPAGNER INSTALLER AUX Début le 13/06/2023 à +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin 08 : 00 +- 7 Jours- Date Début : 13/06/2023 @ 08:00 Fin le 25/06/2023 à 18:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ACCOMPAGNER INSTALLER AUX Début le 13/06/2023 à +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin 08 : 00 +- 7 Jours- Date Début : 13/06/2023 @ 08:00 Fin le 25/06/2023 à 21:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ACCOMPAGNER INSTALLER AUX Début le 13/06/2023 à +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin 08 : 00 +- 7 Jours- Date Début : 13/06/2023 @ 08:00 Fin le 25/06/2023 à 06:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — DESINFECTION Début le 14/06/2023 à +ENVIRONNEMENT PATIENT - Matin [8h] - 10 : 31 +pendant 7 Jour(s)- Date Début : 14/06/2023 @ Fin le 21/06/2023 à 08:00 * 1 +10 : 31 08:00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Signé — ESCARRE : PREVENTION - 7h 10h Début le 13/06/2023 à +13h 16h 19h 22h Si besoin - 7 Jours- Date Début : 08:00 +13/06/2023 @ 08 : 00 Fin le 25/06/2023 à 09:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ESCARRE : PREVENTION - 7h 10h Début le 13/06/2023 à +13h 16h 19h 22h Si besoin - 7 Jours- Date Début : 08:00 +13/06/2023 @ 08 : 00 Fin le 25/06/2023 à 12:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +Signé — ESCARRE : PREVENTION - 7h 10h [NOM] [NOM] +13h 16h 19h 22h Si besoin - 7 Jours- Date Début : Début le 13/06/2023 à 15:00 * 1 +13/06/2023 @ 08 : 00 08:00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 19 de 31 Fin le 25/06/2023 à +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ESCARRE : PREVENTION - 7h 10h Début le 13/06/2023 à +13h 16h 19h 22h Si besoin - 7 Jours- Date Début : 08:00 +13/06/2023 @ 08 : 00 Fin le 25/06/2023 à 18:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ESCARRE : PREVENTION - 7h 10h Début le 13/06/2023 à +13h 16h 19h 22h Si besoin - 7 Jours- Date Début : 08:00 +13/06/2023 @ 08 : 00 Fin le 25/06/2023 à 21:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ESCARRE : PREVENTION - 7h 10h Début le 13/06/2023 à +13h 16h 19h 22h Si besoin - 7 Jours- Date Début : 08:00 +13/06/2023 @ 08 : 00 Fin le 25/06/2023 à 06:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — LIT : REFECTION COMPLETE Début le 14/06/2023 à +- Matin [8h] - pendant 7 Jour(s)- Date Début : 10:31 +14/06/2023 @ 10 : 31 Fin le 21/06/2023 à 08:00 * 1 +08 : 00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 13/06/2023 à +6h) - pendant 15 Jour(s)- Date Début : 13/06/2023 20:00 +@ 20 : 00 Fin le 28/06/2023 à 22:00 * 1 +06 : 00 +Admin le 21/06/2023 à +06 : 00 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 13/06/2023 à +6h) - pendant 15 Jour(s)- Date Début : 13/06/2023 20:00 +@ 20 : 00 Fin le 28/06/2023 à 02:00 * 1 +06 : 00 +Admin le 21/06/2023 à +06 : 00 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 13/06/2023 à +6h) - pendant 15 Jour(s)- Date Début : 13/06/2023 20:00 +@ 20 : 00 Fin le 28/06/2023 à 06:00 * 1 +06 : 00 +Admin le 21/06/2023 à +06 : 00 +[NOM] [NOM] +Réalisé — TOILETTE DOUCHE : AIDE Début le 14/06/2023 à +PARTIELLE - Matin [8h] - pendant 7 Jour(s)- 10 : 31 +Date Début : 14/06/2023 @ 10:31 Fin le 21/06/2023 à 08:00 * 1 +08 : 00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — VESSIE DE GLACE - Ttes les 8H Début le 15/06/2023 à +[6h 14h 22h] - pendant 7 Jour(s)- Date Début : 16:24 +15/06/2023 @ 16 : 24 Fin le 22/06/2023 à 14:00 * 1 +Notes de professionel de santé : 14:00 +sur MSD Admin le 21/06/2023 à +06 : 00 +Réalisé — VESSIE DE GLACE - Ttes les 8H [NOM] [NOM] +[6h 14h 22h] - pendant 7 Jour(s)- Date Début : Début le 15/06/2023 à +15/06/2023 @ 16 : 24 16:24 22:00 * 1 +Notes de professionel de santé : Fin le 22/06/2023 à +sur MSD 14 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 20 de 31 Admin le 21/06/2023 à +06 : 00 +[NOM] [NOM] +Réalisé — VESSIE DE GLACE - Ttes les 8H Début le 15/06/2023 à +[6h 14h 22h] - pendant 7 Jour(s)- Date Début : 16:24 +15/06/2023 @ 16 : 24 Fin le 22/06/2023 à 06:00 * 1 +Notes de professionel de santé : 14:00 +sur MSD Admin le 21/06/2023 à +06 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 13/06/2023 à +8h 14h 20h] - 10 Jours- Date Début : 13/06/2023 16:16 +@ 16 : 16 Fin le 23/06/2023 à 14:00 * 1 +14 : 00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 13/06/2023 à +8h 14h 20h] - 10 Jours- Date Début : 13/06/2023 16:16 +@ 16 : 16 Fin le 23/06/2023 à 20:00 * 1 +14 : 00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 13/06/2023 à +8h 14h 20h] - 10 Jours- Date Début : 13/06/2023 16:16 +@ 16 : 16 Fin le 23/06/2023 à 02:00 * 1 +14 : 00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 13/06/2023 à +8h 14h 20h] - 10 Jours- Date Début : 13/06/2023 16:16 +@ 16 : 16 Fin le 23/06/2023 à 08:00 * 1 +14 : 00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, Début le 13/06/2023 à +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h 16 : 16 +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ Fin le 13/07/2023 à 14:00 * 1 +16 : 16 14:00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, Début le 13/06/2023 à +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h 16 : 16 +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ Fin le 13/07/2023 à 20:00 * 1 +16 : 16 14:00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, Début le 13/06/2023 à +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h 16 : 16 +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ Fin le 13/07/2023 à 02:00 * 1 +16 : 16 14:00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, Début le 13/06/2023 à +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h 16 : 16 +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ Fin le 13/07/2023 à 08:00 * 1 +16 : 16 14:00 +Admin le 21/06/2023 à +08 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 21 de 31 Plan de soins Jour J + 1 du 22/06/2023 07h00 au 23/06/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +Signé — REGIME NORMAL - Matin midi Début le 13/06/2023 à +goûter soir - 10 Jours- Date Début : 13/06/2023 @ 16:16 +16 : 16 Fin le 23/06/2023 à 08:00 * 1 +Notes de professionel de santé : 16:00 +Dés retour du bloc opératoire Admin le 21/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — REGIME NORMAL - Matin midi Début le 13/06/2023 à +goûter soir - 10 Jours- Date Début : 13/06/2023 @ 16:16 +16 : 16 Fin le 23/06/2023 à 12:00 * 1 +Notes de professionel de santé : 16:00 +Dés retour du bloc opératoire Admin le 21/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — REGIME NORMAL - Matin midi Début le 13/06/2023 à +goûter soir - 10 Jours- Date Début : 13/06/2023 @ 16:16 +16 : 16 Fin le 23/06/2023 à 16:00 * 1 +Notes de professionel de santé : 16:00 +Dés retour du bloc opératoire Admin le 21/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — REGIME NORMAL - Matin midi Début le 13/06/2023 à +goûter soir - 10 Jours- Date Début : 13/06/2023 @ 16:16 +16 : 16 Fin le 23/06/2023 à 19:00 * 1 +Notes de professionel de santé : 16:00 +Dés retour du bloc opératoire Admin le 21/06/2023 à +12 : 00 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 08:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 10:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 12:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 14:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 16:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 22 de 31 Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 18:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 20:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 22:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 00:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 02:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 04:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM] +[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à +Début presc. : 19/06/2023 @ 12:30 12:30 06:20 * 1 +si douleur — Nombre de prises max par 24h : 12 Fin le 20/07/2023 à CPR +16 : 20 +Notes de professionel de santé : +Admin le 21/06/2023 à +si douleur à 30min de la prise d'ABSTRAL 12 : 20 +possibilité de redonner ABSTRAL 400 +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le 12/06/2023 à +500ML V1 - 1,4G/100ML solution (500 mL) - 15 : 20 +Dose 10 ml - [NOM] - Matin midi soir - 1ère Fin le 22/06/2023 à 08 : 00 * 10 ml +dose : 12/06/2023 @ 19:00 12:00 +Admin le 21/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le 12/06/2023 à +500ML V1 - 1,4G/100ML solution (500 mL) - 15 : 20 +Dose 10 ml - [NOM] - Matin midi soir - 1ère Fin le 22/06/2023 à 12 : 00 * 10 ml +dose : 12/06/2023 @ 19:00 12:00 +Admin le 21/06/2023 à +12 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 23 de 31 Signé — FUNGIZONE 10% SUSP BUV FL [NOM] [NOM] +40ML - 10G/100ML suspension (40 mL) - Dose Début le 12/06/2023 à +1 [NOM](S) [NOM] (5 ml) - ORALE - Matin 15 : 20 08:00 * 1 +midi soir - 1ère dose : 12/06/2023 @ 19:00 Fin le 12/07/2023 à [NOM](S) +Notes de professionel de santé : 12:00 [NOM] (5 ml) +Admin le 21/06/2023 à +en bain de bouche puis à avaler +12 : 00 +Signé — FUNGIZONE 10% SUSP BUV FL [NOM] [NOM] +40ML - 10G/100ML suspension (40 mL) - Dose Début le 12/06/2023 à +1 [NOM](S) [NOM] (5 ml) - ORALE - Matin 15 : 20 12:00 * 1 +midi soir - 1ère dose : 12/06/2023 @ 19:00 Fin le 12/07/2023 à [NOM](S) +Notes de professionel de santé : 12:00 [NOM] (5 ml) +Admin le 21/06/2023 à +en bain de bouche puis à avaler +12 : 00 +Signé — FUNGIZONE 10% SUSP BUV FL [NOM] [NOM] +40ML - 10G/100ML suspension (40 mL) - Dose Début le 12/06/2023 à +1 [NOM](S) [NOM] (5 ml) - ORALE - Matin 15 : 20 19:00 * 1 +midi soir - 1ère dose : 12/06/2023 @ 19:00 Fin le 12/07/2023 à [NOM](S) +Notes de professionel de santé : 12:00 [NOM] (5 ml) +Admin le 21/06/2023 à +en bain de bouche puis à avaler +12 : 00 +[NOM] [NOM] +Signé — KETOPROFENE ARW LP 100MG Début le 20/06/2023 à +CPR - 100MG comprime - Dose 1 CPR - ORALE 14 : 20 +- +1 +9M : 0a 0tin soir (8h - 19h) - 1ère dose: 20/06/2023 @ F 08in + : 0 +l 0e 20/07/2023 à 0 C8 P : R00 * 1 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — KETOPROFENE ARW LP 100MG Début le 20/06/2023 à +CPR - 100MG comprime - Dose 1 CPR - ORALE 14 : 20 +- +1 +9M : 0a 0tin soir (8h - 19h) - 1ère dose: 20/06/2023 @ F 08in + : 0 +l 0e 20/07/2023 à 1 C9 P : R00 * 1 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — LANSOPRAZOLE BGA 30 MG Début le 13/06/2023 à +CPR OROD - 30MG comprime - Dose 1 CPR 16 : 16 +- +1 +3O /0R 6A /2L 0E +2 +3- P @ri s 1e +9 + : u 0n 0ique à 19h - 1ère dose: F 19in + : 0 +l 0e 12/07/2023 à 1 C9 P : R00 * 1 +Admin le 20/06/2023 à +18 : 57 +[NOM] [NOM] +Signé — LYRICA 75 MG GELULE - 75MG Début le 12/06/2023 à +gelule - Dose 75 mg - ORALE - Matin soir (8h - 13 : 24 08:00 * 75 +20h) - 1ère dose : 12/06/2023 @ 20:00 Fin le 12/07/2023 à mg +08 : 00 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — LYRICA 75 MG GELULE - 75MG Début le 12/06/2023 à +gelule - Dose 75 mg - ORALE - Matin soir (8h - 13 : 24 20:00 * 75 +20h) - 1ère dose : 12/06/2023 @ 20:00 Fin le 12/07/2023 à mg +08 : 00 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — MOVENTIG 25MG CPR - 25MG Début le 17/06/2023 à +comprime - Dose 1 CPR - ORALE - Matin [8h] - 10 : 39 08:00 * 1 +1ère dose : 18/06/2023 @ 08:00 Fin le 17/07/2023 à CPR +08 : 00 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — OMEPRAZOLE ACF 20MG GELULE - Début le 12/06/2023 à +20MG gelule - Dose 2 GEL - ORALE - Soir [19h] 13 : 24 19:00 * 2 +- 1ère dose : 12/06/2023 @ 19:00 Fin le 11/07/2023 à GEL +19 : 00 +Admin le 20/06/2023 à +19 : 00 +Signé — OXYCODONE VIATRIS LP 80MG [NOM] [NOM] 08 : 00 * 70 +CPR - 80MG comprime - Dose 70 mg - ORALE mg +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 24 de 31 Début le 18/06/2023 à +- Matin soir (8h - 20h) - 1ère dose : 18/06/2023 @ 16:13 +20 : 00 Fin le 18/07/2023 à +08 : 00 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — OXYCODONE VIATRIS LP 80MG Début le 18/06/2023 à +CPR - 80MG comprime - Dose 70 mg - ORALE 16 : 13 +- +2 +0M : 0a 0tin soir (8h - 20h) - 1ère dose: 18/06/2023 @ F 08in + : 0 +l 0e 18/07/2023 à 2 m0 g : 00 * 70 +Admin le 21/06/2023 à +08 : 45 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 20/06/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 14 : 21 +O 20R /0A 6L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 20/07/2023 à 0 G8 E : 0 L0 * 2 +Admin le 21/06/2023 à +12 : 14 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 20/06/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 14 : 21 +O 20R /0A 6L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 20/07/2023 à 1 G2 E : 0 L0 * 2 +Admin le 21/06/2023 à +12 : 14 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 20/06/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 14 : 21 +O 20R /0A 6L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 20/07/2023 à 1 G9 E : 0 L0 * 2 +Admin le 21/06/2023 à +12 : 14 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 20/06/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 14 : 21 +O 20R /0A 6L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 20/07/2023 à 2 G1 E : 0 L0 * 2 +Admin le 21/06/2023 à +12 : 14 +[NOM] [NOM] +Signé — PRIMPERAN 10MG CPR - 10MG Début le 20/06/2023 à +comprime - Dose 1 CPR - ORALE - Toutes les 8 14 : 22 14:22 * 1 +Heure(s) - 1ère dose : 20/06/2023 @ 14:22 Fin le 20/07/2023 à CPR +06 : 22 +Admin le 21/06/2023 à +06 : 22 +[NOM] [NOM] +Signé — PRIMPERAN 10MG CPR - 10MG Début le 20/06/2023 à +comprime - Dose 1 CPR - ORALE - Toutes les 8 14 : 22 22:22 * 1 +Heure(s) - 1ère dose : 20/06/2023 @ 14:22 Fin le 20/07/2023 à CPR +06 : 22 +Admin le 21/06/2023 à +06 : 22 +[NOM] [NOM] +Signé — PRIMPERAN 10MG CPR - 10MG Début le 20/06/2023 à +comprime - Dose 1 CPR - ORALE - Toutes les 8 14 : 22 06:22 * 1 +Heure(s) - 1ère dose : 20/06/2023 @ 14:22 Fin le 20/07/2023 à CPR +06 : 22 +Admin le 21/06/2023 à +06 : 22 +Signé — LOVENOX 4000UI AXA/0,4ML [NOM] [NOM] +INJ SER +S - 4000UI solution (0,4 mL) - Dose Début le 13/06/2023 à +1 SERINGUE(S) [NOM](S) - SOUS- 19 : 25 08:00 * 1 +CUTANEE Directe - Matin [8h] - 1ère dose : Fin le 13/07/2023 à SERINGUE(S) +14/06/2023 @ 08 : 00 08:00 [NOM](S) +Admin le 21/06/2023 à +08 : 00 +Signé — ACCOMPAGNER INSTALLER AUX [NOM] [NOM] +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin Début le 13/06/2023 à 09 : 00 * 1 +- 7 Jours- Date Début : 13/06/2023 @ 08:00 08:00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 25 de 31 Fin le 25/06/2023 à +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ACCOMPAGNER INSTALLER AUX Début le 13/06/2023 à +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin 08 : 00 +- 7 Jours- Date Début : 13/06/2023 @ 08:00 Fin le 25/06/2023 à 12:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ACCOMPAGNER INSTALLER AUX Début le 13/06/2023 à +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin 08 : 00 +- 7 Jours- Date Début : 13/06/2023 @ 08:00 Fin le 25/06/2023 à 15:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ACCOMPAGNER INSTALLER AUX Début le 13/06/2023 à +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin 08 : 00 +- 7 Jours- Date Début : 13/06/2023 @ 08:00 Fin le 25/06/2023 à 18:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ACCOMPAGNER INSTALLER AUX Début le 13/06/2023 à +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin 08 : 00 +- 7 Jours- Date Début : 13/06/2023 @ 08:00 Fin le 25/06/2023 à 21:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ACCOMPAGNER INSTALLER AUX Début le 13/06/2023 à +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin 08 : 00 +- 7 Jours- Date Début : 13/06/2023 @ 08:00 Fin le 25/06/2023 à 06:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ESCARRE : PREVENTION - 7h 10h Début le 13/06/2023 à +13h 16h 19h 22h Si besoin - 7 Jours- Date Début : 08:00 +13/06/2023 @ 08 : 00 Fin le 25/06/2023 à 09:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ESCARRE : PREVENTION - 7h 10h Début le 13/06/2023 à +13h 16h 19h 22h Si besoin - 7 Jours- Date Début : 08:00 +13/06/2023 @ 08 : 00 Fin le 25/06/2023 à 12:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ESCARRE : PREVENTION - 7h 10h Début le 13/06/2023 à +13h 16h 19h 22h Si besoin - 7 Jours- Date Début : 08:00 +13/06/2023 @ 08 : 00 Fin le 25/06/2023 à 15:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ESCARRE : PREVENTION - 7h 10h Début le 13/06/2023 à +13h 16h 19h 22h Si besoin - 7 Jours- Date Début : 08:00 +13/06/2023 @ 08 : 00 Fin le 25/06/2023 à 18:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +Signé — ESCARRE : PREVENTION - 7h 10h [NOM] [NOM] +13h 16h 19h 22h Si besoin - 7 Jours- Date Début : Début le 13/06/2023 à +13/06/2023 @ 08 : 00 08:00 21:00 * 1 +Fin le 25/06/2023 à +06 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 26 de 31 Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Signé — ESCARRE : PREVENTION - 7h 10h Début le 13/06/2023 à +13h 16h 19h 22h Si besoin - 7 Jours- Date Début : 08:00 +13/06/2023 @ 08 : 00 Fin le 25/06/2023 à 06:00 * 1 +06 : 00 +Admin le 18/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 13/06/2023 à +6h) - pendant 15 Jour(s)- Date Début : 13/06/2023 20:00 +@ 20 : 00 Fin le 28/06/2023 à 22:00 * 1 +06 : 00 +Admin le 21/06/2023 à +06 : 00 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 13/06/2023 à +6h) - pendant 15 Jour(s)- Date Début : 13/06/2023 20:00 +@ 20 : 00 Fin le 28/06/2023 à 02:00 * 1 +06 : 00 +Admin le 21/06/2023 à +06 : 00 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 13/06/2023 à +6h) - pendant 15 Jour(s)- Date Début : 13/06/2023 20:00 +@ 20 : 00 Fin le 28/06/2023 à 06:00 * 1 +06 : 00 +Admin le 21/06/2023 à +06 : 00 +[NOM] [NOM] +Réalisé — VESSIE DE GLACE - Ttes les 8H Début le 15/06/2023 à +[6h 14h 22h] - pendant 7 Jour(s)- Date Début : 16:24 +15/06/2023 @ 16 : 24 Fin le 22/06/2023 à 14:00 * 1 +Notes de professionel de santé : 14:00 +sur MSD Admin le 21/06/2023 à +06 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 13/06/2023 à +8h 14h 20h] - 10 Jours- Date Début : 13/06/2023 16:16 +@ 16 : 16 Fin le 23/06/2023 à 08:00 * 1 +14 : 00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 13/06/2023 à +8h 14h 20h] - 10 Jours- Date Début : 13/06/2023 16:16 +@ 16 : 16 Fin le 23/06/2023 à 14:00 * 1 +14 : 00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 13/06/2023 à +8h 14h 20h] - 10 Jours- Date Début : 13/06/2023 16:16 +@ 16 : 16 Fin le 23/06/2023 à 20:00 * 1 +14 : 00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 13/06/2023 à +8h 14h 20h] - 10 Jours- Date Début : 13/06/2023 16:16 +@ 16 : 16 Fin le 23/06/2023 à 02:00 * 1 +14 : 00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, Début le 13/06/2023 à +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h 16 : 16 +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ Fin le 13/07/2023 à 08:00 * 1 +16 : 16 14:00 +Admin le 21/06/2023 à +08 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 27 de 31 [NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, Début le 13/06/2023 à +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h 16 : 16 +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ Fin le 13/07/2023 à 14:00 * 1 +16 : 16 14:00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, Début le 13/06/2023 à +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h 16 : 16 +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ Fin le 13/07/2023 à 20:00 * 1 +16 : 16 14:00 +Admin le 21/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, Début le 13/06/2023 à +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h 16 : 16 +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ Fin le 13/07/2023 à 02:00 * 1 +16 : 16 14:00 +Admin le 21/06/2023 à +08 : 00 +Résultats de radiologie +Prescription Date Résultat +Compte rendu au format texte +Bayonne, le 13/06/2023 +Docteur +Nom de naissance : [NOM] +Nom utilisé : [NOM] +Prénom de naissance : [NOM] +Prénom utilisé : [NOM] +[DATE_NAISSANCE] +Lieu de naissance : 64422 +Sexe : M +Matricule INS : (NIR) [NIR] +Examen du : 13/06/2023 +Compte-rendu validé électroniquement par Dr [NOM] le 13/06/2023 +RADIOGRAPHIES DU BRAS [NOM] +Indication : +Antécédent de cancer bronchopulmonaire métastatique à l'os avec métastase humérale droite connue. Douleur brutale du bras [NOM]. +13/06/2023 +CR RX-Echo +06 : 25 +RESULTATS : +On trouve l'image ostéolytique diaphysaire proximale humérale droite, centromédullaire avec des érosions endostées, en rapport +avec la lésion secondaire déjà connue. Il s'y associe un trait de fracture déplacé passant par la lésion. +Dr [NOM] +Technique : +PDS : 1.743 dGy.cm² +A l'entrée : 0.387 mGy +Protocole d'acquisition : Avant-bras +Cet examen rendu anonyme est accessible sur le site WEB de l'établissement pour une durée de 10 mois : www.ch-cote-basque.fr +« accès examens d'imagerie » +N° d'examen : RAD[TEL] +[DATE_NAISSANCE] +Compte rendu au format texte +CR Bayonne, le 13/06/2023 +13/06/2023 +Vasculaire ou Docteur [NOM] +14 : 12 +Interventionnelle Nom de naissance : [NOM] +Nom utilisé : [NOM] +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 28 de 31 Prénom de naissance : [NOM] +Prénom utilisé : [NOM] +[DATE_NAISSANCE] +Lieu de naissance : 64422 +Sexe : M +Matricule INS : (NIR) [NIR] +Examen du : 13/06/2023 +Compte-rendu validé électroniquement par Dr [NOM] le 13/06/2023 +[NOM] DU [NOM] [NOM] [NOM] +Indication : +Volumineuse lésion ostéolytique symptomatique du [NOM] [NOM] dans un contexte de néoplasie pulmonaire. +RESULTATS : +Examen pratiqué sous anesthésie générale : Docteur [NOM] +[NOM] [NOM] initiale retrouve la lésion lytique du [NOM] [NOM] avec rupture corticale. +En condition d'asepsie stricte, positionnement d'un trocart 11 gauges au sein du [NOM] [NOM] par voie antérieure. +Au total, 20 ml de ciment de type MENDEC SPINE sont injectés permettant de combler presque totalement la lésion lytique. +Bonne extension au sein du mur postérieur du [NOM]. +Fuites modérées au sein des ruptures corticales latérales de l'aile iliaque. +Retour en chambre, repos en décubitus pendant 2 heures. Lever autorisé au décours selon l'état clinique du patient. +Si marche possible au sein du service, réévaluation de la douleur inguinale droite. +Retour à domicile autorisé à J1 en absence de symptomatologie particulière en rapport avec la cimentoplastie du [NOM]. +Prise en charge des suites opératoires du membre supérieur [NOM] par l'équipe d'orthopédie. +Dr [NOM] +Technique : +PDS : 333.767 dGy.cm² +A l'entrée : 1 dGy +Temps de scopie : 773 s +Protocole d'acquisition : BCIMENTO +Cet examen rendu anonyme est accessible sur le site WEB de l'établissement pour une durée de 10 mois : www.ch-cote-basque.fr +« accès examens d'imagerie » +N° d'examen : A102660059 +[DATE_NAISSANCE] +Résultats de laboratoire +20/06/2023 08 : 56 14/06/2023 11:21 12/06/2023 13:25 +Résultat de labo +(5982833) (5978503) (5977163) +Albumine 32,2 g/l +Amylase 87 U/l +Bilirubine totale 8 µmol/l 7 µmol/l 6 µmol/l +Score Fibrosis-4 (FIB4) 2,31 4,85 2,03 +Le score Fibrosis-4 est Le score Fibrosis-4 est Le score Fibrosis-4 est +un test de dépistage de un test de dépistage de un test de dépistage de +la fibrose hépatique. la fibrose hépatique. la fibrose hépatique. +S?il existe une cause S?il existe une cause S?il existe une cause +connue de cytolyse connue de cytolyse connue de cytolyse +hépatique ou de hépatique ou de hépatique ou de +thrombopénie, il ne thrombopénie, il ne thrombopénie, il ne +Commentaire score Fibrosis-4 +faut pas tenir compte faut pas tenir compte faut pas tenir compte +de ce résultat. Dans de ce résultat. Dans de ce résultat. Dans +les autres cas, si la les autres cas, si la les autres cas, si la +valeur est > : 2,67, valeur est > 2,67, valeur est > 2,67, +un avis en hépatologie un avis en hépatologie un avis en hépatologie +est recommandé. Si la est recommandé. Si la est recommandé. Si la +valeur est < : 1,3, il valeur est < 1,3, il valeur est < 1,3, il +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 29 de 31 n?existe pas de maladie n?existe pas de maladie n?existe pas de maladie +hépatique sévère. hépatique sévère. hépatique sévère. +Dans les autres cas, un Dans les autres cas, un Dans les autres cas, un +contrôle à distance est contrôle à distance est contrôle à distance est +recommandé. recommandé. recommandé. +ASAT 26 U/l 50 U/l 31 U/l +Bilirubine totale < : Bilirubine totale < Bilirubine totale < +21 µmol/L : dosage des 21 µmol/L : dosage des 21 µmol/L : dosage des +Commentaire bilirubine totale fractions conjuguée fractions conjuguée fractions conjuguée +et non conjugée non et non conjugée non et non conjugée non +réalisé. réalisé. réalisé. +Non-applicable en cas Non-applicable en cas Non-applicable en cas +d'insuffisance rénale d'insuffisance rénale d'insuffisance rénale +aigue. Estimation du aigue. Estimation du aigue. Estimation du +DFG non validée dans DFG non validée dans DFG non validée dans +les situations suivantes : les situations suivantes: les situations suivantes: +- patients âgés > : 75 - patients âgés > 75 - patients âgés > 75 +ans - poids extrêmes ans - poids extrêmes ans - poids extrêmes +Commentaire CKD-EPI +et variations de la et variations de la et variations de la +[NOM] musculaire - [NOM] musculaire - [NOM] musculaire - +alimentation pauvre alimentation pauvre alimentation pauvre +en protéines animales en protéines animales en protéines animales +et patients dénutris - et patients dénutris - et patients dénutris - +patients d'origine non patients d'origine non patients d'origine non +caucasienne caucasienne caucasienne +Gamma GT 89 U/l 109 U/l 126 U/l +NT-proBNP 699 ng/l +Zone grise : +insuffisance cardiaque +moins plausible. +Interprétation NT-proBNP +Envisager d?autres +causes d?augmentation +du NT-proBNP. +Phosphatase alcaline 120 U/l 117 U/l 110 U/l +Troponine hypersensible < : 1.5 ng/l +Changement de réactif +de troponine à compter +du 17/03/2021 : +mise en place d?un +réactif de troponine +hypersensible. +Nouvelle valeur de +référence au 99ème +percentile : < 11 +ng/L Si dosage dans +le cadre d'un SCA +non ST+ : nouveau +protocole avec 2 +dosages systématiques +de troponine à 1 heure +d?intervalle. Le 2ème +prélèvement doit être +fait sans attendre le +Commentaire troponine +résultat du premier +et il doit être réalisé +au moins 3 heures +après le début de la +douleur thoracique. +Etiologie coronarienne +peu probable si H0 +< : 2 ng/L et variation +H0-H1 < : 1ng/L +Infarctus du myocarde +probable si H0 > : = +40 ng/L ou H0 entre 2 +et 40 ng/L et variation +H0-H1 > : = 4 ng/ +L : avis cardiologique +Zone grise dans +les autres cas : avis +cardiologique +Calcium 2,21 mmol/l 2,16 mmol/l 2,30 mmol/l +Calcium corrigé 2,40 mmol/l +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 30 de 31 Estimation du DFG (CKD- +114 ml/mn/1.73 m2 114 ml/mn/1.73 m2 101 ml/mn/1.73 m2 +EPI) +Chlore 108 mmol/l 105 mmol/l 105 mmol/l +Créatinine 45 µmol/l 45 µmol/l 60 µmol/l +CRP 43 mg/l 1 mg/l +Compte-rendu laboratoire Labo230620105157-1.pdfLabo230614153510-1.pdfLabo230612155818-1.pdf +Polynucléaires neutrophiles +58,3 % 80,3 % 78,4 % +(%) +Polynucléaires neutrophiles +2,32 10.9/l 7,10 10.9/l 4,47 10.9/l +(#) +Polynucléaires éosinophiles +6,8 % 0,5 % 1,1 % +(%) +Polynucléaires éosinophiles +0,27 10.9/l 0,04 10.9/l 0,06 10.9/l +(#) +Polynucléaires basophiles (%) 0,5 % 0,2 % 0,4 % +Polynucléaires basophiles (#) 0,02 10.9/l 0,02 10.9/l 0,02 10.9/l +Lymphocytes (%) 11,8 % 4,1 % 7,5 % +Lymphocytes (#) 0,47 10.9/l 0,36 10.9/l 0,43 10.9/l +Monocytes (%) 22,6 % 14,9 % 12,6 % +Monocytes (#) 0,90 10.9/l 1,32 10.9/l 0,72 10.9/l +ALAT 16 U/l 17 U/l 19 U/l +réalisée sur automate réalisée sur automate réalisée sur automate +Formule sanguine +XN (Sysmex) XN (Sysmex) XN (Sysmex) +Hématocrite (%) 27,9 % 31,7 % 36,2 % +Indice de distribution des +17,2 % 17,7 % 17,9 % +hématies +Héparine de bas poids +Traitement anticoagulant Inconnu +moléculaire +Cible de l'INR pour Cible de l'INR pour +un patient sous AVK un patient sous AVK +selon l'indication : - selon l'indication: - +Indications autres que Indications autres que +prothèses mécaniques : prothèses mécaniques : +INR cible = 2.5 (2.0 INR cible = 2.5 (2.0 +Valeurs normales INR à 3.0) - Prothèses à 3.0) - Prothèses +mécaniques : INR mécaniques: INR +cible entre 2.5 et 4.0 cible entre 2.5 et 4.0 +selon les facteurs de selon les facteurs de +risque du patient et le risque du patient et le +risque intrinsèque de la risque intrinsèque de la +prothèse prothèse +INR 1,12 0,96 +Potassium 3,8 mmol/l 4,3 mmol/l 4,2 mmol/l +LDH 633 U/l 213 U/l +Leucocytes 3,98 10.9/l 8,84 10.9/l 5,70 10.9/l +Hématies 3,18 10.12/l (t/l) 3,53 10.12/l (t/l) 4,06 10.12/l (t/l) +Hémoglobine 8,8 g/dl 9,9 g/dl 11,5 g/dl +VGM 87,7 fl 89,8 fl 89,2 fl +TCMH 27,7 pg 28,0 pg 28,3 pg +CCMH 31,5 g/dl 31,2 g/dl 31,8 g/dl +Sodium 138 mmol/l 133 mmol/l 136 mmol/l +Plaquettes 180 10.9/l 160 10.9/l 224 10.9/l +Protéines 61 g/l 67 g/l +Réserve alcaline 26 mmol/l 23 mmol/l 24 mmol/l +Dr. [NOM] +Validation et diffusion sous la +Dr [NOM] [NOM] [NOM] [NOM] +responsabilité du biologiste +[NOM] +Réticulocytes (%) 2,48 % +Réticulocytes (#) 87,5 10.9/l +Trou anionique 8 9 11 +TCA 32,9 secondes 31,8 secondes +TCA ratio 1,09 1,05 +TP 85 % 109 % +Volume plaquettaire moyen 10,0 fl 9,6 fl 10,0 fl +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302 +Le 21/06/2023 14 : 29 Page 31 de 31 + + +Nom de naissance : [NOM] IPP : [IPP] +Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE] +Sexe : Masculin Lieu de naissance: [VILLE] +Nationalité : FRANCE [CODE_POSTAL] +Adresse : [ADRESSE]: [VILLE] +Episode No : [EPISODE] +Localisation : PNEUMOLOGIE PHTISIOLOGIE HC Médecin courant: DR. [NOM] +Date d'admission : 12/06/2023 Heure d'admission: 13:22 +Date de sortie : 21/06/2023 Heure de sortie: 13:32 +Nom : Adresse Téléphone +DR. [NOM] [NOM] : [ADRESSE][CODE_POSTAL] 59.63.06.65 +Type de contact : Relation Nom Prénom Adresse Tél. domicile Tél. +professionel Mobile +Personne à prévenir +(Trakcare) : Epouse [NOM] FRANCE [TEL] +Personne à prévenir +(Clinicom) : Epouse [NOM] [NOM] +HELENE FRANCE [TEL] +Personne de +confiance : Epouse [NOM] [NOM] +HELENE [TEL] +Motif : Principal Date de mise à jour [NOM] +[NOM] , douleur au domicile : 12/06/2023 14:12 [NOM] [NOM] +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Item de +surveillance : 20/06/2023 +23:49 20/06/2023 +20:55 20/06/2023 +15:46 20/06/2023 +08:12 19/06/2023 +19:09 19/06/2023 +09:01 18/06/2023 +15:50 18/06/2023 +11:58 17/06/2023 +16:43 17/06/2023 +07:54 17/06/2023 +00:01 16/06/2023 +15:48 16/06/2023 +08:41 +Température : 37,30 36,50 36,30 37,30 37,20 36,60 37,10 36,20 37,10 37,30 +Pouls : 86 85 90 89 93 99 103 83 95 99 +Saturation +O² : 92 94 92 92 93 93 92 94 92 90 +Ventilation : Ventilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant +Echelle +douleur : EN EN EN ALGOPL USEN EN EN EN EN EN +Score au +repos : 1 1 4 3 8 2 2 6 1 5 +PA +Systolique : 111 106 129 118 110 142 124 125 +PA +Diastolique : 64 59 65 60 58 70 65 64 +Transit : Normal Normal Normal Absence Peu Absence Absence Absence Absence + +Débit O² +[L/mn] +Item de +surveillance : 12/06/2023 +13:35 +Poids [kg] : 77 +Taille [cm] : 178 +Indice +de [NOM] +corporelle : 24,30 +Surface +corporelle : 1,95 +Item de +surveillance : 20/06/2023 +23:49 20/06/2023 +15:46 20/06/2023 +08:12 19/06/2023 +09:01 18/06/2023 +15:50 18/06/2023 +11:58 17/06/2023 +16:43 17/06/2023 +07:54 17/06/2023 +00:01 16/06/2023 +15:48 16/06/2023 +08:41 15/06/2023 +16:10 15/06/2023 +12:45 +Température : 37,30 36,50 36,30 37,30 37,20 36,60 37,10 36,20 37,10 37,30 35,90 +Pouls : 86 85 90 89 93 99 103 83 95 99 83 +Saturation +O² : 92 94 92 92 93 93 92 94 92 90 92 92 +PA +Systolique : 111 106 129 118 110 142 124 125 109 +PA +Diastolique : 64 59 65 60 58 70 65 64 59 +Transit : Normal Normal Normal Absence Peu Absence +Item de +surveillance : 20/06/2023 +23:49 20/06/2023 +15:46 20/06/2023 +08:12 19/06/2023 +09:01 18/06/2023 +15:50 18/06/2023 +11:58 17/06/2023 +16:43 17/06/2023 +07:54 17/06/2023 +00:01 16/06/2023 +15:48 16/06/2023 +08:41 15/06/2023 +16:10 15/06/2023 +12:45 +Température : 37,30 36,50 36,30 37,30 37,20 36,60 37,10 36,20 37,10 37,30 35,90 +Pouls : 86 85 90 89 93 99 103 83 95 99 83 +Saturation +O² : 92 94 92 92 93 93 92 94 92 90 92 92 +PA +Systolique : 111 106 129 118 110 142 124 125 109 +PA +Diastolique : 64 59 65 60 58 70 65 64 59 +Transit : Normal Normal Normal Absence Peu Absence +Type d'observation : Nom Date Commentaires +Conclusion Clinique : DR. [NOM] +[NOM] 21/06/2023 +10:22 Hospitalisation du 12/06 au 21/06/23 pour équilibration des douleurs chez un patient suivi pour +un ADK bronchique stade IV en 5e ligne par TAXOL hebdo. +Moins de 24H après son entrée, fracture pathologique de l’humerus [NOM] ayant necessité +enclouage centromedullaire le 14/06 avec hematome post-opératoire d’evolution favorable. +Réalisation d’une cimentoplastie du [NOM] [NOM] le 13/06 sans complication. +Devant une équilibration des douleurs avec la PCA de morphine, relai par morphine oral le +18/06. Analgésie mutlimodale par OXYCONTIN LP 70mg matin et soir, prise d’ABSTRAL +400 si besoin, PARACETAMOL 4g/jour , KETOPROFENE LP 100mg matin et soir et reprise du +cannabis thérapeutique. +Devant l’état général alteré du patient, discussion sur un arret de la chimiothérapie afin de +privilégier les soins de confort. Pour le moment, cela n’est pas entendable pour le patient. +Il reviendra le 4/07 en HDJ pour une réévaluation clinique +/- chimio si son état général le +permet. +RAD le 21/06. +Note d'évolution : DR. [NOM] +[NOM] 20/06/2023 +13:53 20/06 : LM +Reveil ce matin à 1H et 4H bien soulagé par prise d'ABASTRAL. +Non douloureux lors de mon passage. Hematome du bras en diminution. +Majoration OXYCONTIN LP 70 matin et soir +Arret hydratation IV +Souhaite RAD demain. +Note d'évolution : DR. [NOM] +[NOM] 19/06/2023 +16:30 recrudescence douloureuse chez un patient en prise en charge palliative symptomatique d'un +adénocarcinome pulmonaire métastatique osseux +En cours d'expérimentation sur le cannabis thérapeutique +Reprise mélange équilibré CBD/THC 25mg/ml 0.4ml matin, midi et soir + +Note d'évolution : DR. [NOM] +[NOM] 19/06/2023 +12:39 19/06 : LM +A passé une bonne nuit sans douleur. +Au réveil, accès douloureux intense ++ finalement soulagé après prise d'OXYNORMORO +Lors de mon passage, dort donc longue discussion avec son épouse. +Proposition de tenter l'ABSTRAL et poursuite OXYCONTIN LP +Vu avec Dr [NOM] : ABSTRAL 400. Si acces douloureux non soulagé après 30min, +possible de lui redonner un nouveau ABSTRAL. +Intervalle de 2 à 4H entre chaque prise +Pas de vomissement. Bonne hydratation per os +Arret hydratation IV +Projet de RAD quand douleur équilibrée +Note d'évolution : DR. [NOM] +[NOM] 18/06/2023 +16:19 18/06 : LM +Douleur bien équilibrée avec PCA +A la demande du patient, tentative relai per os +-> Relai OXYCONTIN LP 65mg à 20H avec arret PCA à 22H00 +Note d'évolution : DR. [NOM] +[NOM] 17/06/2023 +15:10 17/06 : LM +A passé une bonne nuit. Douleur au reveil mais calmée par PCA +Vomissement après ACUPAN donc arret ACUPAN +Note d'évolution : DR. [NOM] +[NOM] 16/06/2023 +19:36 16/06 : LM +Reste douloureux ++ +Majoration PCA à 3.8mg/h et majoration bolus à 9mg +Nauséeux. Introduction de PRIMPERAN +A eu des selles +Note d'évolution : DR. [NOM] +[NOM] 15/06/2023 +13:22 message laissé au secrétariat pour demander si l'interne peut passer pour examiner le bras car +hématome post op mais probablement normal. +merci +Note d'évolution : DR. [NOM] +[NOM] 15/06/2023 +12:15 15 6 23 SS +annulation de la radiothérapie séance de ce jour car patient non mobilisable. +ce matin a réussi à dormir cette nuit mais encore inconfortable, réveillable , discret myosis , parle +sans problème . je lui explique que si je majore les doses de morphine, il y a un risque d'être +ensuqué à cause de la morphine. Après discussion, nous convenons +- de garder la même dose de morphine de fond pour la journée à 3,5 mg/heure IVSE +- de majorer la dose de fond pendant le nuit uniquement de 22h à 8 h à 3,8 mg / heure IVSE +(prescrit dans commentaire sur trackare) +[NOM], et [NOM] si constipé +pas de globe, arrive à uriner +réévaluation au jour le jour de Mr [NOM] + +Note d'évolution : DR. [NOM] +[NOM] 13/06/2023 +17:09 [NOM] [NOM] [NOM] +Intervention réalisée sans complication. Comblement satisfaisant de la lésion lytique du [NOM] +[NOM]. +Au retour en chambre, repos en décubitus dorsal pendant 2 heures. En fonction de l'état du +patient au décours, lever autorisé. Si marche possible, réévaluation de la douleur inguinale droite. +En rapport avec l'intervention du [NOM], retour à domicile autorisé à J1 en absence de +symptomatologie particulière. +Note d'évolution : DR. [NOM] +[NOM] 13/06/2023 +10:55 Dr [NOM] +ok pour la chirurgie +bon faxé au bloc +demande anesthésiste en urgence +Note d'évolution : DR. [NOM] +[NOM] 13/06/2023 +10:17 13 06 23 SS +fracture humérus [NOM] cette nuit sur méta os +a eu 20 mg en titration de morphine IVD pour être soulagé +ce matin à jeun +attitude vicieuse MSD +calmé de la douleur si il reste immobile +Appel Dr [NOM] , pas de réponse ( car connaît le patient) +Appel Dr [NOM] : au bloc opératoire, me rappelle +ECG, groupe rhésus RAI, hémostase réalisée +PCA de morphine à 5 mg en bolus toutes les 10 minutes si besoin mais sans ttt de fond pour le +moment +prescriptions à revoir dans la journée en fonction de son évolution +en attente de l'avis du chirurgien orthopédique +Note d'évolution : Tess [NOM] 13/06/2023 +05:19 Appel IDE pour douleur brutal bras [NOM] en se retournant dans le lit. ( méta huméral droite +connu ) +A entendu un craquement en se retournant dans le lit. +EN 10/10 patient en pleur +Examen impossible, pas d'hématome visible, humérus instable +> Titration morphinique +> Rx demandé +> mise en place d'un dujarier + +Item de +surveillance : 20/06/2023 +23:49 20/06/2023 +15:46 20/06/2023 +08:12 19/06/2023 +09:01 18/06/2023 +15:50 18/06/2023 +11:58 17/06/2023 +16:43 17/06/2023 +07:54 17/06/2023 +00:01 16/06/2023 +15:48 16/06/2023 +08:41 15/06/2023 +16:10 15/06/2023 +12:45 +Température : 37,30 36,50 36,30 37,30 37,20 36,60 37,10 36,20 37,10 37,30 35,90 +Pouls : 86 85 90 89 93 99 103 83 95 99 83 +Saturation +O² : 92 94 92 92 93 93 92 94 92 90 92 92 +PA +Systolique : 111 106 129 118 110 142 124 125 109 +PA +Diastolique : 64 59 65 60 58 70 65 64 59 +Transit : Normal Normal Normal Absence Peu Absence Absence Absence Absence Absence +Type de note : Nom Date Note +Note IDE : [NOM] [NOM] 21/06/2023 +13:32 DOULEUR : soulagé à 8 h avec le Paracétamol et le CBD +DEVENIR : sortie domicile avec son épouse à13h30 + +Note IDE : [NOM] [NOM] 21/06/2023 +01:03 DOULEUR: +ATG3 donné à 01h puis 5h30 +ATG1 à 07h +Patient assis au bord du lit à chaque appel pour la douleur, ne semble pas soulagé cette nuit par l' +ATG3 +A peu dormit +Note IDE : [NOM] [NOM] 20/06/2023 +19:54 DOULEUR: ATG3 LI donné en début d'après midi et à 18h00; dit etre bien calmé par ailleurs +Dose ATG3 LP augmentée à 70mg +Relai per os des ATG en vue de la sortie +ALIMENTATION: A bien mangé au gouter, sa femme dit qu'il n'a pas mangé comme ça depuis +plusieurs semaines +DEVENIR: RAD prévue demain avec son épouse, ordo données à sa femme pour les +morphiniques +Note +Kinésithérapeute : Yvan HUGUES 20/06/2023 +16:02 Mobilisation douce acceptée ce jour +Passive et active aidée car très bien ressentie +Aucune douleur +Note IDE : [NOM] [NOM] 20/06/2023 +13:43 DOULEUR : non algique ce matin ==> paracétamol fait en systématique + Ketoprofene +[NOM] : épaule refait ==> plaie propre +DEVENIR : probable sortie domicile demain avec son épouse car refuse l'Ambulance +Note IDE : [NOM] [NOM] 20/06/2023 +01:24 Douleur: ATG3 donné à 01h20 et 04h45 +Note IDE : [NOM] [NOM] 19/06/2023 +21:21 DOULEUR: A 16h patient très algique --> vu avec med, ATG3 LI + Dose CBD administrés +A 18h non soulagé --> ATG1 +A 20h toujours aussi douloureux --> AINS + ATG3 LP + Dose CBD administré ce soir +--> Encouragé à sonner si douleurs persistantes +Douleurs localisées au niveau des interventions au bras et à la hanche +ALIMENTATION: Ne mange plus et ne boit plus, la femme dit ne pas avoir vu la diet --> +Message laissé à la diet pour qu'elle passe +Pas d'hydratation per os de la journée --> hydrat laissé en place, a voir pour ablation demain +SOINS DE SUPPORT: CBD en chambre, administration de 0,4ml au cours des repas +Note IDE : [NOM] [NOM] 19/06/2023 +13:41 DOULEUR : algique +++ à 8h30 avec EN à 8 h ==> soulagé dans la matinée avec ATG 3 LI + +AINS +==> Tentative de l'Abstral pour un soulagement rapide lors des crises douloureuses +==> Abstral 400 donné à 12h30 ==> dotation exceptionnelle faite +SOINS DE SUPPORT : allo Dr [NOM] pour prescrire CBD qui est périmé +DEEVNIR : sortie domicile dès que possible +Note IDE : [NOM] [NOM] 18/06/2023 +18:53 Douleur: projet d'un RAD prochainement +Relais PCA IV pour PO ce soir +TTT donné à 20h30 --> Arrêt PCA 22h30 +Note IDE : [NOM] [NOM] 18/06/2023 +14:17 DOULEUR : EN à 2 au réveil et au repos e matin , faciès détendu , a très bien dormi , 32 +demandes pour 24 perfusées +NAUSEES : prend le chocolat au lait en fractionné car nausées tjs présentes malgré ATE mis en +systématique quand commence à boire , est parvenu à le boire en entier tout de même en prenant +le temps +MOBILISATION : patient ok pour essayer le matelas dynamique => installé dans la matinée , va +faire la sieste avec et voir s'il le tolère bien +ETAT GENERAL : patient se sent plus en forme ce matin mais fatigue très vite au moindre effort +[NOM] : au niveau de l'épaule et du bras [NOM] => plaie propre non inflammatoire , pas +d'écoulement , berges saines et soudées => réfection en 4 temps + [NOM] sec +CONSTIPATION : pas de selles depuis pls jours => sachets de laxatifs donnés => + a eu des +selles normales + liquides par la suite +Note IDE : [NOM] [NOM] 17/06/2023 +19:15 Douleur: réveil important des dlr ce soir à 19h +--> ATG 1 IV mis en systématique et encouragé à appuyer sur la PCA en l'abs de sa compagne +Transit: dis ne pas avoir eu de selles depuis 3 jours, ne sais plus si présence de gaz ou non +--> proposition de laxatifs demain matin + +Note IDE : [NOM] [NOM] 17/06/2023 +00:02 douleur=) +patient confortable début de nuit ATG1+2 fait et PCA en cours +Note IDE : [NOM] [NOM] 16/06/2023 +22:34 Risque d'escarre : +Le patient ne s'alimente pas depuis plusieurs jours car pas d'appétit, se mobilise peu --> Sa +femme m'informe avoir quelques points d'appuis : matelas à air commandé. +Douleur : +Dit être soulagé par les antalgiques administrés. +Pas de nausées ce soir car anti émétique donné avant l'administration de l'ATG2. +Refus la prise kiné mob cet AM, car a peur d'être trop douloureux. +A réévaluer début de semaine. +Note +Kinésithérapeute : Yvan HUGUES 16/06/2023 +15:53 Refus de la prise en soin ce jour +Note IDE : [NOM] [NOM] 16/06/2023 +14:51 DOULEUR: EN à 7/10 ce matin mais faciès détendu --> ATG 2 + AINS --> Pas de plaintes par +la suite +28 demandes pour 20 bolus administrés +Majoration débit de fond et des bolus +DIGESTIF: Nausées et vomissement dans la matinée induit par ATG2 --> Prescription ATE en +systématique avant administration ATG2 +FRACTURE: Oèdeme membre sup gauche avec hématome étendu +Consignes chir --> Surélever le bras avec un coussin + vessie de glace +Note IDE : [NOM] [NOM] 16/06/2023 +13:40 DOULEUR: EN à 7/10 ce matin mais faciès détendu --> ATG 2 + AINS --> Pas de plaintes par +la suite +PCA repassé au débit de journée soit 3.5mg, 28 demandes pour 20 bolus administrés +Majoration débit vu par med +DIGESTIF: Nausées et vomissement dans la matinée induit par ATG2 --> Prescription ATE en +systématique après administration ATG2 +FRACTURE: Oèdeme membre sup gauche avec hématome étendu +Consignes chir --> Surélever le bras avec un coussin + vessie de glace +Note IDE : [NOM] EXILAR 16/06/2023 +01:51 Douleur: +Patient confortable en début de nuit. +PCA ATG 3 en cours, 18 demandes pour 12 perfusées à 0h00. +Réveil des douleurs à 6h30, ATG 1 administré en systématique. +Dig: +Absence de nausées, vomissements sur la nuit, dit avoir été soulagé par ATE de 21h. +Note IDE : [NOM] [NOM] 15/06/2023 +22:31 Douleur : +Douleur très importante à la mobilisation mais maitrisée au repos. +Majoration de la dose de fond de la PCA --> Fait ce soir à diminuer demain matin. +Œdème du membre supérieur [NOM] : +Avis du Dr [NOM] : Symptômes normaux en post chirurgie : Il préconise de surélever le bras par +un oreiller, si le patient ne souhaite pas l'écharpe contre écharpe, pas de nécessité de la mettre, +glacer le bras en si besoin + séances de kiné à faire prescrire SVP. +Vomissements : +Le patient ne s'alimente plus depuis quelques temps, pas d'appétit --> A vomit à 2 reprises cet +AM, vomissements d'origine biliaire. +Anti émétique donné ce soir en IV à 21h, a faire prescrire car non prescrit. + +Note IDE : [NOM] EXILAR 15/06/2023 +03:46 Douleur: +Patient non algique en début de nuit ayant un faciès détendu. +PCA ATG 3 refaite à 3h30 avec dotation exceptionnelle. +A 6h: EN à 5, ATG IV administré en systématique. +Elimination: +A uriné dans la nuit selon sa femme. +Bladder à 415 ml à 6h, proposition de réaliser un sondage évacuateur mais refus du patient. +Note IDE : [NOM] [NOM] 14/06/2023 +19:39 ELIMINATION URINAIRE : dit avoir uriné en début d'après midi , bladder fait = 300ml à 17h +DOULEUR : patient reste algique au niveau du bras [NOM] , [NOM] refait au niveau du pli du coude +car se décolle , présence de 4 agrafes , propre non inflammatoire , pas d'écoulement , bras +oedematié EN à 7/8 => AINS + ATG1+ ATG2 prescrits en IV en systématique n ce soir se sent +un peu moins douloureux dans l'ensemble notamment en position allongée mais grimace à la +moindre mobilisation, non confortable en début d'après midi , plus confortable ce soir +Proposition de mettre l'écharpe contre écharpe , la met qq minutes puis l'enlève ne la supporte pas +Ce soir EN à 5 faciès plus détendu , plus confortable , plus réveillé +EFFETS SECONDAIRES : patient somnolent mais tout à fait réveillable , qq propos confus , +pupilles en myosis serré , sat limite mais refuse de mettre l'O2 car ne se sent pas gêné et les +lunettes à O2 le gène +Note IDE : [NOM] [NOM] 14/06/2023 +13:15 URINAIRE: Bladder à 650cc à 12h, n'est pas favorable à la SV, proposé d'aller uriner aux +toilettes avec l'aide de sa femme +DOULEUR: PCA en cours, 101 demandes pour 40 bolus administrés, 21ml restant à 12h +Augmentation du dosage passant de 60 à 84mg/jour avec bolus de 5mg/10min, PCA +à refaire dans l'après-midi, en attente de la dotation exceptionnel en morphinique +Patient très algique toute la matinée +COMPORTEMENT: Patient apathique, attitude fermé +PLAIES: Pansement cimento renforcé +En attente de consignes des chir pour réfection des pansements +RESPI: SpO2 à 90% sous 2L, eupnéique +EXAMENS: Radiothérapie maintenu pour demain, ambu commandée pour 14h15 +Note IDE : [NOM] [NOM] 13/06/2023 +23:35 respi=) +sevrage O2 fait début de nuit avec un maintien de la sat entre 90 et 93% surveillance ultérieure +infectieux=) +patient apyrétique +élimination =) +a réussi à uriner début de nuit +bloc=) +pansement épaule droite propre +pansement cimento hanche droite délimité +douleur=) +PCA en cours 26 demandes pour 16 reçues changement de PCA cette nuit à 01h15 attention +concentration 5mg/ml +très algique milieu de nuit =) ATG1 01h30; ATG2 03H3 +allo interne de garde ca( patient en pleurs à 04h45 + +Note IDE : [NOM] [NOM] 13/06/2023 +13:54 Douleur: ttt ATG 3 Lp donné ce matin +--> Changement de support avec installation de PCA ATG 3 uniquement en bolus pour le +moment +Ortho: bloc ok pour traité la fracture et faire cimento en même temps +Descendue à 11h30 (pas de possibilité de mobiliser le patient, tee shirt découpé, calçons laissé) +Radio thérapie prévue la semaine pro pour méta humérus [NOM] --> à annuler ? +Note IDE : [NOM] [NOM] 12/06/2023 +23:11 pas de douleur signalée début de nuit +patient eupnéique apyrétique +05h =) lors d'une mobilisation a entendu un crac au niveau de son bras [NOM] impotence +fonctionnelle totale patient en pleurs =) allo interne de garde pour imagerie et ATG3 li donné +vu avec l'interne de garde devant la douleur trop intense titration de morphine =) 20mg en tout +administré jusqu'à 06h15 +06h17 le patient descend à la radio avec écharpe contre écharpe récupérée en ortho le patient +étant moyennement soulagé +Note IDE : [NOM] [NOM] [NOM] +[NOM] 12/06/2023 +21:26 algie: patient non douloureuse cet am ni ce soir --> ttt. LP administre selon presc. +mycose: débutes soins de bouches ce soir +devenir: cimentoplastie hanche gh prévu pour demain 13/06, anesthésiste passe cet am: à jeun +demain matin à partir 9h, on peut lui donner un café / thé à 7H, dossier bloc prête +--> rdv radioTP prévu pour le 15/06 +Note IDE : [NOM] [NOM] 12/06/2023 +13:46 Entré pour douleurs diffuse, [NOM], perte d'appétit, perte d'autonomie +patient ayant un cancer multi métastasé +Bénéficie cimento des 2 bras, devait avoir une cimento demain a la hanche gauche, a revoir +A aussi des rayons aux épaules (prochains rdv jeudi 15/06 a 14h) +Ne mange presque plus depuis 10 jours et n'avale vraiment plus rien depuis samedi. Sa femme +qui gère tout a été obligé d'augmenter les doses d'ATG3 après avis médical +Ce jour, patient très affaibli, a perdu 3kg en 10 jours, pas trop le moral car dit que le TAXOL le +détraque +Ne mange plus rien de solide depuis samedi, il n'y a que l'eau qui passe +Douleurs épaules: très algique malgré 60mg d'ATG 3 LI 11h30 +A son arrivée, perfusé sur PAC, RV +, bio, hydrat mise, ECG fait +Sa femme souhaite dormir la ce soir car patient en aide partielle , sa femme lui fait bcp de choses +au domicile (habillage, aide aux repas...) +Prescription : Dose Fréquence Date de début Date de dernière +administration Note Docteur +MORPHINE PCA IV +[NOM]+Bolus (5 à 30 MG/J) +seringue 50ML - BSFP : - Normal 14/06/2023 05:00 14/06/2023 08:58 Notes de la +prescription: +Max : 6 Bolus / +1 heure(s) Notes +du professionel +de santé: +Concentration +recherchée 1mg/ +ml soit 50 mg pour +50 ml: 1 ampoule +de 50mg/5ml + +45ml de NaCl +0.9% majoration +de la dose à 3,8 +mg /h IVSE de +22h à 8h DR. [NOM] +ADO +ACUPAN 20MG/2ML SOL +INJ [5] Ampoule(s) : 1 AMP - Ttes les 8h [0h 8h +16h] Normal 13/06/2023 16:47 17/06/2023 07:53 Le débit a été +modifié. Le débit +en cours est : 4 +par . Notes du +professionel de +santé: à diluer +dans 100ML de +NaCl ou G5% DR. [NOM] +[NOM] + +KETOPROFENE [NOM] +100MG/4ML SOL INJ [10] +Ampoule(s) : 100 mg - Matin soir (8h - +19h) Normal 14/06/2023 18:00 20/06/2023 08:08 DR. [NOM] +[NOM] +METOCLOPRAMIDE CHL +REN 10MG/2ML INJ [100] +Ampoule(s) : 1 AMP - Normal 16/06/2023 13:47 20/06/2023 12:21 Le débit a été +modifié. Le débit +en cours est : 4 +par . DR. [NOM] +[NOM] +MORPHINE PSE 50ML +[NOM] 1MG/ML+Droleptan +2.5MG - BSFP : - Normal 13/06/2023 09:58 14/06/2023 04:39 Notes de la +prescription: +Max : 6 Bolus / 1 +heure(s) DR. [NOM] +[NOM] +PARACETAMOL BBM +10MG/ML INJ 100ML [10] +Flacon(s) : 1 G - Ttes les 6h [2h 8h +14h 20h] Normal 14/06/2023 18:00 20/06/2023 12:22 Le débit a été +modifié. Le débit +en cours est : 400 +par . DR. [NOM] +[NOM] +POLYIONIQUE 1A G5 +BAX POC VFO 500ML [1] +POCHE(S) : - Normal 12/06/2023 15:46 19/06/2023 09:00 Le débit en +cours est : +41.66666666666666 +ML par 1 hrs. DR. [NOM] +4SCHNEIDER +MORPHINE CHL REN +10MG/ML INJ 1ML +Ampoule(s) : 3 mg - Normal 13/06/2023 05:15 13/06/2023 06:16 Notes du +professionel de +santé: titration: 2 +à 3 mg toutes les +5 min Dose MAX +20 mg => avis +médical Tess [NOM] +FUNGIZONE 10% SUSP +BUV FL 40ML [8] Flacon(s) : 1 +[NOM](S) +[NOM] (5 ml) - Matin midi soir +Normal 12/06/2023 15:20 21/06/2023 12:00 Notes du +professionel de +santé: en bain de +bouche puis à +avaler DR. [NOM] +[NOM] +KETOPROFENE ACT +LP 100MG CPR [20] +COMPRIME(S) : 1 CPR - Matin soir (8h - +19h) Normal 20/06/2023 14:20 21/06/2023 08:45 DR. [NOM] +[NOM] +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR - Prise unique à 19h +Normal 13/06/2023 16:16 20/06/2023 18:57 DR. [NOM] +[NOM] +LYRICA 75MG GELULE +[56] Gelule(s) : 75 mg - Matin soir (8h - +20h) Normal 12/06/2023 13:24 21/06/2023 08:45 DR. [NOM] +[NOM] +MOVENTIG 25 MG CPR +[90] CPR(s) : 1 CPR - Matin [8h] Normal 17/06/2023 10:39 21/06/2023 08:45 DR. [NOM] +[NOM] +OMEPRAZOLE ACF 20MG +GELULE [28] Gelule(s) : 2 GEL - Soir [19h] Normal 12/06/2023 13:24 20/06/2023 19:00 DR. [NOM] +[NOM] +OXYCODONE MYL LP +80MG CPR [28] CPR(s) : 70 mg - Matin soir (8h - +20h) Normal 18/06/2023 16:13 21/06/2023 08:45 DR. [NOM] +[NOM] +PARACETAMOL ARW +500MG GELULE [12] +Gelule(s) : 2 GEL - Matin midi soir nuit +Normal 20/06/2023 14:21 21/06/2023 12:14 DR. [NOM] +[NOM] +PRIMPERAN 10MG CPR +[40] COMPRIME(S) : 1 CPR - Normal 20/06/2023 14:22 21/06/2023 06:22 DR. [NOM] +[NOM] +KETOPROFENE ACT +LP 100MG CPR [20] +COMPRIME(S) : 1 CPR - Matin soir (8h - +20h) Normal 12/06/2023 13:24 14/06/2023 09:00 DR. [NOM] +[NOM] +MOVENTIG 12.5 MG CPR +[30] CPR(s) : 1 CPR - 1xJour [8h] Normal 14/06/2023 13:02 17/06/2023 07:52 DR. [NOM] +[NOM] +OXYCODONE MYL LP +20MG CPR [28] CPR(s) : 20 mg - Matin soir (8h - +19h) Normal 12/06/2023 15:15 19/06/2023 08:00 DR. [NOM] +[NOM] +OXYCODONE MYL LP +40MG CPR [28] CPR(s) : 40 mg - Matin soir (8h - +19h) Normal 12/06/2023 15:15 19/06/2023 08:00 DR. [NOM] +[NOM] +OXYNORMORO +10MG CPR DISP [14] +COMPRIME(S) : 20 mg - Normal 18/06/2023 22:00 19/06/2023 10:00 DR. [NOM] +[NOM] +OXYNORMORO +20MG CPR DISP [14] +COMPRIME(S) : 3 CPR - Ttes les 4H [0h +4h ... 16h 20h] +Normal 12/06/2023 15:15 19/06/2023 12:00 DR. [NOM] +[NOM] +PARACETAMOL ARW +500MG GELULE [12] +Gelule(s) : 2 GEL - Matin midi soir +Normal 12/06/2023 15:13 14/06/2023 12:00 DR. [NOM] +[NOM] + +FUNGIZONE 10% SUSP +BUV FL 40ML [8] Flacon(s) : 1 +[NOM](S) +[NOM] (5 ml) - Matin midi soir +Presc. de Sortie 21/06/2023 13:10 Notes du +professionel de +santé: en bain de +bouche puis à +avaler DR. [NOM] +[NOM] +KETOPROFENE ACT +LP 100MG CPR [20] +COMPRIME(S) : 1 CPR - Matin soir (8h - +19h) Presc. de Sortie 21/06/2023 13:10 DR. [NOM] +[NOM] +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR - Prise unique à 19h +Presc. de Sortie 21/06/2023 13:10 DR. [NOM] +[NOM] +LYRICA 75MG GELULE +[56] Gelule(s) : 75 mg - Matin soir (8h - +20h) Presc. de Sortie 21/06/2023 13:10 DR. [NOM] +[NOM] +MOVENTIG 25 MG CPR +[90] CPR(s) : 1 CPR - Matin [8h] Presc. de +Sortie 21/06/2023 13:10 DR. [NOM] +[NOM] +OMEPRAZOLE ACF 20MG +GELULE [28] Gelule(s) : 2 GEL - Soir [19h] Presc. de +Sortie 21/06/2023 13:10 DR. [NOM] +[NOM] +PARACETAMOL ARW +500MG GELULE [12] +Gelule(s) : 2 GEL - Matin midi soir nuit +Presc. de Sortie 21/06/2023 13:10 DR. [NOM] +[NOM] +PRIMPERAN 10MG CPR +[40] COMPRIME(S) : 1 CPR - Presc. de Sortie 21/06/2023 13:10 DR. [NOM] +[NOM] +[NOM] AD +SORBITOL SOL RECTALE +[4] RECIPIENT(S) +UNIDOSE(S) : 1 +UNIDOSE(S) - 1 seule fois 1 seule +fois 15/06/2023 12:15 DR. [NOM] +[NOM] +[NOM] [NOM] +AD SOL RECTALE +[1] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - 1 seule fois 1 seule +fois 15/06/2023 12:15 DR. [NOM] +[NOM] +LOVENOX 4000UI +AXa/0,4ML INJ SER ++S [2] SERINGUE(S) +[NOM](S) : 1 +SERINGUE(S) +[NOM] - Matin [8h] Normal +(S) 13/06/2023 19:25 21/06/2023 08:00 DR. [NOM] +[NOM] +LOVENOX 4000UI +AXa/0,4ML INJ SER ++S [2] SERINGUE(S) +[NOM](S) : 1 +SERINGUE(S) +[NOM] - Matin [8h] Presc. de +Sortie +(S) 21/06/2023 13:10 DR. [NOM] +[NOM] +ABSTRAL 400MICROG +CPR [10] COMPRIME(S) : 1 CPR - Normal 19/06/2023 12:30 21/06/2023 12:20 Notes du +professionel de +santé: si douleur +à 30min de la +prise d'ABSTRAL +possibilité +de redonner +ABSTRAL 400 DR. [NOM] +[NOM] +SODIUM BIC BAX 1,4% +POC CFX 500ML V1 [1] +POCHE(S) : 10 ml - Matin midi soir +Normal 12/06/2023 15:20 21/06/2023 12:00 DR. [NOM] +[NOM] +SODIUM BIC BAX 1,4% +POC CFX 500ML V1 [1] +POCHE(S) : 10 ml - Matin midi soir +Presc. de Sortie 21/06/2023 13:10 DR. [NOM] +[NOM] +Date début : Heure +début Prescription Date +exécution Heure +exécution Statut Docteur Note +13/06/2023 : 06:25 Humérus [NOM] F P 13/06/2023 06:31 Réalisé Tess [NOM] +13/06/2023 : 17:58 Humérus [NOM] F P 13/06/2023 18:28 Réalisé [NOM] +[NOM] +Date : Heure Prescription Docteur Date de +collection Note + +12/06/2023 : 13:24 TP+INR ( si AVK ) DR. [NOM] 12/06/2023 +13:25 +12/06/2023 : 13:24 Ionogramme ( Na, K, CL ) DR. [NOM] 12/06/2023 +13:25 +12/06/2023 : 13:24 Créatinine sang ( dosage ) DR. [NOM] 12/06/2023 +13:25 +13/06/2023 : 14:12 Biopsie ordinaire ( Atlantic- +Pathologie ) [NOM] [NOM] 13/06/2023 +14:13 +14/06/2023 : 07:00 TP+INR ( si AVK ) DR. [NOM] 14/06/2023 +11:21 +14/06/2023 : 07:00 Ionogramme ( Na, K, CL ) DR. [NOM] 14/06/2023 +11:21 +14/06/2023 : 07:00 Créatinine sang ( dosage ) DR. [NOM] 14/06/2023 +11:21 +20/06/2023 : 07:00 Ionogramme ( Na, K, CL ) DR. [NOM] 20/06/2023 +08:56 +20/06/2023 : 07:00 Créatinine sang ( dosage ) DR. [NOM] 20/06/2023 +08:56 +20/06/2023 : 07:00 Bilirubine ( totale + conjuguée + +non conjuguée ) sang ( dosage ) DR. [NOM] 20/06/2023 +08:56 +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +REGIME NORMAL : Signé 10 Jours - Matin midi +goûter soir Normal 13/06/2023 +16:16 Notes du +professionel +de santé: +Dés retour +du bloc +opératoire DR. [NOM] +[NOM] +ACCOMPAGNER +INSTALLER AUX +TOILETTES : Signé 7 Jours - 7h 10h 13h +16h 19h 22h Normal 13/06/2023 +08:00 [NOM] +[NOM] +AIDE A LA PRISE +MEDICAMENTS : Signé - 1 seule fois 1 seule +fois 13/06/2023 +21:25 [NOM] +[NOM] +[NOM] : AIDE +PARTIELLE Signé - 1 seule fois 1 seule +fois 13/06/2023 +21:25 [NOM] +[NOM] +DESINFECTION +ENVIRONNEMENT +PATIENT : Signé - 1 seule fois 1 seule +fois 13/06/2023 +21:25 [NOM] +[NOM] +ESCARRE : PREVENTION Signé 7 Jours - 7h 10h 13h +16h 19h 22h Normal 13/06/2023 +08:00 [NOM] +[NOM] +HABILLAGE : AIDE +PARTIELLE Signé - 1 seule fois 1 seule +fois 13/06/2023 +21:25 [NOM] +[NOM] +CHANGES ADULTE : Réalisé - 1 seule fois 1 seule +fois 13/06/2023 +21:25 [NOM] +[NOM] +DESINFECTION +ENVIRONNEMENT +PATIENT : Réalisé - Matin [8h] Normal 14/06/2023 +10:31 [NOM] +[NOM] +LIT : REFECTION +COMPLETE Réalisé - Matin [8h] Normal 14/06/2023 +10:31 [NOM] +[NOM] +REPAS : INSTALLATION Réalisé - 1 seule fois 1 seule +fois 13/06/2023 +21:25 [NOM] +[NOM] +SOMMEIL : SURV. Réalisé - 3x/Nuit (22h 2h 6h) +Normal 13/06/2023 +20:00 [NOM] +[NOM] +TOILETTE DOUCHE : AIDE PARTIELLE Réalisé - Matin [8h] Normal 14/06/2023 +10:31 [NOM] +[NOM] +URINAL / BASSIN : VIDER Réalisé - 1 seule fois 1 seule +fois 13/06/2023 +21:25 [NOM] +[NOM] +VESSIE DE GLACE : Réalisé - Ttes les 8H [6h 14h +22h] Normal 15/06/2023 +16:24 Notes du +professionel +de santé: sur +MSD DR. [NOM] +[NOM] +DOULEUR : SURV Réalisé 10 Jours - Ttes les +6h [2h 8h 14h 20h] +Normal 13/06/2023 +16:16 DR. [NOM] +[NOM] +SIGNES VITAUX (Pls, +TA, FR, T°, Glyc, Miction, +Transit) : Réalisé 1 Mois (30j) - Ttes +les 6h [2h 8h 14h +20h] Normal 13/06/2023 +16:16 DR. [NOM] +[NOM] +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur + +KETOPROFENE ACT +LP 100MG CPR [20] +COMPRIME(S) : 1 CPR +ORALE Réalisé - Matin soir (8h - +19h) Presc. de Sortie 21/06/2023 +13:10 0/60 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR +ORALE Réalisé - Prise unique à 19h +Presc. de Sortie 21/06/2023 +13:10 0/30 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +LOVENOX 4000UI +AXa/0,4ML INJ SER ++S [2] SERINGUE(S) +[NOM](S) : 1 +SERINGUE(S) +[NOM] +SOUS- +CUTANEE (SS)igné - Matin [8h] Presc. de +Sortie 21/06/2023 +13:10 0/30 : Non administré +A valider DR. +[NOM] +[NOM] +LYRICA 75MG GELULE +[56] Gelule(s) : 75 mg +ORALE Réalisé - Matin soir (8h - +20h) Presc. de Sortie 21/06/2023 +13:10 0/60 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +MOVENTIG 25 MG CPR +[90] CPR(s) : 1 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 21/06/2023 +13:10 0/30 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +OMEPRAZOLE ACF 20MG +GELULE [28] Gelule(s) : 2 GEL +ORALE Réalisé - Soir [19h] Presc. de +Sortie 21/06/2023 +13:10 0/60 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +PARACETAMOL ARW +500MG GELULE [12] +Gelule(s) : 2 GEL +ORALE Réalisé - Matin midi soir nuit +Presc. de Sortie 21/06/2023 +13:10 0/240 : Non +administré Révisé/ +Traité DR. +[NOM] +[NOM] +PRIMPERAN 10MG CPR +[40] COMPRIME(S) : 1 CPR +ORALE Réalisé - Presc. de Sortie 21/06/2023 +13:10 0/90 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +SODIUM BIC BAX 1,4% +POC CFX 500ML V1 [1] +POCHE(S) : 10 ml +[NOM] Réalisé - Matin midi soir +Presc. de Sortie 21/06/2023 +13:10 0/2 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — REGIME NORMAL - Matin midi +goûter soir - 10 Jours- Date Début : 13/06/2023 @ +16:16 +Notes de professionel de santé : +Dés retour du bloc opératoire [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +16:00 +Admin le 21/06/2023 à +12:00 16:00 * 1 +Signé — REGIME NORMAL - Matin midi +goûter soir - 10 Jours- Date Début : 13/06/2023 @ +16:16 +Notes de professionel de santé : +Dés retour du bloc opératoire [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +16:00 +Admin le 21/06/2023 à +12:00 19:00 * 1 +Signé — REGIME NORMAL - Matin midi +goûter soir - 10 Jours- Date Début : 13/06/2023 @ +16:16 +Notes de professionel de santé : +Dés retour du bloc opératoire [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +16:00 +Admin le 21/06/2023 à +12:00 08:00 * 1 +Signé — REGIME NORMAL - Matin midi +goûter soir - 10 Jours- Date Début : 13/06/2023 @ +16:16 +Notes de professionel de santé : +Dés retour du bloc opératoire [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +16:00 +Admin le 21/06/2023 à +12:00 12:00 * 1 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 14:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 16:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 18:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 20:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 22:20 * 1 +CPR + +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 00:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 02:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 04:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 06:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 08:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 10:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 12:20 * 1 +CPR +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - [NOM] - Matin midi soir - 1ère +dose : 12/06/2023 @ 19:00 [NOM] [NOM] +Début le 12/06/2023 à +15:20 +Fin le 22/06/2023 à +12:00 +Admin le 21/06/2023 à +12:00 19:00 * 10 ml +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - [NOM] - Matin midi soir - 1ère +dose : 12/06/2023 @ 19:00 [NOM] [NOM] +Début le 12/06/2023 à +15:20 +Fin le 22/06/2023 à +12:00 +Admin le 21/06/2023 à +12:00 08:00 * 10 ml + +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - [NOM] - Matin midi soir - 1ère +dose : 12/06/2023 @ 19:00 [NOM] [NOM] +Début le 12/06/2023 à +15:20 +Fin le 22/06/2023 à +12:00 +Admin le 21/06/2023 à +12:00 12:00 * 10 ml +Signé — FUNGIZONE 10% SUSP BUV FL +40ML - 10G/100ML suspension (40 mL) - Dose +1 [NOM](S) [NOM] (5 ml) - ORALE - Matin +midi soir - 1ère dose : 12/06/2023 @ 19:00 +Notes de professionel de santé : +en bain de bouche puis à avaler [NOM] [NOM] +Début le 12/06/2023 à +15:20 +Fin le 12/07/2023 à +12:00 +Admin le 21/06/2023 à +12:00 19:00 * 1 +[NOM](S) +[NOM] (5 ml) +Signé — FUNGIZONE 10% SUSP BUV FL +40ML - 10G/100ML suspension (40 mL) - Dose +1 [NOM](S) [NOM] (5 ml) - ORALE - Matin +midi soir - 1ère dose : 12/06/2023 @ 19:00 +Notes de professionel de santé : +en bain de bouche puis à avaler [NOM] [NOM] +Début le 12/06/2023 à +15:20 +Fin le 12/07/2023 à +12:00 +Admin le 21/06/2023 à +12:00 08:00 * 1 +[NOM](S) +[NOM] (5 ml) +Signé — FUNGIZONE 10% SUSP BUV FL +40ML - 10G/100ML suspension (40 mL) - Dose +1 [NOM](S) [NOM] (5 ml) - ORALE - Matin +midi soir - 1ère dose : 12/06/2023 @ 19:00 +Notes de professionel de santé : +en bain de bouche puis à avaler [NOM] [NOM] +Début le 12/06/2023 à +15:20 +Fin le 12/07/2023 à +12:00 +Admin le 21/06/2023 à +12:00 12:00 * 1 +[NOM](S) +[NOM] (5 ml) +Signé — KETOPROFENE ARW LP 100MG +CPR - 100MG comprime - Dose 1 CPR - ORALE +- Matin soir (8h - 19h) - 1ère dose : 20/06/2023 @ +19:00 [NOM] [NOM] +Début le 20/06/2023 à +14:20 +Fin le 20/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 19:00 * 1 +CPR +Signé — KETOPROFENE ARW LP 100MG +CPR - 100MG comprime - Dose 1 CPR - ORALE +- Matin soir (8h - 19h) - 1ère dose : 20/06/2023 @ +19:00 [NOM] [NOM] +Début le 20/06/2023 à +14:20 +Fin le 20/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 08:45 * 1 +CPR +Signé — LANSOPRAZOLE BGA 30 MG +CPR OROD - 30MG comprime - Dose 1 CPR +- ORALE - Prise unique à 19h - 1ère dose : 13/06/2023 @ 19:00 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 12/07/2023 à +19:00 +Admin le 20/06/2023 à +18:57 19:00 * 1 +CPR +Signé — LYRICA 75 MG GELULE - 75MG +gelule - Dose 75 mg - ORALE - Matin soir (8h - +20h) - 1ère dose : 12/06/2023 @ 20:00 [NOM] [NOM] +Début le 12/06/2023 à +13:24 +Fin le 12/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 20:00 * 75 +mg +Signé — LYRICA 75 MG GELULE - 75MG +gelule - Dose 75 mg - ORALE - Matin soir (8h - +20h) - 1ère dose : 12/06/2023 @ 20:00 [NOM] [NOM] +Début le 12/06/2023 à +13:24 +Fin le 12/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 08:45 * 75 +mg +Signé — MOVENTIG 25MG CPR - 25MG +comprime - Dose 1 CPR - ORALE - Matin [8h] - +1ère dose : 18/06/2023 @ 08:00 [NOM] [NOM] +Début le 17/06/2023 à +10:39 +Fin le 17/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 08:45 * 1 +CPR + +Signé — OMEPRAZOLE ACF 20MG GELULE - +20MG gelule - Dose 2 GEL - ORALE - Soir [19h] +- 1ère dose : 12/06/2023 @ 19:00 [NOM] [NOM] +Début le 12/06/2023 à +13:24 +Fin le 11/07/2023 à +19:00 +Admin le 20/06/2023 à +19:00 19:00 * 2 +GEL +Signé — OXYCODONE VIATRIS LP 80MG +CPR - 80MG comprime - Dose 70 mg - ORALE +- Matin soir (8h - 20h) - 1ère dose : 18/06/2023 @ +20:00 [NOM] [NOM] +Début le 18/06/2023 à +16:13 +Fin le 18/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 20:00 * 70 +mg +Signé — OXYCODONE VIATRIS LP 80MG +CPR - 80MG comprime - Dose 70 mg - ORALE +- Matin soir (8h - 20h) - 1ère dose : 18/06/2023 @ +20:00 [NOM] [NOM] +Début le 18/06/2023 à +16:13 +Fin le 18/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 08:45 * 70 +mg +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 20/06/2023 @ 19:00 [NOM] [NOM] +Début le 20/06/2023 à +14:21 +Fin le 20/07/2023 à +12:00 +Admin le 21/06/2023 à +12:14 19:00 * 2 +GEL +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 20/06/2023 @ 19:00 [NOM] [NOM] +Début le 20/06/2023 à +14:21 +Fin le 20/07/2023 à +12:00 +Admin le 21/06/2023 à +12:14 21:00 * 2 +GEL +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 20/06/2023 @ 19:00 [NOM] [NOM] +Début le 20/06/2023 à +14:21 +Fin le 20/07/2023 à +12:00 +Admin le 21/06/2023 à +12:14 07:00 * 2 +GEL +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 20/06/2023 @ 19:00 [NOM] [NOM] +Début le 20/06/2023 à +14:21 +Fin le 20/07/2023 à +12:00 +Admin le 21/06/2023 à +12:14 12:14 * 2 +GEL +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) - 1ère dose : 20/06/2023 @ 14:22 [NOM] [NOM] +Début le 20/06/2023 à +14:22 +Fin le 20/07/2023 à +06:22 +Admin le 21/06/2023 à +06:22 14:22 * 1 +CPR +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) - 1ère dose : 20/06/2023 @ 14:22 [NOM] [NOM] +Début le 20/06/2023 à +14:22 +Fin le 20/07/2023 à +06:22 +Admin le 21/06/2023 à +06:22 22:22 * 1 +CPR +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) - 1ère dose : 20/06/2023 @ 14:22 [NOM] [NOM] +Début le 20/06/2023 à +14:22 +Fin le 20/07/2023 à +06:22 +Admin le 21/06/2023 à +06:22 06:22 * 1 +CPR + + + +Signé — ACCOMPAGNER INSTALLER AUX +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin +- 7 Jours- Date Début : 13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 09:00 * 1 +Signé — ACCOMPAGNER INSTALLER AUX +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin +- 7 Jours- Date Début : 13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 12:00 * 1 +Signé — ACCOMPAGNER INSTALLER AUX +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin +- 7 Jours- Date Début : 13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 15:00 * 1 +Signé — ACCOMPAGNER INSTALLER AUX +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin +- 7 Jours- Date Début : 13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 18:00 * 1 +Signé — ACCOMPAGNER INSTALLER AUX +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin +- 7 Jours- Date Début : 13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 21:00 * 1 +Signé — ACCOMPAGNER INSTALLER AUX +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin +- 7 Jours- Date Début : 13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 06:00 * 1 +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - +pendant 7 Jour(s)- Date Début : 14/06/2023 @ +10:31 [NOM] [NOM] +Début le 14/06/2023 à +10:31 +Fin le 21/06/2023 à +08:00 +Admin le 21/06/2023 à +08:00 08:00 * 1 +Signé — ESCARRE : PREVENTION - 7h 10h +13h 16h 19h 22h Si besoin - 7 Jours- Date Début: +13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 09:00 * 1 +Signé — ESCARRE : PREVENTION - 7h 10h +13h 16h 19h 22h Si besoin - 7 Jours- Date Début: +13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 12:00 * 1 + +Signé — ESCARRE : PREVENTION - 7h 10h +13h 16h 19h 22h Si besoin - 7 Jours- Date Début: +13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 18:00 * 1 +Signé — ESCARRE : PREVENTION - 7h 10h +13h 16h 19h 22h Si besoin - 7 Jours- Date Début: +13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 21:00 * 1 +Signé — ESCARRE : PREVENTION - 7h 10h +13h 16h 19h 22h Si besoin - 7 Jours- Date Début: +13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 06:00 * 1 +Réalisé — LIT : REFECTION COMPLETE +- Matin [8h] - pendant 7 Jour(s)- Date Début: +14/06/2023 @ 10:31 [NOM] [NOM] +Début le 14/06/2023 à +10:31 +Fin le 21/06/2023 à +08:00 +Admin le 21/06/2023 à +08:00 08:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 15 Jour(s)- Date Début: 13/06/2023 +@ 20:00 [NOM] [NOM] +Début le 13/06/2023 à +20:00 +Fin le 28/06/2023 à +06:00 +Admin le 21/06/2023 à +06:00 22:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 15 Jour(s)- Date Début: 13/06/2023 +@ 20:00 [NOM] [NOM] +Début le 13/06/2023 à +20:00 +Fin le 28/06/2023 à +06:00 +Admin le 21/06/2023 à +06:00 02:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 15 Jour(s)- Date Début: 13/06/2023 +@ 20:00 [NOM] [NOM] +Début le 13/06/2023 à +20:00 +Fin le 28/06/2023 à +06:00 +Admin le 21/06/2023 à +06:00 06:00 * 1 +Réalisé — TOILETTE DOUCHE : AIDE +PARTIELLE - Matin [8h] - pendant 7 Jour(s)- +Date Début: 14/06/2023 @ 10:31 [NOM] [NOM] +Début le 14/06/2023 à +10:31 +Fin le 21/06/2023 à +08:00 +Admin le 21/06/2023 à +08:00 08:00 * 1 +Réalisé — VESSIE DE GLACE - Ttes les 8H +[6h 14h 22h] - pendant 7 Jour(s)- Date Début : 15/06/2023 @ 16:24 +Notes de professionel de santé : +sur MSD [NOM] [NOM] +Début le 15/06/2023 à +16:24 +Fin le 22/06/2023 à +14:00 +Admin le 21/06/2023 à +06:00 14:00 * 1 + +Réalisé — VESSIE DE GLACE - Ttes les 8H +[6h 14h 22h] - pendant 7 Jour(s)- Date Début : 15/06/2023 @ 16:24 +Notes de professionel de santé : +sur MSD [NOM] [NOM] +Début le 15/06/2023 à +16:24 +Fin le 22/06/2023 à +14:00 +Admin le 21/06/2023 à +06:00 06:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 13/06/2023 +@ 16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +14:00 +Admin le 21/06/2023 à +08:00 14:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 13/06/2023 +@ 16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +14:00 +Admin le 21/06/2023 à +08:00 20:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 13/06/2023 +@ 16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +14:00 +Admin le 21/06/2023 à +08:00 02:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 13/06/2023 +@ 16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +14:00 +Admin le 21/06/2023 à +08:00 08:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ +16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 13/07/2023 à +14:00 +Admin le 21/06/2023 à +08:00 14:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ +16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 13/07/2023 à +14:00 +Admin le 21/06/2023 à +08:00 20:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ +16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 13/07/2023 à +14:00 +Admin le 21/06/2023 à +08:00 02:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ +16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 13/07/2023 à +14:00 +Admin le 21/06/2023 à +08:00 08:00 * 1 + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — REGIME NORMAL - Matin midi +goûter soir - 10 Jours- Date Début : 13/06/2023 @ +16:16 +Notes de professionel de santé : +Dés retour du bloc opératoire [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +16:00 +Admin le 21/06/2023 à +12:00 08:00 * 1 +Signé — REGIME NORMAL - Matin midi +goûter soir - 10 Jours- Date Début : 13/06/2023 @ +16:16 +Notes de professionel de santé : +Dés retour du bloc opératoire [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +16:00 +Admin le 21/06/2023 à +12:00 12:00 * 1 +Signé — REGIME NORMAL - Matin midi +goûter soir - 10 Jours- Date Début : 13/06/2023 @ +16:16 +Notes de professionel de santé : +Dés retour du bloc opératoire [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +16:00 +Admin le 21/06/2023 à +12:00 16:00 * 1 +Signé — REGIME NORMAL - Matin midi +goûter soir - 10 Jours- Date Début : 13/06/2023 @ +16:16 +Notes de professionel de santé : +Dés retour du bloc opératoire [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +16:00 +Admin le 21/06/2023 à +12:00 19:00 * 1 +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 08:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 10:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 12:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 14:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 16:20 * 1 +CPR + +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 18:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 20:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 22:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 00:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 02:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 04:20 * 1 +CPR +Signé — ABSTRAL 400MICROG CPR +- 400MICROG comprime - Dose 1 CPR - +[NOM] - Toutes les 2 Heure(s) Si besoin - +Début presc. : 19/06/2023 @ 12:30 +si douleur — Nombre de prises max par 24h : 12 +Notes de professionel de santé : +si douleur à 30min de la prise d'ABSTRAL +possibilité de redonner ABSTRAL 400 [NOM] [NOM] +Début le 19/06/2023 à +12:30 +Fin le 20/07/2023 à +16:20 +Admin le 21/06/2023 à +12:20 06:20 * 1 +CPR +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - [NOM] - Matin midi soir - 1ère +dose : 12/06/2023 @ 19:00 [NOM] [NOM] +Début le 12/06/2023 à +15:20 +Fin le 22/06/2023 à +12:00 +Admin le 21/06/2023 à +12:00 08:00 * 10 ml +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - [NOM] - Matin midi soir - 1ère +dose : 12/06/2023 @ 19:00 [NOM] [NOM] +Début le 12/06/2023 à +15:20 +Fin le 22/06/2023 à +12:00 +Admin le 21/06/2023 à +12:00 12:00 * 10 ml + +Signé — FUNGIZONE 10% SUSP BUV FL +40ML - 10G/100ML suspension (40 mL) - Dose +1 [NOM](S) [NOM] (5 ml) - ORALE - Matin +midi soir - 1ère dose : 12/06/2023 @ 19:00 +Notes de professionel de santé : +en bain de bouche puis à avaler [NOM] [NOM] +Début le 12/06/2023 à +15:20 +Fin le 12/07/2023 à +12:00 +Admin le 21/06/2023 à +12:00 08:00 * 1 +[NOM](S) +[NOM] (5 ml) +Signé — FUNGIZONE 10% SUSP BUV FL +40ML - 10G/100ML suspension (40 mL) - Dose +1 [NOM](S) [NOM] (5 ml) - ORALE - Matin +midi soir - 1ère dose : 12/06/2023 @ 19:00 +Notes de professionel de santé : +en bain de bouche puis à avaler [NOM] [NOM] +Début le 12/06/2023 à +15:20 +Fin le 12/07/2023 à +12:00 +Admin le 21/06/2023 à +12:00 12:00 * 1 +[NOM](S) +[NOM] (5 ml) +Signé — FUNGIZONE 10% SUSP BUV FL +40ML - 10G/100ML suspension (40 mL) - Dose +1 [NOM](S) [NOM] (5 ml) - ORALE - Matin +midi soir - 1ère dose : 12/06/2023 @ 19:00 +Notes de professionel de santé : +en bain de bouche puis à avaler [NOM] [NOM] +Début le 12/06/2023 à +15:20 +Fin le 12/07/2023 à +12:00 +Admin le 21/06/2023 à +12:00 19:00 * 1 +[NOM](S) +[NOM] (5 ml) +Signé — KETOPROFENE ARW LP 100MG +CPR - 100MG comprime - Dose 1 CPR - ORALE +- Matin soir (8h - 19h) - 1ère dose : 20/06/2023 @ +19:00 [NOM] [NOM] +Début le 20/06/2023 à +14:20 +Fin le 20/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 08:00 * 1 +CPR +Signé — KETOPROFENE ARW LP 100MG +CPR - 100MG comprime - Dose 1 CPR - ORALE +- Matin soir (8h - 19h) - 1ère dose : 20/06/2023 @ +19:00 [NOM] [NOM] +Début le 20/06/2023 à +14:20 +Fin le 20/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 19:00 * 1 +CPR +Signé — LANSOPRAZOLE BGA 30 MG +CPR OROD - 30MG comprime - Dose 1 CPR +- ORALE - Prise unique à 19h - 1ère dose : 13/06/2023 @ 19:00 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 12/07/2023 à +19:00 +Admin le 20/06/2023 à +18:57 19:00 * 1 +CPR +Signé — LYRICA 75 MG GELULE - 75MG +gelule - Dose 75 mg - ORALE - Matin soir (8h - +20h) - 1ère dose : 12/06/2023 @ 20:00 [NOM] [NOM] +Début le 12/06/2023 à +13:24 +Fin le 12/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 08:00 * 75 +mg +Signé — LYRICA 75 MG GELULE - 75MG +gelule - Dose 75 mg - ORALE - Matin soir (8h - +20h) - 1ère dose : 12/06/2023 @ 20:00 [NOM] [NOM] +Début le 12/06/2023 à +13:24 +Fin le 12/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 20:00 * 75 +mg +Signé — MOVENTIG 25MG CPR - 25MG +comprime - Dose 1 CPR - ORALE - Matin [8h] - +1ère dose : 18/06/2023 @ 08:00 [NOM] [NOM] +Début le 17/06/2023 à +10:39 +Fin le 17/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 08:00 * 1 +CPR +Signé — OMEPRAZOLE ACF 20MG GELULE - +20MG gelule - Dose 2 GEL - ORALE - Soir [19h] +- 1ère dose : 12/06/2023 @ 19:00 [NOM] [NOM] +Début le 12/06/2023 à +13:24 +Fin le 11/07/2023 à +19:00 +Admin le 20/06/2023 à +19:00 19:00 * 2 +GEL + +Signé — OXYCODONE VIATRIS LP 80MG +CPR - 80MG comprime - Dose 70 mg - ORALE +- Matin soir (8h - 20h) - 1ère dose : 18/06/2023 @ +20:00 [NOM] [NOM] +Début le 18/06/2023 à +16:13 +Fin le 18/07/2023 à +08:00 +Admin le 21/06/2023 à +08:45 20:00 * 70 +mg +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 20/06/2023 @ 19:00 [NOM] [NOM] +Début le 20/06/2023 à +14:21 +Fin le 20/07/2023 à +12:00 +Admin le 21/06/2023 à +12:14 08:00 * 2 +GEL +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 20/06/2023 @ 19:00 [NOM] [NOM] +Début le 20/06/2023 à +14:21 +Fin le 20/07/2023 à +12:00 +Admin le 21/06/2023 à +12:14 12:00 * 2 +GEL +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 20/06/2023 @ 19:00 [NOM] [NOM] +Début le 20/06/2023 à +14:21 +Fin le 20/07/2023 à +12:00 +Admin le 21/06/2023 à +12:14 19:00 * 2 +GEL +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 20/06/2023 @ 19:00 [NOM] [NOM] +Début le 20/06/2023 à +14:21 +Fin le 20/07/2023 à +12:00 +Admin le 21/06/2023 à +12:14 21:00 * 2 +GEL +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) - 1ère dose : 20/06/2023 @ 14:22 [NOM] [NOM] +Début le 20/06/2023 à +14:22 +Fin le 20/07/2023 à +06:22 +Admin le 21/06/2023 à +06:22 14:22 * 1 +CPR +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) - 1ère dose : 20/06/2023 @ 14:22 [NOM] [NOM] +Début le 20/06/2023 à +14:22 +Fin le 20/07/2023 à +06:22 +Admin le 21/06/2023 à +06:22 22:22 * 1 +CPR +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) - 1ère dose : 20/06/2023 @ 14:22 [NOM] [NOM] +Début le 20/06/2023 à +14:22 +Fin le 20/07/2023 à +06:22 +Admin le 21/06/2023 à +06:22 06:22 * 1 +CPR +Signé — LOVENOX 4000UI AXA/0,4ML +INJ SER +S - 4000UI solution (0,4 mL) - Dose +1 SERINGUE(S) [NOM](S) - SOUS- +CUTANEE Directe - Matin [8h] - 1ère dose : 14/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +19:25 +Fin le 13/07/2023 à +08:00 +Admin le 21/06/2023 à +08:00 08:00 * 1 +SERINGUE(S) +[NOM]( S) + + + +Signé — ACCOMPAGNER INSTALLER AUX +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin +- 7 Jours- Date Début : 13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 12:00 * 1 +Signé — ACCOMPAGNER INSTALLER AUX +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin +- 7 Jours- Date Début : 13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 15:00 * 1 +Signé — ACCOMPAGNER INSTALLER AUX +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin +- 7 Jours- Date Début : 13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 18:00 * 1 +Signé — ACCOMPAGNER INSTALLER AUX +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin +- 7 Jours- Date Début : 13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 21:00 * 1 +Signé — ACCOMPAGNER INSTALLER AUX +TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin +- 7 Jours- Date Début : 13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 06:00 * 1 +Signé — ESCARRE : PREVENTION - 7h 10h +13h 16h 19h 22h Si besoin - 7 Jours- Date Début: +13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 09:00 * 1 +Signé — ESCARRE : PREVENTION - 7h 10h +13h 16h 19h 22h Si besoin - 7 Jours- Date Début: +13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 12:00 * 1 +Signé — ESCARRE : PREVENTION - 7h 10h +13h 16h 19h 22h Si besoin - 7 Jours- Date Début: +13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 15:00 * 1 +Signé — ESCARRE : PREVENTION - 7h 10h +13h 16h 19h 22h Si besoin - 7 Jours- Date Début: +13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 18:00 * 1 + +Signé — ESCARRE : PREVENTION - 7h 10h +13h 16h 19h 22h Si besoin - 7 Jours- Date Début: +13/06/2023 @ 08:00 [NOM] [NOM] +Début le 13/06/2023 à +08:00 +Fin le 25/06/2023 à +06:00 +Admin le 18/06/2023 à +12:00 06:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 15 Jour(s)- Date Début: 13/06/2023 +@ 20:00 [NOM] [NOM] +Début le 13/06/2023 à +20:00 +Fin le 28/06/2023 à +06:00 +Admin le 21/06/2023 à +06:00 22:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 15 Jour(s)- Date Début: 13/06/2023 +@ 20:00 [NOM] [NOM] +Début le 13/06/2023 à +20:00 +Fin le 28/06/2023 à +06:00 +Admin le 21/06/2023 à +06:00 02:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 15 Jour(s)- Date Début: 13/06/2023 +@ 20:00 [NOM] [NOM] +Début le 13/06/2023 à +20:00 +Fin le 28/06/2023 à +06:00 +Admin le 21/06/2023 à +06:00 06:00 * 1 +Réalisé — VESSIE DE GLACE - Ttes les 8H +[6h 14h 22h] - pendant 7 Jour(s)- Date Début : 15/06/2023 @ 16:24 +Notes de professionel de santé : +sur MSD [NOM] [NOM] +Début le 15/06/2023 à +16:24 +Fin le 22/06/2023 à +14:00 +Admin le 21/06/2023 à +06:00 14:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 13/06/2023 +@ 16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +14:00 +Admin le 21/06/2023 à +08:00 08:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 13/06/2023 +@ 16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +14:00 +Admin le 21/06/2023 à +08:00 14:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 13/06/2023 +@ 16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +14:00 +Admin le 21/06/2023 à +08:00 20:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 13/06/2023 +@ 16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 23/06/2023 à +14:00 +Admin le 21/06/2023 à +08:00 02:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ +16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 13/07/2023 à +14:00 +Admin le 21/06/2023 à +08:00 08:00 * 1 + +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ +16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 13/07/2023 à +14:00 +Admin le 21/06/2023 à +08:00 14:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ +16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 13/07/2023 à +14:00 +Admin le 21/06/2023 à +08:00 20:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, +Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h +20h] - 1 Mois (30j)- Date Début : 13/06/2023 @ +16:16 [NOM] [NOM] +Début le 13/06/2023 à +16:16 +Fin le 13/07/2023 à +14:00 +Admin le 21/06/2023 à +08:00 02:00 * 1 +Prescription : Date Résultat +CR RX-Echo : 13/06/2023 +06:25 Compte rendu au format texte +Bayonne, le 13/06/2023 +Docteur +Nom de naissance : [NOM] +Nom utilisé : [NOM] +Prénom de naissance : [NOM] +Prénom utilisé : [NOM] +[DATE_NAISSANCE] +Lieu de naissance : 64422 +Sexe : M +Matricule INS : (NIR) [NIR] +Examen du : 13/06/2023 +Compte-rendu validé électroniquement par Dr [NOM] le 13/06/2023 +RADIOGRAPHIES DU BRAS [NOM] +Indication : +Antécédent de cancer bronchopulmonaire métastatique à l'os avec métastase humérale droite connue. Douleur brutale du bras [NOM]. +RESULTATS : +On trouve l'image ostéolytique diaphysaire proximale humérale droite, centromédullaire avec des érosions endostées, en rapport +avec la lésion secondaire déjà connue. Il s'y associe un trait de fracture déplacé passant par la lésion. +Dr [NOM] +Technique : +PDS : 1.743 dGy.cm² +A l'entrée : 0.387 mGy +Protocole d'acquisition : Avant-bras +Cet examen rendu anonyme est accessible sur le site WEB de l'établissement pour une durée de 10 mois : www.ch-cote-basque.fr +« accès examens d'imagerie » +N° d'examen : RAD[TEL] +[DATE_NAISSANCE] + +Résultat de labo : 20/06/2023 08:56 +(5982833) 14/06/2023 11:21 +(5978503) 12/06/2023 13:25 +(5977163) +Albumine : 32,2 g/l +Amylase : 87 U/l +Bilirubine totale : 8 µmol/l 7 µmol/l 6 µmol/l +Score Fibrosis-4 (FIB4) : 2,31 4,85 2,03 + +ASAT : 26 U/l 50 U/l 31 U/l +Commentaire bilirubine totale : Bilirubine totale < +21 µmol/L : dosage des +fractions conjuguée +et non conjugée non +réalisé. Bilirubine totale < +21 µmol/L : dosage des +fractions conjuguée +et non conjugée non +réalisé. Bilirubine totale < +21 µmol/L : dosage des +fractions conjuguée +et non conjugée non +réalisé. +Commentaire CKD-EPI : Non-applicable en cas +d'insuffisance rénale +aigue. Estimation du +DFG non validée dans +les situations suivantes: +- patients âgés > 75 +ans - poids extrêmes +et variations de la +[NOM] musculaire - +alimentation pauvre +en protéines animales +et patients dénutris - +patients d'origine non +caucasienne Non-applicable en cas +d'insuffisance rénale +aigue. Estimation du +DFG non validée dans +les situations suivantes: +- patients âgés > 75 +ans - poids extrêmes +et variations de la +[NOM] musculaire - +alimentation pauvre +en protéines animales +et patients dénutris - +patients d'origine non +caucasienne Non-applicable en cas +d'insuffisance rénale +aigue. Estimation du +DFG non validée dans +les situations suivantes: +- patients âgés > 75 +ans - poids extrêmes +et variations de la +[NOM] musculaire - +alimentation pauvre +en protéines animales +et patients dénutris - +patients d'origine non +caucasienne +Gamma GT : 89 U/l 109 U/l 126 U/l +NT-proBNP : 699 ng/l +Interprétation NT-proBNP : Zone grise : +insuffisance cardiaque +moins plausible. +Envisager d?autres +causes d?augmentation +du NT-proBNP. +Phosphatase alcaline : 120 U/l 117 U/l 110 U/l +Troponine hypersensible : <1.5 ng/l +Commentaire troponine : Changement de réactif +de troponine à compter +du 17/03/2021 : +mise en place d?un +réactif de troponine +hypersensible. +Nouvelle valeur de +référence au 99ème +percentile : < 11 +ng/L Si dosage dans +le cadre d'un SCA +non ST+ : nouveau +protocole avec 2 +dosages systématiques +de troponine à 1 heure +d?intervalle. Le 2ème +prélèvement doit être +fait sans attendre le +résultat du premier +et il doit être réalisé +au moins 3 heures +après le début de la +douleur thoracique. +Etiologie coronarienne +peu probable si H0 +< 2 ng/L et variation +H0-H1 < 1ng/L +Infarctus du myocarde +probable si H0 >= +40 ng/L ou H0 entre 2 +et 40 ng/L et variation +H0-H1 >= 4 ng/ +L : avis cardiologique +Zone grise dans +les autres cas : avis +cardiologique +Calcium : 2,21 mmol/l 2,16 mmol/l 2,30 mmol/l +Calcium corrigé : 2,40 mmol/l + +Estimation du DFG (CKD- +EPI) : 114 ml/mn/1.73 m2 114 ml/mn/1.73 m2 101 ml/mn/1.73 m2 +Chlore : 108 mmol/l 105 mmol/l 105 mmol/l +Créatinine : 45 µmol/l 45 µmol/l 60 µmol/l +CRP : 43 mg/l 1 mg/l +Compte-rendu laboratoire : Labo230620105157-1.pd fLabo230614153510-1.pd fLabo230612155818-1.pd f +Polynucléaires neutrophiles +(%) : 58,3 % 80,3 % 78,4 % +Polynucléaires neutrophiles +(#) : 2,32 10.9/l 7,10 10.9/l 4,47 10.9/l +Polynucléaires éosinophiles +(%) : 6,8 % 0,5 % 1,1 % +Polynucléaires éosinophiles +(#) : 0,27 10.9/l 0,04 10.9/l 0,06 10.9/l +Polynucléaires basophiles (%) : 0,5 % 0,2 % 0,4 % +Polynucléaires basophiles (#) : 0,02 10.9/l 0,02 10.9/l 0,02 10.9/l +Lymphocytes (%) : 11,8 % 4,1 % 7,5 % +Lymphocytes (#) : 0,47 10.9/l 0,36 10.9/l 0,43 10.9/l +Monocytes (%) : 22,6 % 14,9 % 12,6 % +Monocytes (#) : 0,90 10.9/l 1,32 10.9/l 0,72 10.9/l +ALAT : 16 U/l 17 U/l 19 U/l +Formule sanguine : réalisée sur automate +XN (Sysmex) réalisée sur automate +XN (Sysmex) réalisée sur automate +XN (Sysmex) +Hématocrite (%) : 27,9 % 31,7 % 36,2 % +Indice de distribution des +hématies : 17,2 % 17,7 % 17,9 % +Traitement anticoagulant : Héparine de bas poids +moléculaire Inconnu +Valeurs normales INR : Cible de l'INR pour +un patient sous AVK +selon l'indication: - +Indications autres que +prothèses mécaniques : +INR cible = 2.5 (2.0 +à 3.0) - Prothèses +mécaniques: INR +cible entre 2.5 et 4.0 +selon les facteurs de +risque du patient et le +risque intrinsèque de la +prothèse Cible de l'INR pour +un patient sous AVK +selon l'indication: - +Indications autres que +prothèses mécaniques : +INR cible = 2.5 (2.0 +à 3.0) - Prothèses +mécaniques: INR +cible entre 2.5 et 4.0 +selon les facteurs de +risque du patient et le +risque intrinsèque de la +prothèse +INR : 1,12 0,96 +Potassium : 3,8 mmol/l 4,3 mmol/l 4,2 mmol/l +LDH : 633 U/l 213 U/l +Leucocytes : 3,98 10.9/l 8,84 10.9/l 5,70 10.9/l +Hématies : 3,18 10.12/l (t/l) 3,53 10.12/l (t/l) 4,06 10.12/l (t/l) +Hémoglobine : 8,8 g/dl 9,9 g/dl 11,5 g/dl +VGM : 87,7 fl 89,8 fl 89,2 fl +TCMH : 27,7 pg 28,0 pg 28,3 pg +CCMH : 31,5 g/dl 31,2 g/dl 31,8 g/dl +Sodium : 138 mmol/l 133 mmol/l 136 mmol/l +Plaquettes : 180 10.9/l 160 10.9/l 224 10.9/l +Protéines : 61 g/l 67 g/l +Réserve alcaline : 26 mmol/l 23 mmol/l 24 mmol/l +Validation et diffusion sous la +responsabilité du biologiste : Dr [NOM] [NOM] Dr [NOM] [NOM] Dr. [NOM] +[NOM] +[NOM] +Réticulocytes (%) : 2,48 % +Réticulocytes (#) : 87,5 10.9/l +Trou anionique 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a/tests/ground_truth/pdfs/baseline_anonymized/026_complexe_trackare_trackare-15000536-23074384_15000536_23074384.pseudonymise.txt b/tests/ground_truth/pdfs/baseline_anonymized/026_complexe_trackare_trackare-15000536-23074384_15000536_23074384.pseudonymise.txt new file mode 100644 index 0000000..ec3eb67 --- /dev/null +++ b/tests/ground_truth/pdfs/baseline_anonymized/026_complexe_trackare_trackare-15000536-23074384_15000536_23074384.pseudonymise.txt @@ -0,0 +1,3504 @@ +CENTRE HOSPITALIER COTE BASQUE +*640N0° F0in0ess162* +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +640000162 +MEDECINE PEDIATRIE - PEDIATRIE GENERALE +Dossier Patient +Détails des patients +Nom de naissance : [NOM] IPP : [IPP] +Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE] +Sexe : Masculin Lieu de naissance: [VILLE] +Nationalité : FRANCE [CODE_POSTAL] +Adresse : MAISON ST JOSEPH [ADRESSE]: [NOM] +Détails épisode +Episode No : [EPISODE] +Localisation : PEDIATRIE GENERALE Médecin courant: DR. [NOM] +Date d'admission : 15/04/2023 Heure d'admission: 13:07 +Date de sortie : 20/04/2023 Heure de sortie: 18:03 +Médecin traitant +Nom Adresse Téléphone +DR. [NOM] [ADRESSE][CODE_POSTAL] +Passage aux Urgences +Episode - Date 15/04/2023 +Episode - Heure 13 : 07 +Mode de transport à l'arrivée Véhicule personnel +Médicalisation du transport Aucune médicalisation +Mode d'entrée Autres admissions urgentes +Date d'orientation 15/04/2023 +Heure d'orientation 13 : 15 +IAO [NOM] Laure +Priorité Priorité 2 +Sous-type épisode Pédiatrie +Motif de prise en charge AEG/Asthénie +Depuis 13/04 : [NOM] et depuis 14/04: hyperthermie +Le 14/04 à 19h30 : agitation avec propos incohérents, SMUR venu sur place +Observ. IDE Urg Cette nuit deux [NOM], dernier à 4h. ne s'alimente pas +Ici, difficulté à tenir debout, trouble de l'élocution, calme, lèvres sèches +++. mère le trouve incohérent +Signalé à interne, installé en box +Médecin de la prise en charge médicale [NOM] [NOM] +Date de prise en charge médicale 15/04/2023 +Heure de prise en charge médicale 13 : 07 +CCMU , +Médecin de la décision médicale [NOM] [NOM] +Date de décision médicale 15/04/2023 +Heure de décision médicale 18 : 37 +Décision médicale Hospitalisation MCO +Orientation du patient hospitalisation dans une [MASK], SI, REA +Date de sortie des urgences 15/04/2023 +Heure de sortie des Urgences 18 : 38 +US de destination US PEDIATRIE +UF de destination PEDIATRIE GENERALE +Diagnostic aux urgences +Type Etat Code Date +Principal actif R41.0 Désorientation, sans précision [CMA2] 15/04/2023 17 : 52 +Antécédents (texte libre) +Type de note Nom Date Heure Note +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 1 de 25 Aucune donnée +renseignée +Antécédents habitus (texte libre) +Type de note Nom Date Heure Note +Aucune donnée +renseignée +Signes vitaux +Item de 20/04/2023 20/04/2023 20/04/2023 20/04/2023 20/04/2023 20/04/2023 19/04/2023 19/04/2023 19/04/2023 19/04/2023 19/04/2023 19/04/2023 18/04/2023 +surveillance 13 : 01 11:30 09:18 05:46 05:45 02:35 23:24 23:22 19:42 12:24 09:40 06:08 23:21 +Température 36,80 36,20 36,20 36,10 36,70 37,30 36,90 37,20 36,90 +Pouls 69 75 71 83 74 91 60 +PA +88 100 92 96 101 88 +Systolique +PA +52 59 54 57 55 49 +Diastolique +[NOM] +[NOM] [NOM] EVENDOLEVENDOL EVS [NOM] [NOM] [NOM] [NOM] +douleur +Score au +0 0 0 0 0 0 0 0 0 0 0 +repos +Saturation +98 98 98 99 +O² +Ventilation Ventilation Ventilation Ventilation Ventilation +spontanée spontanée spontanée spontanée spontanée +Ventilation +Air Air Air Air Air +ambiant ambiant ambiant ambiant ambiant +Débit O² +0 +[L/mn] +[NOM] 15 15 +Transit +Fréq. +respiratoire +Glycémie +capillaire +PA +Latéralité +Poids/Taille +Item de 15/04/2023 +surveillance 13 : 27 +Taille [cm] 125 +Poids [kg] 25,20 +Surv. Isolement et Contention +Item de 20/04/2023 20/04/2023 20/04/2023 20/04/2023 19/04/2023 19/04/2023 19/04/2023 19/04/2023 19/04/2023 18/04/2023 18/04/2023 18/04/2023 18/04/2023 +surveillance 13 : 01 11:30 09:18 05:45 23:22 19:42 12:24 09:40 06:08 23:21 23:15 19:32 15:49 +Température 36,80 36,20 36,20 36,10 36,70 37,30 36,90 37,20 36,90 37 37,10 37,40 +Pouls 69 75 71 83 74 91 60 79 68 +PA +88 100 92 96 101 88 94 87 +Systolique +PA +52 59 54 57 55 49 53 50 +Diastolique +Saturation +98 98 98 99 +O² +Transit +Fréq. +respiratoire +Surv. Contention +Item de 20/04/2023 20/04/2023 20/04/2023 20/04/2023 19/04/2023 19/04/2023 19/04/2023 19/04/2023 19/04/2023 18/04/2023 18/04/2023 18/04/2023 18/04/2023 +surveillance 13 : 01 11:30 09:18 05:45 23:22 19:42 12:24 09:40 06:08 23:21 23:15 19:32 15:49 +Température 36,80 36,20 36,20 36,10 36,70 37,30 36,90 37,20 36,90 37 37,10 37,40 +Pouls 69 75 71 83 74 91 60 79 68 +PA +88 100 92 96 101 88 94 87 +Systolique +PA +52 59 54 57 55 49 53 50 +Diastolique +Saturation +98 98 98 99 +O² +[NOM] 15 +Transit +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 2 de 25 Glycémie +capillaire +Observations médicales +Type d'observation Nom Date Commentaires +Etat confusionnel fébrile +Antécédents personnels : +- Troubles des apprentissage et du langage oral suivi au [ETABLISSEMENT] x3/semaine avec orthophonie et +psychomotricité +Antécédents familiaux : Frère ainé [NOM] +Traitement en cours : Aucun +Allergies connues : Aucune +Vaccinations : A jour +Histoire de la maladie : +- Le 14/04 : [NOM] fébriles. En fin de journée, modification du comportement (agitation +et propos incohérents) Pas de mouvements tonico-cloniques. Intervention du SMUR : fièvre à +38.5°C, conclu à un délire sur fièvre, pas d'orientation vers un centre hospitalier. +- Le 15/04 : persistance d'un tableau confusionnel avec propos incohérents, +désorientation temporo-spatiale, et apparition de mouvements dystoniques des membres +supérieurs. Malaise d'allure vagale avec perte de connaissance brève vers 4h du matin motivant la +consultation aux urgences pédiatriques. +Examen clinique aux urgences : apyrétique, hémodynamique stable, pas de détresse +respiratoire. Dextro 0.79 g/L. Sur le plan neurologique : G14, ralentissement idéo-moteur. +Marche à petit pas, instable. Pas de déficit sensitivo moteur, ROT +/+, paires crâniennes +normales, pas de trouble oculomoteur, pupilles réactives et symétriques. Pas de syndrome +méningé. Pas d'éruption cutanée, pas de purpura. +Examens complémentaires réalisés : +- Explorations biologiques : +. NFS 18/04 : Leuco 3.90, CRP 13, Hb 13.1, Pq 260, +. CRP 3 mg/L, Na 137 mM, K 4.1 mM, calcémie corrigée 2.36 mM, RA 18, créatinine 27 µM, +CPK 34 U/L +TSH 1.75 mUI/L, ASAT 33 UI/L, ALAT 20 UI/L, ammoniémie 20 µM +. Electrophorèse des protéines sériques : profil normal +. Sérologie : anticorps antinucléaires titrage < 1/80 (négatif), antithyroglobuline 13 UI/mL (N < +Histoire de la DR. [NOM] 20/04/2023 18) antithyroperoxydase 13 UI/mL (N < 37) +maladie [NOM] 16 : 08 . Hémocultures : absence de pousse après 48h. +. Ponction lombaire le 15/04/2023 : lactates 1.9 mM, protéinorachie 0.19 g/L glycorachie 0.49 g/ +L, culture négative à J5, PCR HSV négative, PCR entérovirus négative. +- PCR virales : +. grippe : négatif +. HSV sur LCR : négatif +. Entérovirus sur LCR : négatif +. Entérovirus sur écouvillon rectal : négatif +- Toxiques urinaires négatifs (testés : amphétamines, cocaïne, barbituriques, opiacés, méthadone, +cannabis, benzodiazépines) +- Scanner cérébral le 15/04/2023 : Pas d'hyperdensité spontanée axiale ou extra-axiale anormale. +Absence de processus expansif intra ou extra-axial ou de collection péricérébrale. +Pas d'anomalie de la densité parenchymateuse. Pas de signe scannographique d'hypertension +intracrânienne ou de signe d'engagement cérébral. Les structures médianes restent en place et le +système ventriculaire est respecté. CONCLUSION : Scanner cérébral sans particularité +N° d'examen : RAD[TEL] +- EEG (17/04/2023 - Analyse par Dr V [NOM], [NOM] des explorations fonctionnelles, [ETABLISSEMENT] +de Bordeaux) : tracé de veille bien organisé, symétrique et réactif sans signes de focalisation +ni figures comitiales. Le rythme de fond est dans la bande alpha. La transition veille / sommeil +est bonne. Au cours du sommeil on retrouve les figures physiologiques. Il existe quelques +sursauts non épileptiques en début de sommeil. CONCLUSION : tracé physiologique dépourvu +d'anomalies épileptiques. Pas d'arguments EEG pour une encéphalite +- IRM (21/04/2023 - Analyse par le Dr C [NOM], radiologie pédiatrique [NOM]) : Absence de +stigmate de saignement. Absence d'anomalie objectivée sur les séquences de diffusion. Repères +anatomiques en place. Système ventriculaire en place, symétrique, de taille normale. Absence +de décollement cranio-encéphalique ou d'élargissement des espaces péricérébraux. Absence +d'anomalie focalisée du signal de la substance blanche. Absence de prise de contraste focalisée. +Absence de prise de contraste méningée. Absence de disparité de calibre des artères cérébrales. +Le ruban cortical est fin et régulier. Absence d'anomalie décelée de la morphologie et du signal +du vermis et des hémisphères cérébelleux. +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 3 de 25 Les citernes de la fosse postérieure et les angles ponto-cérébelleux sont libres. Absence de signal +pathologique du tronc cérébral. Absence d'anomalie de la jonction cervico-occipitale. +CONCLUSION : IRM encéphalique sans particularité pathologique ce jour. N° d'examen : +A102628790 +Evolution dans le service de pédiatrie : +- Sur le plan infectieux, pic fébrile le 16/04 bien toléré, mise en place d'une thérapie antivirale +par ACICLOVIR IV pendant 24h secondairement interrompue après réception de la PCR HSV +(négative) Pas d'étiologie infectieuse retrouvée. +- Sur le plan neurologique, amélioration progressive de l'examen avec reprise de la marche +normale à J3, absence de trouble mnésique ni mouvements anormaux constatés. Persistance +d'une apraxie idéo-motrice (difficultés à jouer à des jeux habituels). Bilan étiologique ne +permettant pas d'expliquer le tableau clinique (examen d'imagerie normaux, explorations +biologiques normales, EEG normal). +Devant l'amélioration spontanée et l'absence d'élément en faveur d'une encéphalite +aigue évolutive, retour au domicile le 20/04 avec suivi neuropédiatrique rapproché organisé. +Synthèse : Etat confusionnel aigu dans un contexte de virose digestive sans argument pour +une encéphalite aigue virale. Bilan neurologique : IRMc, EEG, LCR normal. +Amélioration clinique spontanée avec persistance de troubles praxiques légers +difficilement discernables des troubles des apprentissages pré existants. Suivi +neuropédiatrique programmé. +Traitement de sortie : aucun +Suivi prévu : +- Consultation spécialisée Dr [NOM] le 6 juin à 10h +- Consultation pédiatre de ville +Mère informée de la démarche diagnostique et thérapeutique +amélioration de comportement avec un retour à l'état antérieur d'après la maman +une phase de désorientation hier soir accompagné de céphalées résolutives après prise de +paracétamol +céphalalgique au changement de position, encore ce matin mais controlée par ATG1 +DR. [NOM] 19/04/2023 ex neurologique : doute sur une dysmétrie à gauche, pas d'autre anomalie +Note d'évolution +[NOM] 17 : 17 +IRM c sur un créneau des urgences vers 12h demain, Dr [NOM] informée +prémédication par [NOM] MELATONINE prescrite pour 11h, à confirmer avec les manip +demain avec administration +permission pour l'apres midi autorisée +Amélioration de l'examen par rapport à hier : parait un peu plus vif, marche talon /pointe +possible, sur une ligne impossible : Ralentissement toujours présent. +Maman le trouve beaucoup mieux, se pose la question de son état de base. +Tentative IRM cérébrale ce jour mais très agité, a priori sur la séquence interprétable pas +d'anomalie morphologique pas d'anomalie de la SB. Vu avec Dr [NOM], contrôle jeudi sous +DR. [NOM] 18/04/2023 +Note d'évolution nembuthal. +[NOM] 17 : 40 +EEG normal. +Bilan complémentaire ce jour : ionogramme équilibré, EPS normale, TSH normale +Anti TPO anti Tyroglobuline en cours AAN en cours +PCR multiplex en cours +Poursuite surveillance clinique en hospitalisation +Pierre-[NOM] 17/04/2023 PCR multiplex à réaliser sur le LCR (David Leyssenne) +Note d'évolution +[NOM] 17 : 48 IRMc demandée +Motif d'hospitalisation : Bilan de confusion +Antécédents personnels : +- Dyslexie et dysorthographie suivi ? +Antécédents familiaux : Aucun +Traitement en cours : Aucun +Histoire de la Pierre-[NOM] 17/04/2023 Allergies connues : Aucune +maladie [NOM] 16 : 49 +Vaccinations : A jour +Histoire de la maladie : +- [NOM] depuis le 13/04. +- 14/04 : apparition d'une fièvre initialement bien tolérée. En fin de journée, modification +du comportement (agitation et propos incohérents) Pas de mouvements tonico- +cloniques. Intervention du SMUR : fièvre à 38.5°C, conclusion : délire fébrile. +- 15/04 : persistance d'un tableau confusionnel avec propos incohérents, désorientation temporo- +spatiale, et apparition de clonies de membres supérieurs. De plus, malaise d'allure vagal avec +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 4 de 25 perte de connaissance brève vers 4h du matin motivant la consultation aux urgences pédiatriques. +Pas de diarrhée. Pas de perte de poids. +- Aux urgences : apyrétique à l'entrée, hémodynamique stable, pas de détresse respiratoire. +Dextro 0.79 g/L. Sur le plan neurologique : G14, ralentissement idéo-moteur. Marche à petit +pas, instable. Pas de déficit sensitivo moteur, ROT +/+, paires crâniennes normales, pas de +trouble oculomoteur, pupilles réactives et symétriques. Pas de syndrome méningé. Pas d'éruption +cutanée, pas de purpura. +- Bilan initial réalisé aux urgences : TDM cérébral normal, pas d'éléments évocateurs d'une +méningite bactérienne à la ponction lombaire. +Evolution dans le service de pédiatrie : +- Hydratation IV +- Sur le plan infectieux, pic fébrile le 16/04 bien toléré, mise en place d'une thérapie antivirale +par ACICLOVIR IV pendant 24h secondairement interrompue après réception de la PCR HSV +(négative) Pas d'étiologie infectieuse retrouvée à l'épisode. +- Sur le plan neurologique, amélioration progressive de l'examen avec reprise de la marche +normale à J3 le 19/04 mais persistance d'un état confusionnel avec désorientation temporo- +spatiale, apraxie idéo-motrice (difficultés à jouer à des jeux habituels) Bilan étiologique ne +permettant pas d'expliquer le tableau clinique (examen d'imagerie normaux, explorations +biologiques normales, EEG normal) +Examens complémentaires réalisés : +- Explorations biologiques : +. NFS 18/04 : Leuco 3.90, CRP 13, Hb 13.1, Pq 260, +. Biochimie 16/04 complétée le 18/04 : CRP 3 mg/L Na 137, K 4.1, calcémie corrigée 2.36 mM, +RA 18, Glycémie 0.77 g/L, créatinine 27 µM, CPK 34 U/L TSH1.75 mUI/L ASAT 33 UI/L +ALAT 20 UI/L ammoniémie 20 µM +. Electrophorèse des protéines sériques : absence de pathologie clonale, profil normal +. Sérologie : anticorps antinucléaires titrage < 1/80 (négatif) antithyroglobuline 13 UI/mL (N < +18) antithyroperoxydase 13 UI/mL (N < 37) +. Hémocultures : absence de pousse après 48h. +. Ponction lombaire le 15/04/2023 : lactates 1.9 mM protéinorachie 0.19 g/L glycorachie 0.49 g/ +L, pas de germes au direct, PCR HSV négative, PCR entérovirus négative. +- PCR virales : +. grippe : négatif +. HSV sur LCR : négatif +. Entérovirus sur LCR : négatif +. Entérovirus sur écouvillon rectal : négatif +- Toxiques urinaires négatifs (testés : amphétamines, cocaïne, barbituriques, opiacés, méthadone, +cannabis, benzodiazépines) +- Scanner cérébral le 15/04/2023 : Pas d'hyperdensité spontanée axiale ou extra-axiale anormale. +Absence de processus expansif intra ou extra-axial ou de collection péricérébrale. +Pas d'anomalie de la densité parenchymateuse. Pas de signe scannographique d'hypertension +intracrânienne ou de signe d'engagement cérébral. Les structures médianes restent en place et le +système ventriculaire est respecté. CONCLUSION : Scanner cérébral sans particularité +N° d'examen : RAD[TEL] +- EEG (17/04/2023 - Analyse par Dr V [NOM], [NOM] des explorations fonctionnelles, [ETABLISSEMENT] +de Bordeaux) : tracé de veille bien organisé, symétrique et réactif sans signes de focalisation +ni figures comitiales. Le rythme de fond est dans la bande alpha. La transition veille / sommeil +est bonne. Au cours du sommeil on retrouve les figures physiologiques. Il existe quelques +sursauts non épileptiques en début de sommeil. CONCLUSION : tracé physiologique dépourvu +d'anomalies épileptiques. Pas d'arguments EEG pour une encéphalite +- IRM (21/04/2023 - Analyse par le Dr C [NOM], radiologie pédiatrique [NOM]) : Absence de +stigmate de saignement. Absence d'anomalie objectivée sur les séquences de diffusion. Repères +anatomiques en place. Système ventriculaire en place, symétrique, de taille normale. Absence +de décollement cranio-encéphalique ou d'élargissement des espaces péricérébraux. Absence +d'anomalie focalisée du signal de la substance blanche. Absence de prise de contraste focalisée. +Absence de prise de contraste méningée. Absence de disparité de calibre des artères cérébrales. +Le ruban cortical est fin et régulier. Absence d'anomalie décelée de la morphologie et du signal +du vermis et des hémisphères cérébelleux. +Les citernes de la fosse postérieure et les angles ponto-cérébelleux sont libres. Absence de signal +pathologique du tronc cérébral. Absence d'anomalie de la jonction cervico-occipitale. +CONCLUSION : IRM encéphalique sans particularité pathologique ce jour. N° d'examen : +A102628790 +Synthèse : +Traitement de sortie : aucun +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 5 de 25 Points à suivre : +- Examen neurologique +- Développement psychomoteur +Suivi prévu : +- Consultation spécialisée +- Consultation pédiatre de ville +Mère informée de la démarche diagnostique et thérapeutique +Persistance d'un ralentissement idéo moteur avec quelques incohérence temporo spatiales +ROTS perçus facilement aux MS mais difficilement trouvés au MI +RCP ok +RCA limites +Pas de sd cérébelleux +paires crâniennes ok +Pas de sd méningé +Pierre-[NOM] 17/04/2023 +Note d'évolution pas de déficit senstif, difficulté à la marche peut être léger déficit 4+/5 des releveurs +[NOM] 15 : 32 +=< poursuite aciclovir en attente résultats pcr +=> EEG à 15h (prémed melatonine) +Allo labo +- PCR entérovirus écouvillon rectal : négatif +- PCR entérovirus LCR : négatif +- PCR HSV LCR : négatif +Persistance d'un ralentissement idéo moteur avec quelques incohérence temporo spatiales +ROTS perçus facilement aux MS mais difficilement trouvés au MI +RCP ok +RCA limites +Pas de sd cérébelleux +DR. [NOM] 17/04/2023 +Note d'évolution paires crâniennes ok +[NOM] 12 : 06 +Pas de sd méningé +pas de déficit senstif, difficulté à la marche peut être léger déficit 4+/5 des releveurs +=< poursuite aciclovir en attente résultats pcr +=> EEG à 15h (prémed melatonine) +DR. [NOM] 16/04/2023 +Note d'évolution devant la fievre ce jour et le ralentissement, introduction d'aciclovir +[NOM] 19 : 25 +examen ce matin : +maman trouve un comportement plus normal +pas d'hallucination, pas de confusion +apyrétique, pas de diarrhées (1 selle liquide samedi) et pas de vomissement +pas d'eruption +pas de signe de focalisation +ROT non trouvés +se lève difficilement car tête qui tourne +ralentissement psycho moteur encore présent +DR. [NOM] 16/04/2023 pas de franc syndrome cérébelleux +Note d'évolution +[NOM] 17 : 18 maman décrit hier des clies de l'œil droit +quelques mouvements étranges de la couhe pendant mon examen +CAT : +surveillance comportmeent et mouvements anormaux +EEG demain +PL rassurante sur le plan infectieux +Perfusion à poursuivre (mange peu) +CRP entérovirus +Encéphalite virale ? immuno ? +Interne [NOM] L. / Sénior Dr [NOM] +Motif de consultation : déshydratation et propos incohérents +Antécédents personnels : Aucun +Antécédents familiaux : Aucun +Histoire de la 15/04/2023 Traitement en cours : Aucun +[NOM] [NOM] +maladie 14 : 01 Allergies connues : Aucune +Vaccinations : A jour +Histoire de la maladie : +-[NOM] depuis jeudi. Apparition de fièvre vendredi. Vendredi soir : une crise d'environ 5 +min avec agitation et propos incohérents. Pas de mouvements tonico-cloniques. Intervention du +SMUR : fièvre à 38.5°C => délire fébrile. +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 6 de 25 -Ce matin : propos toujours incohérents, quelques clonies des membres supérieurs. 1 malaise +d'allure vagal ce matin, avec perte de connaissance brève et retour à la conscience rapide. +-Alimentation : un peu d'eau sucrée depuis 48h + une glace à l'eau ce matin. Pas de +[NOM] depuis 4h ce matin. Pas de diarrhée. Pas de perte de poids. +Examen clinique à l’entrée +Poids : 25.2 kg +T 37.1°C +FC 82 bpm +PA 105/69 mmHg +Sat 02 99 % +Dextro 0.79 g/L +-Hémodynamique stable. Pâleur, marbrures sur les membres inférieurs habituelles selon la +maman. TRC < 3sec. Extrémités chaudes. Langue sèche, cernés. +-Cardio-pulmonaire : Battements cardiaques réguliers, sans souffle, pouls périphériques perçus +-Eupnéique en air ambiant, murmure vésiculaire clair et symétrique, sans bruits surajoutés, pas de +toux +-Abdomen souple, dépressible, indolore, sans masse palpable, pas de trouble du transit, +[NOM], BHA+, pas de SFU, percussion lombaire indolore. +-Examen ORL : pharynx normal, tympan droit non vu car bouchon de cerumen, tympan gauche +normal. +-Aires ganglionnaires libres +-Gsc 15, ralentissement idéo-moteur. Marche à petit pas, instable. Pas de déficit sensitivo +moteur, ROT +/+, paires crâniennes normales, pas de trouble oculomoteur, pupilles réactives et +symétriques. Pas de syndrome méningé. +-Pas d’éruption cutanée, pas de purpura +Examens complémentaires réalisés : +-Biologie +Leuco 3.90, CRP 13 +Hb 13.1, Pq 260 +Na 137, K 4.1, RA 18 +Glycémie 0.77 g/L +Hémocultures en cours +-PCR virales négatives +-Toxiques urinaires négatives +-Scanner cérébral sans particularité +-Ponction lombaire +Evolution aux urgences : +-Réhydratation IV +-Etat clinique stable +Hypothèse diagnostique : confusion fébrile +-Hospitalisation en pédiatrie +-Hydratation IV +-Paracétamol +Parents informés de la démarche diagnostique et thérapeutique +Surveillance Psychiatrie +Item de 20/04/2023 20/04/2023 20/04/2023 20/04/2023 19/04/2023 19/04/2023 19/04/2023 19/04/2023 19/04/2023 18/04/2023 18/04/2023 18/04/2023 18/04/2023 +surveillance 13 : 01 11:30 09:18 05:45 23:22 19:42 12:24 09:40 06:08 23:21 23:15 19:32 15:49 +Température 36,80 36,20 36,20 36,10 36,70 37,30 36,90 37,20 36,90 37 37,10 37,40 +Pouls 69 75 71 83 74 91 60 79 68 +PA +88 100 92 96 101 88 94 87 +Systolique +PA +52 59 54 57 55 49 53 50 +Diastolique +Saturation +98 98 98 99 99 99 98 100 99 +O² +Transit +Fréq. +respiratoire +Notes paramédicales +Type de note Nom Date Note +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 7 de 25 [NOM] 20/04/2023 +Note IDE Patient sortant après passage du Dr [NOM], sera revu en consult +[NOM] 18 : 02 +Examen : +IRM réalisée sans problème après prémédication po + IR +En attente des résultats. +A mangé à son retour vers 13h. +20/04/2023 +Note IDE [NOM] [NOM] +13 : 57 +Neuro : +Bon comportement, bien orienté +mais persistance de tbs mnésiques (ne se souvient pas de sa date de naissance par exemple, +erreurs dans la superposition des couleurs dans le jeu de UNO qu'il connaît bien) +20/04/2023 Propos cohérent en début de nuit +Note IDE [NOM] [NOM] +03 : 57 Bon sommeil par la suite +Retour de permission ce soir, apyrétique, non algique, bon comportement, surveillance neuro ok, +19/04/2023 maman le trouve beaucoup mieux. +Note IDE [NOM] [NOM] +20 : 37 Examen: IRM cérébral prévu demain vers midi, prémédication prescrite, appeler l'IRM demain +matin pour confirmer l'heure avant de donner la PM. +[NOM] : se plaint de céphalée ce matin => ATG1 fait à 10h +Neuro : GSC 15, aucun épisode de désorientation +[NOM] 19/04/2023 IRM prévu demain mais interne doit faxé la demande. A prévoir prémédication +Note IDE +[NOM] 15 : 00 +Autorisation à aller en permission cet après-midi +ALGIE +confortable +absence de céphalées +NEURO +18/04/2023 +Note IDE [NOM] [NOM] +23 : 16 G15, réveillable +cohérent et orienté +léger ralentissement +VVP +KTO +Alimentation : a bien mangé ce soir , a bu 3 verres entiers +Douleur : s'est plaint de céphalées cette après-midi mais ce sont résorbés rapidement +18/04/2023 +Note IDE [NOM] [NOM] +21 : 21 Neuro: mieux ce jour , moins ralenti +Apyrétique ce jour +Aucune nouvelles pour une date pour l'IRM cérébral +Neuro : mieux ce jour, moins ralenti qu'hier. A eu IRM cérébral ce matin : examen difficilement +réalisable. Sera à refaire à distance. +Reste jusqu'à jeudi. +[NOM] 18/04/2023 +Note IDE +[NOM] 13 : 25 Alimentation : A mangé ce matin. A midi, très fatigué. +Mis en KTO à 9h. +Douleur : se plaint de céphalées à midi : ATG1 fait, dort par la suite. +ALGIE +confortable +absence de céphalées +THERMIE +normotherme +17/04/2023 +Note IDE [NOM] [NOM] +22 : 49 NEURO +G15, réveillable +cohérent et orienté +VVP +fonctionnelle, +hydratation en cours +17/04/2023 Examens : A eu EEG cet après midi : rassurant, la maman a vu Dr [NOM]. +Note IDE [NOM] [NOM] +21 : 14 Arrêt ATV. IRM demandé. +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 8 de 25 Neuro : Pas de mouvements anormaux mais reste ralenti. +A beaucoup dormi aujourd'hui suite à la prémédication. +Douleur : s'est plaint de céphalées. ATG fait vers 17h, mieux ensuite. +Alimentation : a mangé un peu, à stimuler. +Neuro : ralenti, désorientation temporo spatial encore ce matin +EEG prévu à 15h ce jour +[NOM] 17/04/2023 +Note IDE +[NOM] 13 : 30 Apyrétique +Alimentation : a mangé 3 madeleines et du soda ce matin, de la purée et une banane à midi +apyrétique cette nuit +17/04/2023 +Note IDE [NOM] [NOM] antiviral fait à 4h +05 : 44 +le levée jusqu'à la salle de bain c'est bien passé +Neuro : cohérent cet après midi mais fatigué. A marché un peu. +Maman le trouve de nouveau incohérent ce soir à 21h30. Sait qu'elle doit filmer si mouvements +anormaux +16/04/2023 +Note IDE [NOM] [NOM] Hyperthermie : a eu un pic à 39.2 bien toléré, ATP et glaçage des tubulures : efficace. +21 : 43 +Mais 38° à 21h30 +BS avec hémoc fait ce soir et 2ème KT posé pour ATViral débuté à 20h30. +Alimentation : a mangé léger +NEURO : ralentit ce matin , ne comprend pas bien les ordres simples +16/04/2023 DOULEURS ABDOS : à 9h ==> soulagé par ATG1 // mange une madeleine ce matin et ne +Note IDE [NOM] [NOM] +14 : 30 mange pas à midi , boit de l'oasis +THERMIE : apyrétique ce matin , 38.1° à 13h30 ==> découvert // PCR entérovirus prélevé +cathéter refixé en début de nuit +16/04/2023 pas de mouvements anormaux constatés ni signalés +Note IDE [NOM] [NOM] +06 : 00 antalgique fait en début de nuit pour confort +hydratation en cours +Apyrétique, non algique. +Neuro : clignements des yeux et enroulement des mains décrits par la maman, non constaté vers +15/04/2023 20h30. La maman filmera la prochaine fois. +Note IDE [NOM] [NOM] +21 : 19 Laissé allongé en prévention du syndrome post PL +Alimentation : a mangé léger. +Traitements médicamenteux +Date de dernière +Prescription Dose Fréquence Date de début Note Docteur +administration +Voie d`administration : INTRAVEINEUSE +Statut des prescriptions : Signé +Le débit en cours +est : 160 ML par +PARACETAMOL BBM +1 hrs. Notes du +10MG/ML INJ 100ML [10] 400 mg - Normal 15/04/2023 15 : 44 20/04/2023 15:44 [NOM] [NOM] +professionel de +Flacon(s) +santé : MAX 1G/ +INJ +Statut des prescriptions : Arrêté +Le débit a été +ACICLOVIR MYL 500MG modifié. Le débit DR. [NOM] +500 mg - Normal 16/04/2023 19 : 23 17/04/2023 12:10 +PDR INJ [5] Flacon(s) en cours est : 1 [NOM] +par . +Statut des prescriptions : En cours +Le débit a été +BIONOLYTE G5 INJ FPE modifié. Le débit +- Normal 15/04/2023 13 : 49 17/04/2023 16:54 [NOM] [NOM] +500ML [10] Flacon(s) en cours est : 30 +ML par 1 hrs. +Voie d`administration : ORALE +Statut des prescriptions : Signé +PARACETAMOL [NOM] 1 DOSE(S) Pierre-[NOM] +- Normal 18/04/2023 11 : 54 20/04/2023 17:54 +SOL BUV KILO [NOM] +Statut des prescriptions : Réalisé +ATARAX 0,2G/100ML +- 1 seule fois 1 seule Pierre-[NOM] +SIROP FL 200ML [200] 25 mg 18/04/2023 09 : 40 18/04/2023 10:00 +fois [NOM] +Flacon(s) +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 9 de 25 MELATONINE 2MG - 1 seule fois 1 seule DR. [NOM] +2 GEL 17/04/2023 12 : 06 17/04/2023 14:36 +GELULE fois [NOM] +MELATONINE - +MELATONINE GEL - 1 seule fois 1 seule Pierre-[NOM] +6 mg 18/04/2023 09 : 39 18/04/2023 10:00 +[NOM] [NOM] , fois [NOM] +AMPPMAN0104 +MELATONINE - +MELATONINE GEL - 1 seule fois 1 seule DR. [NOM] +6 mg 20/04/2023 11 : 00 20/04/2023 11:30 +[NOM] [NOM] , fois [NOM] +AMPPMAN0104 +Voie d`administration : RECTALE +Statut des prescriptions : Réalisé +- 1 seule fois 1 seule DR. [NOM] +[NOM] 60MG 120 mg 20/04/2023 11 : 00 20/04/2023 11:30 +fois [NOM] +Prescriptions de radiologie +Heure Date Heure +Date début Prescription Statut Docteur [NOM] +début exécution exécution +15/04/2023 15 : 54 Scanner Cérébral 15/04/2023 16:04 Réalisé [NOM] [NOM] +18/04/2023 09 : 41 IRM [NOM] PEDIATRIE 18/04/2023 10:07 Réalisé DR. [NOM] +19/04/2023 15 : 23 IRM [NOM] PEDIATRIE Arrêté DR. [NOM] +20/04/2023 11 : 56 IRM [NOM] PEDIATRIE 20/04/2023 14:17 Réalisé +Prescriptions de laboratoire +Date de +Date Heure Prescription Docteur [NOM] +collection +16/04/2023 +16/04/2023 19 : 26 Sérum à garder DR. [NOM] +20 : 56 +Prescriptions de soins +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +10 Jours - Matin midi 15/04/2023 [NOM] +REGIME NORMAL Signé +soir nuit Normal 17 : 53 [NOM] +DESINFECTION +15/04/2023 [NOM] +ENVIRONNEMENT Réalisé - Matin [8h] Normal +21 : 25 [NOM] +PATIENT +LIT : REFECTION 15/04/2023 [NOM] +Réalisé - Matin [8h] Normal +COMPLETE 21 : 25 [NOM] +LIT : REFECTION 17/04/2023 [NOM] +Réalisé - Matin [8h] Normal +COMPLETE 02 : 35 [NOM] +TOILETTE : DOUCHE 15/04/2023 [NOM] +Réalisé - Matin [8h] Normal +ENFANT 21 : 26 [NOM] +Notes du +professionel +de santé : +DE 0-6 +ans : EVENDOL +10 Jours - Ttes les A PARTIR +15/04/2023 [NOM] +DOULEUR : SURV Réalisé 6h [2h 8h 14h 20h] de 6 +17 : 53 [NOM] +Normal ans : [NOM] +[NOM] A +PARIR de 8 +ans : [NOM] +numérique +0-10 +1 Semaine - Ttes les +15/04/2023 [NOM] +[NOM] : SURV. Réalisé 3H [2h 5h ... 20h +17 : 53 [NOM] +23h] Normal +Notes du +professionel +de santé : +surv +1 Semaine - Ttes +15/04/2023 perméable/ [NOM] +KT COURT : SURV. Réalisé les 8H [6h 14h 22h] +17 : 53 non [NOM] +Normal +inflammatoire/ +pas de +diffusion/pas +d'hématome +SIGNES VITAUX (Pls, - Ttes les 4H [0h +15/04/2023 [NOM] +TA, FR, T°, Glyc, Miction, Réalisé 4h ... 16h 20h] +17 : 53 [NOM] +Transit) Normal +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 10 de 25 Notes du +professionel +10 Jours - Ttes les 3H +SURV. NEUROLOGIQUE 15/04/2023 de santé : [NOM] +Réalisé [2h 5h ... 20h 23h] +TTES LES 3H 17 : 53 Conscience/ [NOM] +Normal +pupilles/ +comportement +TRANSIT/ +10 Jours - Matin midi 15/04/2023 [NOM] +[NOM]/POIDS : Réalisé +soir nuit Normal 17 : 53 [NOM] +SURV +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 11 de 25 Plan de soins Jour J du 20/04/2023 07h00 au 21/04/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +Début le 15/04/2023 à +Signé — REGIME NORMAL - Matin midi soir 17 : 53 +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 19:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +Début le 15/04/2023 à +Signé — REGIME NORMAL - Matin midi soir 17 : 53 +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 21:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +Début le 15/04/2023 à +Signé — REGIME NORMAL - Matin midi soir 17 : 53 +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 08:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +Début le 15/04/2023 à +Signé — REGIME NORMAL - Matin midi soir 17 : 53 +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 12:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +En cours — BIONOLYTE G5 INJ FPE 500ML Début le 15/04/2023 à +- 5G/L + 2G/L ... solution (500 mL) - Poso 30 13 : 49 +m prl e/ sh ce .u + : +r 1e +5 +- +/ +0I 4N /T 20R 2A 3V @E I 1N 3E : 4U 9SE Continue - Début F 11in + : 3 +l 4e 20/04/2023 à 11 : 34 * 1 +Admin le 17/04/2023 à +16 : 54 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 400 mg - sur Début le 15/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 15 : 44 21:44 * 400 +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 Fin le 25/04/2023 à mg +Notes de professionel de santé : 09:44 +Admin le 20/04/2023 à +MAX 1G/ INJ +15 : 44 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 400 mg - sur Début le 15/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 15 : 44 03:44 * 400 +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 Fin le 25/04/2023 à mg +Notes de professionel de santé : 09:44 +Admin le 20/04/2023 à +MAX 1G/ INJ +15 : 44 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 400 mg - sur Début le 15/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 15 : 44 09:44 * 400 +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 Fin le 25/04/2023 à mg +Notes de professionel de santé : 09:44 +Admin le 20/04/2023 à +MAX 1G/ INJ +15 : 44 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 400 mg - sur Début le 15/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 15 : 44 15:44 * 400 +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 Fin le 25/04/2023 à mg +Notes de professionel de santé : 09:44 +Admin le 20/04/2023 à +MAX 1G/ INJ +15 : 44 +[NOM] [NOM]- +Réalisé — MELATONINE GEL [NOM] [NOM] +[NOM] - MG gelule - Dose 6 mg - ORALE - 1 Début le 20/04/2023 à +seule fois - 1ère dose : 20/04/2023 @ 11:00 11:00 11:30 * 6 mg +Fin le 20/04/2023 à +11 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 12 de 25 Admin le 20/04/2023 à +11 : 30 +[NOM] Pierre- +Signé — PARACETAMOL [NOM] SOL BUV - [NOM] +2 T4 oM uteG +s +s leir so 6p H- D euo rs ee +( +s1 +) +D +- +1O èS reE d(S o) +s +eK + : +I 1L 8O +/0 +4- /O 20R 2A 3L @E - D 11é : b 5u 4t le 18/04/2023 à 2 D3 O:5 S4 +E +* +(S +1 +) +11 : 54 Fin le 28/04/2023 à KILO +05 : 54 +Admin le 20/04/2023 à +17 : 54 +[NOM] Pierre- +Signé — PARACETAMOL [NOM] SOL BUV - [NOM] +2 T4 oM uteG +s +s leir so 6p H- D euo rs ee +( +s1 +) +D +- +1O èS reE d(S o) +s +eK + : +I 1L 8O +/0 +4- /O 20R 2A 3L @E - D 11é : b 5u 4t le 18/04/2023 à 0 D5 O:5 S4 +E +* +(S +1 +) +11 : 54 Fin le 28/04/2023 à KILO +05 : 54 +Admin le 20/04/2023 à +17 : 54 +[NOM] Pierre- +Signé — PARACETAMOL [NOM] SOL BUV - [NOM] +2 T4 oM uteG +s +s leir so 6p H- D euo rs ee +( +s1 +) +D +- +1O èS reE d(S o) +s +eK + : +I 1L 8O +/0 +4- /O 20R 2A 3L @E - D 11é : b 5u 4t le 18/04/2023 à 1 D1 O:5 S4 +E +* +(S +1 +) +11 : 54 Fin le 28/04/2023 à KILO +05 : 54 +Admin le 20/04/2023 à +17 : 54 +[NOM] Pierre- +Signé — PARACETAMOL [NOM] SOL BUV - [NOM] +2 T4 oM uteG +s +s leir so 6p H- D euo rs ee +( +s1 +) +D +- +1O èS reE d(S o) +s +eK + : +I 1L 8O +/0 +4- /O 20R 2A 3L @E - D 11é : b 5u 4t le 18/04/2023 à 1 D7 O:5 S4 +E +* +(S +1 +) +11 : 54 Fin le 28/04/2023 à KILO +05 : 54 +Admin le 20/04/2023 à +17 : 54 +[NOM] [NOM]- +[NOM] +Réalisé — [NOM] 60MG - 60MG Début le 20/04/2023 à +suppositoire - Dose 120 mg - RECTALE - 1 seule 11 : 00 11:30 * 120 +fois - 1ère dose : 20/04/2023 @ 11:00 Fin le 20/04/2023 à mg +11 : 00 +Admin le 20/04/2023 à +11 : 30 +[NOM] [NOM] +Réalisé — DESINFECTION Début le 15/04/2023 à +ENVIRONNEMENT PATIENT - Matin [8h] - 21 : 25 +pendant 7 Jour(s)- Date Début : 15/04/2023 @ Fin le 22/04/2023 à 10:45 * 1 +21 : 25 08:00 +Admin le 20/04/2023 à +10 : 45 +[NOM] [NOM] +Réalisé — LIT : REFECTION COMPLETE Début le 15/04/2023 à +- Matin [8h] - pendant 7 Jour(s)- Date Début : 21:25 +15/04/2023 @ 21 : 25 Fin le 22/04/2023 à 10:45 * 1 +08 : 00 +Admin le 20/04/2023 à +10 : 45 +[NOM] [NOM] +Réalisé — TOILETTE : DOUCHE ENFANT Début le 15/04/2023 à +- Matin [8h] - pendant 7 Jour(s)- Date Début : 21:26 +15/04/2023 @ 21 : 26 Fin le 22/04/2023 à 11:47 * 1 +08 : 00 +Admin le 20/04/2023 à +11 : 47 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 15/04/2023 Début le 15/04/2023 à +@ 17 : 53 17:53 +Notes de professionel de santé : Fin le 25/04/2023 à 20:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 14:00 +ans : [NOM] [NOM] A PARIR de 8 ans: [NOM] Admin le 20/04/2023 à +numérique 0-10 14 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début : 15/04/2023 [NOM] [NOM] +@ 17 : 53 Début le 15/04/2023 à 02:00 * 1 +Notes de professionel de santé : 17:53 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 13 de 25 Fin le 25/04/2023 à +DE 0-6 ans : EVENDOL A PARTIR de 6 +14 : 00 +ans : [NOM] [NOM] A PARIR de 8 ans: [NOM] +Admin le 20/04/2023 à +numérique 0-10 +14 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 15/04/2023 Début le 15/04/2023 à +@ 17 : 53 17:53 +Notes de professionel de santé : Fin le 25/04/2023 à 14:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 14:00 +ans : [NOM] [NOM] A PARIR de 8 ans: [NOM] Admin le 20/04/2023 à +numérique 0-10 14 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 20:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 23:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 02:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 05:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 08:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 11:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 14:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 17:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +Réalisé — KT COURT : SURV. - Ttes les 8H [6h [NOM] [NOM] +14h 22h] - 1 Semaine- Date Début : 15/04/2023 @ Début le 15/04/2023 à +17 : 53 17:53 22:00 * 1 +Notes de professionel de santé : Fin le 22/04/2023 à +14 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 14 de 25 surv perméable/non inflammatoire/pas de Admin le 20/04/2023 à +diffusion/pas d'hématome 14 : 00 +Réalisé — KT COURT : SURV. - Ttes les 8H [6h [NOM] [NOM] +14h 22h] - 1 Semaine- Date Début : 15/04/2023 @ Début le 15/04/2023 à +17 : 53 17:53 +Notes de professionel de santé : Fin le 22/04/2023 à 06:00 * 1 +14 : 00 +surv perméable/non inflammatoire/pas de +Admin le 20/04/2023 à +diffusion/pas d'hématome +14 : 00 +Réalisé — KT COURT : SURV. - Ttes les 8H [6h [NOM] [NOM] +14h 22h] - 1 Semaine- Date Début : 15/04/2023 @ Début le 15/04/2023 à +17 : 53 17:53 +Notes de professionel de santé : Fin le 22/04/2023 à 14:00 * 1 +14 : 00 +surv perméable/non inflammatoire/pas de +Admin le 20/04/2023 à +diffusion/pas d'hématome +14 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 25/04/2023 à 20:00 * 1 +15/04/2023 @ 17 : 53 16:00 +Admin le 20/04/2023 à +16 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 25/04/2023 à 00:00 * 1 +15/04/2023 @ 17 : 53 16:00 +Admin le 20/04/2023 à +16 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 25/04/2023 à 04:00 * 1 +15/04/2023 @ 17 : 53 16:00 +Admin le 20/04/2023 à +16 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 25/04/2023 à 08:00 * 1 +15/04/2023 @ 17 : 53 16:00 +Admin le 20/04/2023 à +16 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 25/04/2023 à 12:00 * 1 +15/04/2023 @ 17 : 53 16:00 +Admin le 20/04/2023 à +16 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 25/04/2023 à 16:00 * 1 +15/04/2023 @ 17 : 53 16:00 +Admin le 20/04/2023 à +16 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 20:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 23:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 15 de 25 [NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 02:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 05:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 08:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 11:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 14:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 17:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — TRANSIT/[NOM]/ Début le 15/04/2023 à +POIDS : SURV - Matin midi soir nuit - 10 Jours- 17:53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 19:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — TRANSIT/[NOM]/ Début le 15/04/2023 à +POIDS : SURV - Matin midi soir nuit - 10 Jours- 17:53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 21:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — TRANSIT/[NOM]/ Début le 15/04/2023 à +POIDS : SURV - Matin midi soir nuit - 10 Jours- 17:53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 08:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — TRANSIT/[NOM]/ Début le 15/04/2023 à +POIDS : SURV - Matin midi soir nuit - 10 Jours- 17:53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 12:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 16 de 25 Plan de soins Jour J + 1 du 21/04/2023 07h00 au 22/04/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +Début le 15/04/2023 à +Signé — REGIME NORMAL - Matin midi soir 17 : 53 +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 08:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +Début le 15/04/2023 à +Signé — REGIME NORMAL - Matin midi soir 17 : 53 +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 12:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +Début le 15/04/2023 à +Signé — REGIME NORMAL - Matin midi soir 17 : 53 +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 19:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +Début le 15/04/2023 à +Signé — REGIME NORMAL - Matin midi soir 17 : 53 +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 21:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 400 mg - sur Début le 15/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 15 : 44 09:44 * 400 +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 Fin le 25/04/2023 à mg +Notes de professionel de santé : 09:44 +Admin le 20/04/2023 à +MAX 1G/ INJ +15 : 44 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 400 mg - sur Début le 15/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 15 : 44 15:44 * 400 +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 Fin le 25/04/2023 à mg +Notes de professionel de santé : 09:44 +Admin le 20/04/2023 à +MAX 1G/ INJ +15 : 44 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 400 mg - sur Début le 15/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 15 : 44 21:44 * 400 +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 Fin le 25/04/2023 à mg +Notes de professionel de santé : 09:44 +Admin le 20/04/2023 à +MAX 1G/ INJ +15 : 44 +Signé — PARACETAMOL BBM 1000 MG INJ - [NOM] [NOM] +10MG/ML solution (100 mL) - Dose 400 mg - sur Début le 15/04/2023 à +15 min - INTRAVEINEUSE Discontinue - Toutes 15 : 44 03:44 * 400 +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 Fin le 25/04/2023 à mg +Notes de professionel de santé : 09:44 +Admin le 20/04/2023 à +MAX 1G/ INJ +15 : 44 +[NOM] Pierre- +Signé — PARACETAMOL [NOM] SOL BUV - [NOM] +2 T4 oM uteG +s +s leir so 6p H- D euo rs ee +( +s1 +) +D +- +1O èS reE d(S o) +s +eK + : +I 1L 8O +/0 +4- /O 20R 2A 3L @E - D 11é : b 5u 4t le 18/04/2023 à 1 D1 O:5 S4 +E +* +(S +1 +) +11 : 54 Fin le 28/04/2023 à KILO +05 : 54 +Admin le 20/04/2023 à +17 : 54 +Signé — PARACETAMOL [NOM] SOL BUV - [NOM] Pierre- +2 T4 oM uteG s s leir so 6p H- D euo rs ee ( s1 ) D - 1O èS reE d(S o) s eK : I 1L 8O /0 4- /O 20R 2A 3L @E - A Dx ébel ut le 18/04/2023 à 1 D7 O:5 S4 E * (S 1 ) +11 : 54 11:54 KILO +Fin le 28/04/2023 à +05 : 54 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 17 de 25 Admin le 20/04/2023 à +17 : 54 +[NOM] Pierre- +Signé — PARACETAMOL [NOM] SOL BUV - [NOM] +2 T4 oM uteG +s +s leir so 6p H- D euo rs ee +( +s1 +) +D +- +1O èS reE d(S o) +s +eK + : +I 1L 8O +/0 +4- /O 20R 2A 3L @E - D 11é : b 5u 4t le 18/04/2023 à 2 D3 O:5 S4 +E +* +(S +1 +) +11 : 54 Fin le 28/04/2023 à KILO +05 : 54 +Admin le 20/04/2023 à +17 : 54 +[NOM] Pierre- +Signé — PARACETAMOL [NOM] SOL BUV - [NOM] +2 T4 oM uteG +s +s leir so 6p H- D euo rs ee +( +s1 +) +D +- +1O èS reE d(S o) +s +eK + : +I 1L 8O +/0 +4- /O 20R 2A 3L @E - D 11é : b 5u 4t le 18/04/2023 à 0 D5 O:5 S4 +E +* +(S +1 +) +11 : 54 Fin le 28/04/2023 à KILO +05 : 54 +Admin le 20/04/2023 à +17 : 54 +[NOM] [NOM] +Réalisé — DESINFECTION Début le 15/04/2023 à +ENVIRONNEMENT PATIENT - Matin [8h] - 21 : 25 +pendant 7 Jour(s)- Date Début : 15/04/2023 @ Fin le 22/04/2023 à 08:00 * 1 +21 : 25 08:00 +Admin le 20/04/2023 à +10 : 45 +[NOM] [NOM] +Réalisé — LIT : REFECTION COMPLETE Début le 15/04/2023 à +- Matin [8h] - pendant 7 Jour(s)- Date Début : 21:25 +15/04/2023 @ 21 : 25 Fin le 22/04/2023 à 08:00 * 1 +08 : 00 +Admin le 20/04/2023 à +10 : 45 +[NOM] [NOM] +Réalisé — TOILETTE : DOUCHE ENFANT Début le 15/04/2023 à +- Matin [8h] - pendant 7 Jour(s)- Date Début : 21:26 +15/04/2023 @ 21 : 26 Fin le 22/04/2023 à 08:00 * 1 +08 : 00 +Admin le 20/04/2023 à +11 : 47 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 15/04/2023 Début le 15/04/2023 à +@ 17 : 53 17:53 +Notes de professionel de santé : Fin le 25/04/2023 à 08:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 14:00 +ans : [NOM] [NOM] A PARIR de 8 ans: [NOM] Admin le 20/04/2023 à +numérique 0-10 14 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 15/04/2023 Début le 15/04/2023 à +@ 17 : 53 17:53 +Notes de professionel de santé : Fin le 25/04/2023 à 14:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 14:00 +ans : [NOM] [NOM] A PARIR de 8 ans: [NOM] Admin le 20/04/2023 à +numérique 0-10 14 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 15/04/2023 Début le 15/04/2023 à +@ 17 : 53 17:53 +Notes de professionel de santé : Fin le 25/04/2023 à 20:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 14:00 +ans : [NOM] [NOM] A PARIR de 8 ans: [NOM] Admin le 20/04/2023 à +numérique 0-10 14 : 00 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h [NOM] [NOM] +8h 14h 20h] - 10 Jours- Date Début : 15/04/2023 Début le 15/04/2023 à +@ 17 : 53 17:53 +Notes de professionel de santé : Fin le 25/04/2023 à 02:00 * 1 +DE 0-6 ans : EVENDOL A PARTIR de 6 14:00 +ans : [NOM] [NOM] A PARIR de 8 ans: [NOM] Admin le 20/04/2023 à +numérique 0-10 14 : 00 +Réalisé — [NOM] : SURV. - Ttes les 3H [NOM] [NOM] +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : Début le 15/04/2023 à +15/04/2023 @ 17 : 53 17:53 08:00 * 1 +Fin le 22/04/2023 à +17 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 18 de 25 Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 11:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 14:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 17:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 20:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 23:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 02:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — [NOM] : SURV. - Ttes les 3H Début le 15/04/2023 à +[2h 5h ... 20h 23h] - 1 Semaine- Date Début : 17:53 +15/04/2023 @ 17 : 53 Fin le 22/04/2023 à 05:00 * 1 +17 : 00 +Admin le 20/04/2023 à +17 : 00 +Réalisé — KT COURT : SURV. - Ttes les 8H [6h [NOM] [NOM] +14h 22h] - 1 Semaine- Date Début : 15/04/2023 @ Début le 15/04/2023 à +17 : 53 17:53 +Notes de professionel de santé : Fin le 22/04/2023 à 14:00 * 1 +14 : 00 +surv perméable/non inflammatoire/pas de +Admin le 20/04/2023 à +diffusion/pas d'hématome +14 : 00 +Réalisé — KT COURT : SURV. - Ttes les 8H [6h [NOM] [NOM] +14h 22h] - 1 Semaine- Date Début : 15/04/2023 @ Début le 15/04/2023 à +17 : 53 17:53 +Notes de professionel de santé : Fin le 22/04/2023 à 22:00 * 1 +14 : 00 +surv perméable/non inflammatoire/pas de +Admin le 20/04/2023 à +diffusion/pas d'hématome +14 : 00 +Réalisé — KT COURT : SURV. - Ttes les 8H [6h [NOM] [NOM] +14h 22h] - 1 Semaine- Date Début : 15/04/2023 @ Début le 15/04/2023 à +17 : 53 17:53 +Notes de professionel de santé : Fin le 22/04/2023 à 06:00 * 1 +14 : 00 +surv perméable/non inflammatoire/pas de +Admin le 20/04/2023 à +diffusion/pas d'hématome +14 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 19 de 25 [NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 25/04/2023 à 08:00 * 1 +15/04/2023 @ 17 : 53 16:00 +Admin le 20/04/2023 à +16 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 25/04/2023 à 12:00 * 1 +15/04/2023 @ 17 : 53 16:00 +Admin le 20/04/2023 à +16 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 25/04/2023 à 16:00 * 1 +15/04/2023 @ 17 : 53 16:00 +Admin le 20/04/2023 à +16 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 25/04/2023 à 20:00 * 1 +15/04/2023 @ 17 : 53 16:00 +Admin le 20/04/2023 à +16 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 25/04/2023 à 00:00 * 1 +15/04/2023 @ 17 : 53 16:00 +Admin le 20/04/2023 à +16 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à +T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53 +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : Fin le 25/04/2023 à 04:00 * 1 +15/04/2023 @ 17 : 53 16:00 +Admin le 20/04/2023 à +16 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 08:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 11:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 14:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 17:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 20 de 25 [NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 20:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 23:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 02:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 05:00 * 1 +Notes de professionel de santé : 17:00 +" Conscience/pupilles/comportement" Admin le 20/04/2023 à +17 : 00 +[NOM] [NOM] +Réalisé — TRANSIT/[NOM]/ Début le 15/04/2023 à +POIDS : SURV - Matin midi soir nuit - 10 Jours- 17:53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 08:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — TRANSIT/[NOM]/ Début le 15/04/2023 à +POIDS : SURV - Matin midi soir nuit - 10 Jours- 17:53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 12:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — TRANSIT/[NOM]/ Début le 15/04/2023 à +POIDS : SURV - Matin midi soir nuit - 10 Jours- 17:53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 19:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — TRANSIT/[NOM]/ Début le 15/04/2023 à +POIDS : SURV - Matin midi soir nuit - 10 Jours- 17:53 +Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 21:00 * 1 +12 : 00 +Admin le 20/04/2023 à +12 : 00 +Résultats de radiologie +Prescription Date Résultat +Compte rendu au format texte +Bayonne, le 15/04/2023 +Docteur +Nom de naissance : [NOM] +Nom utilisé : [NOM] +15/04/2023 Prénom de naissance : [NOM] +CR Scanner +15 : 54 Prénom utilisé : [NOM] +[DATE_NAISSANCE] +Lieu de naissance : 99999 +Sexe : M +Matricule INS : +Examen du : 15/04/2023 +Compte-rendu validé électroniquement par Dr [NOM] le 15/04/2023 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 21 de 25 SCANNER CEREBRAL +Indication : +Confusion fébrile depuis 48 heures. Recherche de signe d'HTIC avant ponction lombaire +Protocole : +Examen réalisé sans injection de produit de contraste. +RESULTATS : +Pas d'hyperdensité spontanée axiale ou extra-axiale anormale. Absence de processus expansif intra ou extra-axial ou de collection +péricérébrale. +Pas d'anomalie de la densité parenchymateuse. +Pas de signe scannographique d'hypertension intracrânienne ou de signe d'engagement cérébral. +Les structures médianes restent en place et le système ventriculaire est respecté. +CONCLUSION : +Scanner cérébral sans particularité +Dr [NOM] +Technique : +GE Revolution Frontier CT B225007 +PDL : 427.36 mGy.cm CTDI : 21.88 mGy +Protocole d'acquisition : 11.3 [NOM] 5 - 10 ANS * +Cet examen rendu anonyme est accessible sur le site WEB de l'établissement pour une durée de 10 mois : www.ch-cote-basque.fr +« accès examens d'imagerie » +N° d'examen : RAD[TEL] +[DATE_NAISSANCE] +Compte rendu au format texte +Bayonne, le 18/04/2023 +Docteur [NOM] +Nom de naissance : [NOM] +Nom utilisé : [NOM] +Prénom de naissance : [NOM] +Prénom utilisé : [NOM] +[DATE_NAISSANCE] +Lieu de naissance : 99999 +Sexe : M +Matricule INS : +Examen du : 18/04/2023 +Compte-rendu validé électroniquement par Dr [NOM][DATE_NAISSANCE] +IRM [NOM] +18/04/2023 +CR IRM +09 : 41 Indication : +Syndrome confusionnel fébrile. +Protocole : +Sagittal cube T2 FLAIR, axial et coronal T2, axial T2 FLAIR +RESULTATS : +Malgré la répétition des séquences, il n'a pas été possible d'obtenir des images analysables, du fait des artéfacts de mouvement. +Sur les séquences axiales pondérées T2 et FLAIR, on note un respect des structures anatomiques, d'aspect symétrique. Il ne +semble pas exister d'anomalie focalisée du signal de la substance blanche. Le système ventriculaire est en place, de taille normale. +Absence de décollement cranio-encéphalique. Jonction cervico-occipitale sans particularité. +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 22 de 25 Dr [NOM] +Technique : +Cet examen rendu anonyme est accessible sur le site WEB de l'établissement pour une durée de 10 mois : www.ch-cote-basque.fr +« accès examens d'imagerie » +N° d'examen : RAD[TEL] +[DATE_NAISSANCE] +Compte rendu au format texte +Bayonne, le 20/04/2023 +Docteur [NOM] +Nom de naissance : [NOM] +Nom utilisé : [NOM] +Prénom de naissance : [NOM] +Prénom utilisé : [NOM] +[DATE_NAISSANCE] +Lieu de naissance : 99999 +Sexe : M +Matricule INS : +Examen du : 20/04/2023 +Compte-rendu non validé ! +IRM [NOM] +Indication : +Syndrome confusionnel fébrile en cours de régression. +Protocole : +Axial 3D T1 IR, sagittal T2 cube flair, axial diffusion, T2 écho de gradient, coronales T2 IR, axial 3D TOF, cube T1 après injection +de produit de contraste en écho de gradient et spin écho. +.RESULTATS : +Absence de stigmate de saignement. Absence d'anomalie objectivée sur les séquences de diffusion. Repères anatomiques en place. +Système ventriculaire en place, symétrique, de taille normale. Absence de décollement cranio-encéphalique ou d'élargissement des +espaces péricérébraux. Absence d'anomalie focalisée du signal de la substance blanche. Absence de prise de contraste focalisée. +Absence de prise de contraste méningée. Absence de disparité de calibre des artères cérébrales.. Le ruban cortical est fin et +20/04/2023 +CR IRM régulier. +11 : 56 +Absence d'anomalie décelée de la morphologie et du signal du vermis et des hémisphères cérébelleux. +Les citernes de la fosse postérieure et les angles ponto-cérébelleux sont libres. +Absence de signal pathologique du tronc cérébral. +Absence d'anomalie de la jonction cervico-occipitale. +CONCLUSION : +IRM encéphalique sans particularité pathologique ce jour. +Dr [NOM] +Technique : +Cet examen rendu anonyme est accessible sur le site WEB de l'établissement pour une durée de 10 mois : www.ch-cote-basque.fr +« accès examens d'imagerie » +N° d'examen : A102628790 +[DATE_NAISSANCE] +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 23 de 25 Résultats de laboratoire +18/04/2023 09 : 45 16/04/2023 20:56 16/04/2023 20:56 16/04/2023 20:56 16/04/2023 20:56 +Résultat de labo +(5933693) (5932873) (5932872) (5932871) (5932870) +Titre Anticorps anti-noyau Négatif (< : 1/80) +Aspect de la fluorescence "" +Anticorps antithyroglobuline Reçu le 20/04/23 +Ac Anti-Thyropéroxydase Reçu le 20/04/23 +Lactates 1,7 mmol/l 2,4 mmol/l +Ammoniémie 19,6 µmol/l +Score Fibrosis-4 (FIB4) 0,26 +Le score Fibrosis-4 est +un test de dépistage de +la fibrose hépatique. +S?il existe une cause +connue de cytolyse +hépatique ou de +thrombopénie, il ne +faut pas tenir compte +de ce résultat. Dans +Commentaire score Fibrosis-4 les autres cas, si la +valeur est > : 2,67, +un avis en hépatologie +est recommandé. Si la +valeur est < : 1,3, il +n?existe pas de maladie +hépatique sévère. +Dans les autres cas, un +contrôle à distance est +recommandé. +FIO2 Non renseigné(e) % +Bicarbonates 25,2 mmol/l +Origine Veineux +Non renseigné(e) L/ +Débit +min +Non renseignée (rendu +Température pour une température +de 37°C) °C +ASAT 33 U/l +CPK 34 U/l +TSH 3ème génération 1,75 mUI/L +Calcium 2,26 mmol/l 2,16 mmol/l +Chlore 105 mmol/l 105 mmol/l +Créatinine 27 µmol/l 29 µmol/l +CRP 3 mg/l +Compte rendu Bactériologie Bact230416210005-1.pdf +Compte-rendu laboratoire Labo230420100641-1.pdf Labo230416212007-1.pdfLabo230417093446-1.pdfLabo230417093450-1.pdf +Protéines (sérum) 65 g/l +Albumine (électrophorèse) 36,9 g/l +Alpha 1 3,4 g/l +Alpha 2 9,3 g/l +Gamma 9,4 g/l +Profil sensiblement +normal +quantitativement. +Profil +électrophorétique +Electrophorèse des protéines +qualitativement +sériques (conclusion) +normal : absence de +pathologie clonale +visible. Validé et +interprété par Dr [NOM] +[NOM] +[NOM] 1 3,2 g/l +[NOM] 2 2,8 g/l +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 24 de 25 Polynucléaires neutrophiles +40,0 % 64,5 % +(%) +Polynucléaires neutrophiles +1,44 10.9/l 4,32 10.9/l +(#) +Polynucléaires éosinophiles +2,0 % 0,4 % +(%) +Polynucléaires éosinophiles +0,07 10.9/l 0,03 10.9/l +(#) +Polynucléaires basophiles (%) 1,0 % 0,3 % +Polynucléaires basophiles (#) 0,04 10.9/l 0,02 10.9/l +Lymphocytes (%) 42,0 % 20,9 % +Lymphocytes (#) 1,51 10.9/l 1,40 10.9/l +Monocytes (%) 11,0 % 13,9 % +Monocytes (#) 0,40 10.9/l 0,93 10.9/l +Formule vérifiée par le +Oui +technicien +Lymphocytes +4,0 % +Hyperbasophiles (%) +Lymphocytes +0,14 10.9/l +Hyperbasophiles (#) +Glucose 5,6 mmol/l 6,7 mmol/l +pH 7,42 +pO2 49 mmHg +Saturation O2 86,6 % +pCO2 39 mmHg +ALAT 20 U/l +réalisée sur frottis réalisée sur automate +Formule sanguine +sanguin au microscope XN (Sysmex) +Hématocrite (%) 35,0 % 34,1 % +Indice de distribution des +12,8 % 12,9 % +hématies +Potassium 4,1 mmol/l 3,6 mmol/l +Leucocytes 3,60 10.9/l 6,69 10.9/l +Sur voie veineuse +Localisation hémoculture +périphérique +Résultat automate flacon +En cours +pédiatrique +Hématies 4,35 10.12/l (t/l) 4,24 10.12/l (t/l) +Hémoglobine 12,2 g/dl 11,9 g/dl +VGM 80,5 fl 80,4 fl +TCMH 28,0 pg 28,1 pg +CCMH 34,9 g/dl 34,9 g/dl +Sodium 137 mmol/l 135 mmol/l +Prélèvement non +Non conformité validé initialement par +[MASK] 280 mOSM/l 277 mOSM/l +Plaquettes 194 10.9/l 225 10.9/l +Protéines 65 g/l +Réserve alcaline 23 mmol/l +Validation et diffusion sous la Dr. [NOM]. [NOM] Dr. [NOM] +Dr [NOM] [NOM] [NOM] +responsabilité du biologiste [NOM] [NOM] [NOM] +Trou anionique 11 +Volume plaquettaire moyen 10,0 fl 9,3 fl +Compte-rendu CERBA rslt33598833.tif +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 ) +Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128 +Le 20/04/2023 18 : 29 Page 25 de 25 + + +Nom de naissance : [NOM] IPP : [IPP] +Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE] +Sexe : Masculin Lieu de naissance: [VILLE] +Nationalité : FRANCE [CODE_POSTAL] +Adresse : MAISON ST JOSEPH [ADRESSE]: [NOM] +Episode No : [EPISODE] +Localisation : PEDIATRIE GENERALE Médecin courant: DR. [NOM] +Date d'admission : 15/04/2023 Heure d'admission: 13:07 +Date de sortie : 20/04/2023 Heure de sortie: 18:03 +Nom : Adresse Téléphone +DR. [NOM] [NOM] : [ADRESSE][CODE_POSTAL] +Episode - Date : 15/04/2023 +Episode - Heure : 13:07 +Mode de transport à l'arrivée : Véhicule personnel +Médicalisation du transport : Aucune médicalisation +Mode d'entrée : Autres admissions urgentes +Date d'orientation : 15/04/2023 +Heure d'orientation : 13:15 +IAO : [NOM] Laure +Priorité : Priorité 2 +Sous-type épisode : Pédiatrie +Motif de prise en charge : AEG/Asthénie +Observ. IDE Urg : Depuis 13/04: [NOM] et depuis 14/04: hyperthermie +Le 14/04 à 19h30: agitation avec propos incohérents, SMUR venu sur place +Cette nuit deux [NOM], dernier à 4h. ne s'alimente pas +Ici, difficulté à tenir debout, trouble de l'élocution, calme, lèvres sèches +++. mère le trouve incohérent +Signalé à interne, installé en box +Médecin de la prise en charge médicale : [NOM] [NOM] +Date de prise en charge médicale : 15/04/2023 +Heure de prise en charge médicale : 13:07 +CCMU : , +Médecin de la décision médicale : [NOM] [NOM] +Date de décision médicale : 15/04/2023 +Heure de décision médicale : 18:37 +Décision médicale : Hospitalisation MCO +Orientation du patient : hospitalisation dans une [MASK], SI, REA +Date de sortie des urgences : 15/04/2023 +Heure de sortie des Urgences : 18:38 +US de destination : US PEDIATRIE +UF de destination : PEDIATRIE GENERALE +Type : Etat Code Date +Principal : actif R41.0 Désorientation, sans précision [CMA2] 15/04/2023 17:52 +Type de note : Nom Date Heure Note + +Aucune donnée +renseignée +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Item de +surveillance : 20/04/2023 +13:01 20/04/2023 +11:30 20/04/2023 +09:18 20/04/2023 +05:46 20/04/2023 +05:45 20/04/2023 +02:35 19/04/2023 +23:24 19/04/2023 +23:22 19/04/2023 +19:42 19/04/2023 +12:24 19/04/2023 +09:40 19/04/2023 +06:08 18/04/2023 +23:21 +Température : 36,80 36,20 36,20 36,10 36,70 37,30 36,90 37,20 36,90 +Pouls : 69 75 71 83 74 91 60 +PA +Systolique : 88 100 92 96 101 88 +PA +Diastolique : 52 59 54 57 55 49 +[NOM] +douleur : [NOM] EVENDO LEVENDO LEVENDO L EVENDO LEVENDO L EVS [NOM] [NOM] [NOM] [NOM] +Score au +repos : 0 0 0 0 0 0 0 0 0 0 0 +Saturation +O² : 98 98 98 99 +Ventilation : Ventilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant n +Débit O² +[L/mn] : 0 +[NOM] : 15 15 +Transit +Fréq. +respiratoire +Glycémie +capillaire +PA +Latéralité +Item de +surveillance : 15/04/2023 +13:27 +Taille [cm] : 125 +Poids [kg] : 25,20 +Item de +surveillance : 20/04/2023 +13:01 20/04/2023 +11:30 20/04/2023 +09:18 20/04/2023 +05:45 19/04/2023 +23:22 19/04/2023 +19:42 19/04/2023 +12:24 19/04/2023 +09:40 19/04/2023 +06:08 18/04/2023 +23:21 18/04/2023 +23:15 18/04/2023 +19:32 18/04/2023 +15:49 +Température : 36,80 36,20 36,20 36,10 36,70 37,30 36,90 37,20 36,90 37 37,10 37,40 +Pouls : 69 75 71 83 74 91 60 79 68 +PA +Systolique : 88 100 92 96 101 88 94 87 +PA +Diastolique : 52 59 54 57 55 49 53 50 +Saturation +O² : 98 98 98 99 +Transit +Fréq. +respiratoire +Item de +surveillance : 20/04/2023 +13:01 20/04/2023 +11:30 20/04/2023 +09:18 20/04/2023 +05:45 19/04/2023 +23:22 19/04/2023 +19:42 19/04/2023 +12:24 19/04/2023 +09:40 19/04/2023 +06:08 18/04/2023 +23:21 18/04/2023 +23:15 18/04/2023 +19:32 18/04/2023 +15:49 +Température : 36,80 36,20 36,20 36,10 36,70 37,30 36,90 37,20 36,90 37 37,10 37,40 +Pouls : 69 75 71 83 74 91 60 79 68 +PA +Systolique : 88 100 92 96 101 88 94 87 +PA +Diastolique : 52 59 54 57 55 49 53 50 +Saturation +O² : 98 98 98 99 +[NOM] : 15 +Transit + +Glycémie +capillaire +Type d'observation : Nom Date Commentaires + +Note d'évolution : DR. [NOM] +[NOM] 19/04/2023 +17:17 amélioration de comportement avec un retour à l'état antérieur d'après la maman +une phase de désorientation hier soir accompagné de céphalées résolutives après prise de +paracétamol +céphalalgique au changement de position, encore ce matin mais controlée par ATG1 +ex neurologique : doute sur une dysmétrie à gauche, pas d'autre anomalie +IRM c sur un créneau des urgences vers 12h demain, Dr [NOM] informée +prémédication par [NOM] MELATONINE prescrite pour 11h, à confirmer avec les manip +demain avec administration +permission pour l'apres midi autorisée +Note d'évolution : DR. [NOM] +[NOM] 18/04/2023 +17:40 Amélioration de l'examen par rapport à hier : parait un peu plus vif, marche talon /pointe +possible, sur une ligne impossible; Ralentissement toujours présent. +Maman le trouve beaucoup mieux, se pose la question de son état de base. +Tentative IRM cérébrale ce jour mais très agité, a priori sur la séquence interprétable pas +d'anomalie morphologique pas d'anomalie de la SB. Vu avec Dr [NOM], contrôle jeudi sous +nembuthal. +EEG normal. +Bilan complémentaire ce jour : ionogramme équilibré, EPS normale, TSH normale +Anti TPO anti Tyroglobuline en cours AAN en cours +PCR multiplex en cours +Poursuite surveillance clinique en hospitalisation +Note d'évolution : Pierre-[NOM] +[NOM] 17/04/2023 +17:48 PCR multiplex à réaliser sur le LCR (David Leyssenne) +IRMc demandée + +Note d'évolution : Pierre-[NOM] +[NOM] 17/04/2023 +15:32 Persistance d'un ralentissement idéo moteur avec quelques incohérence temporo spatiales +ROTS perçus facilement aux MS mais difficilement trouvés au MI +RCP ok +RCA limites +Pas de sd cérébelleux +paires crâniennes ok +Pas de sd méningé +pas de déficit senstif, difficulté à la marche peut être léger déficit 4+/5 des releveurs +=< poursuite aciclovir en attente résultats pcr +=> EEG à 15h (prémed melatonine) +Allo labo +- PCR entérovirus écouvillon rectal : négatif +- PCR entérovirus LCR : négatif +- PCR HSV LCR : négatif +Note d'évolution : DR. [NOM] +[NOM] 17/04/2023 +12:06 Persistance d'un ralentissement idéo moteur avec quelques incohérence temporo spatiales +ROTS perçus facilement aux MS mais difficilement trouvés au MI +RCP ok +RCA limites +Pas de sd cérébelleux +paires crâniennes ok +Pas de sd méningé +pas de déficit senstif, difficulté à la marche peut être léger déficit 4+/5 des releveurs +=< poursuite aciclovir en attente résultats pcr +=> EEG à 15h (prémed melatonine) +Note d'évolution : DR. [NOM] +[NOM] 16/04/2023 +19:25 devant la fievre ce jour et le ralentissement, introduction d'aciclovir +Note d'évolution : DR. [NOM] +[NOM] 16/04/2023 +17:18 examen ce matin : +maman trouve un comportement plus normal +pas d'hallucination, pas de confusion +apyrétique, pas de diarrhées (1 selle liquide samedi) et pas de vomissement +pas d'eruption +pas de signe de focalisation +ROT non trouvés +se lève difficilement car tête qui tourne +ralentissement psycho moteur encore présent +pas de franc syndrome cérébelleux +maman décrit hier des clies de l'œil droit +quelques mouvements étranges de la couhe pendant mon examen +CAT : +surveillance comportmeent et mouvements anormaux +EEG demain +PL rassurante sur le plan infectieux +Perfusion à poursuivre (mange peu) +CRP entérovirus +Encéphalite virale ? immuno ? + +Item de +surveillance : 20/04/2023 +13:01 20/04/2023 +11:30 20/04/2023 +09:18 20/04/2023 +05:45 19/04/2023 +23:22 19/04/2023 +19:42 19/04/2023 +12:24 19/04/2023 +09:40 19/04/2023 +06:08 18/04/2023 +23:21 18/04/2023 +23:15 18/04/2023 +19:32 18/04/2023 +15:49 +Température : 36,80 36,20 36,20 36,10 36,70 37,30 36,90 37,20 36,90 37 37,10 37,40 +Pouls : 69 75 71 83 74 91 60 79 68 +PA +Systolique : 88 100 92 96 101 88 94 87 +PA +Diastolique : 52 59 54 57 55 49 53 50 +Saturation +O² : 98 98 98 99 99 99 98 100 99 +Transit +Fréq. +respiratoire +Type de note : Nom Date Note + +Note IDE : [NOM] +[NOM] 20/04/2023 +18:02 Patient sortant après passage du Dr [NOM], sera revu en consult +Note IDE : [NOM] [NOM] 20/04/2023 +13:57 Examen: +IRM réalisée sans problème après prémédication po + IR +En attente des résultats. +A mangé à son retour vers 13h. +Neuro: +Bon comportement, bien orienté +mais persistance de tbs mnésiques (ne se souvient pas de sa date de naissance par exemple, +erreurs dans la superposition des couleurs dans le jeu de UNO qu'il connaît bien) +Note IDE : [NOM] [NOM] 20/04/2023 +03:57 Propos cohérent en début de nuit +Bon sommeil par la suite +Note IDE : [NOM] [NOM] 19/04/2023 +20:37 Retour de permission ce soir, apyrétique, non algique, bon comportement, surveillance neuro ok, +maman le trouve beaucoup mieux. +Examen: IRM cérébral prévu demain vers midi, prémédication prescrite, appeler l'IRM demain +matin pour confirmer l'heure avant de donner la PM. +Note IDE : [NOM] +[NOM] 19/04/2023 +15:00 Douleur : se plaint de céphalée ce matin => ATG1 fait à 10h +Neuro : GSC 15, aucun épisode de désorientation +IRM prévu demain mais interne doit faxé la demande. A prévoir prémédication +Autorisation à aller en permission cet après-midi +Note IDE : [NOM] [NOM] 18/04/2023 +23:16 ALGIE +confortable +absence de céphalées +NEURO +G15, réveillable +cohérent et orienté +léger ralentissement +VVP +KTO +Note IDE : [NOM] [NOM] 18/04/2023 +21:21 Alimentation : a bien mangé ce soir , a bu 3 verres entiers +Douleur : s'est plaint de céphalées cette après-midi mais ce sont résorbés rapidement +Neuro: mieux ce jour , moins ralenti +Apyrétique ce jour +Aucune nouvelles pour une date pour l'IRM cérébral +Note IDE : [NOM] +[NOM] 18/04/2023 +13:25 Neuro : mieux ce jour, moins ralenti qu'hier. A eu IRM cérébral ce matin : examen difficilement +réalisable. Sera à refaire à distance. +Reste jusqu'à jeudi. +Alimentation : A mangé ce matin. A midi, très fatigué. +Mis en KTO à 9h. +Douleur : se plaint de céphalées à midi : ATG1 fait, dort par la suite. +Note IDE : [NOM] [NOM] 17/04/2023 +22:49 ALGIE +confortable +absence de céphalées +THERMIE +normotherme +NEURO +G15, réveillable +cohérent et orienté +VVP +fonctionnelle, +hydratation en cours + +Note IDE : [NOM] +[NOM] 17/04/2023 +13:30 Neuro : ralenti, désorientation temporo spatial encore ce matin +EEG prévu à 15h ce jour +Apyrétique +Alimentation : a mangé 3 madeleines et du soda ce matin, de la purée et une banane à midi +Note IDE : [NOM] [NOM] 17/04/2023 +05:44 apyrétique cette nuit +antiviral fait à 4h +le levée jusqu'à la salle de bain c'est bien passé +Note IDE : [NOM] [NOM] 16/04/2023 +21:43 Neuro : cohérent cet après midi mais fatigué. A marché un peu. +Maman le trouve de nouveau incohérent ce soir à 21h30. Sait qu'elle doit filmer si mouvements +anormaux +Hyperthermie : a eu un pic à 39.2 bien toléré, ATP et glaçage des tubulures : efficace. +Mais 38° à 21h30 +BS avec hémoc fait ce soir et 2ème KT posé pour ATViral débuté à 20h30. +Alimentation : a mangé léger +Note IDE : [NOM] [NOM] 16/04/2023 +14:30 NEURO : ralentit ce matin , ne comprend pas bien les ordres simples +DOULEURS ABDOS : à 9h ==> soulagé par ATG1 // mange une madeleine ce matin et ne +mange pas à midi , boit de l'oasis +THERMIE : apyrétique ce matin , 38.1° à 13h30 ==> découvert // PCR entérovirus prélevé +Note IDE : [NOM] [NOM] 16/04/2023 +06:00 cathéter refixé en début de nuit +pas de mouvements anormaux constatés ni signalés +antalgique fait en début de nuit pour confort +hydratation en cours +Note IDE : [NOM] [NOM] 15/04/2023 +21:19 Apyrétique, non algique. +Neuro : clignements des yeux et enroulement des mains décrits par la maman, non constaté vers +20h30. La maman filmera la prochaine fois. +Laissé allongé en prévention du syndrome post PL +Alimentation : a mangé léger. +Prescription : Dose Fréquence Date de début Date de dernière +administration Note Docteur +PARACETAMOL BBM +10MG/ML INJ 100ML [10] +Flacon(s) : 400 mg - Normal 15/04/2023 15:44 20/04/2023 15:44 Le débit en cours +est : 160 ML par +1 hrs. Notes du +professionel de +santé: MAX 1G/ +INJ [NOM] [NOM] +ACICLOVIR MYL 500MG +PDR INJ [5] Flacon(s) : 500 mg - Normal 16/04/2023 19:23 17/04/2023 12:10 Le débit a été +modifié. Le débit +en cours est : 1 +par . DR. [NOM] +[NOM] +BIONOLYTE G5 INJ FPE +500ML [10] Flacon(s) : - Normal 15/04/2023 13:49 17/04/2023 16:54 Le débit a été +modifié. Le débit +en cours est : 30 +ML par 1 hrs. [NOM] [NOM] +PARACETAMOL [NOM] +SOL BUV : 1 DOSE(S) +KILO - Normal 18/04/2023 11:54 20/04/2023 17:54 Pierre-[NOM] +[NOM] +ATARAX 0,2G/100ML +SIROP FL 200ML [200] +Flacon(s) : 25 mg - 1 seule fois 1 seule +fois 18/04/2023 09:40 18/04/2023 10:00 Pierre-[NOM] +[NOM] + +MELATONINE 2MG +GELULE : 2 GEL - 1 seule fois 1 seule +fois 17/04/2023 12:06 17/04/2023 14:36 DR. [NOM] +[NOM] +MELATONINE - +MELATONINE GEL +[NOM] [NOM] , +AMPPMAN0104 : 6 mg - 1 seule fois 1 seule +fois 18/04/2023 09:39 18/04/2023 10:00 Pierre-[NOM] +[NOM] +MELATONINE - +MELATONINE GEL +[NOM] [NOM] , +AMPPMAN0104 : 6 mg - 1 seule fois 1 seule +fois 20/04/2023 11:00 20/04/2023 11:30 DR. [NOM] +[NOM] +[NOM] 60MG : 120 mg - 1 seule fois 1 seule +fois 20/04/2023 11:00 20/04/2023 11:30 DR. [NOM] +[NOM] +Date début : Heure +début Prescription Date +exécution Heure +exécution Statut Docteur Note +15/04/2023 : 15:54 Scanner Cérébral 15/04/2023 16:04 Réalisé [NOM] [NOM] +18/04/2023 : 09:41 IRM [NOM] PEDIATRIE 18/04/2023 10:07 Réalisé DR. [NOM] +19/04/2023 : 15:23 IRM [NOM] PEDIATRIE Arrêté DR. [NOM] +20/04/2023 : 11:56 IRM [NOM] PEDIATRIE 20/04/2023 14:17 Réalisé +Date : Heure Prescription Docteur Date de +collection Note +16/04/2023 : 19:26 Sérum à garder DR. [NOM] 16/04/2023 +20:56 +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +REGIME NORMAL : Signé 10 Jours - Matin midi +soir nuit Normal 15/04/2023 +17:53 [NOM] +[NOM] +DESINFECTION +ENVIRONNEMENT +PATIENT : Réalisé - Matin [8h] Normal 15/04/2023 +21:25 [NOM] +[NOM] +LIT : REFECTION +COMPLETE Réalisé - Matin [8h] Normal 15/04/2023 +21:25 [NOM] +[NOM] +LIT : REFECTION +COMPLETE Réalisé - Matin [8h] Normal 17/04/2023 +02:35 [NOM] +[NOM] +TOILETTE : DOUCHE +ENFANT Réalisé - Matin [8h] Normal 15/04/2023 +21:26 [NOM] +[NOM] +DOULEUR : SURV Réalisé 10 Jours - Ttes les +6h [2h 8h 14h 20h] +Normal 15/04/2023 +17:53 Notes du +professionel +de santé: +DE 0-6 +ans :EVENDO +A PARTIR +de 6 +ans:[NOM] +[NOM] A +PARIR de 8 +ans: [NOM] +numérique +0-10 L +[NOM] +[NOM] +[NOM] : SURV. Réalisé 1 Semaine - Ttes les +3H [2h 5h ... 20h +23h] Normal 15/04/2023 +17:53 [NOM] +[NOM] +KT COURT : SURV. Réalisé 1 Semaine - Ttes +les 8H [6h 14h 22h] +Normal 15/04/2023 +17:53 Notes du +professionel +de santé: +surv +perméable/ +non +inflammatoire/ +pas de +diffusion/pas +d'hématome [NOM] +[NOM] +SIGNES VITAUX (Pls, +TA, FR, T°, Glyc, Miction, +Transit) : Réalisé - Ttes les 4H [0h +4h ... 16h 20h] +Normal 15/04/2023 +17:53 [NOM] +[NOM] + +SURV. NEUROLOGIQUE +TTES LES 3H : Réalisé 10 Jours - Ttes les 3H +[2h 5h ... 20h 23h] +Normal 15/04/2023 +17:53 Notes du +professionel +de santé: +Conscience/ +pupilles/ +comportement [NOM] +[NOM] +TRANSIT/ +[NOM]/POIDS : SURV Réalisé 10 Jours - Matin midi +soir nuit Normal 15/04/2023 +17:53 [NOM] +[NOM] + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — REGIME NORMAL - Matin midi soir +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 19:00 * 1 +Signé — REGIME NORMAL - Matin midi soir +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 21:00 * 1 +Signé — REGIME NORMAL - Matin midi soir +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 08:00 * 1 +Signé — REGIME NORMAL - Matin midi soir +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 12:00 * 1 +En cours — BIONOLYTE G5 INJ FPE 500ML +- 5G/L + 2G/L ... solution (500 mL) - Poso 30 +ml/heure - INTRAVEINEUSE Continue - Début +presc. : 15/04/2023 @ 13:49 [NOM] [NOM] +Début le 15/04/2023 à +13:49 +Fin le 20/04/2023 à +11:34 +Admin le 17/04/2023 à +16:54 11:34 * 1 +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 400 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 15/04/2023 à +15:44 +Fin le 25/04/2023 à +09:44 +Admin le 20/04/2023 à +15:44 21:44 * 400 +mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 400 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 15/04/2023 à +15:44 +Fin le 25/04/2023 à +09:44 +Admin le 20/04/2023 à +15:44 03:44 * 400 +mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 400 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 15/04/2023 à +15:44 +Fin le 25/04/2023 à +09:44 +Admin le 20/04/2023 à +15:44 09:44 * 400 +mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 400 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 15/04/2023 à +15:44 +Fin le 25/04/2023 à +09:44 +Admin le 20/04/2023 à +15:44 15:44 * 400 +mg + + + + + + + + + + + +Signé — PARACETAMOL [NOM] SOL BUV - +24MG sirop - Dose 1 DOSE(S) KILO - ORALE - +Toutes les 6 Heure(s) - 1ère dose : 18/04/2023 @ +11:54 [NOM] Pierre- +[NOM] +Début le 18/04/2023 à +11:54 +Fin le 28/04/2023 à +05:54 +Admin le 20/04/2023 à +17:54 23:54 * 1 +DOSE(S) +KILO +Signé — PARACETAMOL [NOM] SOL BUV - +24MG sirop - Dose 1 DOSE(S) KILO - ORALE - +Toutes les 6 Heure(s) - 1ère dose : 18/04/2023 @ +11:54 [NOM] Pierre- +[NOM] +Début le 18/04/2023 à +11:54 +Fin le 28/04/2023 à +05:54 +Admin le 20/04/2023 à +17:54 05:54 * 1 +DOSE(S) +KILO +Signé — PARACETAMOL [NOM] SOL BUV - +24MG sirop - Dose 1 DOSE(S) KILO - ORALE - +Toutes les 6 Heure(s) - 1ère dose : 18/04/2023 @ +11:54 [NOM] Pierre- +[NOM] +Début le 18/04/2023 à +11:54 +Fin le 28/04/2023 à +05:54 +Admin le 20/04/2023 à +17:54 11:54 * 1 +DOSE(S) +KILO +Signé — PARACETAMOL [NOM] SOL BUV - +24MG sirop - Dose 1 DOSE(S) KILO - ORALE - +Toutes les 6 Heure(s) - 1ère dose : 18/04/2023 @ +11:54 [NOM] Pierre- +[NOM] +Début le 18/04/2023 à +11:54 +Fin le 28/04/2023 à +05:54 +Admin le 20/04/2023 à +17:54 17:54 * 1 +DOSE(S) +KILO +Réalisé — [NOM] 60MG - 60MG +suppositoire - Dose 120 mg - RECTALE - 1 seule +fois - 1ère dose : 20/04/2023 @ 11:00 [NOM] [NOM]- +[NOM] +Début le 20/04/2023 à +11:00 +Fin le 20/04/2023 à +11:00 +Admin le 20/04/2023 à +11:30 11:30 * 120 +mg +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - +pendant 7 Jour(s)- Date Début : 15/04/2023 @ +21:25 [NOM] [NOM] +Début le 15/04/2023 à +21:25 +Fin le 22/04/2023 à +08:00 +Admin le 20/04/2023 à +10:45 10:45 * 1 +Réalisé — LIT : REFECTION COMPLETE +- Matin [8h] - pendant 7 Jour(s)- Date Début: +15/04/2023 @ 21:25 [NOM] [NOM] +Début le 15/04/2023 à +21:25 +Fin le 22/04/2023 à +08:00 +Admin le 20/04/2023 à +10:45 10:45 * 1 +Réalisé — TOILETTE : DOUCHE ENFANT +- Matin [8h] - pendant 7 Jour(s)- Date Début: +15/04/2023 @ 21:26 [NOM] [NOM] +Début le 15/04/2023 à +21:26 +Fin le 22/04/2023 à +08:00 +Admin le 20/04/2023 à +11:47 11:47 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 15/04/2023 +@ 17:53 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:[NOM] [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +14:00 +Admin le 20/04/2023 à +14:00 20:00 * 1 + +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 15/04/2023 +@ 17:53 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:[NOM] [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +14:00 +Admin le 20/04/2023 à +14:00 14:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 20:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 23:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 02:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 05:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 08:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 11:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 14:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 17:00 * 1 + +Réalisé — KT COURT : SURV. - Ttes les 8H [6h +14h 22h] - 1 Semaine- Date Début: 15/04/2023 @ +17:53 +Notes de professionel de santé : +surv perméable/non inflammatoire/pas de +diffusion/pas d'hématome [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +14:00 +Admin le 20/04/2023 à +14:00 06:00 * 1 +Réalisé — KT COURT : SURV. - Ttes les 8H [6h +14h 22h] - 1 Semaine- Date Début: 15/04/2023 @ +17:53 +Notes de professionel de santé : +surv perméable/non inflammatoire/pas de +diffusion/pas d'hématome [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +14:00 +Admin le 20/04/2023 à +14:00 14:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +16:00 +Admin le 20/04/2023 à +16:00 20:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +16:00 +Admin le 20/04/2023 à +16:00 00:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +16:00 +Admin le 20/04/2023 à +16:00 04:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +16:00 +Admin le 20/04/2023 à +16:00 08:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +16:00 +Admin le 20/04/2023 à +16:00 12:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +16:00 +Admin le 20/04/2023 à +16:00 16:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 20:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 23:00 * 1 + +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 02:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 05:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 08:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 11:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 14:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 17:00 * 1 +Réalisé — TRANSIT/[NOM]/ +POIDS : SURV - Matin midi soir nuit - 10 Jours- +Date Début: 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 19:00 * 1 +Réalisé — TRANSIT/[NOM]/ +POIDS : SURV - Matin midi soir nuit - 10 Jours- +Date Début: 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 21:00 * 1 +Réalisé — TRANSIT/[NOM]/ +POIDS : SURV - Matin midi soir nuit - 10 Jours- +Date Début: 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 08:00 * 1 +Réalisé — TRANSIT/[NOM]/ +POIDS : SURV - Matin midi soir nuit - 10 Jours- +Date Début: 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 12:00 * 1 + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — REGIME NORMAL - Matin midi soir +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 08:00 * 1 +Signé — REGIME NORMAL - Matin midi soir +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 12:00 * 1 +Signé — REGIME NORMAL - Matin midi soir +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 19:00 * 1 +Signé — REGIME NORMAL - Matin midi soir +nuit - 10 Jours- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 21:00 * 1 +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 400 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 15/04/2023 à +15:44 +Fin le 25/04/2023 à +09:44 +Admin le 20/04/2023 à +15:44 09:44 * 400 +mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 400 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 15/04/2023 à +15:44 +Fin le 25/04/2023 à +09:44 +Admin le 20/04/2023 à +15:44 15:44 * 400 +mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 400 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 15/04/2023 à +15:44 +Fin le 25/04/2023 à +09:44 +Admin le 20/04/2023 à +15:44 21:44 * 400 +mg +Signé — PARACETAMOL BBM 1000 MG INJ - +10MG/ML solution (100 mL) - Dose 400 mg - sur +15 min - INTRAVEINEUSE Discontinue - Toutes +les 6 Heure(s) - 1ère dose : 15/04/2023 @ 15:44 +Notes de professionel de santé : +MAX 1G/ INJ [NOM] [NOM] +Début le 15/04/2023 à +15:44 +Fin le 25/04/2023 à +09:44 +Admin le 20/04/2023 à +15:44 03:44 * 400 +mg +Signé — PARACETAMOL [NOM] SOL BUV - +24MG sirop - Dose 1 DOSE(S) KILO - ORALE - +Toutes les 6 Heure(s) - 1ère dose : 18/04/2023 @ +11:54 [NOM] Pierre- +[NOM] +Début le 18/04/2023 à +11:54 +Fin le 28/04/2023 à +05:54 +Admin le 20/04/2023 à +17:54 11:54 * 1 +DOSE(S) +KILO + + + + + + + + + +Signé — PARACETAMOL [NOM] SOL BUV - +24MG sirop - Dose 1 DOSE(S) KILO - ORALE - +Toutes les 6 Heure(s) - 1ère dose : 18/04/2023 @ +11:54 [NOM] Pierre- +[NOM] +Début le 18/04/2023 à +11:54 +Fin le 28/04/2023 à +05:54 +Admin le 20/04/2023 à +17:54 23:54 * 1 +DOSE(S) +KILO +Signé — PARACETAMOL [NOM] SOL BUV - +24MG sirop - Dose 1 DOSE(S) KILO - ORALE - +Toutes les 6 Heure(s) - 1ère dose : 18/04/2023 @ +11:54 [NOM] Pierre- +[NOM] +Début le 18/04/2023 à +11:54 +Fin le 28/04/2023 à +05:54 +Admin le 20/04/2023 à +17:54 05:54 * 1 +DOSE(S) +KILO +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - +pendant 7 Jour(s)- Date Début : 15/04/2023 @ +21:25 [NOM] [NOM] +Début le 15/04/2023 à +21:25 +Fin le 22/04/2023 à +08:00 +Admin le 20/04/2023 à +10:45 08:00 * 1 +Réalisé — LIT : REFECTION COMPLETE +- Matin [8h] - pendant 7 Jour(s)- Date Début: +15/04/2023 @ 21:25 [NOM] [NOM] +Début le 15/04/2023 à +21:25 +Fin le 22/04/2023 à +08:00 +Admin le 20/04/2023 à +10:45 08:00 * 1 +Réalisé — TOILETTE : DOUCHE ENFANT +- Matin [8h] - pendant 7 Jour(s)- Date Début: +15/04/2023 @ 21:26 [NOM] [NOM] +Début le 15/04/2023 à +21:26 +Fin le 22/04/2023 à +08:00 +Admin le 20/04/2023 à +11:47 08:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 15/04/2023 +@ 17:53 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:[NOM] [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +14:00 +Admin le 20/04/2023 à +14:00 08:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 15/04/2023 +@ 17:53 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:[NOM] [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +14:00 +Admin le 20/04/2023 à +14:00 14:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 15/04/2023 +@ 17:53 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:[NOM] [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +14:00 +Admin le 20/04/2023 à +14:00 20:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 15/04/2023 +@ 17:53 +Notes de professionel de santé : +DE 0-6 ans :EVENDOL A PARTIR de 6 +ans:[NOM] [NOM] A PARIR de 8 ans: [NOM] +numérique 0-10 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +14:00 +Admin le 20/04/2023 à +14:00 02:00 * 1 + +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 11:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 14:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 17:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 20:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 23:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 02:00 * 1 +Réalisé — [NOM] : SURV. - Ttes les 3H +[2h 5h ... 20h 23h] - 1 Semaine- Date Début: +15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 05:00 * 1 +Réalisé — KT COURT : SURV. - Ttes les 8H [6h +14h 22h] - 1 Semaine- Date Début: 15/04/2023 @ +17:53 +Notes de professionel de santé : +surv perméable/non inflammatoire/pas de +diffusion/pas d'hématome [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +14:00 +Admin le 20/04/2023 à +14:00 14:00 * 1 +Réalisé — KT COURT : SURV. - Ttes les 8H [6h +14h 22h] - 1 Semaine- Date Début: 15/04/2023 @ +17:53 +Notes de professionel de santé : +surv perméable/non inflammatoire/pas de +diffusion/pas d'hématome [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +14:00 +Admin le 20/04/2023 à +14:00 22:00 * 1 +Réalisé — KT COURT : SURV. - Ttes les 8H [6h +14h 22h] - 1 Semaine- Date Début: 15/04/2023 @ +17:53 +Notes de professionel de santé : +surv perméable/non inflammatoire/pas de +diffusion/pas d'hématome [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 22/04/2023 à +14:00 +Admin le 20/04/2023 à +14:00 06:00 * 1 + +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +16:00 +Admin le 20/04/2023 à +16:00 08:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +16:00 +Admin le 20/04/2023 à +16:00 12:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +16:00 +Admin le 20/04/2023 à +16:00 16:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +16:00 +Admin le 20/04/2023 à +16:00 20:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +16:00 +Admin le 20/04/2023 à +16:00 00:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, +T°, Glyc, Miction, Transit) - Ttes les 4H [0h +4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +16:00 +Admin le 20/04/2023 à +16:00 04:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 08:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 11:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 14:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 17:00 * 1 + +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 20:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 23:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 02:00 * 1 +Réalisé — SURV. NEUROLOGIQUE TTES LES +3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- +Date Début : 15/04/2023 @ 17:53 +Notes de professionel de santé : +" Conscience/pupilles/comportement" [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +17:00 +Admin le 20/04/2023 à +17:00 05:00 * 1 +Réalisé — TRANSIT/[NOM]/ +POIDS : SURV - Matin midi soir nuit - 10 Jours- +Date Début: 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 08:00 * 1 +Réalisé — TRANSIT/[NOM]/ +POIDS : SURV - Matin midi soir nuit - 10 Jours- +Date Début: 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 12:00 * 1 +Réalisé — TRANSIT/[NOM]/ +POIDS : SURV - Matin midi soir nuit - 10 Jours- +Date Début: 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 19:00 * 1 +Réalisé — TRANSIT/[NOM]/ +POIDS : SURV - Matin midi soir nuit - 10 Jours- +Date Début: 15/04/2023 @ 17:53 [NOM] [NOM] +Début le 15/04/2023 à +17:53 +Fin le 25/04/2023 à +12:00 +Admin le 20/04/2023 à +12:00 21:00 * 1 +Prescription : Date Résultat + +Résultat de labo : 18/04/2023 09:45 +(5933693) 16/04/2023 20:56 +(5932873) 16/04/2023 20:56 +(5932872) 16/04/2023 20:56 +(5932871) 16/04/2023 20:56 +(5932870) +Titre Anticorps anti-noyau : Négatif (< 1/80) +Aspect de la fluorescence : "" +Anticorps antithyroglobuline : Reçu le 20/04/23 +Ac Anti-Thyropéroxydase : Reçu le 20/04/23 +Lactates : 1,7 mmol/l 2,4 mmol/l +Ammoniémie : 19,6 µmol/l +Score Fibrosis-4 (FIB4) : 0,26 +Commentaire score Fibrosis-4 : Le score Fibrosis-4 est +un test de dépistage de +la fibrose hépatique. +S?il existe une cause +connue de cytolyse +hépatique ou de +thrombopénie, il ne +faut pas tenir compte +de ce résultat. Dans +les autres cas, si la +valeur est > 2,67, +un avis en hépatologie +est recommandé. Si la +valeur est < 1,3, il +n?existe pas de maladie +hépatique sévère. +Dans les autres cas, un +contrôle à distance est +recommandé. +FIO2 : Non renseigné(e) % +Bicarbonates : 25,2 mmol/l +Origine : Veineux +Débit : Non renseigné(e) L/ +min +Température : Non renseignée (rendu +pour une température +de 37°C) °C +ASAT : 33 U/l +CPK : 34 U/l +TSH 3ème génération : 1,75 mUI/L +Calcium : 2,26 mmol/l 2,16 mmol/l +Chlore : 105 mmol/l 105 mmol/l +Créatinine : 27 µmol/l 29 µmol/l +CRP : 3 mg/l +Compte rendu Bactériologie : Bact230416210005-1.pdf +Compte-rendu laboratoire : Labo230420100641-1.pd f Labo230416212007-1.pd fLabo230417093446-1.pd fLabo230417093450-1.pd +Protéines (sérum) : 65 g/l +Albumine (électrophorèse) : 36,9 g/l +Alpha 1 : 3,4 g/l +Alpha 2 : 9,3 g/l +Gamma : 9,4 g/l +Electrophorèse des protéines +sériques (conclusion) : Profil sensiblement +normal +quantitativement. +Profil +électrophorétique +qualitativement +normal : absence de +pathologie clonale +visible. Validé et +interprété par Dr [NOM] +[NOM] +[NOM] 1 : 3,2 g/l +[NOM] 2 : 2,8 g/l + +Polynucléaires neutrophiles +(%) : 40,0 % 64,5 % +Polynucléaires neutrophiles +(#) : 1,44 10.9/l 4,32 10.9/l +Polynucléaires éosinophiles +(%) : 2,0 % 0,4 % +Polynucléaires éosinophiles +(#) : 0,07 10.9/l 0,03 10.9/l +Polynucléaires basophiles (%) : 1,0 % 0,3 % +Polynucléaires basophiles (#) : 0,04 10.9/l 0,02 10.9/l +Lymphocytes (%) : 42,0 % 20,9 % +Lymphocytes (#) : 1,51 10.9/l 1,40 10.9/l +Monocytes (%) : 11,0 % 13,9 % +Monocytes (#) : 0,40 10.9/l 0,93 10.9/l +Formule vérifiée par le +technicien : Oui +Lymphocytes +Hyperbasophiles (%) : 4,0 % +Lymphocytes +Hyperbasophiles (#) : 0,14 10.9/l +Glucose : 5,6 mmol/l 6,7 mmol/l +pH : 7,42 +pO2 : 49 mmHg +Saturation O2 : 86,6 % +pCO2 : 39 mmHg +ALAT : 20 U/l +Formule sanguine : réalisée sur frottis +sanguin au microscope réalisée sur automate +XN (Sysmex) +Hématocrite (%) : 35,0 % 34,1 % +Indice de distribution des +hématies : 12,8 % 12,9 % +Potassium : 4,1 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"VILLE_GLOBAL", "original": "PARIS", "placeholder": "[VILLE]", "bbox_hint": null} +{"page": -1, "kind": "VILLE_GLOBAL", "original": "BOUCAU", "placeholder": "[VILLE]", "bbox_hint": null} +{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64109 BAYONNE CEDEX", "placeholder": "[CODE_POSTAL]", "bbox_hint": null} +{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "Code Postal: 64340", "placeholder": "[CODE_POSTAL]", "bbox_hint": null} +{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64340", "placeholder": "[CODE_POSTAL]", "bbox_hint": null} +{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64100 BAYONNE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE_GLOBAL", "original": "23183041", "placeholder": "[EPISODE]", "bbox_hint": null} +{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "4 RUE DU PETIT NANOT", "placeholder": "[ADRESSE]", "bbox_hint": null} +{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "4 RUE DU PETIT NANOT Ville de résidence", "placeholder": "[ADRESSE]", "bbox_hint": null} +{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "4 RUE DU PETIT NANOT\tVille de résidence", "placeholder": "[ADRESSE]", "bbox_hint": null} +{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "1, PLACE PEREIRE", "placeholder": "[ADRESSE]", "bbox_hint": null} +{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "LOEB BP 8", "placeholder": "[ADRESSE]", "bbox_hint": null} +{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "13, Avenue de l'Interne J", "placeholder": "[ADRESSE]", "bbox_hint": null} +{"page": -1, "kind": "DATE_NAISSANCE_GLOBAL", "original": "Date de naissance: 12/06/1971", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null} +{"page": -1, "kind": "DATE_NAISSANCE_GLOBAL", "original": "née le 12/06/1971", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "001205621", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "06.45.55.95.38", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "0617381939", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "0634226193", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "ETAB_GLOBAL", "original": "unité de Chirurgie hors SC", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null} +{"page": -1, "kind": "ETAB_GLOBAL", "original": "Service Madame BEDOUET MARIE-LINE", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null} diff --git a/tests/ground_truth/pdfs/baseline_anonymized/027_complexe_trackare_trackare-10027557-23183041_10027557_23183041.pseudonymise.txt b/tests/ground_truth/pdfs/baseline_anonymized/027_complexe_trackare_trackare-10027557-23183041_10027557_23183041.pseudonymise.txt new file mode 100644 index 0000000..20b695e --- /dev/null +++ b/tests/ground_truth/pdfs/baseline_anonymized/027_complexe_trackare_trackare-10027557-23183041_10027557_23183041.pseudonymise.txt @@ -0,0 +1,3068 @@ +CENTRE HOSPITALIER COTE BASQUE +*640N0° F0in0ess162* +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +640000162 +CHIRURGIE VISCERALE - CHIRURGIE VISCERALE +Dossier Patient +Détails des patients +Nom de naissance : [NOM] IPP : [IPP] +Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE] +Sexe : Féminin Lieu de naissance: [VILLE] +Nationalité : FRANCE [CODE_POSTAL] +Adresse : [ADRESSE]: [NOM] +Détails épisode +Episode No : [EPISODE] +Localisation : CHIRURGIE VISCERALE Médecin courant: DR. [NOM] +Date d'admission : 22/09/2023 Heure d'admission: 19:22 +Date de sortie : 25/09/2023 Heure de sortie: 13:49 +Médecin traitant +Nom Adresse Téléphone +DR. [NOM] [ADRESSE][CODE_POSTAL] +Liste des contacts +Tél. +Type de contact Relation Nom Prénom Adresse Tél. domicile Mobile +professionel +Personne à prévenir +Mère [NOM] FRANCE [TEL] +(Trakcare) +Personne de +Concubin [NOM] [TEL] +confiance +Lien familial +Fille +automatique +Personne à prévenir +Concubin [NOM] [NOM] [TEL] +(Trakcare) +Passage aux Urgences +Episode - Date 22/09/2023 +Episode - Heure 19 : 22 +Mode de transport à l'arrivée Véhicule personnel +Médicalisation du transport Aucune médicalisation +Mode d'entrée Autres admissions urgentes +Date d'orientation 22/09/2023 +Heure d'orientation 19 : 34 +IAO [NOM] Laurie +Priorité Priorité 3 +Sous-type épisode URG - Circuit court +Motif de prise en charge Douleur abdominale +dlr abdo depuis début AM non soulagée par spasfon +nausée et vertiges +Observ. IDE Urg abs de SFU +a déjà eu ce type de dlr mais habituellement passe plus rapidement et moins intense, 2 lanzoprazole 15 donné +antd : by pass +Médecin de la prise en charge médicale [NOM] [NOM] +Date de prise en charge médicale 22/09/2023 +Heure de prise en charge médicale 19 : 22 +Médecin de la décision médicale [NOM] [NOM] +Date de décision médicale 23/09/2023 +Heure de décision médicale 00 : 39 +Décision médicale Hospitalisation MCO +Orientation du patient hospitalisation dans une [MASK], SI, REA +Date de sortie des urgences 23/09/2023 +Heure de sortie des Urgences 01 : 46 +US de destination US Chirurgie Viscérale +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 1 de 20 UF de destination CHIRURGIE VISCERALE +Diagnostic aux urgences +Type Etat Code Date +Principal actif K81.9 Cholécystite, sans précision [CMA2] 23/09/2023 01 : 46 +Antécédents (texte libre) +Type de note Nom Date Heure Note +Aucune donnée +renseignée +Antécédents habitus (texte libre) +Type de note Nom Date Heure Note +Aucune donnée +renseignée +Signes vitaux +Item de 25/09/2023 25/09/2023 24/09/2023 24/09/2023 24/09/2023 24/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 +surveillance 08 : 19 05:10 23:51 15:22 09:15 05:16 23:00 20:22 18:00 08:57 04:14 01:54 01:25 +Température 36,30 37,10 36,40 37,50 37 36,60 36,90 37 35,90 35,70 35,60 35,30 +Pouls 81 78 76 76 70 75 72 78 63 82 +PA +107 144 120 106 109 107 110 125 136 143 +Systolique +PA +57 86 68 58 64 64 61 67 83 75 +Diastolique +Saturation +95 98 97 96 97 96 100 96 100 96 +O² +Echelle +EVS EN EVS EVS EN EN EN EVS EVS EN EN EN EN +douleur +Score au +0 0 2 0 5 0 0 0 0 7 7 4 5 +repos +Transit Gaz Gaz Absence Gaz Absence Absence Absence Absence Absence +Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation +spontanée spontanée spontanée spontanée spontanée spontanée spontanée spontanée spontanée +Ventilation +Air Air Air Air Air Air Air Air Air +ambiant ambiant ambiant ambiant ambiant ambiant ambiant ambiant ambiant +Poids/Taille +Item de 23/09/2023 +surveillance 01 : 59 +Poids [kg] 69 +Taille [cm] 157 +Surv. Isolement et Contention +Item de 25/09/2023 24/09/2023 24/09/2023 24/09/2023 24/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 +surveillance 08 : 19 23:51 15:22 09:15 05:16 23:00 20:22 18:00 08:57 04:14 01:54 01:25 01:24 +Température 36,30 37,10 36,40 37,50 37 36,60 36,90 37 35,90 35,70 35,60 35,30 35,30 +Pouls 81 78 76 76 70 75 72 78 63 82 66 +PA +107 144 120 106 109 107 110 125 136 143 143 +Systolique +PA +57 86 68 58 64 64 61 67 83 75 75 +Diastolique +Saturation +95 98 97 96 97 96 100 96 100 96 95 +O² +Transit Gaz Gaz Absence Gaz Absence Absence Absence Absence Absence +Surv. Contention +Item de 25/09/2023 24/09/2023 24/09/2023 24/09/2023 24/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 +surveillance 08 : 19 23:51 15:22 09:15 05:16 23:00 20:22 18:00 08:57 04:14 01:54 01:25 01:24 +Température 36,30 37,10 36,40 37,50 37 36,60 36,90 37 35,90 35,70 35,60 35,30 35,30 +Pouls 81 78 76 76 70 75 72 78 63 82 66 +PA +107 144 120 106 109 107 110 125 136 143 143 +Systolique +PA +57 86 68 58 64 64 61 67 83 75 75 +Diastolique +Saturation +95 98 97 96 97 96 100 96 100 96 95 +O² +Transit Gaz Gaz Absence Gaz Absence Absence Absence Absence Absence +Observations médicales +Type d'observation Nom Date Commentaires +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 2 de 20 Paul [NOM] 25/09/2023 +Note d'évolution ATBg en cours +[NOM] 09 : 33 +DR. [NOM] 24/09/2023 E.Coli dans la bile poursuivre ATB IV jusqu a l antibiogramme +Note d'évolution +[NOM] 18 : 39 elargir l alimentation +antibiogramme en cours poursuite ATB IV +DR. [NOM] 24/09/2023 +Note d'évolution Apyretique +[NOM] 10 : 41 +realimenter +HemoC positive a BG- +DR. [NOM] 23/09/2023 +Note d'évolution +[NOM] 17 : 05 +CHOECYSTECTOMIE pour cholecystite augue lithiasique tres inflammatoire. +DR. [NOM] 23/09/2023 +Note d'évolution Poursuite ATB jusqu au resultat de la bacterio per op +[NOM] 16 : 32 +realimentation ce jour +SCANNER ABDOMINO-PELVIEN +Indication : + : 52 ans +Recherche : perforation? saignement ? +Protocole : +Examen réalisé avec injection de produit de contraste. +RESULTATS : +Présence de plusieurs calculs centimétriques et supracentimétriques de l'infundibulum +vésiculaire et du canal cystique, avec nette distension de la vésicule biliaire en amont, dont les +parois sont discrètement épaissies, avec une infiltration modérée de la graisse périvésiculaire, +sans solution de continuité pariétale, sans signe de perforation. +Pas d'abcès visible sur le versant hépatique non péritonisée la vésicule. Discrète +hyperartérialisation du parenchyme hépatique pouvant témoigner d'une inflammation. +Perméabilité des veines hépatiques et du réseau veineux mésentéricoportes. +Pas de dilatation de l'arbre biliaire par ailleurs. +Hépatomégalie non dysmorphique, non stéatosique. +Pas d'anomalie des bases pulmonaires. +Prothèse mammaire bilatérale. +23/09/2023 +Note d'évolution [NOM] [NOM] Rate homogène de petite taille. +00 : 31 +Pancréas homogène. +Les deux surrénales sont fines. +Pas d'occlusion digestive. +Appendice rétrocaecal fin. +Pas d'anomalie notable des deux reins en dehors de quelques kystes corticaux simples. +Stigmates chirurgicaux gastriques de type by-pass. +Perméabilité des principaux axes artériels intra-abdominaux. +Formation kystique annexielle droite de 17 mm, sans nécessité d'exploration complémentaire +si la patiente est ménopausée. +Réplétion de la cavité utérine, à confronter au statut ménopausique. +Prothèses mammaires bilatérales. Hyperlordose lombaire, avec remaniements dégénératifs +relativement marqués des articulaires postérieures aux deux derniers étages, antélisthésis +dégénératif de grade I de L4 sur L5. Pas de lésion osseuse suspecte. Pas de signe de +spondylodiscite scanographique. +CONCLUSION : +Aspect continu avec une cholécystite aiguë de vraisemblable origine lithiasique, non +compliquée. Pas de dilatation du reste de l'arbre biliaire par ailleurs. +RAOULT Julien, interne +Motif : douleurs abdominales et vomissements +[AGE] +Antécédent Bypass gastrique +Normalement CI aux AINS mais prend SPIFEN + IPP pour migraines +Cet après-midi +Histoire de la 22/09/2023 Douleur épigastrique d'intensité rapidement progressive +[NOM] [NOM] +maladie 21 : 54 Douleurs connues mais habituellement moins intenses et soulagées par SPASFON +Pas de SFU +Pas de troubles du transit +Pas de prise d'OH +Pas d'atcd de calcul biliaire ou rénal +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 3 de 20 Antécédents +Bypass gastrique +Traitements +Vitamines bypass + zinc +Allergies +Attention AINS : bypass +EXAMEN CLINIQUE +VAS libres sûres +SpO2 99% en AA +MV bilatéral symétrique sans bruit surajouté +Pas de dyspnée pas de signes de lutte +Pas de toux +TA 149/66 mmHg +FC 69/min +bdc réguliers sans souffle +pas de douleur thoracique +pas de signe d'ica +mollets souples indolores +pas de signe d'hypoperfusion périphérique +Hypotherme 34.8°C recontrôlée 35.3°C +Abdomen non évaluable car patiente trop algique +Douleur épigastrique irradiant en postérieur +Douleur intense même à l'effleurement du ventre +Selles avant d'arriver, pas de diarrhées, ne sait pas si méléna/rectorragies +Vomissements lors des pics douloureux, pas de sang +Pas de SFU, urines non malodorantes, a uriné avant les urgences +Sensible à la percussion lombaire de façon bilatérale +CAT +Biologie +BU/ECBU +Hémocultures car hypotherme +Antalgie +Réévaluation après morphine +TDM AP selon bio +EXAMENS COMPLEMENTAIRES +ECG +Sinusal régulier 63/min +Pas de trouble de conduction +QRS fins normoaxés +Ondes T plates +BU +*** +Biologie +Gb 12 G/L, CRP plate +Hb 10.6 g/dl microcytaire 75 fl +Plaquettes 245 G/L +Pas de trouble de coagulation +Pas de trouble ionique, créatinine 41 µmol/L +Bilan hépatique sans anomalie notamment lipasémie normale pas de cholestase ou cytolyse +hCG négatives +TDM AP +Aspect continu avec une cholécystite aiguë de vraisemblable origine lithiasique, non +compliquée. Pas de dilatation du reste de l'arbre biliaire par ailleurs. +Surveillance Psychiatrie +Item de 25/09/2023 24/09/2023 24/09/2023 24/09/2023 24/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 23/09/2023 +surveillance 08 : 19 23:51 15:22 09:15 05:16 23:00 20:22 18:00 08:57 04:14 01:54 01:25 01:24 +Température 36,30 37,10 36,40 37,50 37 36,60 36,90 37 35,90 35,70 35,60 35,30 35,30 +Pouls 81 78 76 76 70 75 72 78 63 82 66 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 4 de 20 PA +107 144 120 106 109 107 110 125 136 143 143 +Systolique +PA +57 86 68 58 64 64 61 67 83 75 75 +Diastolique +Saturation +95 98 97 96 97 96 100 96 100 96 95 +O² +Transit Gaz Gaz Absence Gaz Absence Absence Absence Absence Absence +Notes paramédicales +Type de note Nom Date Note +- Douleur : peu algique +25/09/2023 +Note IDE [NOM] [NOM] - Transit : G+S- +12 : 58 +- Devenir : RAD ce jour +Risque de douleur : Faible algie à 23h50 --> ATG1+ ATS donné --> Soulagé par la suite +Risque infectieux : Apyrétique +24/09/2023 +Note IDE [NOM] [NOM] +23 : 50 +Digestif : Pas d'épisodes sur la nuit +Transit : G+/S- +Douleur : +- non algique de l'AM +Risque infectieux : +-Apyrétique, plaies colles propres +24/09/2023 Digestif : +Note IDE [NOM] [NOM] +15 : 31 -transit: G+/S- -> normacol non fait +-Alim : po2 bien toléré +Mobilisation : +-est allée marcher +Douleur : en 5/10 soulagée par ttt ATG 1 + ATS +Alimentation : ne souhaite pas manger, stimulation inefficace +Transit : pas de gaz ni de selles, normacol effectué à 12h +24/09/2023 +Note IDE [NOM] [NOM] Mobilisation : ne souhaite pas marcher, stimulation inefficace +09 : 24 +Plaies colles propres. +Risque infectieux : apyrétique, ATB X2 administré +Risque de douleur : Non algique +Risque infectieux : Apyrétique +HDM : Normocarde, normotendue +23/09/2023 +Note IDE [NOM] [NOM] +22 : 58 +Respi : Sat ok en AA +Digestif : Pas d'épisodes sur la nuit +Transit : G-/S- +Retour de bloc / cholecystite lithiasique +surveillance post op : +Douleur : +-non algique, a eu ATG1 et ATG3 à 15h -> soulagée par la suite +Risque infectieux : +-Apyrétique ATBx2 hemoc+ +23/09/2023 -plaies colles propres +Note IDE [NOM] [NOM] +18 : 01 +Mobilisation : +-1 er levé fait -> bien toléré +Digestif : +-Transit : G-/S- +-alim : [NOM] -> bien toléré +-Absence de nausées/rots/vomissements +Elimination : +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 5 de 20 -à uriné +Hmd : +-Constantes stables +Patiente nauséeuse + douloureuse (ATS + ATG1 administrés : efficace ) +BLOC départ pour 12h30, dossier bloc ok, patiente prête. +23/09/2023 +Note IDE [NOM] [NOM] +09 : 07 Risque infectieux : hypotherme (hémoc faite le 22/09) --> 1 paire hémoc positive à bacilles +gramme negtaif +ECBU envoyé au labo . ATB administré. +Transfert des urgences de Me B pour cholecystite lithiasique +ATCD : ByPass +Allergie : Non connue +MDV : en activité, est en arrêt jusqu'au 2 octobre, à voir pour prolongation?? Vie avec son +concubin +Examens aux urgences : +- BS +- Hémoc x2 sur hypothermie +- TDM abdo +23/09/2023 +Note IDE [NOM] [NOM] A l'arrivée : +01 : 50 +Risque de douleur : Faible algie à 02h après mobilisation --> Forte algie à 04h, ATG3 donné --> +trouve que ca ne lui a rien fait, ATG1 + ATS donné à 05h20 +Risque infectieux : Hypothermie bien toléré +HDM : Normocarde, normotendue +Respi : Sat ok en AA +Digestif : Nausées à l'arrivée --> Bassine donnée, allo IDG urg --> Prescription orale d'une +ampoule d'o[DOSSIER] IV , faite à 02h, soulagé par la suite +Transit : G+/S+ du 22.09 +a eu TDM TAP = cholécystite +BI ATB thérapie débuté selon PM +[NOM] 23/09/2023 +Note IDE +[NOM] 01 : 40 +DEVENIR = transfert en chir viscérale +DOULEUR = plus confortable +entre pour douleur épigastrique +HYPERALGIQUE en pré-soin +VVP posée avec beaucoup de difficulté : BS + hémocs prélevés +[NOM] 22/09/2023 +Note IDE +[NOM] 23 : 26 DOULEUR = ATG 1 + titration de morphine administrés selon PM +[NOM] = anti émétique fait selon PM +ECG fait +22/09/2023 ecg faitprise constes +Note A-Soignante Chloé DEVESA +22 : 57 +Traitements médicamenteux +Date de dernière +Prescription Dose Fréquence Date de début Note Docteur +administration +Voie d`administration : INTRAVEINEUSE +Statut des prescriptions : Signé +Le débit en cours +est : 3 ML par +1 hrs. Notes du +CEFOTAXIME PAN 1G +1 G - Normal 23/09/2023 00 : 33 25/09/2023 08:33 professionel de [NOM] [NOM] +PDR INJ [25] Flacon(s) +santé : à diluer +dans 100ML de +NACL ou G5% +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 6 de 20 METOCLOPRAMIDE CHL Le débit en cours +REN 10MG/2ML INJ [100] 1 AMP - Normal 22/09/2023 21 : 48 25/09/2023 05:50 est : 6 ML par 1 [NOM] [NOM] +Ampoule(s) hrs. +METRONIDAZOLE BBM Le débit en cours +0,5% INJ POC 100ML [1] 500 mg - Normal 23/09/2023 00 : 33 25/09/2023 08:33 est : 200 ML par 1 [NOM] [NOM] +POCHE(S) hrs. +O[DOSSIER] REN Le débit en cours +4MG/2ML SOL INJ AMP 4 mg - Normal 23/09/2023 02 : 06 25/09/2023 10:10 est : 4 ML par 1 [NOM] [NOM] +[10] Ampoule(s) hrs. +Le débit a été +modifié. Le débit +en cours est : 24 +PHLOROGLUCINOL ARW +par . Notes du +40MG/0,04MG INJ [10] 80 mg - Normal 23/09/2023 00 : 33 25/09/2023 08:35 [NOM] [NOM] +professionel de +Ampoule(s) Bouteille(s) +santé : A préparer +dans 100 mL de +NaCl 0,9% +Statut des prescriptions : Arrêté +MORPHINE CHL 10MG/ML +3 mg - Normal 22/09/2023 21 : 11 22/09/2023 23:21 [NOM] [NOM] +INJ 1ML +PARACETAMOL BBM +10MG/ML INJ 100ML [10] 1 G - Normal 22/09/2023 21 : 11 23/09/2023 05:21 [NOM] [NOM] +Flacon(s) +Voie d`administration : ORALE +Statut des prescriptions : Signé +LANSOPRAZOLE BGA +DR. [NOM] +15MG CPR OROD [14] 15 mg - Matin [8h] Normal 23/09/2023 15 : 11 25/09/2023 08:33 +[NOM] +CPR(s) +MOVICOL PDR [NOM] 1 - 2 DR. [NOM] +- Matin [8h] Normal 23/09/2023 15 : 11 25/09/2023 08:00 +SACHET [20] Sachet(s) SACHET [NOM] +OXYNORMORO +10MG CPR DISP [14] 1 CPR - Normal 23/09/2023 01 : 30 25/09/2023 11:53 [NOM] [NOM] +COMPRIME(S) +PARACETAMOL ARW +- Matin midi soir nuit DR. [NOM] +500MG GELULE [12] 2 GEL 23/09/2023 15 : 11 25/09/2023 12:00 +Normal [NOM] +Gelule(s) +TRAMADOL ARW 50MG - Matin midi soir DR. [NOM] +1 CPR 23/09/2023 15 : 11 25/09/2023 12:00 +CPR [30] COMPRIME(S) Normal [NOM] +Statut des prescriptions : Réalisé +BACTRIM FORTE CPR [10] - Matin soir (8h - DR. Ute +1 CPR 25/09/2023 11 : 18 +COMPRIME(S) 20h) Presc. de Sortie [NOM] +LANSOPRAZOLE BGA 30 - 1 seule fois 1 seule DR. [NOM] +1 CPR 22/09/2023 19 : 49 22/09/2023 19:50 +MG CPR OROD [14] CPR(s) fois [NOM] +PARACETAMOL ARW +- Matin midi soir Paul [NOM] +500MG GELULE [12] 1000 mg 25/09/2023 08 : 07 +Presc. de Sortie [NOM] +Gelule(s) +SPASFON CPR [30] - Matin midi soir Paul [NOM] +2 CPR 25/09/2023 08 : 07 +COMPRIME(S) Presc. de Sortie [NOM] +Notes du +professionel de +TRAMADOL ARW LP +- Matin soir (8h - santé : Si douleur Paul [NOM] +100MG GELULE [30] 1 GEL 25/09/2023 08 : 07 +19h) Presc. de Sortie résistante au [NOM] +Gelule(s) +paracétamol / +spasfon +Prescriptions de radiologie +Heure Date Heure +Date début Prescription Statut Docteur [NOM] +début exécution exécution +22/09/2023 23 : 22 Scanner Abdomino+/-Pelvien 22/09/2023 23:46 Réalisé [NOM] [NOM] +Prescriptions de laboratoire +Date de +Date Heure Prescription Docteur [NOM] +collection +22/09/2023 +22/09/2023 21 : 11 Ionogramme ( Na, K, CL ) [NOM] [NOM] +21 : 22 +23/09/2023 +23/09/2023 01 : 30 Hémoculture Flacons 3 et 4 [NOM] [NOM] +01 : 33 +Pièce opératoire ( Atlantic- 23/09/2023 +23/09/2023 16 : 16 [NOM] [NOM] +Pathologie) 16 : 16 +Ionogramme ( Na, K, CL, créat, +25/09/2023 08 : 07 Paul [NOM] [NOM] +glucose ) +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 7 de 20 Transaminases ASAT + ALAT sang +25/09/2023 08 : 07 Paul [NOM] [NOM] +( dosage ) +25/09/2023 08 : 07 Phosphatase alcaline dosage sang Paul [NOM] [NOM] +Bilirubine ( totale + conjuguée + +25/09/2023 08 : 07 Paul [NOM] [NOM] +non conjuguée ) sang ( dosage ) +25/09/2023 08 : 07 Gamma GT GGT sang ( dosage ) Paul [NOM] [NOM] +25/09/2023 08 : 07 Num +Formule +Plaq Paul [NOM] [NOM] +Prescriptions de soins +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +[NOM] 1 Jour - Matin [8h] 23/09/2023 DR. [NOM] +Signé +ALIMENTAIRE / DESSERT Normal 15 : 11 [NOM] +- 1 seule fois 1 seule 22/09/2023 [NOM] +BANDELETTE URINAIRE Signé +fois 21 : 11 [NOM] +- Matin midi goûter 23/09/2023 Xabi [NOM] +[NOM] SEUL Arrêté +soir Normal 07 : 00 [NOM] +BAS DE CONTENTION : 3 Semaines - à 08h 23/09/2023 DR. [NOM] +Réalisé +POSE Normal 15 : 11 [NOM] +DESINFECTION +23/09/2023 Xabi [NOM] +ENVIRONNEMENT Réalisé - Matin [8h] Normal +07 : 00 [NOM] +PATIENT +- Matin midi goûter 23/09/2023 Xabi [NOM] +LEVER : AU FAUTEUIL Réalisé +soir Normal 07 : 00 [NOM] +LIT : REFECTION 23/09/2023 Xabi [NOM] +Réalisé - Matin [8h] Normal +COMPLETE 07 : 00 [NOM] +- Matin midi goûter 24/09/2023 Xabi [NOM] +REPAS : AUTONOME Réalisé +soir Normal 07 : 00 [NOM] +TOILETTE : AIDE 23/09/2023 Xabi [NOM] +Réalisé - à 08h Normal +PARTIELLE 07 : 00 [NOM] +10 Jours - Ttes les +23/09/2023 DR. [NOM] +DOULEUR : SURV Réalisé 6h [2h 8h 14h 20h] +15 : 11 [NOM] +Normal +Notes du +professionel +- 1 seule fois 1 seule 22/09/2023 [NOM] +ECG (FAIRE RELEVÉ) Réalisé de santé : +fois 21 : 11 [NOM] +ECG 12 +dérivations +- 1 seule fois 1 seule 22/09/2023 [NOM] +VVP : BOUCHON Réalisé +fois 21 : 11 [NOM] +Prescriptions de sortie +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +[NOM] [10] 1 CPR - Matin soir (8h - 25/09/2023 0/12 : Non administré DR. [NOM](S) ORALE 20h) Presc. de Sortie 11 : 18 Révisé/Traité [NOM] +Bilirubine ( totale + +25/09/2023 Paul [NOM] +conjuguée + non conjuguée ) Signé - Presc. de Sortie +08 : 07 [NOM] +sang ( dosage ) +Gamma GT GGT sang 25/09/2023 Paul [NOM] +Signé - Presc. de Sortie +( dosage ) 08 : 07 [NOM] +Ionogramme ( Na, K, CL, 25/09/2023 Paul [NOM] +Signé - Presc. de Sortie +créat, glucose ) 08 : 07 [NOM] +25/09/2023 Paul [NOM] +Num +Formule +Plaq Signé - Presc. de Sortie +08 : 07 [NOM] +PARACETAMOL ARW +1000 mg - Matin midi soir 25/09/2023 0/90 : Non administré Paul [NOM] +500MG GELULE [12] Réalisé +ORALE Presc. de Sortie 08 : 07 Révisé/Traité [NOM] +Gelule(s) +Phosphatase alcaline dosage 25/09/2023 Paul [NOM] +Signé - Presc. de Sortie +sang 08 : 07 [NOM] +SPASFON CPR [30] 2 CPR - Matin midi soir 25/09/2023 0/90 : Non administré Paul [NOM] +Réalisé +COMPRIME(S) ORALE Presc. de Sortie 08 : 07 Révisé/Traité [NOM] +TRAMADOL ARW LP +1 GEL - Matin soir (8h - 25/09/2023 0/4 : Non administré Paul [NOM] +100MG GELULE [30] Réalisé +ORALE 19h) Presc. de Sortie 08 : 07 Révisé/Traité [NOM] +Gelule(s) +Transaminases ASAT + 25/09/2023 Paul [NOM] +Signé - Presc. de Sortie +ALAT sang ( dosage ) 08 : 07 [NOM] +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 8 de 20 Plan de soins Jour J du 25/09/2023 07h00 au 26/09/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — CEFOTAXIME PAN 1 G PDR INJ - [NOM] [NOM] +1000MG poudre (1 mL) - Dose 1 G - sur 20 min Début le 23/09/2023 à +- INTRAVEINEUSE Discontinue - Toutes les 8 00 : 33 +Heure(s) - 1ère dose : 23/09/2023 @ 00:33 Fin le 29/09/2023 à 16:33 * 1 G +Notes de professionel de santé : 16:33 +Admin le 25/09/2023 à +à diluer dans 100ML de NACL ou G5% +08 : 33 +Signé — CEFOTAXIME PAN 1 G PDR INJ - [NOM] [NOM] +1000MG poudre (1 mL) - Dose 1 G - sur 20 min Début le 23/09/2023 à +- INTRAVEINEUSE Discontinue - Toutes les 8 00 : 33 +Heure(s) - 1ère dose : 23/09/2023 @ 00:33 Fin le 29/09/2023 à 00:33 * 1 G +Notes de professionel de santé : 16:33 +Admin le 25/09/2023 à +à diluer dans 100ML de NACL ou G5% +08 : 33 +Signé — CEFOTAXIME PAN 1 G PDR INJ - [NOM] [NOM] +1000MG poudre (1 mL) - Dose 1 G - sur 20 min Début le 23/09/2023 à +- INTRAVEINEUSE Discontinue - Toutes les 8 00 : 33 +Heure(s) - 1ère dose : 23/09/2023 @ 00:33 Fin le 29/09/2023 à 08:33 * 1 G +Notes de professionel de santé : 16:33 +Admin le 25/09/2023 à +à diluer dans 100ML de NACL ou G5% +08 : 33 +Signé — METOCLOPRAMIDE CHL REN [NOM] [NOM] +10 MG INJ - 5MG/ML solution (2 mL) - Dose Début le 22/09/2023 à +1 AMP - sur 20 min - INTRAVEINEUSE 21 : 48 +D Di és bc uo tn pti rn eu sce +. + : - 2T 2o /u 0t 9e /s +2 +l 0e 2s +3 +8 +@ +H e 2u 1r : e 4( 8s) Si besoin - F 13in + : 5 +l 0e 25/09/2023 à 1 A3 M : 5 P0 * 1 +si nausées ou vomissements Admin le 25/09/2023 à +05 : 50 +Signé — METRONIDAZOLE BBM 500 MG INJ [NOM] [NOM] +POC - 5MG/ML solution (100 mL) - Dose 500 Début le 23/09/2023 à +mg - sur 30 min - INTRAVEINEUSE Discontinue 00 : 33 16:33 * 500 +- Toutes les 8 Heure(s) - 1ère dose : 23/09/2023 @ Fin le 29/09/2023 à mg +00 : 33 16:33 +Admin le 25/09/2023 à +08 : 33 +Signé — METRONIDAZOLE BBM 500 MG INJ [NOM] [NOM] +POC - 5MG/ML solution (100 mL) - Dose 500 Début le 23/09/2023 à +mg - sur 30 min - INTRAVEINEUSE Discontinue 00 : 33 00:33 * 500 +- Toutes les 8 Heure(s) - 1ère dose : 23/09/2023 @ Fin le 29/09/2023 à mg +00 : 33 16:33 +Admin le 25/09/2023 à +08 : 33 +Signé — METRONIDAZOLE BBM 500 MG INJ [NOM] [NOM] +POC - 5MG/ML solution (100 mL) - Dose 500 Début le 23/09/2023 à +mg - sur 30 min - INTRAVEINEUSE Discontinue 00 : 33 08:33 * 500 +- Toutes les 8 Heure(s) - 1ère dose : 23/09/2023 @ Fin le 29/09/2023 à mg +00 : 33 16:33 +Admin le 25/09/2023 à +08 : 33 +Signé — O[DOSSIER] REN 4 MG SOL INJ +AMP - 2MG/ML solution (2 mL) - Dose 4 mg - [NOM] [NOM] +sur 30 min - INTRAVEINEUSE Discontinue - Début le 23/09/2023 à +Toutes les 8 Heure(s) Si besoin - Début presc. : 02:06 +23/09/2023 @ 02 : 06 Fin le 25/09/2023 à 18:10 * 4 mg +si nausées ou vomissements non soulagés par 18 : 10 +PRIMPERAN Admin le 25/09/2023 à +10 : 10 +Signé — O[DOSSIER] REN 4 MG SOL INJ +AMP - 2MG/ML solution (2 mL) - Dose 4 mg - [NOM] [NOM] +sur 30 min - INTRAVEINEUSE Discontinue - Début le 23/09/2023 à +Toutes les 8 Heure(s) Si besoin - Début presc. : 02:06 +23/09/2023 @ 02 : 06 Fin le 25/09/2023 à 10:10 * 4 mg +si nausées ou vomissements non soulagés par 18 : 10 +PRIMPERAN Admin le 25/09/2023 à +10 : 10 +Signé — PHLOROGLUCINOL ARW +[NOM] [NOM] +40 MG/0,04 MG INJ - 40MG + 0.04MG 14 : 35 * 80 +solution (4 mL) - Dose 80 mg - sur 20 min - Début le 23/09/2023 à mg +INTRAVEINEUSE Discontinue - Toutes les 6 00 : 33 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 9 de 20 Heure(s) Si besoin - Début presc. : 23/09/2023 @ +00 : 33 Fin le 24/10/2023 à +si douleur abdo 02 : 35 +Admin le 25/09/2023 à +Notes de professionel de santé : +08 : 35 +A préparer dans 100 mL de NaCl 0,9% +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG [NOM] [NOM] +solution (4 mL) - Dose 80 mg - sur 20 min - +Début le 23/09/2023 à +INTRAVEINEUSE Discontinue - Toutes les 6 +00 : 33 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ 20:35 * 80 +00 : 33 Fin le 24/10/2023 à mg +02 : 35 +si douleur abdo Admin le 25/09/2023 à +Notes de professionel de santé : 08:35 +A préparer dans 100 mL de NaCl 0,9% +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG [NOM] [NOM] +solution (4 mL) - Dose 80 mg - sur 20 min - +Début le 23/09/2023 à +INTRAVEINEUSE Discontinue - Toutes les 6 +00 : 33 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ 02:35 * 80 +00 : 33 Fin le 24/10/2023 à mg +02 : 35 +si douleur abdo Admin le 25/09/2023 à +Notes de professionel de santé : 08:35 +A préparer dans 100 mL de NaCl 0,9% +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG [NOM] [NOM] +solution (4 mL) - Dose 80 mg - sur 20 min - +Début le 23/09/2023 à +INTRAVEINEUSE Discontinue - Toutes les 6 +00 : 33 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ 08:35 * 80 +00 : 33 Fin le 24/10/2023 à mg +02 : 35 +si douleur abdo Admin le 25/09/2023 à +Notes de professionel de santé : 08:35 +A préparer dans 100 mL de NaCl 0,9% +[NOM] [NOM] +Signé — LANSOPRAZOLE BGA 15MG Début le 23/09/2023 à +CPR OROD - 15MG comprime - Dose 15 mg - 15 : 11 +O 08R : 0A 0LE - Matin [8h] - 1ère dose: 24/09/2023 @ F 08in + : 0 +l 0e 28/09/2023 à 0 m8 g : 33 * 15 +Admin le 25/09/2023 à +08 : 33 +Signé — MOVICOL PDR [NOM] - [NOM] [NOM] +MD poudre - Dose 1 à 2 SACHET - ORALE - Début le 23/09/2023 à +Matin [8h] Si besoin - Début presc. : 23/09/2023 15:11 08:00 * 1-2 +@ 15 : 11 Fin le 23/10/2023 à SACHET +Si constipation secondaire au morphine 08 : 00 +Admin le 25/09/2023 à +08 : 00 +Signé — OXYNORMORO 10MG CPR DISP [NOM] [NOM] +- 10MG comprime - Dose 1 CPR - ORALE - Début le 23/09/2023 à +Toutes les 2 Heure(s) Si besoin - Début presc. : 01:30 13:53 * 1 +23/09/2023 @ 01 : 30 Fin le 26/09/2023 à CPR +si douleur intense non soulagée par paracetamol 01 : 53 +Admin le 25/09/2023 à +11 : 53 +Signé — OXYNORMORO 10MG CPR DISP [NOM] [NOM] +- 10MG comprime - Dose 1 CPR - ORALE - Début le 23/09/2023 à +Toutes les 2 Heure(s) Si besoin - Début presc. : 01:30 15:53 * 1 +23/09/2023 @ 01 : 30 Fin le 26/09/2023 à CPR +si douleur intense non soulagée par paracetamol 01 : 53 +Admin le 25/09/2023 à +11 : 53 +Signé — OXYNORMORO 10MG CPR DISP [NOM] [NOM] +- 10MG comprime - Dose 1 CPR - ORALE - Début le 23/09/2023 à +Toutes les 2 Heure(s) Si besoin - Début presc. : 01:30 17:53 * 1 +23/09/2023 @ 01 : 30 Fin le 26/09/2023 à CPR +si douleur intense non soulagée par paracetamol 01 : 53 +Admin le 25/09/2023 à +11 : 53 +Signé — OXYNORMORO 10MG CPR DISP +[NOM] [NOM] +- 10MG comprime - Dose 1 CPR - ORALE - 19 : 53 * 1 +Toutes les 2 Heure(s) Si besoin - Début presc. : Début le 23/09/2023 à CPR +23/09/2023 @ 01 : 30 01:30 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 10 de 20 Fin le 26/09/2023 à +si douleur intense non soulagée par paracetamol 01 : 53 +Admin le 25/09/2023 à +11 : 53 +Signé — OXYNORMORO 10MG CPR DISP [NOM] [NOM] +- 10MG comprime - Dose 1 CPR - ORALE - Début le 23/09/2023 à +Toutes les 2 Heure(s) Si besoin - Début presc. : 01:30 21:53 * 1 +23/09/2023 @ 01 : 30 Fin le 26/09/2023 à CPR +si douleur intense non soulagée par paracetamol 01 : 53 +Admin le 25/09/2023 à +11 : 53 +Signé — OXYNORMORO 10MG CPR DISP [NOM] [NOM] +- 10MG comprime - Dose 1 CPR - ORALE - Début le 23/09/2023 à +Toutes les 2 Heure(s) Si besoin - Début presc. : 01:30 23:53 * 1 +23/09/2023 @ 01 : 30 Fin le 26/09/2023 à CPR +si douleur intense non soulagée par paracetamol 01 : 53 +Admin le 25/09/2023 à +11 : 53 +Signé — OXYNORMORO 10MG CPR DISP [NOM] [NOM] +- 10MG comprime - Dose 1 CPR - ORALE - Début le 23/09/2023 à +Toutes les 2 Heure(s) Si besoin - Début presc. : 01:30 01:53 * 1 +23/09/2023 @ 01 : 30 Fin le 26/09/2023 à CPR +si douleur intense non soulagée par paracetamol 01 : 53 +Admin le 25/09/2023 à +11 : 53 +Signé — OXYNORMORO 10MG CPR DISP [NOM] [NOM] +- 10MG comprime - Dose 1 CPR - ORALE - Début le 23/09/2023 à +Toutes les 2 Heure(s) Si besoin - Début presc. : 01:30 07:53 * 1 +23/09/2023 @ 01 : 30 Fin le 26/09/2023 à CPR +si douleur intense non soulagée par paracetamol 01 : 53 +Admin le 25/09/2023 à +11 : 53 +Signé — OXYNORMORO 10MG CPR DISP [NOM] [NOM] +- 10MG comprime - Dose 1 CPR - ORALE - Début le 23/09/2023 à +Toutes les 2 Heure(s) Si besoin - Début presc. : 01:30 09:53 * 1 +23/09/2023 @ 01 : 30 Fin le 26/09/2023 à CPR +si douleur intense non soulagée par paracetamol 01 : 53 +Admin le 25/09/2023 à +11 : 53 +Signé — OXYNORMORO 10MG CPR DISP [NOM] [NOM] +- 10MG comprime - Dose 1 CPR - ORALE - Début le 23/09/2023 à +Toutes les 2 Heure(s) Si besoin - Début presc. : 01:30 11:53 * 1 +23/09/2023 @ 01 : 30 Fin le 26/09/2023 à CPR +si douleur intense non soulagée par paracetamol 01 : 53 +Admin le 25/09/2023 à +11 : 53 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 23/09/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 15 : 11 +O 23R /0A 9L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 23/10/2023 à 1 G9 E : 0 L0 * 2 +Admin le 25/09/2023 à +12 : 00 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 23/09/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 15 : 11 +O 23R /0A 9L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 23/10/2023 à 2 G1 E : 0 L0 * 2 +Admin le 25/09/2023 à +12 : 00 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 23/09/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 15 : 11 +O 23R /0A 9L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 23/10/2023 à 0 G8 E : 3 L3 * 2 +Admin le 25/09/2023 à +12 : 00 +Signé — PARACETAMOL ARW 500MG [NOM] [NOM] +GELULE - 500MG gelule - Dose 2 GEL - Début le 23/09/2023 à +O 23R /0A 9L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: 1 F5 in:1 l1 +e 23/10/2023 à +1 G2 E : 0 L0 * 2 +12 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 11 de 20 Admin le 25/09/2023 à +12 : 00 +[NOM] [NOM] +Signé — TRAMADOL ARW 50MG CPR - Début le 23/09/2023 à +50MG comprime - Dose 1 CPR - ORALE - Matin 15 : 11 19:00 * 1 +midi soir - 1ère dose : 23/09/2023 @ 19:00 Fin le 23/10/2023 à CPR +12 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] [NOM] +Signé — TRAMADOL ARW 50MG CPR - Début le 23/09/2023 à +50MG comprime - Dose 1 CPR - ORALE - Matin 15 : 11 08:00 * 1 +midi soir - 1ère dose : 23/09/2023 @ 19:00 Fin le 23/10/2023 à CPR +12 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] [NOM] +Signé — TRAMADOL ARW 50MG CPR - Début le 23/09/2023 à +50MG comprime - Dose 1 CPR - ORALE - Matin 15 : 11 12:00 * 1 +midi soir - 1ère dose : 23/09/2023 @ 19:00 Fin le 23/10/2023 à CPR +12 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — BAS DE CONTENTION : POSE - Début le 23/09/2023 à +à 08h - 3 Semaines- Date Début : 23/09/2023 @ 15:11 +15 : 11 Fin le 14/10/2023 à 08:00 * 1 +08 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] Xabi +Réalisé — DESINFECTION [NOM] +ENVIRONNEMENT PATIENT - Matin [8h] - Début le 23/09/2023 à +pendant 7 Jour(s)- Date Début : 23/09/2023 @ 07:00 08:00 * 1 +07 : 00 Fin le 29/09/2023 à +08 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] Xabi +[NOM] +Réalisé — LEVER : AU FAUTEUIL - Matin Début le 23/09/2023 à +midi goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +23/09/2023 @ 07 : 00 Fin le 29/09/2023 à 16:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — LEVER : AU FAUTEUIL - Matin Début le 23/09/2023 à +midi goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +23/09/2023 @ 07 : 00 Fin le 29/09/2023 à 19:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — LEVER : AU FAUTEUIL - Matin Début le 23/09/2023 à +midi goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +23/09/2023 @ 07 : 00 Fin le 29/09/2023 à 08:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — LEVER : AU FAUTEUIL - Matin Début le 23/09/2023 à +midi goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +23/09/2023 @ 07 : 00 Fin le 29/09/2023 à 12:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +Réalisé — LIT : REFECTION COMPLETE [NOM] Xabi +- Matin [8h] - pendant 7 Jour(s)- Date Début : [NOM] +23/09/2023 @ 07 : 00 Début le 23/09/2023 à 08:00 * 1 +07 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 12 de 20 Fin le 29/09/2023 à +08 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] Xabi +[NOM] +Réalisé — REPAS : AUTONOME - Matin midi Début le 24/09/2023 à +goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +24/09/2023 @ 07 : 00 Fin le 30/09/2023 à 16:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — REPAS : AUTONOME - Matin midi Début le 24/09/2023 à +goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +24/09/2023 @ 07 : 00 Fin le 30/09/2023 à 19:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — REPAS : AUTONOME - Matin midi Début le 24/09/2023 à +goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +24/09/2023 @ 07 : 00 Fin le 30/09/2023 à 08:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — REPAS : AUTONOME - Matin midi Début le 24/09/2023 à +goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +24/09/2023 @ 07 : 00 Fin le 30/09/2023 à 12:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — TOILETTE : AIDE PARTIELLE - à Début le 23/09/2023 à +08h - pendant 10 Jour(s)- Date Début : 23/09/2023 07:00 +@ 07 : 00 Fin le 02/10/2023 à 08:00 * 1 +08 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 23/09/2023 à +8h 14h 20h] - 10 Jours- Date Début : 23/09/2023 15:11 +@ 15 : 11 Fin le 03/10/2023 à 14:00 * 1 +14 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 23/09/2023 à +8h 14h 20h] - 10 Jours- Date Début : 23/09/2023 15:11 +@ 15 : 11 Fin le 03/10/2023 à 20:00 * 1 +14 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 23/09/2023 à +8h 14h 20h] - 10 Jours- Date Début : 23/09/2023 15:11 +@ 15 : 11 Fin le 03/10/2023 à 02:00 * 1 +14 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 23/09/2023 à +8h 14h 20h] - 10 Jours- Date Début : 23/09/2023 15:11 +@ 15 : 11 Fin le 03/10/2023 à 08:00 * 1 +14 : 00 +Admin le 25/09/2023 à +08 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 13 de 20 Plan de soins Jour J + 1 du 26/09/2023 07h00 au 27/09/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — CEFOTAXIME PAN 1 G PDR INJ - [NOM] [NOM] +1000MG poudre (1 mL) - Dose 1 G - sur 20 min Début le 23/09/2023 à +- INTRAVEINEUSE Discontinue - Toutes les 8 00 : 33 +Heure(s) - 1ère dose : 23/09/2023 @ 00:33 Fin le 29/09/2023 à 08:33 * 1 G +Notes de professionel de santé : 16:33 +Admin le 25/09/2023 à +à diluer dans 100ML de NACL ou G5% +08 : 33 +Signé — CEFOTAXIME PAN 1 G PDR INJ - [NOM] [NOM] +1000MG poudre (1 mL) - Dose 1 G - sur 20 min Début le 23/09/2023 à +- INTRAVEINEUSE Discontinue - Toutes les 8 00 : 33 +Heure(s) - 1ère dose : 23/09/2023 @ 00:33 Fin le 29/09/2023 à 16:33 * 1 G +Notes de professionel de santé : 16:33 +Admin le 25/09/2023 à +à diluer dans 100ML de NACL ou G5% +08 : 33 +Signé — CEFOTAXIME PAN 1 G PDR INJ - [NOM] [NOM] +1000MG poudre (1 mL) - Dose 1 G - sur 20 min Début le 23/09/2023 à +- INTRAVEINEUSE Discontinue - Toutes les 8 00 : 33 +Heure(s) - 1ère dose : 23/09/2023 @ 00:33 Fin le 29/09/2023 à 00:33 * 1 G +Notes de professionel de santé : 16:33 +Admin le 25/09/2023 à +à diluer dans 100ML de NACL ou G5% +08 : 33 +Signé — METRONIDAZOLE BBM 500 MG INJ [NOM] [NOM] +POC - 5MG/ML solution (100 mL) - Dose 500 Début le 23/09/2023 à +mg - sur 30 min - INTRAVEINEUSE Discontinue 00 : 33 08:33 * 500 +- Toutes les 8 Heure(s) - 1ère dose : 23/09/2023 @ Fin le 29/09/2023 à mg +00 : 33 16:33 +Admin le 25/09/2023 à +08 : 33 +Signé — METRONIDAZOLE BBM 500 MG INJ [NOM] [NOM] +POC - 5MG/ML solution (100 mL) - Dose 500 Début le 23/09/2023 à +mg - sur 30 min - INTRAVEINEUSE Discontinue 00 : 33 16:33 * 500 +- Toutes les 8 Heure(s) - 1ère dose : 23/09/2023 @ Fin le 29/09/2023 à mg +00 : 33 16:33 +Admin le 25/09/2023 à +08 : 33 +Signé — METRONIDAZOLE BBM 500 MG INJ [NOM] [NOM] +POC - 5MG/ML solution (100 mL) - Dose 500 Début le 23/09/2023 à +mg - sur 30 min - INTRAVEINEUSE Discontinue 00 : 33 00:33 * 500 +- Toutes les 8 Heure(s) - 1ère dose : 23/09/2023 @ Fin le 29/09/2023 à mg +00 : 33 16:33 +Admin le 25/09/2023 à +08 : 33 +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG [NOM] [NOM] +solution (4 mL) - Dose 80 mg - sur 20 min - +Début le 23/09/2023 à +INTRAVEINEUSE Discontinue - Toutes les 6 +00 : 33 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ 08:35 * 80 +00 : 33 Fin le 24/10/2023 à mg +02 : 35 +si douleur abdo Admin le 25/09/2023 à +Notes de professionel de santé : 08:35 +A préparer dans 100 mL de NaCl 0,9% +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG [NOM] [NOM] +solution (4 mL) - Dose 80 mg - sur 20 min - +Début le 23/09/2023 à +INTRAVEINEUSE Discontinue - Toutes les 6 +00 : 33 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ 14:35 * 80 +00 : 33 Fin le 24/10/2023 à mg +02 : 35 +si douleur abdo Admin le 25/09/2023 à +Notes de professionel de santé : 08:35 +A préparer dans 100 mL de NaCl 0,9% +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG [NOM] [NOM] +solution (4 mL) - Dose 80 mg - sur 20 min - Début le 23/09/2023 à +INTRAVEINEUSE Discontinue - Toutes les 6 00 : 33 20:35 * 80 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ Fin le 24/10/2023 à mg +00 : 33 02:35 +si douleur abdo Admin le 25/09/2023 à +08 : 35 +Notes de professionel de santé : +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 14 de 20 A préparer dans 100 mL de NaCl 0,9% +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG [NOM] [NOM] +solution (4 mL) - Dose 80 mg - sur 20 min - +Début le 23/09/2023 à +INTRAVEINEUSE Discontinue - Toutes les 6 +00 : 33 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ 02:35 * 80 +00 : 33 Fin le 24/10/2023 à mg +02 : 35 +si douleur abdo Admin le 25/09/2023 à +Notes de professionel de santé : 08:35 +A préparer dans 100 mL de NaCl 0,9% +[NOM] [NOM] +Signé — LANSOPRAZOLE BGA 15MG Début le 23/09/2023 à +CPR OROD - 15MG comprime - Dose 15 mg - 15 : 11 +O 08R : 0A 0LE - Matin [8h] - 1ère dose: 24/09/2023 @ F 08in + : 0 +l 0e 28/09/2023 à 0 m8 g : 00 * 15 +Admin le 25/09/2023 à +08 : 33 +Signé — MOVICOL PDR [NOM] - [NOM] [NOM] +MD poudre - Dose 1 à 2 SACHET - ORALE - Début le 23/09/2023 à +Matin [8h] Si besoin - Début presc. : 23/09/2023 15:11 08:00 * 1-2 +@ 15 : 11 Fin le 23/10/2023 à SACHET +Si constipation secondaire au morphine 08 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 23/09/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 15 : 11 +O 23R /0A 9L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 23/10/2023 à 0 G8 E : 0 L0 * 2 +Admin le 25/09/2023 à +12 : 00 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 23/09/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 15 : 11 +O 23R /0A 9L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 23/10/2023 à 1 G2 E : 0 L0 * 2 +Admin le 25/09/2023 à +12 : 00 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 23/09/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 15 : 11 +O 23R /0A 9L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 23/10/2023 à 1 G9 E : 0 L0 * 2 +Admin le 25/09/2023 à +12 : 00 +[NOM] [NOM] +Signé — PARACETAMOL ARW 500MG Début le 23/09/2023 à +GELULE - 500MG gelule - Dose 2 GEL - 15 : 11 +O 23R /0A 9L /2E +0 +2- 3M @at i 1n +9 +m : 0i 0di soir nuit - 1ère dose: F 12in + : 0 +l 0e 23/10/2023 à 2 G1 E : 0 L0 * 2 +Admin le 25/09/2023 à +12 : 00 +[NOM] [NOM] +Signé — TRAMADOL ARW 50MG CPR - Début le 23/09/2023 à +50MG comprime - Dose 1 CPR - ORALE - Matin 15 : 11 08:00 * 1 +midi soir - 1ère dose : 23/09/2023 @ 19:00 Fin le 23/10/2023 à CPR +12 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] [NOM] +Signé — TRAMADOL ARW 50MG CPR - Début le 23/09/2023 à +50MG comprime - Dose 1 CPR - ORALE - Matin 15 : 11 12:00 * 1 +midi soir - 1ère dose : 23/09/2023 @ 19:00 Fin le 23/10/2023 à CPR +12 : 00 +Admin le 25/09/2023 à +12 : 00 +Signé — TRAMADOL ARW 50MG CPR - [NOM] [NOM] +50MG comprime - Dose 1 CPR - ORALE - Matin Début le 23/09/2023 à 19 : 00 * 1 +midi soir - 1ère dose : 23/09/2023 @ 19:00 15:11 CPR +Fin le 23/10/2023 à +12 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 15 de 20 Admin le 25/09/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — BAS DE CONTENTION : POSE - Début le 23/09/2023 à +à 08h - 3 Semaines- Date Début : 23/09/2023 @ 15:11 +15 : 11 Fin le 14/10/2023 à 08:00 * 1 +08 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] Xabi +Réalisé — DESINFECTION [NOM] +ENVIRONNEMENT PATIENT - Matin [8h] - Début le 23/09/2023 à +pendant 7 Jour(s)- Date Début : 23/09/2023 @ 07:00 08:00 * 1 +07 : 00 Fin le 29/09/2023 à +08 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] Xabi +[NOM] +Réalisé — LEVER : AU FAUTEUIL - Matin Début le 23/09/2023 à +midi goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +23/09/2023 @ 07 : 00 Fin le 29/09/2023 à 08:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — LEVER : AU FAUTEUIL - Matin Début le 23/09/2023 à +midi goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +23/09/2023 @ 07 : 00 Fin le 29/09/2023 à 12:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — LEVER : AU FAUTEUIL - Matin Début le 23/09/2023 à +midi goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +23/09/2023 @ 07 : 00 Fin le 29/09/2023 à 16:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — LEVER : AU FAUTEUIL - Matin Début le 23/09/2023 à +midi goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +23/09/2023 @ 07 : 00 Fin le 29/09/2023 à 19:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — LIT : REFECTION COMPLETE Début le 23/09/2023 à +- Matin [8h] - pendant 7 Jour(s)- Date Début : 07:00 +23/09/2023 @ 07 : 00 Fin le 29/09/2023 à 08:00 * 1 +08 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] Xabi +[NOM] +Réalisé — REPAS : AUTONOME - Matin midi Début le 24/09/2023 à +goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +24/09/2023 @ 07 : 00 Fin le 30/09/2023 à 08:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — REPAS : AUTONOME - Matin midi Début le 24/09/2023 à +goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +24/09/2023 @ 07 : 00 Fin le 30/09/2023 à 12:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 16 de 20 [NOM] Xabi +[NOM] +Réalisé — REPAS : AUTONOME - Matin midi Début le 24/09/2023 à +goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +24/09/2023 @ 07 : 00 Fin le 30/09/2023 à 16:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — REPAS : AUTONOME - Matin midi Début le 24/09/2023 à +goûter soir - pendant 7 Jour(s)- Date Début : 07:00 +24/09/2023 @ 07 : 00 Fin le 30/09/2023 à 19:00 * 1 +19 : 00 +Admin le 25/09/2023 à +12 : 00 +[NOM] Xabi +[NOM] +Réalisé — TOILETTE : AIDE PARTIELLE - à Début le 23/09/2023 à +08h - pendant 10 Jour(s)- Date Début : 23/09/2023 07:00 +@ 07 : 00 Fin le 02/10/2023 à 08:00 * 1 +08 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 23/09/2023 à +8h 14h 20h] - 10 Jours- Date Début : 23/09/2023 15:11 +@ 15 : 11 Fin le 03/10/2023 à 08:00 * 1 +14 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 23/09/2023 à +8h 14h 20h] - 10 Jours- Date Début : 23/09/2023 15:11 +@ 15 : 11 Fin le 03/10/2023 à 14:00 * 1 +14 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 23/09/2023 à +8h 14h 20h] - 10 Jours- Date Début : 23/09/2023 15:11 +@ 15 : 11 Fin le 03/10/2023 à 20:00 * 1 +14 : 00 +Admin le 25/09/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 23/09/2023 à +8h 14h 20h] - 10 Jours- Date Début : 23/09/2023 15:11 +@ 15 : 11 Fin le 03/10/2023 à 02:00 * 1 +14 : 00 +Admin le 25/09/2023 à +08 : 00 +Résultats de radiologie +Prescription Date Résultat +Compte rendu au format texte +Bayonne, le 22/09/2023 +Docteur +Nom de naissance : [NOM] +Nom utilisé : [NOM] +Prénom de naissance : [NOM] +Prénom utilisé : [NOM] +[DATE_NAISSANCE] +22/09/2023 +CR Scanner Lieu de naissance : 99999 +23 : 22 +Sexe : F +Matricule INS : +Examen du : 22/09/2023 +Compte-rendu validé électroniquement par RAOULT Julien le 23/09/2023 +SCANNER ABDOMINO-PELVIEN +Indication : +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 17 de 20 : 52 ans +Recherche : perforation? saignement ? +Protocole : +Examen réalisé avec injection de produit de contraste. +RESULTATS : +Présence de plusieurs calculs centimétriques et supracentimétriques de l'infundibulum vésiculaire et du canal cystique, avec nette +distension de la vésicule biliaire en amont, dont les parois sont discrètement épaissies, avec une infiltration modérée de la graisse +périvésiculaire, sans solution de continuité pariétale, sans signe de perforation. +Pas d'abcès visible sur le versant hépatique non péritonisée la vésicule. Discrète hyperartérialisation du parenchyme hépatique +pouvant témoigner d'une inflammation. +Perméabilité des veines hépatiques et du réseau veineux mésentéricoportes. +Pas de dilatation de l'arbre biliaire par ailleurs. +Hépatomégalie non dysmorphique, non stéatosique. +Pas d'anomalie des bases pulmonaires. +Prothèse mammaire bilatérale. +Rate homogène de petite taille. +Pancréas homogène. +Les deux surrénales sont fines. +Pas d'occlusion digestive. +Appendice rétrocaecal fin. +Pas d'anomalie notable des deux reins en dehors de quelques kystes corticaux simples. +Stigmates chirurgicaux gastriques de type by-pass. +Perméabilité des principaux axes artériels intra-abdominaux. +Formation kystique annexielle droite de 17 mm, sans nécessité d'exploration complémentaire si la patiente est ménopausée. +Réplétion de la cavité utérine, à confronter au statut ménopausique. +Prothèses mammaires bilatérales. Hyperlordose lombaire, avec remaniements dégénératifs relativement marqués des articulaires +postérieures aux deux derniers étages, antélisthésis dégénératif de grade I de L4 sur L5. Pas de lésion osseuse suspecte. Pas de +signe de spondylodiscite scanographique. +CONCLUSION : +Aspect continu avec une cholécystite aiguë de vraisemblable origine lithiasique, non compliquée. Pas de dilatation du reste de +l'arbre biliaire par ailleurs. +RAOULT Julien, interne +Technique : +PDL : 1121.11 mGy.cm CTDI : 50.09 mGy +Protocole d'acquisition : 6.1 AbdoPelvis +IOMERON 400 mg d'iode/mL 200mL 3E62964 100.00 ml +Cet examen rendu anonyme est accessible sur le site WEB de l'établissement pour une durée de 10 mois : www.ch-cote-basque.fr +« accès examens d'imagerie » +N° d'examen : RAD[TEL] +[DATE_NAISSANCE] +Résultats de laboratoire +23/09/2023 16 : 16 23/09/2023 12:00 23/09/2023 01:33 23/09/2023 01:33 23/09/2023 01:28 +Résultat de labo +(6059402) (6058979) (6059045) (6059044) (6059013) +1 AMOXICILLINE 1 AMOXICILLINE +Résistant Résistant +AMOXICILLINE + AMOXICILLINE + +AC.CLAVULANIQUE AC.CLAVULANIQUE +Résistant Résistant +TICARCILLINE TICARCILLINE +Résistant Résistant +Antibiogramme +PIPERACILLINE PIPERACILLINE ++ TAZOBACTAM + TAZOBACTAM +Résistant Résistant +CEFOXITINE CEFOXITINE +Sensible Sensible +CEFOTAXIME CEFOTAXIME +Sensible Sensible +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 18 de 20 CEFTAZIDIME CEFTAZIDIME +Sensible Sensible +ERTAPENEME ERTAPENEME +Sensible Sensible +IMIPENEME Sensible IMIPENEME Sensible +AMIKACINE Sensible AMIKACINE Sensible +TOBRAMYCINE TOBRAMYCINE +Sensible Sensible +GENTAMICINE GENTAMICINE +Sensible ACIDE Sensible ACIDE +NALIDIXIQUE NALIDIXIQUE +Sensible Sensible +OFLOXACINE OFLOXACINE +Sensible Sensible +CIPROFLOXACINE CIPROFLOXACINE +Sensible Sensible +TRIMETHOPRIME TRIMETHOPRIME ++ SULFAMIDES + SULFAMIDES +Sensible Sensible +Compte rendu Bactériologie Bact230925140441-1.pdf Bact230925111211-1.pdf Bact230925140421-1.pdf Bact230925140424-1.pdf +Compte-rendu laboratoire Labo230923015616-1.pdf +Nombreuses colonies +Culture PUSP TK de Escherichia col + +Antibiogramme +Examen Direct Négatif +Localisation pus profond Abdomen +Nature du prélèvement Pus profond Urine Milieu de jet +Présence de Présence de +Culture flacon aérobie TK +Escherichia coli Escherichia coli +Présence de Bacilles à Présence de Bacilles à +Examen direct flacon aérobie +Gram négatif Gram négatif +Résultat Automate flacon +Positif Positif +aérobie +Le volume de sang Le volume de sang +présent dans le flacon présent dans le flacon +est insuffisant : risque est insuffisant : risque +de résultat faussement de résultat faussement +négatif Pour mémoire, négatif Pour mémoire, +Volume sang flacon aérobie il est nécessaire de il est nécessaire de +prélever 8 à 10 mL prélever 8 à 10 mL +de sang par flacon de sang par flacon +afin d'avoir une afin d'avoir une +sensibilité optimale de sensibilité optimale de +l'hémoculture l'hémoculture +Présence de +Présence de +Culture flacon anaérobie TK Escherichia col + +Escherichia coli +Antibiogramme +Examen direct flacon Présence de Bacilles à Présence de Bacilles à +anaérobie Gram négatif Gram négatif +Résultat automate flacon +Positif Positif +anaérobie +Le volume de sang Le volume de sang +présent dans le flacon présent dans le flacon +est insuffisant : risque est insuffisant : risque +de résultat faussement de résultat faussement +négatif Pour mémoire, négatif Pour mémoire, +Volume sang flacon anaérobie il est nécessaire de il est nécessaire de +prélever 8 à 10 mL prélever 8 à 10 mL +de sang par flacon de sang par flacon +afin d'avoir une afin d'avoir une +sensibilité optimale de sensibilité optimale de +l'hémoculture l'hémoculture +Sur voie veineuse Sur voie veineuse +Localisation hémoculture +périphérique périphérique +Culture ECBU TK Stérile. +Leucocytes 44 /µL +Prélèvement non +Non conformité validé initialement par +[MASK] [NOM] [NOM] [NOM] Dr [NOM] [NOM] [NOM] Dr [NOM] +responsabilité du biologiste +Lettres +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 19 de 20 Date +Type Texte Utilisateur +d'impression +Bayonne, le 25/09/2023 +Cher Confrère, +Je laisse sortir du [MASK] [DATE_NAISSANCE], +qui a été opérée d'une cholécystectomie dans le contexte d'une cholécystite aigue lithiasique très +inflammatoire en peropératoire. +Le geste s'est réalisé par cœlioscopie, de manière satisfaisante. +Les suites ont été simples, nous poursuivrons une antibiothérapie IV par C3G et Métronidazole dans 25/09/2023 [NOM] +Sortie Postop +la phase initiale. Devant un prélèvement bactériologique positif à E.Coli nous avons ensuite adapté 11 : 21 Paul [NOM] +l'antibiothérapie per os par Bactrim qui sera à poursuivre pendant une durée de 6 jours. +Nous la reverrons en consultation dans mois pour juger de l'évolution. +Nous indiquons la réalisation d'un bilan biologique de contrôle, à ramener à la consultation post- +opératoire. +Nous restons disponible si les suites opératoires ne s'avéraient pas pleinement satisfaisante. +Bien confraternellement. +DR. [NOM] +10101421062 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 ) +Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993 +Le 25/09/2023 15 : 33 Page 20 de 20 + + +Nom de naissance : [NOM] IPP : [IPP] +Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE] +Sexe : Féminin Lieu de naissance: [VILLE] +Nationalité : FRANCE [CODE_POSTAL] +Adresse : [ADRESSE]: [NOM] +Episode No : [EPISODE] +Localisation : CHIRURGIE VISCERALE Médecin courant: DR. [NOM] +Date d'admission : 22/09/2023 Heure d'admission: 19:22 +Date de sortie : 25/09/2023 Heure de sortie: 13:49 +Nom : Adresse Téléphone +DR. [NOM] [NOM] : [ADRESSE][CODE_POSTAL] +Type de contact : Relation Nom Prénom Adresse Tél. domicile Tél. +professionel Mobile +Personne à prévenir +(Trakcare) : Mère [NOM] FRANCE [TEL] +Personne de +confiance : Concubin [NOM] [TEL] +Lien familial +automatique : Fille +Personne à prévenir +(Trakcare) : Concubin [NOM] [NOM] [TEL] +Episode - Date : 22/09/2023 +Episode - Heure : 19:22 +Mode de transport à l'arrivée : Véhicule personnel +Médicalisation du transport : Aucune médicalisation +Mode d'entrée : Autres admissions urgentes +Date d'orientation : 22/09/2023 +Heure d'orientation : 19:34 +IAO : [NOM] Laurie +Priorité : Priorité 3 +Sous-type épisode : URG - Circuit court +Motif de prise en charge : Douleur abdominale +Observ. IDE Urg : dlr abdo depuis début AM non soulagée par spasfon +nausée et vertiges +abs de SFU +a déjà eu ce type de dlr mais habituellement passe plus rapidement et moins intense, 2 lanzoprazole 15 donné +antd : by pass +Médecin de la prise en charge médicale : [NOM] [NOM] +Date de prise en charge médicale : 22/09/2023 +Heure de prise en charge médicale : 19:22 +Médecin de la décision médicale : [NOM] [NOM] +Date de décision médicale : 23/09/2023 +Heure de décision médicale : 00:39 +Décision médicale : Hospitalisation MCO +Orientation du patient : hospitalisation dans une [MASK], SI, REA +Date de sortie des urgences : 23/09/2023 +Heure de sortie des Urgences : 01:46 +US de destination : US Chirurgie Viscérale + +UF de destination : CHIRURGIE VISCERALE +Type : Etat Code Date +Principal : actif K81.9 Cholécystite, sans précision [CMA2] 23/09/2023 01:46 +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Item de +surveillance : 25/09/2023 +08:19 25/09/2023 +05:10 24/09/2023 +23:51 24/09/2023 +15:22 24/09/2023 +09:15 24/09/2023 +05:16 23/09/2023 +23:00 23/09/2023 +20:22 23/09/2023 +18:00 23/09/2023 +08:57 23/09/2023 +04:14 23/09/2023 +01:54 23/09/2023 +01:25 +Température : 36,30 37,10 36,40 37,50 37 36,60 36,90 37 35,90 35,70 35,60 35,30 +Pouls : 81 78 76 76 70 75 72 78 63 82 +PA +Systolique : 107 144 120 106 109 107 110 125 136 143 +PA +Diastolique : 57 86 68 58 64 64 61 67 83 75 +Saturation +O² : 95 98 97 96 97 96 100 96 100 96 +Echelle +douleur : EVS EN EVS EVS EN EN EN EVS EVS EN EN EN EN +Score au +repos : 0 0 2 0 5 0 0 0 0 7 7 4 5 +Transit : Gaz Gaz Absence Gaz Absence Absence Absence Absence Absence +Ventilation : Ventilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant n +Item de +surveillance : 23/09/2023 +01:59 +Poids [kg] : 69 +Taille [cm] : 157 +Item de +surveillance : 25/09/2023 +08:19 24/09/2023 +23:51 24/09/2023 +15:22 24/09/2023 +09:15 24/09/2023 +05:16 23/09/2023 +23:00 23/09/2023 +20:22 23/09/2023 +18:00 23/09/2023 +08:57 23/09/2023 +04:14 23/09/2023 +01:54 23/09/2023 +01:25 23/09/2023 +01:24 +Température : 36,30 37,10 36,40 37,50 37 36,60 36,90 37 35,90 35,70 35,60 35,30 35,30 +Pouls : 81 78 76 76 70 75 72 78 63 82 66 +PA +Systolique : 107 144 120 106 109 107 110 125 136 143 143 +PA +Diastolique : 57 86 68 58 64 64 61 67 83 75 75 +Saturation +O² : 95 98 97 96 97 96 100 96 100 96 95 +Transit : Gaz Gaz Absence Gaz Absence Absence Absence Absence Absence +Item de +surveillance : 25/09/2023 +08:19 24/09/2023 +23:51 24/09/2023 +15:22 24/09/2023 +09:15 24/09/2023 +05:16 23/09/2023 +23:00 23/09/2023 +20:22 23/09/2023 +18:00 23/09/2023 +08:57 23/09/2023 +04:14 23/09/2023 +01:54 23/09/2023 +01:25 23/09/2023 +01:24 +Température : 36,30 37,10 36,40 37,50 37 36,60 36,90 37 35,90 35,70 35,60 35,30 35,30 +Pouls : 81 78 76 76 70 75 72 78 63 82 66 +PA +Systolique : 107 144 120 106 109 107 110 125 136 143 143 +PA +Diastolique : 57 86 68 58 64 64 61 67 83 75 75 +Saturation +O² : 95 98 97 96 97 96 100 96 100 96 95 +Transit : Gaz Gaz Absence Gaz Absence Absence Absence Absence Absence +Type d'observation : Nom Date Commentaires + +Note d'évolution : Paul [NOM] +[NOM] 25/09/2023 +09:33 ATBg en cours +Note d'évolution : DR. [NOM] +[NOM] 24/09/2023 +18:39 E.Coli dans la bile poursuivre ATB IV jusqu a l antibiogramme +elargir l alimentation +Note d'évolution : DR. [NOM] +[NOM] 24/09/2023 +10:41 antibiogramme en cours poursuite ATB IV +Apyretique +realimenter +Note d'évolution : DR. [NOM] +[NOM] 23/09/2023 +17:05 HemoC positive a BG- +Note d'évolution : DR. [NOM] +[NOM] 23/09/2023 +16:32 CHOECYSTECTOMIE pour cholecystite augue lithiasique tres inflammatoire. +Poursuite ATB jusqu au resultat de la bacterio per op +realimentation ce jour +Note d'évolution : [NOM] [NOM] 23/09/2023 +00:31 SCANNER ABDOMINO-PELVIEN +Indication : +: 52 ans +Recherche : perforation? saignement ? +Protocole : +Examen réalisé avec injection de produit de contraste. +RESULTATS : +Présence de plusieurs calculs centimétriques et supracentimétriques de l'infundibulum +vésiculaire et du canal cystique, avec nette distension de la vésicule biliaire en amont, dont les +parois sont discrètement épaissies, avec une infiltration modérée de la graisse périvésiculaire, +sans solution de continuité pariétale, sans signe de perforation. +Pas d'abcès visible sur le versant hépatique non péritonisée la vésicule. Discrète +hyperartérialisation du parenchyme hépatique pouvant témoigner d'une inflammation. +Perméabilité des veines hépatiques et du réseau veineux mésentéricoportes. +Pas de dilatation de l'arbre biliaire par ailleurs. +Hépatomégalie non dysmorphique, non stéatosique. +Pas d'anomalie des bases pulmonaires. +Prothèse mammaire bilatérale. +Rate homogène de petite taille. +Pancréas homogène. +Les deux surrénales sont fines. +Pas d'occlusion digestive. +Appendice rétrocaecal fin. +Pas d'anomalie notable des deux reins en dehors de quelques kystes corticaux simples. +Stigmates chirurgicaux gastriques de type by-pass. +Perméabilité des principaux axes artériels intra-abdominaux. +Formation kystique annexielle droite de 17 mm, sans nécessité d'exploration complémentaire +si la patiente est ménopausée. +Réplétion de la cavité utérine, à confronter au statut ménopausique. +Prothèses mammaires bilatérales. Hyperlordose lombaire, avec remaniements dégénératifs +relativement marqués des articulaires postérieures aux deux derniers étages, antélisthésis +dégénératif de grade I de L4 sur L5. Pas de lésion osseuse suspecte. Pas de signe de +spondylodiscite scanographique. +CONCLUSION : +Aspect continu avec une cholécystite aiguë de vraisemblable origine lithiasique, non +compliquée. Pas de dilatation du reste de l'arbre biliaire par ailleurs. +RAOULT Julien, interne + +Item de +surveillance : 25/09/2023 +08:19 24/09/2023 +23:51 24/09/2023 +15:22 24/09/2023 +09:15 24/09/2023 +05:16 23/09/2023 +23:00 23/09/2023 +20:22 23/09/2023 +18:00 23/09/2023 +08:57 23/09/2023 +04:14 23/09/2023 +01:54 23/09/2023 +01:25 23/09/2023 +01:24 +Température : 36,30 37,10 36,40 37,50 37 36,60 36,90 37 35,90 35,70 35,60 35,30 35,30 +Pouls : 81 78 76 76 70 75 72 78 63 82 66 + +PA +Systolique : 107 144 120 106 109 107 110 125 136 143 143 +PA +Diastolique : 57 86 68 58 64 64 61 67 83 75 75 +Saturation +O² : 95 98 97 96 97 96 100 96 100 96 95 +Transit : Gaz Gaz Absence Gaz Absence Absence Absence Absence Absence +Type de note : Nom Date Note +Note IDE : [NOM] [NOM] 25/09/2023 +12:58 - Douleur: peu algique +- Transit: G+S- +- Devenir: RAD ce jour +Note IDE : [NOM] [NOM] 24/09/2023 +23:50 Risque de douleur : Faible algie à 23h50 --> ATG1+ ATS donné --> Soulagé par la suite +Risque infectieux : Apyrétique +Digestif : Pas d'épisodes sur la nuit +Transit : G+/S- +Note IDE : [NOM] [NOM] 24/09/2023 +15:31 Douleur: +- non algique de l'AM +Risque infectieux: +-Apyrétique, plaies colles propres +Digestif: +-transit: G+/S- -> normacol non fait +-Alim: po2 bien toléré +Mobilisation: +-est allée marcher +Note IDE : [NOM] [NOM] 24/09/2023 +09:24 Douleur : en 5/10 soulagée par ttt ATG 1 + ATS +Alimentation : ne souhaite pas manger, stimulation inefficace +Transit : pas de gaz ni de selles, normacol effectué à 12h +Mobilisation : ne souhaite pas marcher, stimulation inefficace +Plaies colles propres. +Risque infectieux : apyrétique, ATB X2 administré +Note IDE : [NOM] [NOM] 23/09/2023 +22:58 Risque de douleur : Non algique +Risque infectieux : Apyrétique +HDM : Normocarde, normotendue +Respi : Sat ok en AA +Digestif : Pas d'épisodes sur la nuit +Transit : G-/S- + +Note IDE : [NOM] [NOM] 23/09/2023 +09:07 Patiente nauséeuse + douloureuse (ATS + ATG1 administrés; efficace ) +BLOC départ pour 12h30, dossier bloc ok, patiente prête. +Risque infectieux : hypotherme (hémoc faite le 22/09) --> 1 paire hémoc positive à bacilles +gramme negtaif +ECBU envoyé au labo . ATB administré. +Note IDE : [NOM] [NOM] 23/09/2023 +01:50 Transfert des urgences de Me B pour cholecystite lithiasique +ATCD : ByPass +Allergie : Non connue +MDV : en activité, est en arrêt jusqu'au 2 octobre, à voir pour prolongation?? Vie avec son +concubin +Examens aux urgences : +- BS +- Hémoc x2 sur hypothermie +- TDM abdo +A l'arrivée : +Risque de douleur : Faible algie à 02h après mobilisation --> Forte algie à 04h, ATG3 donné --> +trouve que ca ne lui a rien fait, ATG1 + ATS donné à 05h20 +Risque infectieux : Hypothermie bien toléré +HDM : Normocarde, normotendue +Respi : Sat ok en AA +Digestif : Nausées à l'arrivée --> Bassine donnée, allo IDG urg --> Prescription orale d'une +ampoule d'o[DOSSIER] IV , faite à 02h, soulagé par la suite +Transit : G+/S+ du 22.09 +Note IDE : [NOM] +[NOM] 23/09/2023 +01:40 a eu TDM TAP = cholécystite +BI ATB thérapie débuté selon PM +DEVENIR = transfert en chir viscérale +DOULEUR = plus confortable +Note IDE : [NOM] +[NOM] 22/09/2023 +23:26 entre pour douleur épigastrique +HYPERALGIQUE en pré-soin +VVP posée avec beaucoup de difficulté; BS + hémocs prélevés +DOULEUR = ATG 1 + titration de morphine administrés selon PM +[NOM] = anti émétique fait selon PM +ECG fait +Note A-Soignante : Chloé DEVESA 22/09/2023 +22:57 ecg faitprise constes +Prescription : Dose Fréquence Date de début Date de dernière +administration Note Docteur +CEFOTAXIME PAN 1G +PDR INJ [25] Flacon(s) : 1 G - Normal 23/09/2023 00:33 25/09/2023 08:33 Le débit en cours +est : 3 ML par +1 hrs. Notes du +professionel de +santé: à diluer +dans 100ML de +NACL ou G5% [NOM] [NOM] + +METOCLOPRAMIDE CHL +REN 10MG/2ML INJ [100] +Ampoule(s) : 1 AMP - Normal 22/09/2023 21:48 25/09/2023 05:50 Le débit en cours +est : 6 ML par 1 +hrs. [NOM] [NOM] +METRONIDAZOLE BBM +0,5% INJ POC 100ML [1] +POCHE(S) : 500 mg - Normal 23/09/2023 00:33 25/09/2023 08:33 Le débit en cours +est : 200 ML par 1 +hrs. [NOM] [NOM] +ONDANSETRON REN +4MG/2ML SOL INJ AMP +[10] Ampoule(s) : 4 mg - Normal 23/09/2023 02:06 25/09/2023 10:10 Le débit en cours +est : 4 ML par 1 +hrs. [NOM] [NOM] +PHLOROGLUCINOL ARW +40MG/0,04MG INJ [10] +Ampoule(s) Bouteille(s) : 80 mg - Normal 23/09/2023 00:33 25/09/2023 08:35 Le débit a été +modifié. Le débit +en cours est : 24 +par . Notes du +professionel de +santé: A préparer +dans 100 mL de +NaCl 0,9% [NOM] [NOM] +MORPHINE CHL 10MG/ML +INJ 1ML : 3 mg - Normal 22/09/2023 21:11 22/09/2023 23:21 [NOM] [NOM] +PARACETAMOL BBM +10MG/ML INJ 100ML [10] +Flacon(s) : 1 G - Normal 22/09/2023 21:11 23/09/2023 05:21 [NOM] [NOM] +LANSOPRAZOLE BGA +15MG CPR OROD [14] +CPR(s) : 15 mg - Matin [8h] Normal 23/09/2023 15:11 25/09/2023 08:33 DR. [NOM] +[NOM] +MOVICOL PDR ORALE +SACHET [20] Sachet(s) : 1 - 2 +SACHET - Matin [8h] Normal 23/09/2023 15:11 25/09/2023 08:00 DR. [NOM] +[NOM] +OXYNORMORO +10MG CPR DISP [14] +COMPRIME(S) : 1 CPR - Normal 23/09/2023 01:30 25/09/2023 11:53 [NOM] [NOM] +PARACETAMOL ARW +500MG GELULE [12] +Gelule(s) : 2 GEL - Matin midi soir nuit +Normal 23/09/2023 15:11 25/09/2023 12:00 DR. [NOM] +[NOM] +TRAMADOL ARW 50MG +CPR [30] COMPRIME(S) : 1 CPR - Matin midi soir +Normal 23/09/2023 15:11 25/09/2023 12:00 DR. [NOM] +[NOM] +BACTRIM FORTE CPR [10] +COMPRIME(S) : 1 CPR - Matin soir (8h - +20h) Presc. de Sortie 25/09/2023 11:18 DR. Ute +[NOM] +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR - 1 seule fois 1 seule +fois 22/09/2023 19:49 22/09/2023 19:50 DR. [NOM] +[NOM] +PARACETAMOL ARW +500MG GELULE [12] +Gelule(s) : 1000 mg - Matin midi soir +Presc. de Sortie 25/09/2023 08:07 Paul [NOM] +[NOM] +SPASFON CPR [30] +COMPRIME(S) : 2 CPR - Matin midi soir +Presc. de Sortie 25/09/2023 08:07 Paul [NOM] +[NOM] +TRAMADOL ARW LP +100MG GELULE [30] +Gelule(s) : 1 GEL - Matin soir (8h - +19h) Presc. de Sortie 25/09/2023 08:07 Notes du +professionel de +santé: Si douleur +résistante au +paracétamol / +spasfon Paul [NOM] +[NOM] +Date début : Heure +début Prescription Date +exécution Heure +exécution Statut Docteur Note +22/09/2023 : 23:22 Scanner Abdomino+/-Pelvien 22/09/2023 23:46 Réalisé [NOM] [NOM] +Date : Heure Prescription Docteur Date de +collection Note +22/09/2023 : 21:11 Ionogramme ( Na, K, CL ) [NOM] [NOM] 22/09/2023 +21:22 +23/09/2023 : 01:30 Hémoculture Flacons 3 et 4 [NOM] [NOM] 23/09/2023 +01:33 +23/09/2023 : 16:16 Pièce opératoire ( Atlantic- +Pathologie) [NOM] [NOM] 23/09/2023 +16:16 +25/09/2023 : 08:07 Ionogramme ( Na, K, CL, créat, +glucose ) Paul [NOM] [NOM] + +25/09/2023 : 08:07 Transaminases ASAT + ALAT sang +( dosage ) Paul [NOM] [NOM] +25/09/2023 : 08:07 Phosphatase alcaline dosage sang Paul [NOM] [NOM] +25/09/2023 : 08:07 Bilirubine ( totale + conjuguée + +non conjuguée ) sang ( dosage ) Paul [NOM] [NOM] +25/09/2023 : 08:07 Gamma GT GGT sang ( dosage ) Paul [NOM] [NOM] +25/09/2023 : 08:07 Num +Formule +Plaq Paul [NOM] [NOM] +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +REGIME REPRISE +ALIMENTAIRE / DESSERT : Signé 1 Jour - Matin [8h] +Normal 23/09/2023 +15:11 DR. [NOM] +[NOM] +BANDELETTE URINAIRE : Signé - 1 seule fois 1 seule +fois 22/09/2023 +21:11 [NOM] +[NOM] +[NOM] SEUL : Arrêté - Matin midi goûter +soir Normal 23/09/2023 +07:00 Xabi [NOM] +[NOM] +BAS DE CONTENTION : POSE Réalisé 3 Semaines - à 08h +Normal 23/09/2023 +15:11 DR. [NOM] +[NOM] +DESINFECTION +ENVIRONNEMENT +PATIENT : Réalisé - Matin [8h] Normal 23/09/2023 +07:00 Xabi [NOM] +[NOM] +LEVER : AU FAUTEUIL Réalisé - Matin midi goûter +soir Normal 23/09/2023 +07:00 Xabi [NOM] +[NOM] +LIT : REFECTION +COMPLETE Réalisé - Matin [8h] Normal 23/09/2023 +07:00 Xabi [NOM] +[NOM] +REPAS : AUTONOME Réalisé - Matin midi goûter +soir Normal 24/09/2023 +07:00 Xabi [NOM] +[NOM] +TOILETTE : AIDE +PARTIELLE Réalisé - à 08h Normal 23/09/2023 +07:00 Xabi [NOM] +[NOM] +DOULEUR : SURV Réalisé 10 Jours - Ttes les +6h [2h 8h 14h 20h] +Normal 23/09/2023 +15:11 DR. [NOM] +[NOM] +ECG (FAIRE RELEVÉ) : Réalisé - 1 seule fois 1 seule +fois 22/09/2023 +21:11 Notes du +professionel +de santé: +ECG 12 +dérivations [NOM] +[NOM] +VVP : BOUCHON Réalisé - 1 seule fois 1 seule +fois 22/09/2023 +21:11 [NOM] +[NOM] +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +BACTRIM FORTE CPR [10] +COMPRIME(S) : 1 CPR +ORALE Réalisé - Matin soir (8h - +20h) Presc. de Sortie 25/09/2023 +11:18 0/12 : Non administré +Révisé/Traité DR. Ute +[NOM] +Bilirubine ( totale + +conjuguée + non conjuguée ) +sang ( dosage ) : Signé - Presc. de Sortie 25/09/2023 +08:07 Paul [NOM] +[NOM] +Gamma GT GGT sang +( dosage ) : Signé - Presc. de Sortie 25/09/2023 +08:07 Paul [NOM] +[NOM] +Ionogramme ( Na, K, CL, +créat, glucose ) : Signé - Presc. de Sortie 25/09/2023 +08:07 Paul [NOM] +[NOM] +Num +Formule +Plaq : Signé - Presc. de Sortie 25/09/2023 +08:07 Paul [NOM] +[NOM] +PARACETAMOL ARW +500MG GELULE [12] +Gelule(s) : 1000 mg +ORALE Réalisé - Matin midi soir +Presc. de Sortie 25/09/2023 +08:07 0/90 : Non administré +Révisé/Traité Paul [NOM] +[NOM] +Phosphatase alcaline dosage +sang : Signé - Presc. de Sortie 25/09/2023 +08:07 Paul [NOM] +[NOM] +SPASFON CPR [30] +COMPRIME(S) : 2 CPR +ORALE Réalisé - Matin midi soir +Presc. de Sortie 25/09/2023 +08:07 0/90 : Non administré +Révisé/Traité Paul [NOM] +[NOM] +TRAMADOL ARW LP +100MG GELULE [30] +Gelule(s) : 1 GEL +ORALE Réalisé - Matin soir (8h - +19h) Presc. de Sortie 25/09/2023 +08:07 0/4 : Non administré +Révisé/Traité Paul [NOM] +[NOM] +Transaminases ASAT + +ALAT sang ( dosage ) : Signé - Presc. de Sortie 25/09/2023 +08:07 Paul [NOM] +[NOM] + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — CEFOTAXIME PAN 1 G PDR INJ - +1000MG poudre (1 mL) - Dose 1 G - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 8 +Heure(s) - 1ère dose : 23/09/2023 @ 00:33 +Notes de professionel de santé : +à diluer dans 100ML de NACL ou G5% [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 29/09/2023 à +16:33 +Admin le 25/09/2023 à +08:33 16:33 * 1 G +Signé — CEFOTAXIME PAN 1 G PDR INJ - +1000MG poudre (1 mL) - Dose 1 G - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 8 +Heure(s) - 1ère dose : 23/09/2023 @ 00:33 +Notes de professionel de santé : +à diluer dans 100ML de NACL ou G5% [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 29/09/2023 à +16:33 +Admin le 25/09/2023 à +08:33 00:33 * 1 G +Signé — CEFOTAXIME PAN 1 G PDR INJ - +1000MG poudre (1 mL) - Dose 1 G - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 8 +Heure(s) - 1ère dose : 23/09/2023 @ 00:33 +Notes de professionel de santé : +à diluer dans 100ML de NACL ou G5% [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 29/09/2023 à +16:33 +Admin le 25/09/2023 à +08:33 08:33 * 1 G +Signé — METOCLOPRAMIDE CHL REN +10 MG INJ - 5MG/ML solution (2 mL) - Dose +1 AMP - sur 20 min - INTRAVEINEUSE +Discontinue - Toutes les 8 Heure(s) Si besoin - +Début presc. : 22/09/2023 @ 21:48 +si nausées ou vomissements [NOM] [NOM] +Début le 22/09/2023 à +21:48 +Fin le 25/09/2023 à +13:50 +Admin le 25/09/2023 à +05:50 13:50 * 1 +AMP +Signé — METRONIDAZOLE BBM 500 MG INJ +POC - 5MG/ML solution (100 mL) - Dose 500 +mg - sur 30 min - INTRAVEINEUSE Discontinue +- Toutes les 8 Heure(s) - 1ère dose : 23/09/2023 @ +00:33 [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 29/09/2023 à +16:33 +Admin le 25/09/2023 à +08:33 16:33 * 500 +mg +Signé — METRONIDAZOLE BBM 500 MG INJ +POC - 5MG/ML solution (100 mL) - Dose 500 +mg - sur 30 min - INTRAVEINEUSE Discontinue +- Toutes les 8 Heure(s) - 1ère dose : 23/09/2023 @ +00:33 [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 29/09/2023 à +16:33 +Admin le 25/09/2023 à +08:33 00:33 * 500 +mg +Signé — METRONIDAZOLE BBM 500 MG INJ +POC - 5MG/ML solution (100 mL) - Dose 500 +mg - sur 30 min - INTRAVEINEUSE Discontinue +- Toutes les 8 Heure(s) - 1ère dose : 23/09/2023 @ +00:33 [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 29/09/2023 à +16:33 +Admin le 25/09/2023 à +08:33 08:33 * 500 +mg +Signé — ONDANSETRON REN 4 MG SOL INJ +AMP - 2MG/ML solution (2 mL) - Dose 4 mg - +sur 30 min - INTRAVEINEUSE Discontinue - +Toutes les 8 Heure(s) Si besoin - Début presc. : 23/09/2023 @ 02:06 +si nausées ou vomissements non soulagés par +PRIMPERAN [NOM] [NOM] +Début le 23/09/2023 à +02:06 +Fin le 25/09/2023 à +18:10 +Admin le 25/09/2023 à +10:10 18:10 * 4 mg +Signé — ONDANSETRON REN 4 MG SOL INJ +AMP - 2MG/ML solution (2 mL) - Dose 4 mg - +sur 30 min - INTRAVEINEUSE Discontinue - +Toutes les 8 Heure(s) Si besoin - Début presc. : 23/09/2023 @ 02:06 +si nausées ou vomissements non soulagés par +PRIMPERAN [NOM] [NOM] +Début le 23/09/2023 à +02:06 +Fin le 25/09/2023 à +18:10 +Admin le 25/09/2023 à +10:10 10:10 * 4 mg + + + + + + + + + + + + + + + + + + + + + +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG +solution (4 mL) - Dose 80 mg - sur 20 min - +INTRAVEINEUSE Discontinue - Toutes les 6 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ +00:33 +si douleur abdo +Notes de professionel de santé : +A préparer dans 100 mL de NaCl 0,9% [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 24/10/2023 à +02:35 +Admin le 25/09/2023 à +08:35 20:35 * 80 +mg +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG +solution (4 mL) - Dose 80 mg - sur 20 min - +INTRAVEINEUSE Discontinue - Toutes les 6 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ +00:33 +si douleur abdo +Notes de professionel de santé : +A préparer dans 100 mL de NaCl 0,9% [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 24/10/2023 à +02:35 +Admin le 25/09/2023 à +08:35 02:35 * 80 +mg +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG +solution (4 mL) - Dose 80 mg - sur 20 min - +INTRAVEINEUSE Discontinue - Toutes les 6 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ +00:33 +si douleur abdo +Notes de professionel de santé : +A préparer dans 100 mL de NaCl 0,9% [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 24/10/2023 à +02:35 +Admin le 25/09/2023 à +08:35 08:35 * 80 +mg +Signé — LANSOPRAZOLE BGA 15MG +CPR OROD - 15MG comprime - Dose 15 mg - +ORALE - Matin [8h] - 1ère dose : 24/09/2023 @ +08:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 28/09/2023 à +08:00 +Admin le 25/09/2023 à +08:33 08:33 * 15 +mg +Signé — MOVICOL PDR ORALE SACHET - +MD poudre - Dose 1 à 2 SACHET - ORALE - +Matin [8h] Si besoin - Début presc. : 23/09/2023 +@ 15:11 +Si constipation secondaire au morphine [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +08:00 +Admin le 25/09/2023 à +08:00 08:00 * 1-2 +SACHET +Signé — OXYNORMORO 10MG CPR DISP +- 10MG comprime - Dose 1 CPR - ORALE - +Toutes les 2 Heure(s) Si besoin - Début presc. : 23/09/2023 @ 01:30 +si douleur intense non soulagée par paracetamol [NOM] [NOM] +Début le 23/09/2023 à +01:30 +Fin le 26/09/2023 à +01:53 +Admin le 25/09/2023 à +11:53 13:53 * 1 +CPR +Signé — OXYNORMORO 10MG CPR DISP +- 10MG comprime - Dose 1 CPR - ORALE - +Toutes les 2 Heure(s) Si besoin - Début presc. : 23/09/2023 @ 01:30 +si douleur intense non soulagée par paracetamol [NOM] [NOM] +Début le 23/09/2023 à +01:30 +Fin le 26/09/2023 à +01:53 +Admin le 25/09/2023 à +11:53 15:53 * 1 +CPR +Signé — OXYNORMORO 10MG CPR DISP +- 10MG comprime - Dose 1 CPR - ORALE - +Toutes les 2 Heure(s) Si besoin - Début presc. : 23/09/2023 @ 01:30 +si douleur intense non soulagée par paracetamol [NOM] [NOM] +Début le 23/09/2023 à +01:30 +Fin le 26/09/2023 à +01:53 +Admin le 25/09/2023 à +11:53 17:53 * 1 +CPR + + + + + + + +Signé — OXYNORMORO 10MG CPR DISP +- 10MG comprime - Dose 1 CPR - ORALE - +Toutes les 2 Heure(s) Si besoin - Début presc. : 23/09/2023 @ 01:30 +si douleur intense non soulagée par paracetamol [NOM] [NOM] +Début le 23/09/2023 à +01:30 +Fin le 26/09/2023 à +01:53 +Admin le 25/09/2023 à +11:53 21:53 * 1 +CPR +Signé — OXYNORMORO 10MG CPR DISP +- 10MG comprime - Dose 1 CPR - ORALE - +Toutes les 2 Heure(s) Si besoin - Début presc. : 23/09/2023 @ 01:30 +si douleur intense non soulagée par paracetamol [NOM] [NOM] +Début le 23/09/2023 à +01:30 +Fin le 26/09/2023 à +01:53 +Admin le 25/09/2023 à +11:53 23:53 * 1 +CPR +Signé — OXYNORMORO 10MG CPR DISP +- 10MG comprime - Dose 1 CPR - ORALE - +Toutes les 2 Heure(s) Si besoin - Début presc. : 23/09/2023 @ 01:30 +si douleur intense non soulagée par paracetamol [NOM] [NOM] +Début le 23/09/2023 à +01:30 +Fin le 26/09/2023 à +01:53 +Admin le 25/09/2023 à +11:53 01:53 * 1 +CPR +Signé — OXYNORMORO 10MG CPR DISP +- 10MG comprime - Dose 1 CPR - ORALE - +Toutes les 2 Heure(s) Si besoin - Début presc. : 23/09/2023 @ 01:30 +si douleur intense non soulagée par paracetamol [NOM] [NOM] +Début le 23/09/2023 à +01:30 +Fin le 26/09/2023 à +01:53 +Admin le 25/09/2023 à +11:53 07:53 * 1 +CPR +Signé — OXYNORMORO 10MG CPR DISP +- 10MG comprime - Dose 1 CPR - ORALE - +Toutes les 2 Heure(s) Si besoin - Début presc. : 23/09/2023 @ 01:30 +si douleur intense non soulagée par paracetamol [NOM] [NOM] +Début le 23/09/2023 à +01:30 +Fin le 26/09/2023 à +01:53 +Admin le 25/09/2023 à +11:53 09:53 * 1 +CPR +Signé — OXYNORMORO 10MG CPR DISP +- 10MG comprime - Dose 1 CPR - ORALE - +Toutes les 2 Heure(s) Si besoin - Début presc. : 23/09/2023 @ 01:30 +si douleur intense non soulagée par paracetamol [NOM] [NOM] +Début le 23/09/2023 à +01:30 +Fin le 26/09/2023 à +01:53 +Admin le 25/09/2023 à +11:53 11:53 * 1 +CPR +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 23/09/2023 @ 19:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +12:00 +Admin le 25/09/2023 à +12:00 19:00 * 2 +GEL +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 23/09/2023 @ 19:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +12:00 +Admin le 25/09/2023 à +12:00 21:00 * 2 +GEL +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 23/09/2023 @ 19:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +12:00 +Admin le 25/09/2023 à +12:00 08:33 * 2 +GEL + +Signé — TRAMADOL ARW 50MG CPR - +50MG comprime - Dose 1 CPR - ORALE - Matin +midi soir - 1ère dose : 23/09/2023 @ 19:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +12:00 +Admin le 25/09/2023 à +12:00 19:00 * 1 +CPR +Signé — TRAMADOL ARW 50MG CPR - +50MG comprime - Dose 1 CPR - ORALE - Matin +midi soir - 1ère dose : 23/09/2023 @ 19:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +12:00 +Admin le 25/09/2023 à +12:00 08:00 * 1 +CPR +Signé — TRAMADOL ARW 50MG CPR - +50MG comprime - Dose 1 CPR - ORALE - Matin +midi soir - 1ère dose : 23/09/2023 @ 19:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +12:00 +Admin le 25/09/2023 à +12:00 12:00 * 1 +CPR +Réalisé — BAS DE CONTENTION : POSE - +à 08h - 3 Semaines- Date Début: 23/09/2023 @ +15:11 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 14/10/2023 à +08:00 +Admin le 25/09/2023 à +08:00 08:00 * 1 +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - +pendant 7 Jour(s)- Date Début : 23/09/2023 @ +07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 29/09/2023 à +08:00 +Admin le 25/09/2023 à +08:00 08:00 * 1 +Réalisé — LEVER : AU FAUTEUIL - Matin +midi goûter soir - pendant 7 Jour(s)- Date Début: +23/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 29/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 16:00 * 1 +Réalisé — LEVER : AU FAUTEUIL - Matin +midi goûter soir - pendant 7 Jour(s)- Date Début: +23/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 29/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 19:00 * 1 +Réalisé — LEVER : AU FAUTEUIL - Matin +midi goûter soir - pendant 7 Jour(s)- Date Début: +23/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 29/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 08:00 * 1 +Réalisé — LEVER : AU FAUTEUIL - Matin +midi goûter soir - pendant 7 Jour(s)- Date Début: +23/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 29/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 12:00 * 1 + +Réalisé — REPAS : AUTONOME - Matin midi +goûter soir - pendant 7 Jour(s)- Date Début: +24/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 24/09/2023 à +07:00 +Fin le 30/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 16:00 * 1 +Réalisé — REPAS : AUTONOME - Matin midi +goûter soir - pendant 7 Jour(s)- Date Début: +24/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 24/09/2023 à +07:00 +Fin le 30/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 19:00 * 1 +Réalisé — REPAS : AUTONOME - Matin midi +goûter soir - pendant 7 Jour(s)- Date Début: +24/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 24/09/2023 à +07:00 +Fin le 30/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 08:00 * 1 +Réalisé — REPAS : AUTONOME - Matin midi +goûter soir - pendant 7 Jour(s)- Date Début: +24/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 24/09/2023 à +07:00 +Fin le 30/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 12:00 * 1 +Réalisé — TOILETTE : AIDE PARTIELLE - à +08h - pendant 10 Jour(s)- Date Début: 23/09/2023 +@ 07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 02/10/2023 à +08:00 +Admin le 25/09/2023 à +08:00 08:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 23/09/2023 +@ 15:11 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 03/10/2023 à +14:00 +Admin le 25/09/2023 à +08:00 14:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 23/09/2023 +@ 15:11 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 03/10/2023 à +14:00 +Admin le 25/09/2023 à +08:00 20:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 23/09/2023 +@ 15:11 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 03/10/2023 à +14:00 +Admin le 25/09/2023 à +08:00 02:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 23/09/2023 +@ 15:11 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 03/10/2023 à +14:00 +Admin le 25/09/2023 à +08:00 08:00 * 1 + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — CEFOTAXIME PAN 1 G PDR INJ - +1000MG poudre (1 mL) - Dose 1 G - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 8 +Heure(s) - 1ère dose : 23/09/2023 @ 00:33 +Notes de professionel de santé : +à diluer dans 100ML de NACL ou G5% [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 29/09/2023 à +16:33 +Admin le 25/09/2023 à +08:33 08:33 * 1 G +Signé — CEFOTAXIME PAN 1 G PDR INJ - +1000MG poudre (1 mL) - Dose 1 G - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 8 +Heure(s) - 1ère dose : 23/09/2023 @ 00:33 +Notes de professionel de santé : +à diluer dans 100ML de NACL ou G5% [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 29/09/2023 à +16:33 +Admin le 25/09/2023 à +08:33 16:33 * 1 G +Signé — CEFOTAXIME PAN 1 G PDR INJ - +1000MG poudre (1 mL) - Dose 1 G - sur 20 min +- INTRAVEINEUSE Discontinue - Toutes les 8 +Heure(s) - 1ère dose : 23/09/2023 @ 00:33 +Notes de professionel de santé : +à diluer dans 100ML de NACL ou G5% [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 29/09/2023 à +16:33 +Admin le 25/09/2023 à +08:33 00:33 * 1 G +Signé — METRONIDAZOLE BBM 500 MG INJ +POC - 5MG/ML solution (100 mL) - Dose 500 +mg - sur 30 min - INTRAVEINEUSE Discontinue +- Toutes les 8 Heure(s) - 1ère dose : 23/09/2023 @ +00:33 [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 29/09/2023 à +16:33 +Admin le 25/09/2023 à +08:33 08:33 * 500 +mg +Signé — METRONIDAZOLE BBM 500 MG INJ +POC - 5MG/ML solution (100 mL) - Dose 500 +mg - sur 30 min - INTRAVEINEUSE Discontinue +- Toutes les 8 Heure(s) - 1ère dose : 23/09/2023 @ +00:33 [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 29/09/2023 à +16:33 +Admin le 25/09/2023 à +08:33 16:33 * 500 +mg +Signé — METRONIDAZOLE BBM 500 MG INJ +POC - 5MG/ML solution (100 mL) - Dose 500 +mg - sur 30 min - INTRAVEINEUSE Discontinue +- Toutes les 8 Heure(s) - 1ère dose : 23/09/2023 @ +00:33 [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 29/09/2023 à +16:33 +Admin le 25/09/2023 à +08:33 00:33 * 500 +mg +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG +solution (4 mL) - Dose 80 mg - sur 20 min - +INTRAVEINEUSE Discontinue - Toutes les 6 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ +00:33 +si douleur abdo +Notes de professionel de santé : +A préparer dans 100 mL de NaCl 0,9% [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 24/10/2023 à +02:35 +Admin le 25/09/2023 à +08:35 08:35 * 80 +mg +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG +solution (4 mL) - Dose 80 mg - sur 20 min - +INTRAVEINEUSE Discontinue - Toutes les 6 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ +00:33 +si douleur abdo +Notes de professionel de santé : +A préparer dans 100 mL de NaCl 0,9% [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 24/10/2023 à +02:35 +Admin le 25/09/2023 à +08:35 14:35 * 80 +mg + + + + + + + + + + + + + + + + + + + +Signé — PHLOROGLUCINOL ARW +40 MG/0,04 MG INJ - 40MG + 0.04MG +solution (4 mL) - Dose 80 mg - sur 20 min - +INTRAVEINEUSE Discontinue - Toutes les 6 +Heure(s) Si besoin - Début presc. : 23/09/2023 @ +00:33 +si douleur abdo +Notes de professionel de santé : +A préparer dans 100 mL de NaCl 0,9% [NOM] [NOM] +Début le 23/09/2023 à +00:33 +Fin le 24/10/2023 à +02:35 +Admin le 25/09/2023 à +08:35 02:35 * 80 +mg +Signé — LANSOPRAZOLE BGA 15MG +CPR OROD - 15MG comprime - Dose 15 mg - +ORALE - Matin [8h] - 1ère dose : 24/09/2023 @ +08:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 28/09/2023 à +08:00 +Admin le 25/09/2023 à +08:33 08:00 * 15 +mg +Signé — MOVICOL PDR ORALE SACHET - +MD poudre - Dose 1 à 2 SACHET - ORALE - +Matin [8h] Si besoin - Début presc. : 23/09/2023 +@ 15:11 +Si constipation secondaire au morphine [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +08:00 +Admin le 25/09/2023 à +08:00 08:00 * 1-2 +SACHET +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 23/09/2023 @ 19:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +12:00 +Admin le 25/09/2023 à +12:00 08:00 * 2 +GEL +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 23/09/2023 @ 19:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +12:00 +Admin le 25/09/2023 à +12:00 12:00 * 2 +GEL +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 23/09/2023 @ 19:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +12:00 +Admin le 25/09/2023 à +12:00 19:00 * 2 +GEL +Signé — PARACETAMOL ARW 500MG +GELULE - 500MG gelule - Dose 2 GEL - +ORALE - Matin midi soir nuit - 1ère dose : 23/09/2023 @ 19:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +12:00 +Admin le 25/09/2023 à +12:00 21:00 * 2 +GEL +Signé — TRAMADOL ARW 50MG CPR - +50MG comprime - Dose 1 CPR - ORALE - Matin +midi soir - 1ère dose : 23/09/2023 @ 19:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +12:00 +Admin le 25/09/2023 à +12:00 08:00 * 1 +CPR +Signé — TRAMADOL ARW 50MG CPR - +50MG comprime - Dose 1 CPR - ORALE - Matin +midi soir - 1ère dose : 23/09/2023 @ 19:00 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 23/10/2023 à +12:00 +Admin le 25/09/2023 à +12:00 12:00 * 1 +CPR + + + +Réalisé — BAS DE CONTENTION : POSE - +à 08h - 3 Semaines- Date Début: 23/09/2023 @ +15:11 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 14/10/2023 à +08:00 +Admin le 25/09/2023 à +08:00 08:00 * 1 +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - +pendant 7 Jour(s)- Date Début : 23/09/2023 @ +07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 29/09/2023 à +08:00 +Admin le 25/09/2023 à +08:00 08:00 * 1 +Réalisé — LEVER : AU FAUTEUIL - Matin +midi goûter soir - pendant 7 Jour(s)- Date Début: +23/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 29/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 08:00 * 1 +Réalisé — LEVER : AU FAUTEUIL - Matin +midi goûter soir - pendant 7 Jour(s)- Date Début: +23/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 29/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 12:00 * 1 +Réalisé — LEVER : AU FAUTEUIL - Matin +midi goûter soir - pendant 7 Jour(s)- Date Début: +23/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 29/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 16:00 * 1 +Réalisé — LEVER : AU FAUTEUIL - Matin +midi goûter soir - pendant 7 Jour(s)- Date Début: +23/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 29/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 19:00 * 1 +Réalisé — LIT : REFECTION COMPLETE +- Matin [8h] - pendant 7 Jour(s)- Date Début: +23/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 29/09/2023 à +08:00 +Admin le 25/09/2023 à +08:00 08:00 * 1 +Réalisé — REPAS : AUTONOME - Matin midi +goûter soir - pendant 7 Jour(s)- Date Début: +24/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 24/09/2023 à +07:00 +Fin le 30/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 08:00 * 1 +Réalisé — REPAS : AUTONOME - Matin midi +goûter soir - pendant 7 Jour(s)- Date Début: +24/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 24/09/2023 à +07:00 +Fin le 30/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 12:00 * 1 + +Réalisé — REPAS : AUTONOME - Matin midi +goûter soir - pendant 7 Jour(s)- Date Début: +24/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 24/09/2023 à +07:00 +Fin le 30/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 16:00 * 1 +Réalisé — REPAS : AUTONOME - Matin midi +goûter soir - pendant 7 Jour(s)- Date Début: +24/09/2023 @ 07:00 [NOM] Xabi +[NOM] +Début le 24/09/2023 à +07:00 +Fin le 30/09/2023 à +19:00 +Admin le 25/09/2023 à +12:00 19:00 * 1 +Réalisé — TOILETTE : AIDE PARTIELLE - à +08h - pendant 10 Jour(s)- Date Début: 23/09/2023 +@ 07:00 [NOM] Xabi +[NOM] +Début le 23/09/2023 à +07:00 +Fin le 02/10/2023 à +08:00 +Admin le 25/09/2023 à +08:00 08:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 23/09/2023 +@ 15:11 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 03/10/2023 à +14:00 +Admin le 25/09/2023 à +08:00 08:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 23/09/2023 +@ 15:11 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 03/10/2023 à +14:00 +Admin le 25/09/2023 à +08:00 14:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 23/09/2023 +@ 15:11 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 03/10/2023 à +14:00 +Admin le 25/09/2023 à +08:00 20:00 * 1 +Réalisé — DOULEUR : SURV - Ttes les 6h [2h +8h 14h 20h] - 10 Jours- Date Début: 23/09/2023 +@ 15:11 [NOM] [NOM] +Début le 23/09/2023 à +15:11 +Fin le 03/10/2023 à +14:00 +Admin le 25/09/2023 à +08:00 02:00 * 1 +Prescription : Date Résultat + +Résultat de labo : 23/09/2023 16:16 +(6059402) 23/09/2023 12:00 +(6058979) 23/09/2023 01:33 +(6059045) 23/09/2023 01:33 +(6059044) 23/09/2023 01:28 +(6059013) + +Compte rendu Bactériologie : Bact230925140441-1.pdf Bact230925111211-1.pdf Bact230925140421-1.pdf Bact230925140424-1.pdf +Compte-rendu laboratoire : Labo230923015616-1.pd +Culture PUSP TK : Nombreuses colonies +de Escherichia col + +Antibiogramme +Examen Direct : Négatif +Localisation pus profond : Abdomen +Nature du prélèvement : Pus profond Urine Milieu de jet +Culture flacon aérobie TK : Présence de +Escherichia coli Présence de +Escherichia coli +Examen direct flacon aérobie : Présence de Bacilles à +Gram négatif Présence de Bacilles à +Gram négatif +Résultat Automate flacon +aérobie : Positif Positif +Volume sang flacon aérobie : Le volume de sang +présent dans le flacon +est insuffisant : risque +de résultat faussement +négatif Pour mémoire, +il est nécessaire de +prélever 8 à 10 mL +de sang par flacon +afin d'avoir une +sensibilité optimale de +l'hémoculture Le volume de sang +présent dans le flacon +est insuffisant : risque +de résultat faussement +négatif Pour mémoire, +il est nécessaire de +prélever 8 à 10 mL +de sang par flacon +afin d'avoir une +sensibilité optimale de +l'hémoculture +Culture flacon anaérobie TK : Présence de +Escherichia col + +Antibiogramme Présence de +Escherichia coli +Examen direct flacon +anaérobie : Présence de Bacilles à +Gram négatif Présence de Bacilles à +Gram négatif +Résultat automate flacon +anaérobie : Positif Positif +Volume sang flacon anaérobie : Le volume de sang +présent dans le flacon +est insuffisant : risque +de résultat faussement +négatif Pour mémoire, +il est nécessaire de +prélever 8 à 10 mL +de sang par flacon +afin d'avoir une +sensibilité optimale de +l'hémoculture Le volume de sang +présent dans le flacon +est insuffisant : risque +de résultat faussement +négatif Pour mémoire, +il est nécessaire de +prélever 8 à 10 mL +de sang par flacon +afin d'avoir une +sensibilité optimale de +l'hémoculture +Localisation hémoculture : Sur voie veineuse +périphérique Sur voie veineuse +périphérique +Culture ECBU TK : Stérile. +Leucocytes : 44 /µL +Non conformité : Prélèvement non +validé initialement par +Service +Validation et diffusion sous la +responsabilité du biologiste : Dr [NOM] [NOM] Dr [NOM] [NOM] Dr [NOM] [NOM] Dr [NOM] [NOM] Dr [NOM] + +Type : Texte Date +d'impression Utilisateur +Sortie Postop : Bayonne, le 25/09/2023 +Cher Confrère, +Je laisse sortir du [MASK] [DATE_NAISSANCE], +qui a été opérée d'une cholécystectomie dans le contexte d'une cholécystite aigue lithiasique très +inflammatoire en peropératoire. +Le geste s'est réalisé par cœlioscopie, de manière satisfaisante. +Les suites ont été simples, nous poursuivrons une antibiothérapie IV par C3G et Métronidazole dans +la phase initiale. Devant un prélèvement bactériologique positif à E.Coli nous avons ensuite adapté +l'antibiothérapie per os par Bactrim qui sera à poursuivre pendant une durée de 6 jours. +Nous la reverrons en consultation dans mois pour juger de l'évolution. +Nous indiquons la réalisation d'un bilan biologique de contrôle, à ramener à la consultation post- +opératoire. +Nous restons disponible si les suites opératoires ne s'avéraient pas pleinement satisfaisante. +Bien confraternellement. +DR. 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"success": true, + "time_s": 0.31412649154663086, + "pii_count": 0, + "files": { + "text": "tests/ground_truth/pdfs/baseline_anonymized/021_moyen_compte_rendu_CRO_23201117.redacted_raster.pseudonymise.txt", + "audit": "tests/ground_truth/pdfs/baseline_anonymized/021_moyen_compte_rendu_CRO_23201117.redacted_raster.audit.jsonl", + "pdf_vector": "tests/ground_truth/pdfs/baseline_anonymized/021_moyen_compte_rendu_CRO_23201117.redacted_raster.redacted_vector.pdf", + "pdf_raster": "tests/ground_truth/pdfs/baseline_anonymized/021_moyen_compte_rendu_CRO_23201117.redacted_raster.redacted_raster.pdf" + } + }, + { + "pdf": "022_moyen_compte_rendu_cro2_516_23187028.pdf", + "success": true, + "time_s": 0.37198877334594727, + "pii_count": 29, + "files": { + "text": "tests/ground_truth/pdfs/baseline_anonymized/022_moyen_compte_rendu_cro2_516_23187028.pseudonymise.txt", + "audit": "tests/ground_truth/pdfs/baseline_anonymized/022_moyen_compte_rendu_cro2_516_23187028.audit.jsonl", + "pdf_vector": "tests/ground_truth/pdfs/baseline_anonymized/022_moyen_compte_rendu_cro2_516_23187028.redacted_vector.pdf", + "pdf_raster": "tests/ground_truth/pdfs/baseline_anonymized/022_moyen_compte_rendu_cro2_516_23187028.redacted_raster.pdf" + } + }, + { + "pdf": "023_complexe_compte_rendu_CRH_23102610.pdf", + "success": true, + "time_s": 4.054161310195923, + "pii_count": 617, + "files": { + "text": "tests/ground_truth/pdfs/baseline_anonymized/023_complexe_compte_rendu_CRH_23102610.pseudonymise.txt", + "audit": "tests/ground_truth/pdfs/baseline_anonymized/023_complexe_compte_rendu_CRH_23102610.audit.jsonl", + "pdf_vector": "tests/ground_truth/pdfs/baseline_anonymized/023_complexe_compte_rendu_CRH_23102610.redacted_vector.pdf", + "pdf_raster": "tests/ground_truth/pdfs/baseline_anonymized/023_complexe_compte_rendu_CRH_23102610.redacted_raster.pdf" + } + }, + { + "pdf": "024_complexe_trackare_trackare-17001141-23066188_17001141_23066188.pdf", + "success": true, + "time_s": 8.550535917282104, + "pii_count": 804, + "files": { + "text": "tests/ground_truth/pdfs/baseline_anonymized/024_complexe_trackare_trackare-17001141-23066188_17001141_23066188.pseudonymise.txt", + "audit": "tests/ground_truth/pdfs/baseline_anonymized/024_complexe_trackare_trackare-17001141-23066188_17001141_23066188.audit.jsonl", + "pdf_vector": "tests/ground_truth/pdfs/baseline_anonymized/024_complexe_trackare_trackare-17001141-23066188_17001141_23066188.redacted_vector.pdf", + "pdf_raster": "tests/ground_truth/pdfs/baseline_anonymized/024_complexe_trackare_trackare-17001141-23066188_17001141_23066188.redacted_raster.pdf" + } + }, + { + "pdf": "025_complexe_trackare_trackare-02016820-23095226_02016820_23095226.pdf", + "success": true, + "time_s": 17.83988666534424, + "pii_count": 1622, + "files": { + "text": "tests/ground_truth/pdfs/baseline_anonymized/025_complexe_trackare_trackare-02016820-23095226_02016820_23095226.pseudonymise.txt", + "audit": "tests/ground_truth/pdfs/baseline_anonymized/025_complexe_trackare_trackare-02016820-23095226_02016820_23095226.audit.jsonl", + "pdf_vector": "tests/ground_truth/pdfs/baseline_anonymized/025_complexe_trackare_trackare-02016820-23095226_02016820_23095226.redacted_vector.pdf", + "pdf_raster": "tests/ground_truth/pdfs/baseline_anonymized/025_complexe_trackare_trackare-02016820-23095226_02016820_23095226.redacted_raster.pdf" + } + }, + { + "pdf": "026_complexe_trackare_trackare-15000536-23074384_15000536_23074384.pdf", + "success": true, + "time_s": 12.040966749191284, + "pii_count": 1056, + "files": { + "text": "tests/ground_truth/pdfs/baseline_anonymized/026_complexe_trackare_trackare-15000536-23074384_15000536_23074384.pseudonymise.txt", + "audit": "tests/ground_truth/pdfs/baseline_anonymized/026_complexe_trackare_trackare-15000536-23074384_15000536_23074384.audit.jsonl", + "pdf_vector": "tests/ground_truth/pdfs/baseline_anonymized/026_complexe_trackare_trackare-15000536-23074384_15000536_23074384.redacted_vector.pdf", + "pdf_raster": "tests/ground_truth/pdfs/baseline_anonymized/026_complexe_trackare_trackare-15000536-23074384_15000536_23074384.redacted_raster.pdf" + } + }, + { + "pdf": "027_complexe_trackare_trackare-10027557-23183041_10027557_23183041.pdf", + "success": true, + "time_s": 8.782238721847534, + "pii_count": 859, + "files": { + "text": "tests/ground_truth/pdfs/baseline_anonymized/027_complexe_trackare_trackare-10027557-23183041_10027557_23183041.pseudonymise.txt", + "audit": "tests/ground_truth/pdfs/baseline_anonymized/027_complexe_trackare_trackare-10027557-23183041_10027557_23183041.audit.jsonl", + "pdf_vector": "tests/ground_truth/pdfs/baseline_anonymized/027_complexe_trackare_trackare-10027557-23183041_10027557_23183041.redacted_vector.pdf", + "pdf_raster": "tests/ground_truth/pdfs/baseline_anonymized/027_complexe_trackare_trackare-10027557-23183041_10027557_23183041.redacted_raster.pdf" + } + } + ] +} \ No newline at end of file diff --git a/tools/batch_anonymize_test_dataset.py b/tools/batch_anonymize_test_dataset.py new file mode 100644 index 0000000..535f96e --- /dev/null +++ b/tools/batch_anonymize_test_dataset.py @@ -0,0 +1,154 @@ +#!/usr/bin/env python3 +""" +Anonymisation en batch du dataset de test (27 documents). + +Ce script anonymise tous les documents sélectionnés pour créer la baseline. +""" +import sys +import json +import time +from pathlib import Path +from datetime import datetime + +# Importer le système d'anonymisation +sys.path.insert(0, str(Path(__file__).parent.parent)) +from anonymizer_core_refactored_onnx import process_pdf + +def anonymize_test_dataset(use_ner: bool = True, use_vlm: bool = False): + """ + Anonymise tous les documents du dataset de test. + + Args: + use_ner: Activer le NER (EDS-Pseudo ou CamemBERT) + use_vlm: Activer le VLM (Ollama) - plus lent + """ + # Répertoires + input_dir = Path("tests/ground_truth/pdfs") + output_dir = Path("tests/ground_truth/pdfs/baseline_anonymized") + output_dir.mkdir(exist_ok=True) + + # Lister les PDFs + pdf_files = sorted(input_dir.glob("*.pdf")) + + if not pdf_files: + print(f"✗ Aucun PDF trouvé dans {input_dir}") + return 1 + + print("="*80) + print("ANONYMISATION EN BATCH DU DATASET DE TEST") + print("="*80) + print(f"\n📁 Répertoire d'entrée: {input_dir}") + print(f"📁 Répertoire de sortie: {output_dir}") + print(f"\n📄 Documents à traiter: {len(pdf_files)}") + print(f"\n⚙️ Configuration:") + print(f" - NER: {'✓ Activé' if use_ner else '✗ Désactivé'}") + print(f" - VLM: {'✓ Activé' if use_vlm else '✗ Désactivé'}") + + # Statistiques + results = [] + start_time = time.time() + + # Traiter chaque document + for i, pdf_path in enumerate(pdf_files, 1): + print(f"\n[{i}/{len(pdf_files)}] {pdf_path.name}") + + doc_start = time.time() + + try: + # Anonymiser + result = process_pdf( + pdf_path=pdf_path, + out_dir=output_dir, + make_vector_redaction=True, + also_make_raster_burn=True, + use_hf=use_ner, + ner_manager=None, # Sera chargé automatiquement si use_hf=True + ) + + doc_time = time.time() - doc_start + + # Compter les PII + audit_path = output_dir / f"{pdf_path.stem}.audit.jsonl" + pii_count = 0 + if audit_path.exists(): + with open(audit_path, 'r', encoding='utf-8') as f: + pii_count = sum(1 for line in f if line.strip()) + + print(f" ✓ Terminé en {doc_time:.2f}s - {pii_count} PII détectés") + + results.append({ + "pdf": pdf_path.name, + "success": True, + "time_s": doc_time, + "pii_count": pii_count, + "files": result + }) + + except Exception as e: + doc_time = time.time() - doc_start + print(f" ✗ Erreur: {e}") + + results.append({ + "pdf": pdf_path.name, + "success": False, + "time_s": doc_time, + "error": str(e) + }) + + # Résumé + total_time = time.time() - start_time + success_count = sum(1 for r in results if r.get("success")) + total_pii = sum(r.get("pii_count", 0) for r in results if r.get("success")) + + print("\n" + "="*80) + print("RÉSUMÉ") + print("="*80) + print(f"\n✓ Documents traités: {success_count}/{len(pdf_files)}") + print(f"✓ PII détectés: {total_pii}") + print(f"✓ Temps total: {total_time:.2f}s") + print(f"✓ Temps moyen: {total_time/len(pdf_files):.2f}s par document") + + if success_count < len(pdf_files): + failed = [r for r in results if not r.get("success")] + print(f"\n⚠ Échecs: {len(failed)}") + for r in failed: + print(f" - {r['pdf']}: {r.get('error', 'Unknown error')}") + + # Sauvegarder les résultats + results_file = output_dir / "batch_results.json" + with open(results_file, 'w', encoding='utf-8') as f: + json.dump({ + "date": datetime.now().isoformat(), + "total_documents": len(pdf_files), + "success_count": success_count, + "total_pii": total_pii, + "total_time_s": total_time, + "avg_time_s": total_time / len(pdf_files), + "use_ner": use_ner, + "use_vlm": use_vlm, + "results": results + }, f, indent=2, ensure_ascii=False) + + print(f"\n📊 Résultats sauvegardés: {results_file}") + print(f"\n📂 Fichiers générés dans: {output_dir}") + + return 0 if success_count == len(pdf_files) else 1 + + +def main(): + import argparse + + parser = argparse.ArgumentParser(description="Anonymiser le dataset de test en batch") + parser.add_argument("--no-ner", action="store_true", help="Désactiver le NER") + parser.add_argument("--vlm", action="store_true", help="Activer le VLM (plus lent)") + + args = parser.parse_args() + + return anonymize_test_dataset( + use_ner=not args.no_ner, + use_vlm=args.vlm + ) + + +if __name__ == "__main__": + sys.exit(main()) diff --git a/tools/run_baseline_benchmark.py b/tools/run_baseline_benchmark.py new file mode 100755 index 0000000..ef06d69 --- /dev/null +++ b/tools/run_baseline_benchmark.py @@ -0,0 +1,199 @@ +#!/usr/bin/env python3 +""" +Benchmark de performance du système d'anonymisation sur le dataset de test. + +Analyse les résultats du batch pour générer un rapport de performance. +""" +import sys +import json +from pathlib import Path +from datetime import datetime +import statistics + +def run_baseline_benchmark(): + """Génère le rapport de benchmark à partir des résultats du batch.""" + + # Répertoires + baseline_dir = Path("tests/ground_truth/pdfs/baseline_anonymized") + results_file = baseline_dir / "batch_results.json" + + if not results_file.exists(): + print(f"✗ Fichier de résultats non trouvé: {results_file}") + print(f" Exécutez d'abord: python3 tools/batch_anonymize_test_dataset.py") + return 1 + + # Charger les résultats du batch + with open(results_file, 'r', encoding='utf-8') as f: + batch_data = json.load(f) + + successful = [r for r in batch_data['results'] if r.get('success')] + + if not successful: + print("✗ Aucun document traité avec succès") + return 1 + + print("="*80) + print("BENCHMARK DE PERFORMANCE - BASELINE") + print("="*80) + print(f"\n📅 Date du batch: {batch_data['date']}") + print(f"📄 Documents: {len(successful)}/{batch_data['total_documents']}") + print(f"🔍 PII détectés: {batch_data['total_pii']:,}") + + # Extraire les métriques + times = [r['time_s'] for r in successful] + pii_counts = [r['pii_count'] for r in successful] + + # Calculer les statistiques + stats = { + "total_documents": len(successful), + "total_time_s": sum(times), + "avg_time_s": statistics.mean(times), + "median_time_s": statistics.median(times), + "min_time_s": min(times), + "max_time_s": max(times), + "stdev_time_s": statistics.stdev(times) if len(times) > 1 else 0.0, + "total_pii": sum(pii_counts), + "avg_pii": statistics.mean(pii_counts), + "median_pii": statistics.median(pii_counts), + "min_pii": min(pii_counts), + "max_pii": max(pii_counts), + "docs_per_second": len(successful) / sum(times), + "pii_per_second": sum(pii_counts) / sum(times) + } + + # Afficher les statistiques + print("\n" + "="*80) + print("STATISTIQUES DE PERFORMANCE") + print("="*80) + + print(f"\n⏱️ Temps de traitement:") + print(f" - Total: {stats['total_time_s']:.2f}s") + print(f" - Moyen: {stats['avg_time_s']:.2f}s par document") + print(f" - Médiane: {stats['median_time_s']:.2f}s") + print(f" - Min: {stats['min_time_s']:.2f}s") + print(f" - Max: {stats['max_time_s']:.2f}s") + print(f" - Écart-type: {stats['stdev_time_s']:.2f}s") + + print(f"\n🔍 PII détectés:") + print(f" - Total: {stats['total_pii']:,}") + print(f" - Moyen: {stats['avg_pii']:.1f} par document") + print(f" - Médiane: {stats['median_pii']:.0f}") + print(f" - Min: {stats['min_pii']}") + print(f" - Max: {stats['max_pii']:,}") + + print(f"\n📊 Débit:") + print(f" - Documents/seconde: {stats['docs_per_second']:.2f}") + print(f" - PII/seconde: {stats['pii_per_second']:.1f}") + + # Identifier les documents lents (> 2× moyenne) + slow_threshold = stats['avg_time_s'] * 2 + slow_docs = [r for r in successful if r['time_s'] > slow_threshold] + if slow_docs: + print(f"\n⚠️ Documents lents (> {slow_threshold:.2f}s):") + for doc in sorted(slow_docs, key=lambda x: x['time_s'], reverse=True)[:5]: + print(f" - {doc['pdf']}: {doc['time_s']:.2f}s ({doc['pii_count']} PII)") + + # Identifier les documents rapides (< 0.5× moyenne) + fast_threshold = stats['avg_time_s'] * 0.5 + fast_docs = [r for r in successful if r['time_s'] < fast_threshold] + if fast_docs: + print(f"\n⚡ Documents rapides (< {fast_threshold:.2f}s):") + for doc in sorted(fast_docs, key=lambda x: x['time_s'])[:5]: + print(f" - {doc['pdf']}: {doc['time_s']:.2f}s ({doc['pii_count']} PII)") + + # Analyser la corrélation PII / temps + print(f"\n📈 Analyse de corrélation:") + # Documents avec beaucoup de PII + high_pii_docs = [r for r in successful if r['pii_count'] > stats['avg_pii'] * 2] + if high_pii_docs: + avg_time_high_pii = statistics.mean([r['time_s'] for r in high_pii_docs]) + print(f" - Documents avec beaucoup de PII (>{stats['avg_pii']*2:.0f}): {len(high_pii_docs)}") + print(f" Temps moyen: {avg_time_high_pii:.2f}s") + + # Documents avec peu de PII + low_pii_docs = [r for r in successful if r['pii_count'] < stats['avg_pii'] * 0.5] + if low_pii_docs: + avg_time_low_pii = statistics.mean([r['time_s'] for r in low_pii_docs]) + print(f" - Documents avec peu de PII (<{stats['avg_pii']*0.5:.0f}): {len(low_pii_docs)}") + print(f" Temps moyen: {avg_time_low_pii:.2f}s") + + # Sauvegarder les résultats + output_dir = Path("tests/ground_truth/benchmarks") + output_dir.mkdir(exist_ok=True) + + benchmark_data = { + "date": datetime.now().isoformat(), + "batch_date": batch_data['date'], + "configuration": { + "use_ner": batch_data.get('use_ner', True), + "use_vlm": batch_data.get('use_vlm', False) + }, + "statistics": stats, + "documents": [ + { + "pdf": r['pdf'], + "time_s": r['time_s'], + "pii_count": r['pii_count'] + } + for r in successful + ] + } + + json_file = output_dir / "baseline_benchmark.json" + with open(json_file, 'w', encoding='utf-8') as f: + json.dump(benchmark_data, f, indent=2, ensure_ascii=False) + print(f"\n📊 Résultats JSON: {json_file}") + + # Export CSV + csv_file = output_dir / "baseline_benchmark.csv" + with open(csv_file, 'w', encoding='utf-8') as f: + f.write("pdf,time_s,pii_count\n") + for r in successful: + f.write(f"{r['pdf']},{r['time_s']},{r['pii_count']}\n") + print(f"📊 Résultats CSV: {csv_file}") + + # Vérifier les objectifs de performance + print("\n" + "="*80) + print("VALIDATION DES OBJECTIFS") + print("="*80) + + target_time_no_vlm = 10.0 # < 10s par PDF (sans VLM) + target_time_with_vlm = 30.0 # < 30s par PDF (avec VLM) + + # On n'a pas utilisé le VLM dans le batch + target = target_time_no_vlm + use_vlm = batch_data.get('use_vlm', False) + + if use_vlm: + target = target_time_with_vlm + + print(f"\n🎯 Objectif: < {target}s par document (VLM: {'✓' if use_vlm else '✗'})") + + if stats['avg_time_s'] <= target: + print(f"✅ Temps moyen atteint: {stats['avg_time_s']:.2f}s ≤ {target}s") + else: + print(f"⚠️ Temps moyen non atteint: {stats['avg_time_s']:.2f}s > {target}s") + print(f" Écart: +{stats['avg_time_s'] - target:.2f}s ({(stats['avg_time_s']/target - 1)*100:.1f}%)") + + if stats['max_time_s'] <= target * 3: + print(f"✅ Temps max acceptable: {stats['max_time_s']:.2f}s ≤ {target * 3}s") + else: + print(f"⚠️ Temps max trop élevé: {stats['max_time_s']:.2f}s > {target * 3}s") + + # Pourcentage de documents dans l'objectif + docs_in_target = sum(1 for r in successful if r['time_s'] <= target) + pct_in_target = (docs_in_target / len(successful)) * 100 + print(f"\n📊 Documents dans l'objectif: {docs_in_target}/{len(successful)} ({pct_in_target:.1f}%)") + + if pct_in_target >= 80: + print(f"✅ Objectif de couverture atteint (≥80%)") + else: + print(f"⚠️ Objectif de couverture non atteint (<80%)") + + print("\n" + "="*80) + + return 0 + + +if __name__ == "__main__": + sys.exit(run_baseline_benchmark()) diff --git a/tools/show_anonymization_example.py b/tools/show_anonymization_example.py new file mode 100755 index 0000000..517430b --- /dev/null +++ b/tools/show_anonymization_example.py @@ -0,0 +1,123 @@ +#!/usr/bin/env python3 +""" +Affiche un exemple d'anonymisation avec statistiques détaillées. +""" +import json +import sys +from pathlib import Path +from collections import Counter + +def show_example(pdf_name: str = None): + """Affiche les détails d'un document anonymisé.""" + + baseline_dir = Path("tests/ground_truth/pdfs/baseline_anonymized") + + # Charger les résultats du batch + results_file = baseline_dir / "batch_results.json" + if not results_file.exists(): + print(f"✗ Fichier de résultats non trouvé: {results_file}") + return 1 + + with open(results_file, 'r', encoding='utf-8') as f: + batch_data = json.load(f) + + # Si pas de PDF spécifié, prendre le premier avec le plus de PII + if not pdf_name: + successful = [r for r in batch_data['results'] if r.get('success')] + if not successful: + print("✗ Aucun document traité avec succès") + return 1 + + # Trier par nombre de PII (décroissant) + successful.sort(key=lambda x: x.get('pii_count', 0), reverse=True) + pdf_name = successful[0]['pdf'] + + # Trouver le résultat + result = next((r for r in batch_data['results'] if r['pdf'] == pdf_name), None) + if not result: + print(f"✗ Document non trouvé: {pdf_name}") + return 1 + + if not result.get('success'): + print(f"✗ Document en échec: {pdf_name}") + print(f" Erreur: {result.get('error', 'Unknown')}") + return 1 + + # Charger l'audit + audit_file = baseline_dir / f"{Path(pdf_name).stem}.audit.jsonl" + if not audit_file.exists(): + print(f"✗ Fichier d'audit non trouvé: {audit_file}") + return 1 + + detections = [] + with open(audit_file, 'r', encoding='utf-8') as f: + for line in f: + if line.strip(): + detections.append(json.loads(line)) + + # Analyser les détections + types_counter = Counter(d.get('kind', d.get('type', 'unknown')) for d in detections) + methods_counter = Counter(d.get('method', 'unknown') for d in detections) + pages_counter = Counter(d['page'] for d in detections) + + # Afficher + print("="*80) + print(f"EXEMPLE D'ANONYMISATION: {pdf_name}") + print("="*80) + + print(f"\n📄 Document: {pdf_name}") + print(f"⏱️ Temps de traitement: {result['time_s']:.2f}s") + print(f"🔍 PII détectés: {result['pii_count']}") + + print(f"\n📊 Répartition par type:") + for pii_type, count in types_counter.most_common(): + print(f" - {pii_type}: {count}") + + print(f"\n🔬 Répartition par méthode de détection:") + for method, count in methods_counter.most_common(): + print(f" - {method}: {count}") + + print(f"\n📖 Répartition par page:") + for page, count in sorted(pages_counter.items()): + print(f" - Page {page}: {count} PII") + + # Exemples de détections + print(f"\n🔍 Exemples de détections (5 premiers):") + for i, det in enumerate(detections[:5], 1): + text = det.get('original', det.get('text', '')) + if len(text) > 40: + text = text[:37] + "..." + pii_type = det.get('kind', det.get('type', 'unknown')) + print(f" {i}. [{pii_type}] \"{text}\" (page {det['page']}, méthode: {det.get('method', 'unknown')})") + + # Fichiers générés + print(f"\n📂 Fichiers générés:") + stem = Path(pdf_name).stem + files = [ + baseline_dir / f"{stem}.pseudonymise.txt", + baseline_dir / f"{stem}.redacted_vector.pdf", + baseline_dir / f"{stem}.redacted_raster.pdf", + baseline_dir / f"{stem}.audit.jsonl" + ] + for f in files: + status = "✓" if f.exists() else "✗" + print(f" {status} {f.name}") + + print("\n" + "="*80) + + return 0 + + +def main(): + import argparse + + parser = argparse.ArgumentParser(description="Afficher un exemple d'anonymisation") + parser.add_argument("pdf", nargs="?", help="Nom du PDF (optionnel, par défaut le plus complexe)") + + args = parser.parse_args() + + return show_example(args.pdf) + + +if __name__ == "__main__": + sys.exit(main()) diff --git a/tools/show_batch_summary.py b/tools/show_batch_summary.py new file mode 100755 index 0000000..94723ba --- /dev/null +++ b/tools/show_batch_summary.py @@ -0,0 +1,85 @@ +#!/usr/bin/env python3 +""" +Affiche un résumé des résultats du batch d'anonymisation. +""" +import json +import sys +from pathlib import Path +from collections import Counter + +def show_summary(): + """Affiche le résumé du batch.""" + + baseline_dir = Path("tests/ground_truth/pdfs/baseline_anonymized") + results_file = baseline_dir / "batch_results.json" + + if not results_file.exists(): + print(f"✗ Fichier de résultats non trouvé: {results_file}") + return 1 + + with open(results_file, 'r', encoding='utf-8') as f: + data = json.load(f) + + # Statistiques globales + print("="*80) + print("RÉSUMÉ DU BATCH D'ANONYMISATION") + print("="*80) + + print(f"\n📅 Date: {data['date']}") + print(f"📄 Documents traités: {data['success_count']}/{data['total_documents']}") + print(f"🔍 PII détectés: {data['total_pii']:,}") + print(f"⏱️ Temps total: {data['total_time_s']:.2f}s") + print(f"⏱️ Temps moyen: {data['avg_time_s']:.2f}s par document") + + # Analyser les résultats + successful = [r for r in data['results'] if r.get('success')] + failed = [r for r in data['results'] if not r.get('success')] + + if successful: + times = [r['time_s'] for r in successful] + pii_counts = [r['pii_count'] for r in successful] + + print(f"\n📊 Statistiques de temps:") + print(f" - Min: {min(times):.2f}s") + print(f" - Max: {max(times):.2f}s") + print(f" - Médiane: {sorted(times)[len(times)//2]:.2f}s") + + print(f"\n📊 Statistiques de PII:") + print(f" - Min: {min(pii_counts)}") + print(f" - Max: {max(pii_counts):,}") + print(f" - Médiane: {sorted(pii_counts)[len(pii_counts)//2]}") + print(f" - Moyenne: {sum(pii_counts)/len(pii_counts):.1f}") + + # Top 5 documents les plus complexes + if successful: + print(f"\n🏆 Top 5 documents les plus complexes (par PII):") + top5 = sorted(successful, key=lambda x: x['pii_count'], reverse=True)[:5] + for i, r in enumerate(top5, 1): + print(f" {i}. {r['pdf']}") + print(f" → {r['pii_count']:,} PII en {r['time_s']:.2f}s") + + # Top 5 documents les plus rapides + if successful: + print(f"\n⚡ Top 5 documents les plus rapides:") + fastest = sorted(successful, key=lambda x: x['time_s'])[:5] + for i, r in enumerate(fastest, 1): + print(f" {i}. {r['pdf']}") + print(f" → {r['time_s']:.2f}s ({r['pii_count']} PII)") + + # Échecs + if failed: + print(f"\n⚠️ Échecs ({len(failed)}):") + for r in failed: + error = r.get('error', 'Unknown error') + if not error: + error = "PDF protégé par mot de passe" + print(f" - {r['pdf']}") + print(f" → {error}") + + print("\n" + "="*80) + + return 0 + + +if __name__ == "__main__": + sys.exit(show_summary())