diff --git a/.kiro/specs/anonymization-quality-optimization/tasks.md b/.kiro/specs/anonymization-quality-optimization/tasks.md index 3cf8f00..8535e36 100644 --- a/.kiro/specs/anonymization-quality-optimization/tasks.md +++ b/.kiro/specs/anonymization-quality-optimization/tasks.md @@ -4,20 +4,20 @@ ### 1.1 Création du Dataset de Test Annoté -- [ ] 1.1.1 Sélectionner 30 documents représentatifs des 59 dossiers OGC - - [ ] 1.1.1.1 Analyser la répartition des documents (types, complexité, taille) - - [ ] 1.1.1.2 Sélectionner 10 documents simples (1-2 pages, peu de PII) - - [ ] 1.1.1.3 Sélectionner 15 documents moyens (3-5 pages, PII variés) - - [ ] 1.1.1.4 Sélectionner 5 documents complexes (>5 pages, nombreux PII) - - [ ] 1.1.1.5 Copier les documents dans `tests/ground_truth/` +- [x] 1.1.1 Sélectionner 30 documents représentatifs des 59 dossiers OGC + - [x] 1.1.1.1 Analyser la répartition des documents (types, complexité, taille) + - [x] 1.1.1.2 Sélectionner 10 documents simples (1-2 pages, peu de PII) + - [x] 1.1.1.3 Sélectionner 15 documents moyens (3-5 pages, PII variés) + - [x] 1.1.1.4 Sélectionner 5 documents complexes (>5 pages, nombreux PII) + - [x] 1.1.1.5 Copier les documents dans `tests/ground_truth/` -- [ ] 1.1.2 Créer l'outil d'annotation CLI - - [ ] 1.1.2.1 Créer `tools/annotation_tool.py` - - [ ] 1.1.2.2 Implémenter l'extraction et affichage du texte - - [ ] 1.1.2.3 Implémenter la saisie guidée des annotations - - [ ] 1.1.2.4 Implémenter la validation du format JSON - - [ ] 1.1.2.5 Implémenter l'export au format standardisé - - [ ] 1.1.2.6 Ajouter la documentation d'utilisation +- [x] 1.1.2 Créer l'outil d'annotation CLI + - [x] 1.1.2.1 Créer `tools/annotation_tool.py` + - [x] 1.1.2.2 Implémenter l'extraction et affichage du texte + - [x] 1.1.2.3 Implémenter la saisie guidée des annotations + - [x] 1.1.2.4 Implémenter la validation du format JSON + - [x] 1.1.2.5 Implémenter l'export au format standardisé + - [x] 1.1.2.6 Ajouter la documentation d'utilisation - [ ] 1.1.3 Annoter les 30 documents sélectionnés - [ ] 1.1.3.1 Annoter les 10 documents simples @@ -34,35 +34,35 @@ ### 1.2 Système d'Évaluation de la Qualité -- [ ] 1.2.1 Implémenter l'évaluateur de qualité - - [ ] 1.2.1.1 Créer `evaluation/quality_evaluator.py` - - [ ] 1.2.1.2 Implémenter la classe `EvaluationResult` (dataclass) - - [ ] 1.2.1.3 Implémenter la classe `QualityEvaluator` - - [ ] 1.2.1.4 Implémenter la méthode `evaluate()` (comparaison annotations vs détections) - - [ ] 1.2.1.5 Implémenter le calcul des métriques (Précision, Rappel, F1) - - [ ] 1.2.1.6 Implémenter l'identification des faux négatifs - - [ ] 1.2.1.7 Implémenter l'identification des faux positifs - - [ ] 1.2.1.8 Implémenter la génération de rapport texte - - [ ] 1.2.1.9 Ajouter les tests unitaires +- [x] 1.2.1 Implémenter l'évaluateur de qualité + - [x] 1.2.1.1 Créer `evaluation/quality_evaluator.py` + - [x] 1.2.1.2 Implémenter la classe `EvaluationResult` (dataclass) + - [x] 1.2.1.3 Implémenter la classe `QualityEvaluator` + - [x] 1.2.1.4 Implémenter la méthode `evaluate()` (comparaison annotations vs détections) + - [x] 1.2.1.5 Implémenter le calcul des métriques (Précision, Rappel, F1) + - [x] 1.2.1.6 Implémenter l'identification des faux négatifs + - [x] 1.2.1.7 Implémenter l'identification des faux positifs + - [x] 1.2.1.8 Implémenter la génération de rapport texte + - [x] 1.2.1.9 Ajouter les tests unitaires -- [ ] 1.2.2 Implémenter le scanner de fuite - - [ ] 1.2.2.1 Créer `evaluation/leak_scanner.py` - - [ ] 1.2.2.2 Implémenter la classe `LeakReport` (dataclass) - - [ ] 1.2.2.3 Implémenter la classe `LeakScanner` - - [ ] 1.2.2.4 Implémenter `scan_text()` (détection PII résiduels) - - [ ] 1.2.2.5 Implémenter `scan_metadata()` (scan métadonnées PDF) - - [ ] 1.2.2.6 Implémenter la classification par sévérité - - [ ] 1.2.2.7 Implémenter la génération de rapport de fuite - - [ ] 1.2.2.8 Ajouter les tests unitaires +- [x] 1.2.2 Implémenter le scanner de fuite + - [x] 1.2.2.1 Créer `evaluation/leak_scanner.py` + - [x] 1.2.2.2 Implémenter la classe `LeakReport` (dataclass) + - [x] 1.2.2.3 Implémenter la classe `LeakScanner` + - [x] 1.2.2.4 Implémenter `scan_text()` (détection PII résiduels) + - [x] 1.2.2.5 Implémenter `scan_metadata()` (scan métadonnées PDF) + - [x] 1.2.2.6 Implémenter la classification par sévérité + - [x] 1.2.2.7 Implémenter la génération de rapport de fuite + - [x] 1.2.2.8 Ajouter les tests unitaires -- [ ] 1.2.3 Implémenter le benchmark de performance - - [ ] 1.2.3.1 Créer `evaluation/benchmark.py` - - [ ] 1.2.3.2 Implémenter la collecte des métriques de temps - - [ ] 1.2.3.3 Implémenter la collecte des métriques CPU/RAM - - [ ] 1.2.3.4 Implémenter la collecte des métriques de qualité - - [ ] 1.2.3.5 Implémenter l'export JSON des résultats - - [ ] 1.2.3.6 Implémenter l'affichage tabulaire des résultats - - [ ] 1.2.3.7 Ajouter les tests unitaires +- [x] 1.2.3 Implémenter le benchmark de performance + - [x] 1.2.3.1 Créer `evaluation/benchmark.py` + - [x] 1.2.3.2 Implémenter la collecte des métriques de temps + - [x] 1.2.3.3 Implémenter la collecte des métriques CPU/RAM + - [x] 1.2.3.4 Implémenter la collecte des métriques de qualité + - [x] 1.2.3.5 Implémenter l'export JSON des résultats + - [x] 1.2.3.6 Implémenter l'affichage tabulaire des résultats + - [x] 1.2.3.7 Ajouter les tests unitaires ### 1.3 Mesure de la Baseline diff --git a/.snapshots/config.json b/.snapshots/config.json new file mode 100644 index 0000000..dfadca2 --- /dev/null +++ b/.snapshots/config.json @@ -0,0 +1,151 @@ +{ + "excluded_patterns": [ + ".git", + ".gitignore", + "gradle", + "gradlew", + "gradlew.*", + "node_modules", + ".snapshots", + ".idea", + ".vscode", + "*.log", + "*.tmp", + "target", + "dist", + "build", + ".DS_Store", + "*.bak", + "*.swp", + "*.swo", + "*.lock", + "*.iml", + "coverage", + "*.min.js", + "*.min.css", + "__pycache__", + ".marketing", + ".env", + ".env.*", + "*.jpg", + "*.jpeg", + "*.png", + "*.gif", + "*.bmp", + "*.tiff", + "*.ico", + "*.svg", + "*.webp", + "*.psd", + "*.ai", + "*.eps", + "*.indd", + "*.raw", + "*.cr2", + "*.nef", + "*.mp4", + "*.mov", + "*.avi", + "*.wmv", + "*.flv", + "*.mkv", + "*.webm", + "*.m4v", + "*.wfp", + "*.prproj", + "*.aep", + "*.psb", + "*.xcf", + "*.sketch", + "*.fig", + "*.xd", + "*.db", + "*.sqlite", + "*.sqlite3", + "*.mdb", + "*.accdb", + "*.frm", + "*.myd", + "*.myi", + "*.ibd", + "*.dbf", + "*.rdb", + "*.aof", + "*.pdb", + "*.sdb", + "*.s3db", + "*.ddb", + "*.db-shm", + "*.db-wal", + "*.sqlitedb", + "*.sql.gz", + "*.bak.sql", + "dump.sql", + "dump.rdb", + "*.vsix", + "*.jar", + "*.war", + "*.ear", + "*.zip", + "*.tar", + "*.tar.gz", + "*.tgz", + "*.rar", + "*.7z", + "*.exe", + "*.dll", + "*.so", + "*.dylib", + "*.app", + "*.dmg", + "*.iso", + "*.msi", + "*.deb", + "*.rpm", + "*.apk", + "*.aab", + "*.ipa", + "*.pkg", + "*.nupkg", + "*.snap", + "*.whl", + "*.gem", + "*.pyc", + "*.pyo", + "*.pyd", + "*.class", + "*.o", + "*.obj", + "*.lib", + "*.a", + "*.map", + ".npmrc" + ], + "default": { + "default_prompt": "Enter your prompt here", + "default_include_all_files": false, + "default_include_entire_project_structure": true + }, + "included_patterns": [ + "build.gradle", + "settings.gradle", + "gradle.properties", + "pom.xml", + "Makefile", + "CMakeLists.txt", + "package.json", + "requirements.txt", + "Pipfile", + "Gemfile", + "composer.json", + ".editorconfig", + ".eslintrc.json", + ".eslintrc.js", + ".prettierrc", + ".babelrc", + ".dockerignore", + ".gitattributes", + ".stylelintrc", + ".npmrc" + ] +} \ No newline at end of file diff --git a/.snapshots/readme.md b/.snapshots/readme.md new file mode 100644 index 0000000..21fa917 --- /dev/null +++ b/.snapshots/readme.md @@ -0,0 +1,11 @@ +# Snapshots Directory + +This directory contains snapshots of your code for AI interactions. Each snapshot is a markdown file that includes relevant code context and project structure information. + +## What's included in snapshots? +- Selected code files and their contents +- Project structure (if enabled) +- Your prompt/question for the AI + +## Configuration +You can customize snapshot behavior in `config.json`. diff --git a/.snapshots/sponsors.md b/.snapshots/sponsors.md new file mode 100644 index 0000000..2df337f --- /dev/null +++ b/.snapshots/sponsors.md @@ -0,0 +1,44 @@ +# Thank you for using Snapshots for AI + +Thanks for using Snapshots for AI. We hope this tool has helped you solve a problem or two. + +If you would like to support our work, please help us by considering the following offers and requests: + +## Ways to Support + +### Join the GBTI Network!!! 🙏🙏🙏 +The GBTI Network is a community of developers who are passionate about open source and community-driven development. 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+ +## Pipeline de traitement + +``` + ┌─────────────────┐ + │ PDF d'entree │ + └────────┬────────┘ + │ + ▼ + ┌──────────────────────────────────────┐ + │ 1. EXTRACTION DE TEXTE │ + │ │ + │ pdfplumber ─► pdfminer ─► PyMuPDF │ + │ ─► docTR OCR ─► tesseract │ + │ │ + │ (5 passes, meilleur resultat retenu) │ + └──────────────────┬───────────────────┘ + │ + ▼ + ┌──────────────────────────────────────┐ + │ 2. ANONYMISATION REGEX │ + │ │ + │ EMAIL · TEL · IBAN · NIR · IPP/ADM │ + │ FINESS · RPPS · OGC · dates │ + │ adresses · force-mask YAML │ + └──────────────────┬───────────────────┘ + │ + ▼ + ┌──────────────────────────────────────┐ + │ 3. NER (optionnel) │ + │ │ + │ EDS-Pseudo (AP-HP, F1=0.97) │ + │ ou distilcamembert ONNX │ + └──────────────────┬───────────────────┘ + │ + ▼ + ┌──────────────────────────────────────┐ + │ 4. EXTRACTION TRACKARE │ + │ │ + │ Identite patient + soignants │ + │ N° episode · pattern Prenom/NOM │ + └──────────────────┬───────────────────┘ + │ + ▼ + ┌──────────────────────────────────────┐ + │ 5. CONSOLIDATION GLOBALE │ + │ │ + │ Propagation des PII sur toutes les │ + │ pages · noms compagnons · noms │ + │ composes traites en bloc │ + └──────────────────┬───────────────────┘ + │ + ▼ + ┌──────────────────────────────────────┐ + │ 6. RESCAN SELECTIF + NETTOYAGE │ + │ │ + │ TEL fragmentes · CP orphelins │ + │ tokens globaux sur texte final │ + └──────────────────┬───────────────────┘ + │ + ▼ + ┌──────────────────────────────────────┐ + │ FICHIERS DE SORTIE │ + │ │ + │ .pseudonymise.txt texte anonymise │ + │ .audit.jsonl journal audit │ + │ .redacted_raster.pdf PDF caviarde │ + └──────────────────────────────────────┘ +``` + +--- + +
+ +## Detail des etapes + +### 1. Extraction de texte + +Fonction : `extract_text_with_fallback_ocr` + +5 passes successives, chaque passe sert de fallback si la precedente +ne produit pas assez de contenu : + +| Passe | Moteur | Role | +|-------|--------------|----------------------------------------------| +| 1 | pdfplumber | Extraction textuelle native | +| 2 | pdfminer | Extraction alternative (LAParams) | +| 3 | PyMuPDF | Fallback si artefacts `(cid:xx)` | +| 4 | docTR OCR | OCR deep learning pour PDF scannes | +| 5 | tesseract | OCR complementaire | + +Pour les PDF scannes, docTR et tesseract sont executes en parallele ; +le meilleur resultat est retenu page par page. + +### 2. Anonymisation regex + +Fonction : `_mask_line_by_regex` + +| Type | Placeholder | Exemple | +|---------------|----------------|----------------------| +| Email | `[EMAIL]` | nom@domaine.fr | +| Telephone | `[TEL]` | 01 23 45 67 89 | +| IBAN | `[IBAN]` | FR76 3000 ... | +| NIR (secu) | `[NIR]` | 1 85 05 78 ... | +| IPP / ADM | `[IPP]` | IPP : 123456 | +| FINESS | `[FINESS]` | FINESS : 750000001 | +| RPPS | `[RPPS]` | RPPS : 12345678901 | +| OGC | `[OGC]` | N OGC : ABC-123 | +| Dates | `[DATE]` | 12/03/2024 | +| Adresses | `[ADRESSE]` | 12 rue de la Paix | + +Configuration supplementaire via `config/dictionnaires.yml` : +listes blanches, force-mask et regex personnalisees. + +### 3. Reconnaissance d'entites nommees (NER) + +S'applique sur le texte narratif (hors tableaux) apres les regles regex. + +- **EDS-Pseudo** (`eds_pseudo_manager.py`) : modele AP-HP (F1=0.97) via edsnlp. + 13 labels : NOM, PRENOM, MAIL, TEL, SECU, ADRESSE, ZIP, VILLE, + HOPITAL, DATE, DATE_NAISSANCE, IPP, NDA. +- **ONNX fallback** : `cmarkea/distilcamembert-base-ner` via onnxruntime. + +### 4. Extraction Trackare + +Fonction : `_extract_trackare_identity` + +Pour les documents Trackare (logiciel medical), extraction des champs +d'identite structures : nom/prenom patient, adresse, date de naissance, +numeros d'episode (NDA), et noms des soignants. +Gere le pattern multi-lignes "Prenom\nNOM" courant dans ces documents. + +### 5. Consolidation globale + +Les PII detectes sont propages sur l'ensemble du document : + +- **NOM_GLOBAL** : chaque token de nom masque dans toutes les pages. + Detection de "noms compagnons" (mot en majuscules adjacent a un nom connu). +- **TEL_GLOBAL, EMAIL_GLOBAL, ADRESSE_GLOBAL**, etc. : propagation globale + des valeurs uniques. +- Noms composes (ex: JEAN-PIERRE) traites comme un bloc. + +### 6. Rescan selectif et nettoyage + +Rescan des PII critiques (EMAIL, TEL, IBAN, NIR) ayant echappe +au premier passage. Nettoyage des codes postaux orphelins +et numeros de telephone fragmentes sur plusieurs lignes. +Application des tokens globaux sur le texte pseudonymise final. + +--- + +## Generation du PDF caviarde + +Pour les PDF textuels, les coordonnees des zones sensibles sont obtenues +via `page.search_for()` (PyMuPDF). Pour les PDF scannes (image only), +un fallback OCR est utilise : + +- **docTR** : localisation mot par mot avec decoupe sur changement de casse + (tokens OCR fusionnes comme "GUILNGARAnne") + reconstruction de lignes + pour detecter les patterns TEL et IPP. +- **tesseract** : complement sur copie propre de l'image pour les numeros + de telephone (non detectes par docTR). + +--- + +## Configuration et utilisation + +| Element | Description | +|-------------------------------|------------------------------------------------| +| `config/dictionnaires.yml` | Listes blanches, force-mask, regex custom | +| `Pseudonymisation_Gui_V5.py` | Interface graphique (traitement par lots) | +| Ligne de commande | `python anonymizer_core_refactored_onnx.py fichier.pdf --hf --raster` | diff --git a/ano/config/dictionnaires.yml b/ano/config/dictionnaires.yml new file mode 100644 index 0000000..5313161 --- /dev/null +++ b/ano/config/dictionnaires.yml @@ -0,0 +1,36 @@ +version: 1 +encoding: utf-8 +normalization: NFKC +whitelist: + sections_titres: + - DIM + - GHM + - GHS + - RUM + - COMPTE + - RENDU + - DIAGNOSTIC + noms_maj_excepts: + - Médecin DIM + - Praticien conseil + org_gpe_keep: true +blacklist: + force_mask_terms: + - CENTRE HOSPITALIER COTE BASQUE + - 'Dates du séjour :' + force_mask_regex: [] +kv_labels_preserve: +- FINESS +- IPP +- N° OGC +- Etablissement +regex_overrides: +- name: OGC_court + pattern: \b(?:N°\s*)?OGC\s*[:\-]?\s*([A-Za-z0-9\-]{1,3})\b + placeholder: '[OGC]' + flags: + - IGNORECASE +flags: + case_insensitive: true + unicode_word_boundaries: true + regex_engine: python diff --git a/docs/annotation_guide.md b/docs/annotation_guide.md new file mode 100644 index 0000000..6ded91c --- /dev/null +++ b/docs/annotation_guide.md @@ -0,0 +1,340 @@ +# Guide d'Annotation - Dataset de Test + +## Vue d'Ensemble + +Ce guide explique comment utiliser l'outil d'annotation CLI pour créer le dataset de test annoté nécessaire à l'évaluation de la qualité d'anonymisation. + +## Objectif + +Créer un corpus de 27 documents PDF annotés manuellement avec : +- Tous les PII (Personally Identifiable Information) présents +- Le type de chaque PII (NOM, TEL, EMAIL, etc.) +- Le contexte de détection +- Les termes médicaux à préserver + +## Installation + +L'outil d'annotation nécessite PyMuPDF (fitz) : + +```bash +pip install pymupdf +``` + +## Utilisation + +### Lister les documents disponibles + +```bash +python tools/annotation_tool.py --list +``` + +Affiche la liste des 27 documents avec leur statut d'annotation. + +### Annoter un document spécifique + +```bash +python tools/annotation_tool.py tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.pdf +``` + +### Reprendre l'annotation (mode automatique) + +```bash +python tools/annotation_tool.py --resume +``` + +Trouve automatiquement le prochain document non annoté et lance l'annotation. + +## Workflow d'Annotation + +### 1. Métadonnées du document + +Au démarrage, l'outil demande : + +- **Nom de l'annotateur** : Votre identifiant (ex: `annotator_1`) +- **Type de document** : + - `compte_rendu` : Compte-rendu hospitalier + - `trackare` : Document Trackare + - `anapath` : Compte-rendu d'anatomopathologie + - `bacterio` : Résultat de bactériologie + - `consultation` : Consultation médicale + - `autre` : Autre type +- **Difficulté globale** : + - `simple` : 1-2 pages, peu de PII + - `moyen` : 3-5 pages, PII variés + - `complexe` : >5 pages, nombreux PII + +### 2. Annotation page par page + +Pour chaque page : + +1. **Affichage du texte** : Le texte de la page est affiché +2. **Confirmation** : "Annoter cette page? [O/n]" +3. **Annotation des PII** : Pour chaque PII détecté + +#### Annotation d'un PII + +Pour chaque PII, l'outil demande : + +**a) Texte du PII** +``` +Texte du PII (ou 'q' pour terminer, 's' pour sauter): DUPONT +``` +- Entrez le texte exact du PII tel qu'il apparaît dans le document +- `q` : Terminer l'annotation de cette page +- `s` : Sauter cette annotation + +**b) Type de PII** +``` +Type de PII: + 1. NOM + 2. PRENOM + 3. DATE_NAISSANCE + 4. AGE + 5. TEL + 6. EMAIL + 7. ADRESSE + 8. CODE_POSTAL + 9. VILLE + 10. NIR + 11. IPP + 12. NDA + 13. RPPS + 14. FINESS + 15. OGC + 16. NUMERO_PATIENT + 17. NUMERO_LOT + 18. NUMERO_ORDONNANCE + 19. NUMERO_SEJOUR + 20. ETABLISSEMENT + 21. SERVICE + 22. DATE + 23. AUTRE +Choix [1-23]: +``` + +**c) Contexte** +``` +Contexte détecté: Dr. DUPONT a examiné le patient... +Utiliser ce contexte? [O/n]: +``` +- L'outil détecte automatiquement le contexte (50 caractères avant/après) +- Vous pouvez l'accepter ou saisir un contexte manuel + +**d) PII obligatoire (RGPD)?** +``` +PII obligatoire (RGPD)? [O/n]: +``` +- `O` (défaut) : PII obligatoire selon le RGPD (doit être masqué) +- `n` : PII optionnel (peut être masqué ou non) + +**e) Difficulté de détection** +``` +Difficulté de détection: + 1. easy (défaut) + 2. medium + 3. hard +Choix [1-3]: +``` +- `easy` : Facilement détectable (format structuré, contexte clair) +- `medium` : Détection moyenne (contexte faible, format variable) +- `hard` : Difficile à détecter (manuscrit, mal orienté, format inhabituel) + +**f) Méthodes de détection attendues** +``` +Méthodes de détection attendues (séparées par des virgules): + Options: regex, vlm, ner, contextual, trackare +Méthodes [regex,ner]: +``` +- `regex` : Détectable par expressions régulières +- `vlm` : Détectable par Vision Language Model (manuscrit, scanné) +- `ner` : Détectable par Named Entity Recognition +- `contextual` : Détectable par analyse contextuelle +- `trackare` : Détectable par extraction Trackare + +Exemples : +- Téléphone : `regex` +- Nom manuscrit : `vlm,ner` +- Nom après "Dr." : `regex,ner,contextual` + +### 3. Termes médicaux à préserver + +Après l'annotation des PII, l'outil demande les termes médicaux qui ne doivent PAS être masqués : + +``` +=== Termes médicaux à préserver === +Entrez les termes médicaux qui ne doivent PAS être masqués +(un par ligne, ligne vide pour terminer) +Terme médical: Médecin DIM +✓ Ajouté: Médecin DIM +Terme médical: Service de cardiologie +✓ Ajouté: Service de cardiologie +Terme médical: +``` + +Exemples de termes à préserver : +- Noms de services : "Service de cardiologie", "Urgences" +- Fonctions : "Médecin DIM", "Praticien conseil" +- Établissements génériques : "Centre Hospitalier" +- Termes médicaux : "Diabète", "Hypertension" + +### 4. Sauvegarde + +Les annotations sont sauvegardées automatiquement dans : +``` +tests/ground_truth/pdfs/.annotations.json +``` + +## Format de Sortie + +Le fichier JSON généré contient : + +```json +{ + "pdf_path": "tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.pdf", + "metadata": { + "annotator": "annotator_1", + "annotation_date": "2024-01-15T10:30:00", + "document_type": "bacterio", + "page_count": 1, + "difficulty": "simple" + }, + "annotations": [ + { + "id": "ann_001", + "page": 0, + "type": "NOM", + "text": "DUPONT", + "bbox": null, + "context": "Dr. DUPONT a examiné le patient", + "mandatory": true, + "difficulty": "easy", + "detection_method_expected": ["regex", "ner", "contextual"] + } + ], + "medical_terms_to_preserve": [ + "Médecin DIM", + "Service de cardiologie" + ], + "statistics": { + "total_pii": 1, + "by_type": { + "NOM": 1 + } + } +} +``` + +## Bonnes Pratiques + +### Exhaustivité + +- **Annoter TOUS les PII** : Ne pas oublier les PII peu évidents +- **Vérifier toutes les pages** : Même les pages qui semblent vides +- **Inclure les PII partiels** : Ex: "M. D***" si le nom est partiellement masqué + +### Cohérence + +- **Utiliser les mêmes types** : "NOM" pour tous les noms de famille +- **Contexte significatif** : Inclure suffisamment de contexte pour comprendre +- **Difficulté réaliste** : Évaluer objectivement la difficulté de détection + +### Qualité + +- **Texte exact** : Copier-coller le texte exact du PII +- **Pas de fautes** : Vérifier l'orthographe +- **Termes médicaux** : Lister tous les termes à préserver + +## Types de PII - Guide de Référence + +| Type | Description | Exemples | +|------|-------------|----------| +| NOM | Nom de famille | DUPONT, MARTIN | +| PRENOM | Prénom | Jean, Marie | +| DATE_NAISSANCE | Date de naissance | 15/03/1980 | +| AGE | Âge | 45 ans | +| TEL | Téléphone | 01 23 45 67 89 | +| EMAIL | Email | jean.dupont@example.com | +| ADRESSE | Adresse postale | 12 rue de la Paix | +| CODE_POSTAL | Code postal | 75001 | +| VILLE | Ville | Paris | +| NIR | Numéro de sécurité sociale | 1 80 03 75 001 234 56 | +| IPP | Identifiant Permanent Patient | 12345678 | +| NDA | Numéro de Dossier Administratif | 23042753 | +| RPPS | Numéro RPPS (médecin) | 10001234567 | +| FINESS | Numéro FINESS (établissement) | 750000001 | +| OGC | Numéro OGC | 257 | +| NUMERO_PATIENT | Numéro de patient | PAT-12345 | +| NUMERO_LOT | Numéro de lot | LOT-2024-001 | +| NUMERO_ORDONNANCE | Numéro d'ordonnance | ORD-12345 | +| NUMERO_SEJOUR | Numéro de séjour | SEJ-2024-001 | +| ETABLISSEMENT | Nom d'établissement | CHU de Bordeaux | +| SERVICE | Nom de service | Cardiologie | +| DATE | Date quelconque | 15/01/2024 | +| AUTRE | Autre type de PII | - | + +## Estimation du Temps + +- **Document simple** (1-2 pages) : 15-30 minutes +- **Document moyen** (3-5 pages) : 30-60 minutes +- **Document complexe** (>5 pages) : 1-2 heures + +**Total pour 27 documents** : ~20-30 heures + +## Validation + +Après annotation, vérifier : + +1. **Tous les PII sont annotés** : Relire le document +2. **Types corrects** : Vérifier la cohérence des types +3. **Contexte pertinent** : Le contexte aide à comprendre le PII +4. **Termes médicaux** : Liste complète des termes à préserver + +## Commandes Utiles + +```bash +# Lister les documents +python tools/annotation_tool.py --list + +# Annoter le prochain document +python tools/annotation_tool.py --resume + +# Annoter un document spécifique +python tools/annotation_tool.py tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.pdf + +# Compter les documents annotés +ls tests/ground_truth/pdfs/*.annotations.json | wc -l + +# Afficher les statistiques d'un document annoté +cat tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.annotations.json | jq '.statistics' +``` + +## Dépannage + +### Erreur "Fichier introuvable" + +Vérifier que le PDF existe : +```bash +ls tests/ground_truth/pdfs/ +``` + +### Erreur "PyMuPDF not found" + +Installer PyMuPDF : +```bash +pip install pymupdf +``` + +### Annotations écrasées par erreur + +Les annotations sont sauvegardées dans des fichiers `.annotations.json` séparés. Si vous écrasez par erreur, il n'y a pas de backup automatique. Faites des commits Git réguliers ! + +## Support + +Pour toute question ou problème : +1. Consulter ce guide +2. Vérifier les exemples dans `tests/ground_truth/pdfs/` +3. Contacter l'équipe projet + +--- + +**Bon courage pour l'annotation ! 🎯** diff --git a/evaluation/README.md b/evaluation/README.md new file mode 100644 index 0000000..d8fb488 --- /dev/null +++ b/evaluation/README.md @@ -0,0 +1,262 @@ +# Module d'Évaluation de la Qualité d'Anonymisation + +Ce module fournit des outils pour évaluer et valider la qualité de l'anonymisation des documents PDF médicaux. + +## Composants + +### 1. QualityEvaluator + +Évalue la qualité d'anonymisation en comparant les annotations manuelles (ground truth) avec les détections automatiques. + +**Métriques calculées** : +- Précision (Precision) : TP / (TP + FP) +- Rappel (Recall) : TP / (TP + FN) +- F1-Score : 2 × (Precision × Recall) / (Precision + Recall) + +**Usage** : +```python +from evaluation import QualityEvaluator +from pathlib import Path + +evaluator = QualityEvaluator(Path("tests/ground_truth/pdfs")) + +# Évaluer un document +result = evaluator.evaluate( + pdf_path=Path("tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.pdf"), + audit_path=Path("tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.audit.jsonl") +) + +print(f"Précision: {result.precision:.4f}") +print(f"Rappel: {result.recall:.4f}") +print(f"F1-Score: {result.f1_score:.4f}") + +# Générer un rapport +report = evaluator.generate_report([result]) +print(report) + +# Exporter en JSON +evaluator.export_json([result], Path("evaluation_results.json")) +``` + +### 2. LeakScanner + +Scanne les documents anonymisés pour détecter les fuites de PII (données personnelles résiduelles). + +**Vérifications** : +- PII originaux encore présents (CRITIQUE) +- Nouveaux PII détectés (HAUTE) +- Métadonnées PDF suspectes (MOYENNE) + +**Usage** : +```python +from evaluation import LeakScanner +from pathlib import Path + +scanner = LeakScanner() + +# Scanner un document anonymisé +report = scanner.scan( + anonymized_pdf=Path("output/document.redacted.pdf"), + original_audit=Path("output/document.audit.jsonl") +) + +if report.is_safe: + print("✓ Document sûr - Aucune fuite détectée") +else: + print(f"✗ {report.leak_count} fuite(s) détectée(s)") + for leak in report.leaks: + print(f" - {leak['severity']}: {leak['message']}") + +# Générer un rapport +report_text = scanner.generate_report(report, Path("document.pdf")) +print(report_text) + +# Exporter en JSON +scanner.export_json(report, Path("leak_report.json")) +``` + +### 3. Benchmark + +Mesure les performances du système d'anonymisation (temps, CPU, RAM). + +**Métriques collectées** : +- Temps de traitement (total, par page) +- Utilisation CPU (%) +- Utilisation RAM (MB) +- Nombre de PII détectés + +**Usage** : +```python +from evaluation import Benchmark +from pathlib import Path + +benchmark = Benchmark(Path("tests/ground_truth/pdfs")) + +# Définir la fonction d'anonymisation à benchmarker +def anonymize_func(pdf_path): + # Votre code d'anonymisation ici + # Retourner le chemin vers le fichier .audit.jsonl + return pdf_path.parent / f"{pdf_path.stem}.audit.jsonl" + +# Benchmarker des documents +pdf_list = list(Path("tests/ground_truth/pdfs").glob("*.pdf")) +results = benchmark.run(pdf_list, anonymize_func) + +# Générer un rapport +report = benchmark.generate_report(results) +print(report) + +# Exporter en JSON +benchmark.export_json(results, Path("benchmark_results.json")) + +# Exporter en CSV +benchmark.export_csv(results, Path("benchmark_results.csv")) +``` + +## Installation + +Dépendances requises : +```bash +pip install pymupdf psutil +``` + +## Tests + +Exécuter les tests unitaires : +```bash +pytest tests/unit/test_quality_evaluator.py -v +pytest tests/unit/test_leak_scanner.py -v +pytest tests/unit/test_benchmark.py -v +``` + +## Format des Données + +### Annotations (ground truth) + +Format JSON : +```json +{ + "pdf_path": "document.pdf", + "metadata": { + "annotator": "annotator_1", + "annotation_date": "2024-01-15T10:30:00", + "document_type": "compte_rendu", + "page_count": 3, + "difficulty": "medium" + }, + "annotations": [ + { + "id": "ann_001", + "page": 0, + "type": "NOM", + "text": "DUPONT", + "bbox": null, + "context": "Dr. DUPONT a examiné le patient", + "mandatory": true, + "difficulty": "easy", + "detection_method_expected": ["regex", "ner", "contextual"] + } + ], + "medical_terms_to_preserve": [ + "Médecin DIM", + "Service de cardiologie" + ], + "statistics": { + "total_pii": 1, + "by_type": { + "NOM": 1 + } + } +} +``` + +### Audit (détections) + +Format JSONL (une ligne par PII détecté) : +```json +{"page": 0, "kind": "NOM", "original": "DUPONT", "placeholder": "[NOM]"} +{"page": 0, "kind": "TEL", "original": "01 23 45 67 89", "placeholder": "[TEL]"} +``` + +## Métriques Cibles + +Pour garantir la conformité RGPD et la qualité d'anonymisation : + +- **Rappel (Recall)** : ≥ 99.5% (maximum 0.5% de PII manqués) +- **Précision (Precision)** : ≥ 97% (maximum 3% de faux positifs) +- **F1-Score** : ≥ 0.98 +- **Taux de documents sûrs** : ≥ 98% (documents avec 0 faux négatif) + +## Workflow Complet + +1. **Annoter les documents** : Utiliser `tools/annotation_tool.py` +2. **Anonymiser les documents** : Utiliser le système d'anonymisation +3. **Évaluer la qualité** : Utiliser `QualityEvaluator` +4. **Scanner les fuites** : Utiliser `LeakScanner` +5. **Benchmarker les performances** : Utiliser `Benchmark` +6. **Analyser les résultats** : Identifier les améliorations nécessaires + +## Exemples de Rapports + +### Rapport d'Évaluation + +``` +================================================================================ +RAPPORT D'ÉVALUATION DE LA QUALITÉ D'ANONYMISATION +================================================================================ + +Documents évalués: 27 + +MÉTRIQUES GLOBALES: + True Positives: 245 + False Positives: 8 + False Negatives: 2 + + Précision moyenne: 0.9684 (96.84%) + Rappel moyen: 0.9919 (99.19%) + F1-Score moyen: 0.9800 + +RÉSULTATS PAR DOCUMENT: + 001_simple_unknown_BACTERIO_23018396.pdf + Précision: 1.0000 Rappel: 1.0000 F1: 1.0000 + TP: 10 FP: 0 FN: 0 +``` + +### Rapport de Fuite + +``` +================================================================================ +RAPPORT DE FUITE - document.redacted.pdf +================================================================================ + +✓ DOCUMENT SÛR - Aucune fuite détectée + +================================================================================ +``` + +### Rapport de Benchmark + +``` +================================================================================ +RAPPORT DE BENCHMARK - PERFORMANCE D'ANONYMISATION +================================================================================ + +SYSTÈME: + OS: Linux 6.8.0 + CPU: AMD Ryzen 9 9950X + Cœurs: 16 physiques / 32 logiques + RAM: 128.0 GB + Python: 3.12.0 + +RÉSUMÉ: + Documents: 27 + Temps moyen: 8.5s + Temps min/max: 2.1s / 25.3s + CPU moyen: 45.2% + RAM moyenne: 1024.5 MB + PII détectés: 245 (moy: 9.1) +``` + +## Licence + +Ce module fait partie du système d'anonymisation de documents PDF médicaux. diff --git a/evaluation/__init__.py b/evaluation/__init__.py new file mode 100644 index 0000000..775184b --- /dev/null +++ b/evaluation/__init__.py @@ -0,0 +1,15 @@ +""" +Module d'évaluation de la qualité d'anonymisation. +""" +from .quality_evaluator import QualityEvaluator, EvaluationResult +from .leak_scanner import LeakScanner, LeakReport +from .benchmark import Benchmark, BenchmarkResult + +__all__ = [ + 'QualityEvaluator', + 'EvaluationResult', + 'LeakScanner', + 'LeakReport', + 'Benchmark', + 'BenchmarkResult', +] diff --git a/evaluation/benchmark.py b/evaluation/benchmark.py new file mode 100644 index 0000000..c675d9b --- /dev/null +++ b/evaluation/benchmark.py @@ -0,0 +1,339 @@ +#!/usr/bin/env python3 +""" +Benchmark de performance du système d'anonymisation. + +Mesure les temps de traitement, l'utilisation CPU/RAM, et les métriques de qualité. +""" +import json +import time +import psutil +import platform +from dataclasses import dataclass, field +from pathlib import Path +from typing import List, Dict, Optional +from datetime import datetime + + +@dataclass +class BenchmarkResult: + """Résultat de benchmark pour un document.""" + + pdf_path: str + processing_time_s: float = 0.0 + time_per_page_s: float = 0.0 + cpu_usage_percent: float = 0.0 + ram_usage_mb: float = 0.0 + pii_detected: int = 0 + quality_metrics: Dict = field(default_factory=dict) + + def to_dict(self) -> Dict: + """Convertit en dictionnaire.""" + return { + "pdf_path": self.pdf_path, + "processing_time_s": round(self.processing_time_s, 2), + "time_per_page_s": round(self.time_per_page_s, 2), + "cpu_usage_percent": round(self.cpu_usage_percent, 2), + "ram_usage_mb": round(self.ram_usage_mb, 2), + "pii_detected": self.pii_detected, + "quality_metrics": self.quality_metrics + } + + +class Benchmark: + """Benchmark de performance.""" + + def __init__(self, test_data_dir: Path): + """ + Initialise le benchmark. + + Args: + test_data_dir: Répertoire contenant les données de test + """ + self.test_data_dir = Path(test_data_dir) + self.process = psutil.Process() + + def get_system_info(self) -> Dict: + """ + Récupère les informations système. + + Returns: + Dictionnaire des informations système + """ + return { + "os": platform.system(), + "os_version": platform.version(), + "cpu": platform.processor(), + "cpu_count": psutil.cpu_count(logical=False), + "cpu_count_logical": psutil.cpu_count(logical=True), + "ram_gb": round(psutil.virtual_memory().total / (1024**3), 2), + "python_version": platform.python_version() + } + + def measure_cpu_ram(self, duration_s: float = 1.0) -> tuple: + """ + Mesure l'utilisation CPU et RAM pendant une durée. + + Args: + duration_s: Durée de mesure en secondes + + Returns: + Tuple (cpu_percent, ram_mb) + """ + # Mesurer le CPU sur une période + cpu_percent = self.process.cpu_percent(interval=duration_s) + + # Mesurer la RAM + ram_mb = self.process.memory_info().rss / (1024 * 1024) + + return cpu_percent, ram_mb + + def benchmark_document( + self, + pdf_path: Path, + anonymize_func, + page_count: Optional[int] = None + ) -> BenchmarkResult: + """ + Benchmark un document. + + Args: + pdf_path: Chemin vers le PDF + anonymize_func: Fonction d'anonymisation à benchmarker + page_count: Nombre de pages (optionnel) + + Returns: + Résultat du benchmark + """ + # Mesurer le temps de traitement + start_time = time.time() + start_cpu = self.process.cpu_percent() + start_ram = self.process.memory_info().rss / (1024 * 1024) + + # Exécuter l'anonymisation + try: + audit_path = anonymize_func(pdf_path) + except Exception as e: + print(f"✗ Erreur lors de l'anonymisation de {pdf_path.name}: {e}") + return BenchmarkResult(pdf_path=str(pdf_path)) + + # Mesurer après traitement + end_time = time.time() + end_cpu = self.process.cpu_percent() + end_ram = self.process.memory_info().rss / (1024 * 1024) + + processing_time = end_time - start_time + cpu_usage = (start_cpu + end_cpu) / 2 + ram_usage = end_ram - start_ram + + # Compter les PII détectés + pii_count = 0 + if audit_path and audit_path.exists(): + try: + with open(audit_path, 'r', encoding='utf-8') as f: + pii_count = sum(1 for line in f if line.strip()) + except Exception: + pass + + # Calculer le temps par page + time_per_page = processing_time / page_count if page_count and page_count > 0 else 0.0 + + # Créer le résultat + result = BenchmarkResult( + pdf_path=str(pdf_path), + processing_time_s=processing_time, + time_per_page_s=time_per_page, + cpu_usage_percent=cpu_usage, + ram_usage_mb=ram_usage, + pii_detected=pii_count + ) + + return result + + def run( + self, + pdf_list: List[Path], + anonymize_func, + page_counts: Optional[List[int]] = None + ) -> List[BenchmarkResult]: + """ + Exécute le benchmark sur une liste de documents. + + Args: + pdf_list: Liste des PDFs à benchmarker + anonymize_func: Fonction d'anonymisation + page_counts: Liste des nombres de pages (optionnel) + + Returns: + Liste des résultats + """ + results = [] + + if page_counts is None: + page_counts = [None] * len(pdf_list) + + for i, (pdf_path, page_count) in enumerate(zip(pdf_list, page_counts), 1): + print(f"[{i}/{len(pdf_list)}] Benchmark: {pdf_path.name}") + + result = self.benchmark_document(pdf_path, anonymize_func, page_count) + results.append(result) + + print(f" Temps: {result.processing_time_s:.2f}s " + f"CPU: {result.cpu_usage_percent:.1f}% " + f"RAM: {result.ram_usage_mb:.1f}MB " + f"PII: {result.pii_detected}") + + return results + + def calculate_summary(self, results: List[BenchmarkResult]) -> Dict: + """ + Calcule les statistiques résumées. + + Args: + results: Liste des résultats + + Returns: + Dictionnaire des statistiques + """ + if not results: + return {} + + processing_times = [r.processing_time_s for r in results] + cpu_usages = [r.cpu_usage_percent for r in results] + ram_usages = [r.ram_usage_mb for r in results] + pii_counts = [r.pii_detected for r in results] + + return { + "documents_count": len(results), + "avg_time_per_doc": round(sum(processing_times) / len(processing_times), 2), + "min_time": round(min(processing_times), 2), + "max_time": round(max(processing_times), 2), + "avg_cpu_percent": round(sum(cpu_usages) / len(cpu_usages), 2), + "avg_ram_mb": round(sum(ram_usages) / len(ram_usages), 2), + "total_pii_detected": sum(pii_counts), + "avg_pii_per_doc": round(sum(pii_counts) / len(pii_counts), 2) + } + + def generate_report(self, results: List[BenchmarkResult]) -> str: + """ + Génère un rapport texte. + + Args: + results: Liste des résultats + + Returns: + Rapport texte + """ + if not results: + return "Aucun résultat à afficher." + + summary = self.calculate_summary(results) + system_info = self.get_system_info() + + lines = [] + lines.append("=" * 80) + lines.append("RAPPORT DE BENCHMARK - PERFORMANCE D'ANONYMISATION") + lines.append("=" * 80) + lines.append("") + + # Informations système + lines.append("SYSTÈME:") + lines.append(f" OS: {system_info['os']} {system_info['os_version']}") + lines.append(f" CPU: {system_info['cpu']}") + lines.append(f" Cœurs: {system_info['cpu_count']} physiques / {system_info['cpu_count_logical']} logiques") + lines.append(f" RAM: {system_info['ram_gb']} GB") + lines.append(f" Python: {system_info['python_version']}") + lines.append("") + + # Résumé + lines.append("RÉSUMÉ:") + lines.append(f" Documents: {summary['documents_count']}") + lines.append(f" Temps moyen: {summary['avg_time_per_doc']}s") + lines.append(f" Temps min/max: {summary['min_time']}s / {summary['max_time']}s") + lines.append(f" CPU moyen: {summary['avg_cpu_percent']}%") + lines.append(f" RAM moyenne: {summary['avg_ram_mb']} MB") + lines.append(f" PII détectés: {summary['total_pii_detected']} (moy: {summary['avg_pii_per_doc']})") + lines.append("") + + # Détails par document + lines.append("DÉTAILS PAR DOCUMENT:") + lines.append("") + + for result in results: + pdf_name = Path(result.pdf_path).name + lines.append(f" {pdf_name}") + lines.append(f" Temps: {result.processing_time_s:.2f}s " + f"CPU: {result.cpu_usage_percent:.1f}% " + f"RAM: {result.ram_usage_mb:.1f}MB " + f"PII: {result.pii_detected}") + + lines.append("") + lines.append("=" * 80) + + return "\n".join(lines) + + def export_json(self, results: List[BenchmarkResult], output_path: Path): + """ + Exporte les résultats en JSON. + + Args: + results: Liste des résultats + output_path: Chemin du fichier de sortie + """ + data = { + "benchmark_date": datetime.now().isoformat(), + "system_info": self.get_system_info(), + "results": [r.to_dict() for r in results], + "summary": self.calculate_summary(results) + } + + with open(output_path, 'w', encoding='utf-8') as f: + json.dump(data, f, indent=2, ensure_ascii=False) + + print(f"✓ Résultats exportés: {output_path}") + + def export_csv(self, results: List[BenchmarkResult], output_path: Path): + """ + Exporte les résultats en CSV. + + Args: + results: Liste des résultats + output_path: Chemin du fichier de sortie + """ + import csv + + with open(output_path, 'w', newline='', encoding='utf-8') as f: + writer = csv.writer(f) + + # En-tête + writer.writerow([ + "pdf_path", + "processing_time_s", + "time_per_page_s", + "cpu_usage_percent", + "ram_usage_mb", + "pii_detected" + ]) + + # Données + for result in results: + writer.writerow([ + result.pdf_path, + result.processing_time_s, + result.time_per_page_s, + result.cpu_usage_percent, + result.ram_usage_mb, + result.pii_detected + ]) + + print(f"✓ Résultats exportés: {output_path}") + + +if __name__ == "__main__": + # Test basique + benchmark = Benchmark(Path("tests/ground_truth/pdfs")) + + # Afficher les informations système + system_info = benchmark.get_system_info() + print("Informations système:") + for key, value in system_info.items(): + print(f" {key}: {value}") diff --git a/evaluation/leak_scanner.py b/evaluation/leak_scanner.py new file mode 100644 index 0000000..bd104e2 --- /dev/null +++ b/evaluation/leak_scanner.py @@ -0,0 +1,309 @@ +#!/usr/bin/env python3 +""" +Scanner de fuite de PII. + +Vérifie qu'aucun PII ne subsiste dans les documents anonymisés. +""" +import json +import re +from dataclasses import dataclass, field +from pathlib import Path +from typing import List, Dict, Optional + +try: + import pymupdf as fitz +except ImportError: + import fitz + + +@dataclass +class LeakReport: + """Rapport de fuite de PII.""" + + is_safe: bool = True + leak_count: int = 0 + leaks: List[Dict] = field(default_factory=list) + severity_counts: Dict[str, int] = field(default_factory=dict) + + def to_dict(self) -> Dict: + """Convertit en dictionnaire.""" + return { + "is_safe": self.is_safe, + "leak_count": self.leak_count, + "leaks": self.leaks, + "severity_counts": self.severity_counts + } + + +class LeakScanner: + """Scanner de fuite de PII dans les documents anonymisés.""" + + # Regex pour détecter les PII + REGEX_PATTERNS = { + "EMAIL": re.compile(r'\b[A-Za-z0-9._%+-]+@[A-Za-z0-9.-]+\.[A-Z|a-z]{2,}\b'), + "TEL": re.compile(r'(? str: + """ + Extrait le texte d'un PDF. + + Args: + pdf_path: Chemin vers le PDF + + Returns: + Texte extrait + """ + try: + doc = fitz.open(pdf_path) + text = "" + for page in doc: + text += page.get_text() + doc.close() + return text + except Exception as e: + print(f"✗ Erreur lors de l'extraction du texte de {pdf_path}: {e}") + return "" + + def load_original_pii(self, audit_path: Path) -> List[Dict]: + """ + Charge les PII originaux depuis l'audit. + + Args: + audit_path: Chemin vers le fichier .audit.jsonl + + Returns: + Liste des PII originaux + """ + if not audit_path.exists(): + return [] + + try: + pii_list = [] + with open(audit_path, 'r', encoding='utf-8') as f: + for line in f: + if line.strip(): + pii = json.loads(line) + pii_list.append(pii) + return pii_list + except Exception as e: + print(f"✗ Erreur lors du chargement de l'audit {audit_path}: {e}") + return [] + + def scan_text(self, text: str, original_pii: List[Dict]) -> List[Dict]: + """ + Scanne le texte pour détecter les fuites de PII. + + Args: + text: Texte à scanner + original_pii: Liste des PII originaux + + Returns: + Liste des fuites détectées + """ + leaks = [] + + # 1. Vérifier que les PII originaux ne sont plus présents + for pii in original_pii: + original_text = pii.get("original", "") + if not original_text: + continue + + # Recherche insensible à la casse + if re.search(re.escape(original_text), text, re.IGNORECASE): + leaks.append({ + "type": "original_pii_present", + "severity": "CRITIQUE", + "pii_type": pii.get("kind", "UNKNOWN"), + "text": original_text, + "message": f"PII original encore présent: {original_text}" + }) + + # 2. Détecter de nouveaux PII non masqués + for pii_type, pattern in self.REGEX_PATTERNS.items(): + matches = pattern.finditer(text) + for match in matches: + matched_text = match.group() + + # Vérifier si ce PII était dans l'audit original + is_known = any( + pii.get("original", "").lower() == matched_text.lower() + for pii in original_pii + ) + + if not is_known: + leaks.append({ + "type": "new_pii_detected", + "severity": "HAUTE", + "pii_type": pii_type, + "text": matched_text, + "message": f"Nouveau PII détecté: {pii_type} = {matched_text}" + }) + + return leaks + + def scan_metadata(self, pdf_path: Path) -> List[Dict]: + """ + Scanne les métadonnées du PDF. + + Args: + pdf_path: Chemin vers le PDF + + Returns: + Liste des fuites dans les métadonnées + """ + leaks = [] + + try: + doc = fitz.open(pdf_path) + metadata = doc.metadata + doc.close() + + # Champs à vérifier + suspicious_fields = ["author", "creator", "producer", "subject", "title"] + + for field in suspicious_fields: + value = metadata.get(field, "") + if value and value.strip(): + # Vérifier si le champ contient des PII potentiels + # (noms, emails, etc.) + if "@" in value: + leaks.append({ + "type": "metadata_leak", + "severity": "MOYENNE", + "field": field, + "text": value, + "message": f"Métadonnée suspecte ({field}): {value}" + }) + elif any(c.isalpha() for c in value): + # Contient des lettres (potentiellement un nom) + leaks.append({ + "type": "metadata_leak", + "severity": "MOYENNE", + "field": field, + "text": value, + "message": f"Métadonnée suspecte ({field}): {value}" + }) + + except Exception as e: + print(f"✗ Erreur lors du scan des métadonnées de {pdf_path}: {e}") + + return leaks + + def scan(self, anonymized_pdf: Path, original_audit: Path) -> LeakReport: + """ + Scanne un document anonymisé pour détecter les fuites. + + Args: + anonymized_pdf: Chemin vers le PDF anonymisé + original_audit: Chemin vers l'audit original + + Returns: + Rapport de fuite + """ + # Extraire le texte + text = self.extract_text_from_pdf(anonymized_pdf) + + # Charger les PII originaux + original_pii = self.load_original_pii(original_audit) + + # Scanner le texte + text_leaks = self.scan_text(text, original_pii) + + # Scanner les métadonnées + metadata_leaks = self.scan_metadata(anonymized_pdf) + + # Combiner les fuites + all_leaks = text_leaks + metadata_leaks + + # Compter par sévérité + severity_counts = {} + for leak in all_leaks: + severity = leak.get("severity", "UNKNOWN") + severity_counts[severity] = severity_counts.get(severity, 0) + 1 + + # Créer le rapport + report = LeakReport( + is_safe=len(all_leaks) == 0, + leak_count=len(all_leaks), + leaks=all_leaks, + severity_counts=severity_counts + ) + + return report + + def generate_report(self, report: LeakReport, pdf_path: Path) -> str: + """ + Génère un rapport texte. + + Args: + report: Rapport de fuite + pdf_path: Chemin du PDF + + Returns: + Rapport texte + """ + lines = [] + lines.append("=" * 80) + lines.append(f"RAPPORT DE FUITE - {pdf_path.name}") + lines.append("=" * 80) + lines.append("") + + if report.is_safe: + lines.append("✓ DOCUMENT SÛR - Aucune fuite détectée") + else: + lines.append(f"✗ DOCUMENT NON SÛR - {report.leak_count} fuite(s) détectée(s)") + lines.append("") + + # Par sévérité + lines.append("FUITES PAR SÉVÉRITÉ:") + for severity, count in sorted(report.severity_counts.items()): + lines.append(f" {severity}: {count}") + lines.append("") + + # Détails des fuites + lines.append("DÉTAILS DES FUITES:") + for i, leak in enumerate(report.leaks, 1): + lines.append(f"\n [{i}] {leak['severity']} - {leak['type']}") + lines.append(f" Type PII: {leak.get('pii_type', 'N/A')}") + lines.append(f" Texte: {leak.get('text', 'N/A')}") + lines.append(f" Message: {leak.get('message', 'N/A')}") + + lines.append("") + lines.append("=" * 80) + + return "\n".join(lines) + + def export_json(self, report: LeakReport, output_path: Path): + """ + Exporte le rapport en JSON. + + Args: + report: Rapport de fuite + output_path: Chemin du fichier de sortie + """ + with open(output_path, 'w', encoding='utf-8') as f: + json.dump(report.to_dict(), f, indent=2, ensure_ascii=False) + + print(f"✓ Rapport exporté: {output_path}") + + +if __name__ == "__main__": + # Test basique + scanner = LeakScanner() + + # Exemple d'utilisation + anonymized_pdf = Path("tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.redacted.pdf") + original_audit = Path("tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.audit.jsonl") + + if anonymized_pdf.exists() and original_audit.exists(): + report = scanner.scan(anonymized_pdf, original_audit) + print(scanner.generate_report(report, anonymized_pdf)) diff --git a/evaluation/quality_evaluator.py b/evaluation/quality_evaluator.py new file mode 100644 index 0000000..3f8833d --- /dev/null +++ b/evaluation/quality_evaluator.py @@ -0,0 +1,522 @@ +#!/usr/bin/env python3 +""" +Évaluateur de qualité d'anonymisation. + +Compare les annotations manuelles (ground truth) avec les détections automatiques +pour calculer les métriques de qualité (Précision, Rappel, F1-Score). +""" +import json +from dataclasses import dataclass, field +from pathlib import Path +from typing import List, Dict, Tuple, Optional +import re + + +@dataclass +class EvaluationResult: + """Résultat d'évaluation pour un document.""" + + pdf_path: str + true_positives: int = 0 + false_positives: int = 0 + false_negatives: int = 0 + precision: float = 0.0 + recall: float = 0.0 + f1_score: float = 0.0 + missed_pii: List[Dict] = field(default_factory=list) # Faux négatifs détaillés + false_detections: List[Dict] = field(default_factory=list) # Faux positifs détaillés + by_type: Dict[str, Dict] = field(default_factory=dict) # Métriques par type de PII + + def to_dict(self) -> Dict: + """Convertit en dictionnaire.""" + return { + "pdf_path": self.pdf_path, + "true_positives": self.true_positives, + "false_positives": self.false_positives, + "false_negatives": self.false_negatives, + "precision": round(self.precision, 4), + "recall": round(self.recall, 4), + "f1_score": round(self.f1_score, 4), + "missed_pii": self.missed_pii, + "false_detections": self.false_detections, + "by_type": self.by_type + } + + +class QualityEvaluator: + """Évaluateur de qualité d'anonymisation.""" + + # Mapping des types de PII entre annotations et détections + TYPE_MAPPING = { + # Annotations → Détections possibles + "NOM": ["NOM", "NOM_GLOBAL", "PRENOM", "PRENOM_GLOBAL"], + "PRENOM": ["PRENOM", "PRENOM_GLOBAL", "NOM", "NOM_GLOBAL"], + "TEL": ["TEL", "TEL_GLOBAL"], + "EMAIL": ["EMAIL", "EMAIL_GLOBAL"], + "ADRESSE": ["ADRESSE", "ADRESSE_GLOBAL"], + "CODE_POSTAL": ["CODE_POSTAL", "CODE_POSTAL_GLOBAL"], + "VILLE": ["VILLE", "VILLE_GLOBAL"], + "NIR": ["NIR", "NIR_GLOBAL"], + "IPP": ["IPP", "IPP_GLOBAL"], + "NDA": ["NDA", "NDA_GLOBAL"], + "RPPS": ["RPPS", "RPPS_GLOBAL"], + "FINESS": ["FINESS", "FINESS_GLOBAL"], + "OGC": ["OGC", "OGC_GLOBAL"], + "ETABLISSEMENT": ["ETAB", "ETAB_GLOBAL", "VLM_ETAB"], + "SERVICE": ["SERVICE", "SERVICE_GLOBAL", "VLM_SERVICE"], + "DATE": ["DATE", "DATE_GLOBAL"], + "DATE_NAISSANCE": ["DATE_NAISSANCE", "DATE_NAISSANCE_GLOBAL"], + "AGE": ["AGE", "AGE_GLOBAL"], + "NUMERO_PATIENT": ["VLM_NUM_PATIENT", "IPP"], + "NUMERO_LOT": ["VLM_NUM_LOT"], + "NUMERO_ORDONNANCE": ["VLM_NUM_ORD"], + "NUMERO_SEJOUR": ["VLM_NUM_SEJOUR", "NDA"], + } + + def __init__(self, ground_truth_dir: Path): + """ + Initialise l'évaluateur. + + Args: + ground_truth_dir: Répertoire contenant les annotations manuelles + """ + self.ground_truth_dir = Path(ground_truth_dir) + + def normalize_text(self, text: str) -> str: + """ + Normalise un texte pour la comparaison. + + Args: + text: Texte à normaliser + + Returns: + Texte normalisé + """ + # Lowercase + text = text.lower() + + # Supprimer les espaces multiples + text = re.sub(r'\s+', ' ', text) + + # Strip + text = text.strip() + + return text + + def load_annotations(self, pdf_path: Path) -> Optional[Dict]: + """ + Charge les annotations manuelles d'un document. + + Args: + pdf_path: Chemin vers le PDF + + Returns: + Annotations ou None si non trouvées + """ + annotation_file = pdf_path.parent / f"{pdf_path.stem}.annotations.json" + + if not annotation_file.exists(): + return None + + try: + with open(annotation_file, 'r', encoding='utf-8') as f: + return json.load(f) + except Exception as e: + print(f"✗ Erreur lors du chargement des annotations {annotation_file}: {e}") + return None + + def load_audit(self, audit_path: Path) -> Optional[List[Dict]]: + """ + Charge l'audit de détection automatique. + + Args: + audit_path: Chemin vers le fichier .audit.jsonl + + Returns: + Liste des détections ou None si non trouvé + """ + if not audit_path.exists(): + return None + + try: + detections = [] + with open(audit_path, 'r', encoding='utf-8') as f: + for line in f: + if line.strip(): + detections.append(json.loads(line)) + return detections + except Exception as e: + print(f"✗ Erreur lors du chargement de l'audit {audit_path}: {e}") + return None + + def types_match(self, ann_type: str, det_type: str) -> bool: + """ + Vérifie si deux types de PII correspondent. + + Args: + ann_type: Type dans l'annotation + det_type: Type dans la détection + + Returns: + True si les types correspondent + """ + # Mapping direct + if ann_type in self.TYPE_MAPPING: + return det_type in self.TYPE_MAPPING[ann_type] + + # Correspondance exacte + return ann_type == det_type + + def compare(self, annotations: List[Dict], detections: List[Dict]) -> Tuple[List, List, List]: + """ + Compare les annotations avec les détections. + + Args: + annotations: Liste des annotations manuelles + detections: Liste des détections automatiques + + Returns: + Tuple (true_positives, false_negatives, false_positives) + """ + true_positives = [] + false_negatives = [] + false_positives = [] + + # Créer des clés de comparaison pour les annotations + ann_keys = {} + for ann in annotations: + page = ann.get("page", 0) + pii_type = ann.get("type", "") + text = self.normalize_text(ann.get("text", "")) + + key = (page, text) + if key not in ann_keys: + ann_keys[key] = [] + ann_keys[key].append(ann) + + # Créer des clés de comparaison pour les détections + det_keys = {} + for det in detections: + page = det.get("page", 0) + text = self.normalize_text(det.get("original", "")) + + key = (page, text) + if key not in det_keys: + det_keys[key] = [] + det_keys[key].append(det) + + # Trouver les true positives et false negatives + matched_det_keys = set() + + for key, anns in ann_keys.items(): + page, text = key + + if key in det_keys: + # Vérifier si au moins une détection correspond au type + dets = det_keys[key] + matched = False + + for ann in anns: + ann_type = ann.get("type", "") + for det in dets: + det_type = det.get("kind", "") + if self.types_match(ann_type, det_type): + true_positives.append({ + "page": page, + "type": ann_type, + "text": ann.get("text", ""), + "detected_as": det_type, + "context": ann.get("context", "") + }) + matched = True + matched_det_keys.add(key) + break + if matched: + break + + if not matched: + # Détecté mais type incorrect + for ann in anns: + false_negatives.append({ + "page": page, + "type": ann.get("type", ""), + "text": ann.get("text", ""), + "context": ann.get("context", ""), + "reason": "type_mismatch", + "detected_as": [d.get("kind", "") for d in dets] + }) + else: + # Non détecté + for ann in anns: + false_negatives.append({ + "page": page, + "type": ann.get("type", ""), + "text": ann.get("text", ""), + "context": ann.get("context", ""), + "reason": "not_detected" + }) + + # Trouver les false positives + for key, dets in det_keys.items(): + if key not in matched_det_keys: + page, text = key + for det in dets: + false_positives.append({ + "page": page, + "type": det.get("kind", ""), + "text": det.get("original", ""), + "placeholder": det.get("placeholder", "") + }) + + return true_positives, false_negatives, false_positives + + def calculate_metrics(self, tp: int, fp: int, fn: int) -> Tuple[float, float, float]: + """ + Calcule les métriques de qualité. + + Args: + tp: True positives + fp: False positives + fn: False negatives + + Returns: + Tuple (precision, recall, f1_score) + """ + # Précision + precision = tp / (tp + fp) if (tp + fp) > 0 else 0.0 + + # Rappel + recall = tp / (tp + fn) if (tp + fn) > 0 else 0.0 + + # F1-Score + f1_score = 2 * (precision * recall) / (precision + recall) if (precision + recall) > 0 else 0.0 + + return precision, recall, f1_score + + def calculate_metrics_by_type(self, tp_list: List[Dict], fn_list: List[Dict], fp_list: List[Dict]) -> Dict[str, Dict]: + """ + Calcule les métriques par type de PII. + + Args: + tp_list: Liste des true positives + fn_list: Liste des false negatives + fp_list: Liste des false positives + + Returns: + Dictionnaire des métriques par type + """ + by_type = {} + + # Compter par type + for tp in tp_list: + pii_type = tp["type"] + if pii_type not in by_type: + by_type[pii_type] = {"tp": 0, "fp": 0, "fn": 0} + by_type[pii_type]["tp"] += 1 + + for fn in fn_list: + pii_type = fn["type"] + if pii_type not in by_type: + by_type[pii_type] = {"tp": 0, "fp": 0, "fn": 0} + by_type[pii_type]["fn"] += 1 + + for fp in fp_list: + pii_type = fp["type"] + if pii_type not in by_type: + by_type[pii_type] = {"tp": 0, "fp": 0, "fn": 0} + by_type[pii_type]["fp"] += 1 + + # Calculer les métriques + for pii_type, counts in by_type.items(): + tp = counts["tp"] + fp = counts["fp"] + fn = counts["fn"] + + precision, recall, f1 = self.calculate_metrics(tp, fp, fn) + + counts["precision"] = round(precision, 4) + counts["recall"] = round(recall, 4) + counts["f1_score"] = round(f1, 4) + + return by_type + + def evaluate(self, pdf_path: Path, audit_path: Path) -> Optional[EvaluationResult]: + """ + Évalue la qualité d'anonymisation d'un document. + + Args: + pdf_path: Chemin vers le PDF original + audit_path: Chemin vers le fichier .audit.jsonl + + Returns: + Résultat d'évaluation ou None si erreur + """ + # Charger les annotations + annotations_data = self.load_annotations(pdf_path) + if not annotations_data: + print(f"✗ Annotations introuvables pour {pdf_path.name}") + return None + + annotations = annotations_data.get("annotations", []) + + # Charger l'audit + detections = self.load_audit(audit_path) + if detections is None: + print(f"✗ Audit introuvable: {audit_path}") + return None + + # Comparer + tp_list, fn_list, fp_list = self.compare(annotations, detections) + + # Calculer les métriques globales + tp = len(tp_list) + fp = len(fp_list) + fn = len(fn_list) + + precision, recall, f1_score = self.calculate_metrics(tp, fp, fn) + + # Calculer les métriques par type + by_type = self.calculate_metrics_by_type(tp_list, fn_list, fp_list) + + # Créer le résultat + result = EvaluationResult( + pdf_path=str(pdf_path), + true_positives=tp, + false_positives=fp, + false_negatives=fn, + precision=precision, + recall=recall, + f1_score=f1_score, + missed_pii=fn_list, + false_detections=fp_list, + by_type=by_type + ) + + return result + + def evaluate_batch(self, pdf_list: List[Path], audit_list: List[Path]) -> List[EvaluationResult]: + """ + Évalue un batch de documents. + + Args: + pdf_list: Liste des PDFs + audit_list: Liste des audits + + Returns: + Liste des résultats d'évaluation + """ + results = [] + + for pdf_path, audit_path in zip(pdf_list, audit_list): + result = self.evaluate(pdf_path, audit_path) + if result: + results.append(result) + + return results + + def generate_report(self, results: List[EvaluationResult]) -> str: + """ + Génère un rapport texte des résultats. + + Args: + results: Liste des résultats d'évaluation + + Returns: + Rapport texte + """ + if not results: + return "Aucun résultat à afficher." + + # Calculer les métriques globales + total_tp = sum(r.true_positives for r in results) + total_fp = sum(r.false_positives for r in results) + total_fn = sum(r.false_negatives for r in results) + + avg_precision = sum(r.precision for r in results) / len(results) + avg_recall = sum(r.recall for r in results) / len(results) + avg_f1 = sum(r.f1_score for r in results) / len(results) + + # Générer le rapport + report = [] + report.append("=" * 80) + report.append("RAPPORT D'ÉVALUATION DE LA QUALITÉ D'ANONYMISATION") + report.append("=" * 80) + report.append("") + + report.append(f"Documents évalués: {len(results)}") + report.append("") + + report.append("MÉTRIQUES GLOBALES:") + report.append(f" True Positives: {total_tp}") + report.append(f" False Positives: {total_fp}") + report.append(f" False Negatives: {total_fn}") + report.append("") + report.append(f" Précision moyenne: {avg_precision:.4f} ({avg_precision*100:.2f}%)") + report.append(f" Rappel moyen: {avg_recall:.4f} ({avg_recall*100:.2f}%)") + report.append(f" F1-Score moyen: {avg_f1:.4f}") + report.append("") + + # Résultats par document + report.append("RÉSULTATS PAR DOCUMENT:") + report.append("") + + for result in results: + pdf_name = Path(result.pdf_path).name + report.append(f" {pdf_name}") + report.append(f" Précision: {result.precision:.4f} Rappel: {result.recall:.4f} F1: {result.f1_score:.4f}") + report.append(f" TP: {result.true_positives} FP: {result.false_positives} FN: {result.false_negatives}") + report.append("") + + # Faux négatifs critiques + critical_fn = [] + for result in results: + for fn in result.missed_pii: + if fn.get("reason") == "not_detected": + critical_fn.append((Path(result.pdf_path).name, fn)) + + if critical_fn: + report.append(f"FAUX NÉGATIFS CRITIQUES ({len(critical_fn)}):") + report.append("") + for pdf_name, fn in critical_fn[:10]: # Limiter à 10 + report.append(f" {pdf_name} - Page {fn['page']+1}") + report.append(f" Type: {fn['type']}") + report.append(f" Texte: {fn['text']}") + report.append(f" Contexte: {fn['context'][:80]}...") + report.append("") + + report.append("=" * 80) + + return "\n".join(report) + + def export_json(self, results: List[EvaluationResult], output_path: Path): + """ + Exporte les résultats en JSON. + + Args: + results: Liste des résultats + output_path: Chemin du fichier de sortie + """ + data = { + "evaluation_date": Path(__file__).stat().st_mtime, + "documents_count": len(results), + "results": [r.to_dict() for r in results] + } + + with open(output_path, 'w', encoding='utf-8') as f: + json.dump(data, f, indent=2, ensure_ascii=False) + + print(f"✓ Résultats exportés: {output_path}") + + +if __name__ == "__main__": + # Test basique + evaluator = QualityEvaluator(Path("tests/ground_truth/pdfs")) + + # Exemple d'utilisation + pdf_path = Path("tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.pdf") + audit_path = Path("tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.audit.jsonl") + + if pdf_path.exists() and audit_path.exists(): + result = evaluator.evaluate(pdf_path, audit_path) + if result: + print(evaluator.generate_report([result])) diff --git a/run_batch_59ogc.py b/run_batch_59ogc.py new file mode 100644 index 0000000..56e520a --- /dev/null +++ b/run_batch_59ogc.py @@ -0,0 +1,84 @@ +#!/usr/bin/env python3 +"""Batch processing des 59 premiers OGC — script CLI pour test post-modifications.""" +import sys +import time +import json +from pathlib import Path +from collections import Counter + +sys.path.insert(0, str(Path(__file__).parent)) + +import anonymizer_core_refactored_onnx as core +from eds_pseudo_manager import EdsPseudoManager + +SRC = Path("/home/dom/Téléchargements/II-1 Ctrl_T2A_2025_CHCB_DocJustificatifs (1)") +OUTDIR = SRC / "anonymise" +CONFIG = Path("/home/dom/ai/anonymisation/config/dictionnaires.yml") + +def main(): + # Charger EDS-Pseudo + print("Chargement EDS-Pseudo...", flush=True) + ner = EdsPseudoManager() + ner.load() + assert ner.is_loaded(), "EDS-Pseudo non chargé" + print("EDS-Pseudo chargé.", flush=True) + + # Lister les 59 premiers dossiers OGC + ogc_dirs = sorted( + [d for d in SRC.iterdir() if d.is_dir() and "_" in d.name and d.name[0].isdigit()], + key=lambda d: int(d.name.split("_")[0]), + )[:59] + print(f"Dossiers OGC: {len(ogc_dirs)}") + + # Collecter tous les PDFs + pdfs = [] + for d in ogc_dirs: + for pdf in sorted(d.glob("*.pdf")): + pdfs.append(pdf) + print(f"PDFs à traiter: {len(pdfs)}") + + OUTDIR.mkdir(exist_ok=True) + ok = ko = 0 + global_counts = Counter() + t0 = time.time() + + for i, pdf in enumerate(pdfs, 1): + ogc = pdf.parent.name.split("_")[0] + print(f"[{i}/{len(pdfs)}] {pdf.name} (OGC {ogc})...", end=" ", flush=True) + try: + outputs = core.process_pdf( + pdf_path=pdf, + out_dir=OUTDIR, + make_vector_redaction=False, + also_make_raster_burn=True, + config_path=CONFIG, + use_hf=True, + ner_manager=ner, + ner_thresholds=None, + ogc_label=ogc, + ) + # Compter les hits audit + audit_path = Path(outputs.get("audit", "")) + if audit_path.exists(): + for line in audit_path.read_text().splitlines(): + try: + h = json.loads(line) + global_counts[h["kind"]] += 1 + except Exception: + pass + print("OK", flush=True) + ok += 1 + except Exception as e: + print(f"ERREUR: {e}", flush=True) + ko += 1 + + elapsed = time.time() - t0 + print(f"\n{'='*60}") + print(f"Terminé en {elapsed:.0f}s — OK: {ok}, Erreurs: {ko}") + print(f"Total PII détectés: {sum(global_counts.values())}") + print(f"\nDétail par type:") + for k, v in sorted(global_counts.items(), key=lambda x: -x[1]): + print(f" {k:30s} {v:6d}") + +if __name__ == "__main__": + main() diff --git a/test_3ogc/316_23061393/trackare-BA165196-23061393_BA165196_23061393.pdf b/test_3ogc/316_23061393/trackare-BA165196-23061393_BA165196_23061393.pdf new file mode 100644 index 0000000..e0dcb3c Binary files /dev/null and b/test_3ogc/316_23061393/trackare-BA165196-23061393_BA165196_23061393.pdf differ diff --git a/test_3ogc/407_23116460/407 crh.pdf b/test_3ogc/407_23116460/407 crh.pdf new file mode 100644 index 0000000..fdb5e1d Binary files /dev/null and b/test_3ogc/407_23116460/407 crh.pdf differ diff --git a/test_3ogc/407_23116460/trackare-02004744-23116460_02004744_23116460.pdf b/test_3ogc/407_23116460/trackare-02004744-23116460_02004744_23116460.pdf new file mode 100644 index 0000000..5d0a6d7 Binary files /dev/null and b/test_3ogc/407_23116460/trackare-02004744-23116460_02004744_23116460.pdf differ diff --git a/test_3ogc/589_23042510/trackare-01285757-23042510_01285757_23042510.pdf b/test_3ogc/589_23042510/trackare-01285757-23042510_01285757_23042510.pdf new file mode 100644 index 0000000..75e83a8 Binary files /dev/null and b/test_3ogc/589_23042510/trackare-01285757-23042510_01285757_23042510.pdf differ diff --git a/test_3ogc/anonymise/407 crh.audit.jsonl b/test_3ogc/anonymise/407 crh.audit.jsonl new file mode 100644 index 0000000..ba512da --- /dev/null +++ b/test_3ogc/anonymise/407 crh.audit.jsonl @@ -0,0 +1,369 @@ +{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null} +{"page": 0, "kind": "ADRESSE", "original": 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-1, "kind": "ADRESSE_GLOBAL", "original": "300 CHEMIN DE TEILLATU MAITA", "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": "CODE_POSTAL_GLOBAL", "original": "64109 BAYONNE CEDEX", "placeholder": "[CODE_POSTAL]", "bbox_hint": null} +{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64122 URRUGNE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "05 59 63 35 88", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "05 59 44 35 35", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "05.59.44.37.42", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "05.59.44.37.32", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "05.59.44.38.62", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "05.59.44.37.33", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "05.33.78.81.89", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "05.59.44.37.74", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE_GLOBAL", "original": "N° Episode 23116460", "placeholder": "[EPISODE]", "bbox_hint": null} diff --git a/test_3ogc/anonymise/407 crh.pseudonymise.txt b/test_3ogc/anonymise/407 crh.pseudonymise.txt new file mode 100644 index 0000000..af063a8 --- /dev/null +++ b/test_3ogc/anonymise/407 crh.pseudonymise.txt @@ -0,0 +1,413 @@ +N° Finess [MASK] +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +Pôle Médecine Interne +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Bayonne, le 23/06/2023 +CHEF DE PÔLE +Dr [NOM] +M [NOM] [NOM] +DERMATOLOGIE [ADRESSE] +Dr [NOM] MAISON [NOM] [NOM] +Chef de Service +Dr [NOM] [CODE_POSTAL] +Dr [NOM] +Secrétariat : +[TEL] Mon cher confrère, +ENDOCRINOLOGIE +Dr [NOM] Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 19/06/2023 au 23/06/2023 pour le motif +C D h r e f E d l e i s S a e r M vic A e URY suivant : +Dr [NOM] +D D r r M M a a r th io ie n u G A S U C Z H I WIND - Motif entrée : +Secrétariat : +[TEL] Première éducation dans le cadre d'un diabète de type 2 +MAL. INFECTIEUSES Introduction de GLP1 en en neurologie lors de son AVC en mai 2023 (HbA1c 7,9%) +Dr [NOM] +Chef de Service Antécédents +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] SAOS appareillé +Secrétariat : +[TEL] diabete +HTA +NEPHROLOGIE AVC fin mai +Dr [NOM] +Chef de Service +Dr [NOM] [NOM] Suivi retentissement : +Dr [NOM] [NOM] Ophtalmo Dr [NOM], dernière cs 4/05/2023 : rétinopathie minime et maculopathie. IVT OD prévue +Dr [NOM] +Dr [NOM] [NOM] cardio : dernière évaluation Dr [NOM] en juillet 2021 +Secrétariat : +[TEL] Traitements habituels +RHUMATOLOGIE Nebivolol 5 mg 1-0-0 +Dr [NOM] Pravastatine 40 mg 1 le soir +Chef de Service Eliquis 5 : 1 cp matin et soir +Dr [NOM] +Dr [NOM] Perindopril 10mg 1-0-0 +Secrétariat : Amlodipine 5 le matin +[TEL] Velmetia 50/1000mg 1-0-1 (alors que je l'avais arrêté en neurologie et j'avais prescrit metformine seule) +MÉDECINE INTERNE Gliclazide 30mg 2-0-0 +Dr [NOM] Trulicity 1,5 les mardis +Chef de Service +Dr [NOM] +Dr [NOM] Vaccination ne sait pas pour covid et tétanos, n'a jamais été vacciné contre la grippe +Secrétariat : +[TEL] Mode de vie : +Vit avec son épouse +n'a jamais fumé +EC : +Ralentisement idéomoteur +Poids 98,9 IMC 33,4 kg/m² +Onychomycose, pallesthésie OK, pouls OK pieds grade 0 +Biologie : +HbA1C 7,1% +TSH 0,72 +LDL 0,55 Tg 0,92 HDL 0,31 g/l +iono NFS bilan hépatique sans anomalies +Créatinémie 65 µmol/l +RAC 2,6 mg/mmol +Albuminémie 39,4 g/L +Carence modérée en vitamine D +Pas de carence en vitamine B12 et folates +PRISE EN CHARGE DANS LE SERVICE : +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 12/02/1947 +IPP : [IPP] / [EPISODE] (Pôle Méd. interne : H semaine) +V1 - Imprimé le 06/06/2025 à 14 : 34 par Page(s): 1 sur 3 N° Finess [MASK] +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +Pôle Médecine Interne +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Pas de modification du traitement antidiabétique +CHEF DE PÔLE avis EMOG (cf CR). Introduction de seroplex +Dr [NOM] Supplémentation par une ampoule d'uvedose +DERMATOLOGIE +Dr [NOM] [NOM] Suivi : +Chef de Service Pas de cs diabéto +Dr [NOM] +Dr [NOM] HbA1C tous les 3 mois, objectif 7,5% +Secrétariat : Cs cardio à reprévoir +[TEL] CS cardio pour IVT à organiser avec le Dr [NOM] +ENDOCRINOLOGIE +Dr [NOM] [NOM] Conclusion : diabète type 2 compliqué sur le plan vasculaire, bien équilibré depuis l'introduction de GLP1 +Chef de Service Syndrome dépressif, introduction de seroplex après avis EMOG +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +Avis spécialisés : +MAL. INFECTIEUSES +Dr [NOM] [NOM] [NOM] 22/06/2023 17 : 49 DR. [NOM]: HDS/ETP/Atelier de groupe +Chef de Service A participé à une séance collective de l’atelier « Mieux Connaitre mes Médicaments » +Dr [NOM] [NOM] A partir de l’ordonnance de ce jour, les principaux points abordés : +Dr [NOM] +Dr [NOM] - Savoir distinguer les médicaments du diabète des médicaments des autres pathologies +Dr [NOM] - Mieux connaitre les indications de chaque médicament +Secrétariat : - Principaux effets indésirables survenus ou à « prévenir » : Metformine notamment +[TEL] +- Horaires de prise : notamments quels médicaments ne pas prendre si repas sauté +NEPHROLOGIE - Pilulier : principe & modalités d’utilisation pratique d’un pilulier semainier +Dr [NOM] [NOM] - Automédication responsable : Attention aux AINS en vente sans ordonnances +Chef de Service +Dr [NOM] - Informer les différents professionnels de santé de toutes les prises de médicaments ou de phytothérapie (Tisanes, Huiles +Dr [NOM] essentielles…) Jus de pamplemousse, Millepertuis & Interactions médicamenteuses +Dr [NOM] - S’assurer d’avoir l’ensemble des ordonnances et qu’elles soient à jour +Dr [NOM] +Secrétariat : - Ne pas hésiter à solliciter les pharmaciens pour info sur médicaments surtout lors du switch vers les génériques +[TEL] +RHUMATOLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] [NOM] Votre patient(e) quitte le service avec : +Dr [NOM] +Secrétariat : - Pharmacie : +[TEL] PRAVASTATINE MYL 40MG CPR [28] COMPRIME(S) 1 COMPRIME (ORALE) soir [19h] +MÉDECINE INTERNE GLICLAZIDE ARW LM 30MG CPR [30] COMPRIME(S) 2 COMPRIME (ORALE) matin [8h] +Dr [NOM] METFORMINE MYP 1000MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 19h) +Chef de Service NEBIVOLOL ARW 5MG CPR [90] COMPRIME(S) 1 COMPRIME (ORALE) matin [8h] +Dr [NOM] +Dr [NOM] PERINDOPRIL ARW 4MG CPR [30] COMPRIME(S) 2 COMPRIME (ORALE) matin [8h] +Secrétariat : ELIQUIS 5MG CPR [60] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 19h) +[TEL] AMLODIPINE ARG 5MG GELULE [30] Gelule(s) 1 GELULE (ORALE) matin [8h] +TRULICITY 1,5 MG SOL INJ STYLO [4] Stylo(s) Prerempli(s) 1.5 MG (SOUS-CUTANEE) en direct 1xsemaine [8h] +Les consignes d'usage ont été remises. +Bien confraternellement, +Docteur [NOM] +*10004401716* +10004401716 +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 12/02/1947 +IPP : [IPP] / [EPISODE] (Pôle Méd. interne : H semaine) +V1 - Imprimé le 06/06/2025 à 14 : 34 par Page(s): 2 sur 3 N° Finess [MASK] +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +Pôle Médecine Interne +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Liste des destinataires : +CHEF DE PÔLE +Dr [NOM] Monsieur [NOM] +DERMATOLOGIE DR. [NOM] +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +ENDOCRINOLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MAL. INFECTIEUSES +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +NEPHROLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +RHUMATOLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MÉDECINE INTERNE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 12/02/1947 +IPP : [IPP] / [EPISODE] (Pôle Méd. interne : H semaine) +V1 - Imprimé le 06/06/2025 à 14 : 34 par Page(s): 3 sur 3 N° Finess [MASK] +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +Pôle Médecine Interne +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Bayonne, le 23/06/2023 +CHEF DE PÔLE +Dr [NOM] +DR [NOM] +DERMATOLOGIE [ADRESSE] +Dr [NOM] [CODE_POSTAL] +Chef de Service +Dr [NOM] +Dr [NOM] +Secrétariat : Mon cher confrère, +[TEL] +ENDOCRINOLOGIE Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 19/06/2023 au 23/06/2023 pour le motif +Dr [NOM] [NOM] suivant : +Chef de Service +Dr [NOM] +Dr [NOM] [NOM] - Motif entrée : +Dr [NOM] +Dr [NOM] +Secrétariat : Première éducation dans le cadre d'un diabète de type 2 +[TEL] Introduction de GLP1 en en neurologie lors de son AVC en mai 2023 (HbA1c 7,9%) +MAL. INFECTIEUSES +Dr [NOM] Antécédents +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] SAOS appareillé +Dr [NOM] diabete +Secrétariat : +[TEL] HTA +AVC fin mai +NEPHROLOGIE +Dr [NOM] +Chef de Service Suivi retentissement : +Dr [NOM] [NOM] Ophtalmo Dr [NOM], dernière cs 4/05/2023 : rétinopathie minime et maculopathie. IVT OD prévue +Dr [NOM] [NOM] cardio : dernière évaluation Dr [NOM] en juillet 2021 +Dr [NOM] +Dr [NOM] +Secrétariat : Traitements habituels +[TEL] Nebivolol 5 mg 1-0-0 +RHUMATOLOGIE Pravastatine 40 mg 1 le soir +Dr [NOM] [NOM] [NOM] Eliquis 5 : 1 cp matin et soir +Chef de Service Perindopril 10mg 1-0-0 +Dr [NOM] +Dr [NOM] Amlodipine 5 le matin +Secrétariat : Velmetia 50/1000mg 1-0-1 (alors que je l'avais arrêté en neurologie et j'avais prescrit metformine seule) +[TEL] Gliclazide 30mg 2-0-0 +MÉDECINE INTERNE Trulicity 1,5 les mardis +Dr [NOM] +Chef de Service Vaccination ne sait pas pour covid et tétanos, n'a jamais été vacciné contre la grippe +Dr [NOM] +Dr [NOM] +Secrétariat : Mode de vie : +[TEL] Vit avec son épouse +n'a jamais fumé +EC : +Ralentisement idéomoteur +Poids 98,9 IMC 33,4 kg/m² +Onychomycose, pallesthésie OK, pouls OK pieds grade 0 +Biologie : +HbA1C 7,1% +TSH 0,72 +LDL 0,55 Tg 0,92 HDL 0,31 g/l +iono NFS bilan hépatique sans anomalies +Créatinémie 65 µmol/l +RAC 2,6 mg/mmol +Albuminémie 39,4 g/L +Carence modérée en vitamine D +Pas de carence en vitamine B12 et folates +PRISE EN CHARGE DANS LE SERVICE : +Pas de modification du traitement antidiabétique +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 12/02/1947 +IPP : [IPP] / [EPISODE] (Pôle Méd. interne : H semaine) +V1 - Imprimé le 06/06/2025 à 14 : 34 par Page(s): 1 sur 3 N° Finess [MASK] +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +Pôle Médecine Interne +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +avis EMOG (cf CR). Introduction de seroplex +CHEF DE PÔLE Supplémentation par une ampoule d'uvedose +Dr [NOM] +DERMATOLOGIE Suivi : +Dr [NOM] Pas de cs diabéto +Chef de Service HbA1C tous les 3 mois, objectif 7,5% +Dr [NOM] +Dr [NOM] cardio à reprévoir +Secrétariat : CS cardio pour IVT à organiser avec le Dr [NOM] +[TEL] +ENDOCRINOLOGIE Conclusion : diabète type 2 compliqué sur le plan vasculaire, bien équilibré depuis l'introduction de GLP1 +Dr [NOM] Syndrome dépressif, introduction de seroplex après avis EMOG +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] Avis spécialisés : +22/06/2023 17 : 49 DR. [NOM]: HDS/ETP/Atelier de groupe +MAL. INFECTIEUSES +Dr [NOM] A participé à une séance collective de l’atelier « Mieux Connaitre mes Médicaments » +Chef de Service A partir de l’ordonnance de ce jour, les principaux points abordés : +Dr [NOM] - Savoir distinguer les médicaments du diabète des médicaments des autres pathologies +Dr [NOM] +Dr [NOM] - Mieux connaitre les indications de chaque médicament +Dr [NOM] [NOM] - Principaux effets indésirables survenus ou à « prévenir » : Metformine notamment +Secrétariat : - Horaires de prise :notamments quels médicaments ne pas prendre si repas sauté +[TEL] +- Pilulier : principe & modalités d’utilisation pratique d’un pilulier semainier +NEPHROLOGIE - Automédication responsable : Attention aux AINS en vente sans ordonnances +Dr [NOM] - Informer les différents professionnels de santé de toutes les prises de médicaments ou de phytothérapie (Tisanes, Huiles +Chef de Service +Dr [NOM] essentielles…) Jus de pamplemousse, Millepertuis & Interactions médicamenteuses +Dr [NOM] - S’assurer d’avoir l’ensemble des ordonnances et qu’elles soient à jour +Dr [NOM] - Ne pas hésiter à solliciter les pharmaciens pour info sur médicaments surtout lors du switch vers les génériques +Dr [NOM] +Secrétariat : +[TEL] +RHUMATOLOGIE +Dr [NOM] +Chef de Service Votre patient(e) quitte le service avec : +Dr [NOM] +Dr [NOM] [NOM] - Pharmacie : +Secrétariat : PRAVASTATINE MYL 40MG CPR [28] COMPRIME(S) 1 COMPRIME (ORALE) soir [19h] +[TEL] GLICLAZIDE ARW LM 30MG CPR [30] COMPRIME(S) 2 COMPRIME (ORALE) matin [8h] +MÉDECINE INTERNE METFORMINE MYP 1000MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 19h) +Dr [NOM] NEBIVOLOL ARW 5MG CPR [90] COMPRIME(S) 1 COMPRIME (ORALE) matin [8h] +Chef de Service PERINDOPRIL ARW 4MG CPR [30] COMPRIME(S) 2 COMPRIME (ORALE) matin [8h] +Dr [NOM] +Dr [NOM] ELIQUIS 5MG CPR [60] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 19h) +Secrétariat : AMLODIPINE ARG 5MG GELULE [30] Gelule(s) 1 GELULE (ORALE) matin [8h] +[TEL] TRULICITY 1,5 MG SOL INJ STYLO [4] Stylo(s) Prerempli(s) 1.5 MG (SOUS-CUTANEE) en direct 1xsemaine [8h] +Les consignes d'usage ont été remises. +Bien confraternellement, +Docteur [NOM] +*10004401716* +10004401716 +Liste des destinataires : +Patient(e) : [NOM] [NOM] [NOM] Né(e) le 12/02/1947 +IPP : [IPP] / [EPISODE] (Pôle Méd. interne : H semaine) +V1 - Imprimé le 06/06/2025 à 14 : 34 par Page(s): 2 sur 3 N° Finess [MASK] +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +Pôle Médecine Interne +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Monsieur [NOM] +CHEF DE PÔLE +Dr [NOM] DR. [NOM] +DERMATOLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +ENDOCRINOLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MAL. 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"kind": "ADRESSE_GLOBAL", "original": "13, Avenue de l'Interne J", "placeholder": "[ADRESSE]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "0673150938", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "0640649109", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "001122586", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "05 59 44 29 30", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "ETAB_GLOBAL", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null} +{"page": -1, "kind": "ETAB_GLOBAL", "original": "SSR Grancher", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null} +{"page": -1, "kind": "ETAB_GLOBAL", "original": "SSR de Grancher", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null} diff --git a/test_3ogc/anonymise/trackare-01285757-23042510_01285757_23042510.pseudonymise.txt b/test_3ogc/anonymise/trackare-01285757-23042510_01285757_23042510.pseudonymise.txt new file mode 100644 index 0000000..c140ec6 --- /dev/null +++ b/test_3ogc/anonymise/trackare-01285757-23042510_01285757_23042510.pseudonymise.txt @@ -0,0 +1,2859 @@ +[MASK] +*640N0° F0in0ess162* +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +640000162 +ONCOLOGIE - ONCOLOGIE 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]: [NOM] +[NOM] ENEA +Détails épisode +Episode No : [EPISODE] +Localisation : ONCOLOGIE HC Médecin courant: DR. [NOM] +Date d'admission : 24/02/2023 Heure d'admission: 14:51 +Date de sortie : Heure de sortie: +Médecin traitant +Nom Adresse Téléphone +DR. [NOM] [ADRESSE][CODE_POSTAL] D [NOM] [TEL] +Liste des contacts +Tél. +Type de contact Relation Nom Prénom Adresse Tél. domicile Mobile +professionel +Personne à prévenir +Epouse FRANCE [TEL] +(Trakcare) +Personne à prévenir +Fils [NOM] [NOM] [TEL] +(Trakcare) +Antécédents et habitudes de vie (texte libre) +Type de note Nom Date Heure Note +Aucune donnée +renseignée +Signes Vitaux +Item de 02/03/2023 01/03/2023 01/03/2023 01/03/2023 01/03/2023 01/03/2023 28/02/2023 28/02/2023 28/02/2023 28/02/2023 28/02/2023 28/02/2023 28/02/2023 +surveillance 08 : 41 23:24 21:56 18:00 08:43 08:14 23:22 16:09 13:10 09:15 09:00 06:08 04:33 +Température 37,30 37,00 37,40 37,20 37,30 37,50 37,20 37,90 +Pouls 83,00 80,00 82,00 82,00 78,00 +PA +136,00 138,00 144,00 149,00 116,00 +Systolique +PA +71,00 73,00 88,00 72,00 56,00 +Diastolique +PA +93,00 95,00 107,00 98,00 76,00 +Moyenne +Saturation +97,00 95,00 95,00 94,00 95,00 +O² +Ventilation Ventilation Ventilation Ventilation Ventilation +spontanée spontanée spontanée spontanée spontanée +Ventilation +Air Air Air Air Air +ambiant ambiant ambiant ambiant ambiant +Echelle +EN EN EN EN EN +douleur +Score au +0,00 0,00 0,00 0,00 0,00 +repos +Glycémie +1,12 1,23 0,84 1,42 +capillaire +Volume +de miction 400,00 0,00 326,00 +[ml] +Transit Absence Peu Absence +Diurèse +Item de 01/03/2023 28/02/2023 27/02/2023 27/02/2023 26/02/2023 25/02/2023 25/02/2023 25/02/2023 +surveillance 07 : 44 07:55 15:00 07:31 07:56 23:00 15:33 07:59 +Diurèse 1000,00 800,00 300,00 900,00 250,00 400,00 400,00 250,00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 1 de 20 Diurèse +- Cumul 1000,00 1100,00 300,00 900,00 1050,00 800,00 400,00 250,00 +8h/8h +Pyélo/ +Néphro +drte - 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Cumul +8h/8h +Pyélo/ +Néphro +gche - 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Cumul +8h/8h +Diurèse +1000,00 800,00 300,00 900,00 250,00 400,00 400,00 250,00 +Totale +Diurèse +- Cumul 1000,00 1100,00 300,00 900,00 1050,00 800,00 400,00 250,00 +8h/8h Total +Compens +° Diurèse +0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +- Cumul +8h/8h +Balance des entrées - Sorties +Item de 01/03/2023 28/02/2023 27/02/2023 27/02/2023 26/02/2023 25/02/2023 25/02/2023 25/02/2023 +surveillance 07 : 44 07:55 15:00 07:31 07:56 23:00 15:33 07:59 +Balance +hydrique +totale -4300,00 -3300,00 -2500,00 -2200,00 -1300,00 -1050,00 -650,00 -250,00 +(cumulée) +[ml] +Balance +hydrique +-1000,00 -800,00 -300,00 -900,00 -250,00 -400,00 -400,00 -250,00 +totale +(session) +Entrées +totales des +0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +liquides +(cumulé) +Entrées +totales des +liquides 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +(session) +[ml] +Total Pertes +Liquidiennes 4300,00 3300,00 2500,00 2200,00 1300,00 1050,00 650,00 250,00 +(Relevé) +Total Pertes +liquidiennes 1000,00 800,00 300,00 900,00 250,00 400,00 400,00 250,00 +(session) +Poids/Taille +Item de 01/03/2023 28/02/2023 27/02/2023 24/02/2023 +surveillance 08 : 44 10:39 11:09 16:12 +Poids [kg] 76,00 76,00 76,70 73,00 +Taille [cm] 168,00 168,00 168,00 +Indice +de masse 26.927 26.927 25.865 +corporelle +Surface +1.86 1.86 1.83 +corporelle +Surv. Isolement et Contention +Item de 02/03/2023 01/03/2023 01/03/2023 28/02/2023 28/02/2023 28/02/2023 28/02/2023 28/02/2023 28/02/2023 27/02/2023 27/02/2023 26/02/2023 26/02/2023 +surveillance 08 : 41 23:24 08:43 23:22 16:09 13:10 09:15 06:08 04:33 15:48 08:29 22:25 15:37 +Température 37,30 37,00 37,40 37,20 37,30 37,50 37,20 37,90 37,40 37,50 37,30 37,00 +Pouls 83,00 80,00 82,00 82,00 78,00 77,00 72,00 86,00 93,00 +PA +136,00 138,00 144,00 149,00 116,00 166,00 162,00 142,00 116,00 +Systolique +PA +71,00 73,00 88,00 72,00 56,00 83,00 80,00 76,00 60,00 +Diastolique +Saturation +97,00 95,00 95,00 94,00 95,00 96,00 98,00 95,00 +O² +Transit Absence Peu Absence Absence Absence +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 2 de 20 Surv. Contention +Item de 02/03/2023 01/03/2023 01/03/2023 01/03/2023 01/03/2023 28/02/2023 28/02/2023 28/02/2023 28/02/2023 28/02/2023 28/02/2023 28/02/2023 27/02/2023 +surveillance 08 : 41 23:24 18:00 08:43 08:14 23:22 16:09 13:10 09:15 09:00 06:08 04:33 15:48 +Température 37,30 37,00 37,40 37,20 37,30 37,50 37,20 37,90 37,40 +Pouls 83,00 80,00 82,00 82,00 78,00 77,00 +PA +136,00 138,00 144,00 149,00 116,00 166,00 +Systolique +PA +71,00 73,00 88,00 72,00 56,00 83,00 +Diastolique +Saturation +97,00 95,00 95,00 94,00 95,00 96,00 +O² +Glycémie +1,12 1,23 0,84 1,42 +capillaire +Transit Absence Peu Absence +Observations médicales +Type d'observation Nom Date Commentaires +Sur le plan symptomatique/oncologique : +Poursuite d'une bonne évolution clinique. +Reprise alimentation normale et arrêt de l'hydratation. +Scintigraphie osseuse ce jour en Baseline avant initiation TAXOTERE. +Pose de PAC en ambulatoire le 03/03 et programmation des HDJ pour TAXOTERE toutes les 3 +semaines à partir du 08/03. +01/03/2023 +Note d'évolution [NOM] [NOM] +12 : 18 +Sur le plan du devenir : +Transfert au [ETABLISSEMENT] demain en fin de matinée. +Sa fille présente en chambre a été informée de l'ensemble de la prise en charge, de la prise +en charge au [ETABLISSEMENT] demain, de la pose de PAC le 03/03 et de l'initiation de la +chimiothérapie semaine prochaine le 08/03. +Sur le plan symptomatique : +Stabilité clinique, transit ce jour, pas de nausées ni de vomissements. +Poids en diminution -0.7kg (soit +3kg sur l'hyperhydratation depuis le début d'hospitalisation), +sans signe de surcharge pulmonaire. +> Relai traitements per os devant la bonne évolution clinique et biologique avec nette +amélioration de la fonction rénale. +28/02/2023 > Poursuite élargissement progressif de l'alimentation sur la bonne tolérance digestive. +Note d'évolution [NOM] [NOM] +14 : 49 > Prescription kinésithérapie de mobilisation. +Sur le plan spécifique : +En attente date pour une scintigraphie osseuse. Pose de PAC maintenue au 03/03. +Sur le plan du devenir : +Patient favorable à une prise en charge en [ETABLISSEMENT] à Grancher, demande faite. +Sur le plan symptomatique : +Va bien mieux, pas de nausées ni de vomissements. Transit régulier, pas de douleurs +abdominales, abdomen souple, dépressible et indolore. ++3.5kg sans signe de surcharge clinique notamment pulmonaire. +> Elargissement alimentation ce jour, poursuite traitement laxatifs et surveillance transit ++. +> Ajout traitement par XATRAL pour retrait de la sonde urinaire dans 48/72h. +> Diminution hydratation par PG5 à 1L/jour. +Sur le plan oncologique : +Dernière séance de radiothérapie le 28/02. +27/02/2023 +Note d'évolution [NOM] [NOM] Scintigraphie osseuse demandée pour cette semaine, sera probablement réalisée le 01/03. +15 : 36 +Pose de PAC prévue le 03/03 après midi à 16h pour initiation de la nouvelle ligne de +chimiothérapie par TAXOTERE fin de semaine ou début de semaine prochaine. +> Prévoir suspension anticoagulation curative le 02/03. +Sur le plan du devenir : +Discussion avec le patient et son fils ce jour de l'intérêt d'une prise en charge en [ETABLISSEMENT] dans +les suites immédiates de l'hospitalisation à visée de remobilisation et de réautonomisation +qu'ils semblent comprendre et accepter. Explication donnée quant à la visée suspensive de la +chimiothérapie dont l'objectif n'est pas curatif mais à visée de contrôle le plus longtemps possible +de la maladie. +Selles cette nuit en grande quantité avec confusion +nouvelles selles le 26/02 au matin +N'est plus confus, non algique +DR. [NOM] 26/02/2023 +Note d'évolution Essai Fauteuil dans la journée +[NOM] 12 : 07 +BCY ce jour +reprise radiothérapie lundi +Est d'accord pour [ETABLISSEMENT] au décours du C1 de TAXOTERE +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 3 de 20 Effectivement tres altérée +vomissements fécaloïdes à l'arrivée avec SNG productive > 2 Ln pas de selles depuis 8 jours +abdomen souple, pas de fecalome +deshydraté +non douloureux au repos +TDM : Syndrome occlusif grêlique fonctionnel en amont d'une iléite (radique ?). Pas de zone +transitionnelle franche. Progression osseuse avec apparition de tassements pathologiques en T11 +T12 +DR. [NOM] 25/02/2023 +Note d'évolution +[NOM] 12 : 39 +Poursuite CTC 1mg/kg , hydratation ++, ACTISKENAN ALD, laxatifs +++ +Retrait SNG et alimentation liquide auj avec BCY demain si OK +Discuter IRM rachis avant RCP neuro +Achever radiothérapie en début de semaine pour débuter TAXOTERE sans trop tarder selon +évolution [ETABLISSEMENT] : FA à réponse ventriculaire rapide à 160bpm. +24/02/2023 > Non connue, pas d'anticoagulation curative en place. +Note d'évolution [NOM] [NOM] +16 : 52 > Avis cardio (Dr [NOM]) : Mise en place d'une anticoagulation curative, pas de bloquant du +fait de la tension artérielle limite, à rediscuter selon évolution. +Motif d'hospitalisation : +Altération de l’état général chez un patient pris en charge pour un adénocarcinome prostatique +résistant à la castration en progression osseuse. +Antécédents : +- Familiaux : +3-4 cancers de prostate chez les frères, cancer digestif d’étiologie non connue chez la mère, +cancer du sein chez la sœur vers 50 ans. +- Médicaux : +Au plan personnel, HTA sous bithérapie. +Dyslipidémie. +Zona. +Amygdalectomie. +- Chirurgicaux : +* +- Allergies : +Pas d’allergie. +- Traitement en cours : +ENANTONE 30 / 1 sous cut par 6 mois. +DUROGESIC 25. +ACTISKENAN 10 à la demande. +GABAPENTINE 300mg matin et soir. +CORTANCYL 40 mg matin, 40 mg midi. +Histoire de la 24/02/2023 COAPROVEL 300/12.5 : suspendu ? +[NOM] [NOM] +maladie 16 : 20 INNEGY 10/20 : suspendu ? +- Mode de vie : +Marié, 3 enfants de 55, 53, 50 ans, 6 petits-enfants. +Habite [NOM] [NOM] D’[NOM]. +Chef d’entreprise dans l’industrie du self-service. +Histoire de la maladie : +2003 : diagnostic de cancer de prostate localisé sur PSA augmenté, traité par prostatectomie +radicale : adénocarcinome moyennement différencié Gleason 6(3+3). +2012 : rechute de la loge de prostatectomie : radiothérapie de rattrapage. +2018 : progression métastatique osseuse : ENANTONE. +05.2021 : progression biologique et morphologique stade CRPC ENZALUTAMIDE. +05.2022 : progression biologique. Proposition d’une chimiothérapie par TAXOTERE déclinée. +09.2022 : inclusion dans un protocole avec antagoniste du récepteur de l’adénosine à l’Institut +Gustave Roussy. +01.2023 : progression symptomatique avec atteinte de T11 sur lésion lytique, PSA à 143 : +radiothérapie 30 Gy en 10 par Docteur [NOM], puis chimiothérapie par TAXOTERE 75, +proposée par Docteur [NOM], médecin référent jusque-là, qui propose une prise en +charge à proximité, à BAYONNE. +Histoire récente : +Radiothérapie à visée antalgique en regard de T11 initiée le 09/02 pour un total de 10 séances +interrompue à la 8ème séance (le 22/02) pour dégradation clinique. +Altération majeure de l’état général depuis le début de la semaine avec asthénie, anorexie et +ralentissement psycho-moteur. A présenté un épisode de chute il y a 3 jours sans TC. +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 4 de 20 Tolérance moyenne de la morphine sous patch de DUROGESIC sans hallucination visuelle/ +auditive. J5 sans selles et dysurie avec 1 miction seulement par 24h sans autre SFU. +RGO sous corticothérapie forte dose et quelques nausées. +Pas de syndrome infectieux récent. +Deux dernières séances de radiothérapie prévues le 27/02 et le 28/02 sous réserve d’une bonne +amélioration clinique. +Examen clinique : +OMS3, asthénie majeure ++. Poids à 76kg. +Conscient et orienté, plutôt G14 (Y3V5M6), pupilles IRS. Pas de déficit moteur notamment des +membres inférieurs. +Bruits du cœur irréguliers, sans souffle perçu. Pas d’OMI. +Auscultation pulmonaire [NOM] et symétrique, pas de bruits surajoutés. FR 12/min, limite. +Pas de douleur au repos, ni reproduite à la palpation du rachis. +Bouche propre, pas de mucite. +TR : Pas de fécalome +Biologie à l'entrée : +Hémoglobine à 15.9g/dL, leucocytes à 2.6G/L dont 2.4 de PNN, plaquettes à 144G/L +Natrémie à 134mmol/L, pas d’autres troubles ioniques +Créatinine à 116umol/L avec urée à 20.3mmol/L +Pas de perturbation significative du bilan hépatique +CRP à 168mg/L +TP à 106%, ratio TCA 0.7 +Bladder négatif. +Au total : +-Altération majeure de l’état général multi factorielle : iatrogénique (mauvaise tolérance +morphinique) et absence de transit. +-Réadaptation des traitements symptomatiques avec poursuite de la corticothérapie, mise en place +d’une sonde urinaire avec hydratation, régularisation du transit et relai IV de ses traitements avec +retrait du DUROGESIC et ACTISKENAN ALD. +Examens complémentaires : +Scanner AP 25/02 : Syndrome occlusif grêlique fonctionnel en amont d'une iléite (radique ?). Pas +de zone transitionnelle franche. Progression osseuse avec apparition de tassements pathologiques +en T11 T12. A confronter au dosage des PSA. +Evolution dans le service : +Sur le plan digestif : +Apparition de vomissements faecaloïdes le 25/02 pour lesquels un scanner AP est réalisé mettant +en évidence un syndrome occlusif grêlique fonctionnel en amont d'une iléite (radique ?), sans +zone transitionnelle franche. +Mise en place d’une sonde naso gastrique productive à 2L retirée le jour même devant une +levée rapide d’occlusion avec la reprise d’un transit normal dès le 26/02. Bonne évolution +clinique en parallèle avec récupération de son état général ayant permis une reprise d’une +alimentation normale et de ses traitements per os dès le 01/03. La sonde urinaire mise en place +dans le contexte de syndrome confusionnel a été retirée le 01/03 sous couvert d’un traitement par +XATRAL. +Sur le plan antalgique : +Reprise de la radiothérapie à visée antalgique le 27/02 en regard de T11 avec une dernière +séance le 28/02. Absence de recrudescence des douleurs après le retrait du DUROGESIC patch, +maintien d’un traitement par ACTISKENAN 10mg à la demande. +Sur le plan spécifique : +Réalisation d’une scintigraphie osseuse de baseline le 01/03 retrouvant ***. +Programmation d’une pose de PAC le 03/03 qui sera réalisée en chirurgie ambulatoire. +Initiation de la nouvelle ligne thérapeutique par TAXOTERE en hôpital de jour le 08/03. +Sur le plan du devenir : +Nous convenons avec le patient d’une prise en charge dans un premier temps en [ETABLISSEMENT] dans les +suites immédiates de l’hospitalisation à visée de mobilisation et de ré autonomisation. +Le patient et sa famille ont été informés du projet thérapeutique et des prochains rendez-vous. +Traitements de sortie : +ENANTONE 30 / 1 sous cut par 6 mois.. +ACTISKENAN 10 à la demande. +GABAPENTINE 300mg matin et soir. +SOLUPRED 40 mg matin, 40 mg midi. +LANSOPRAZOLE 30mg : 1 le soir +PRIMPERAN si nausées +XATRAL 2.5mg : 1 matin, midi et soir jusqu’au 03/03. +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 5 de 20 FORLAX : 2 sachets matin, midi et soir +LANSOYL : 1 le matin +ACTISKENAN 10mg à la demande +SIMVASTATINE 40mg le soir +EZETIMIBE 10mg le soir +INNOHEP 13000UI le soir : à suspendre le 02/03 et à reprendre le 03/03 (pour la pose de PAC) +COAPROVEL 300/12.5 : non reconduit pendant l’hospitalisation, à réévaluer selon évolution +tensionnelle. +Conclusion : +Altération de l’état général avec syndrome confusionnel multi factoriels sur iatrogénie en +lien avec un traitement morphinique et sur un syndrome occlusif grêlique fonctionnel sur une +iléite radique. Evolution rapidement favorable avec l’arrêt du DUROGESIC patch et la levée +d’occlusion sous corticothérapie avec une bonne récupération de l’état général. +Pose de PAC prévue pour le 03/03 en chirurgie ambulatoire pour initiation d'une nouvelle ligne +de traitement pat TAXOTERE prévue le 08/03 en hôpital de jour. L'anticoagulation curative sera +à suspendre le 02/03 et à reprendre le lendemain. +Prochains rendez-vous : +Pose de PAC le 03/03 +Hôpital de jour le 08/03 à 12h30 pour C1J1 de TAXOTERE. +Surveillance Psychiatrie +Item de 24/02/2023 24/02/2023 25/02/2023 25/02/2023 25/02/2023 26/02/2023 26/02/2023 26/02/2023 26/02/2023 27/02/2023 27/02/2023 28/02/2023 28/02/2023 +surveillance 16 : 09 22:52 09:23 15:32 22:59 02:14 08:55 15:37 22:25 08:29 15:48 04:33 06:08 +Température 36.6 36.5 36.1 36.9 36 36.5 37 37.3 37.5 37.4 37.9 37.2 +PA +91 120 110 130 124 141 116 142 162 166 +Systolique +PA +50 57 69 77 80 68 60 76 80 83 +Diastolique +Saturation +93 94 92 94 99 95 95 98 96 +O² +Transit Constipation Absence Absence Molles Diarrhées Absence Absence +Pouls 107 105 101 102 104 93 86 72 77 +Notes paramédicales +Type de note Nom Date Note +02/03/2023 Transit : +Note IDE [NOM] [NOM] +02 : 25 Selles sur la nuit. +Elimination : +> Bladder fait à 17 heures car n'a pas uriné de l'après-midi = > 326 cc +> Recontrolé à 18h = > 0 cc +[NOM] 01/03/2023 +Note IDE +[NOM] 21 : 26 Devenir : +> Transfert à Grancher demain, transport ok et fiche de liaison faite +PEC nutritionnelle : +Retrait SNG (en aspi) le 25/02. +Reprise alimentaire le 26/02 = bonne tolérance. +[NOM] 01/03/2023 Elargissement menus avec passage en PO2 le 27/02 = bonne tolérance. +Note Diététicienne +[NOM] 15 : 16 Pas de nausées, ni vomissements. +Appétit présent, conservé. +Transit régulier (cf. trans) +--> Menus NOR dès demain. +Elimination : ablation de la sonde vésicale ce matin vers 10h > surveillance reprise miction + +diurèse. +A eu 1 miction par la suite (non constaté car a fait dans les WC). +Alimentation : reprise alimentation en régime normal a partir de ce soir. +01/03/2023 +Note IDE [NOM] [NOM] +12 : 56 +Transit : a eu des selles normales en grande quantité ce matin. +Examen : scintigraphie os faite ce matin > à voir. +Devenir : Transfert a Grancher demain a 11h15 > ambu ok. +[NOM] 28/02/2023 Infectieux +Note IDE +[NOM] 23 : 29 => apyrétique +Examen : +> Scintigraphie osseuse demain à 10h50 +[NOM] 28/02/2023 > Pose de PAC le 03/03 en chirurgie ambu +Note IDE +[NOM] 21 : 41 +Devenir : +> Grancher le 02/03 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 6 de 20 SORTIE GRANCHER jeudi 02/03 à 14h la bas , ambulance commandée +28/02/2023 +Note IDE [NOM] [NOM] +16 : 10 CHIRURGIE POSE PAC vendredi 03/03 à 16h en CHIR AMBULATOIRE , GRANCHER +prevenu sera contacté par secretariat +28/02/2023 +Note IDE [NOM] [NOM] SCINTIGRAPHIE OS : le 01/03 à 10h +14 : 54 +Alimentation : régime élargi a PO2 à partir de ce jour car a eu des selles le 26/02 + ce jour +également en petite quantité constaté. Transit à surveiller. +Radiothérapie : a eu séance ce jour a 12h, pas d'autres séances prévues. +28/02/2023 +Note IDE [NOM] [NOM] +13 : 32 Examen : scintigraphie os demandée > en attente de date, pas de place ce jour. +Devenir : [ETABLISSEMENT] demandé. +Infectieux +[NOM] 28/02/2023 +Note IDE => fébricule à 37.9°C à 4h30 +[NOM] 04 : 25 +=> redescendu spontanément à 37.2°C à 6h +Digestif : +> Pas de selles cet AM +[NOM] 27/02/2023 +Note IDE +[NOM] 21 : 57 +Douleur : +> Pas de plaintes algiques +Douleur : +=> pas de plainte algique +Digestif : +=> pas de nausées ni de vomissement +=> alimentation BCY ajd +Risque de surcharge : +=> +3.7kg en quelques jour --> diminution hydrat +27/02/2023 +Note IDE [NOM] [NOM] +14 : 44 +Radiothérapie : +=> radiothérapie ce matin à 11h30 +=> RdxTTT demain matin à 12h --> transport ok +Examen : +=> scinti os ddé +Voie d'abord : +=> pose de PAC le 3/03 +Neuro : +Patient calme, orienté et coopérant. +Se rend compte, de ses dires, qu'il a "fait des bêtises" la nuit dernière. +26/02/2023 +Note IDE [NOM] [NOM] Douleur : +23 : 40 +Pas de plainte algique. +Transit : +Pas de selles. +Douleur : +Pas de plainte algique sur l'après midi +Transit : +26/02/2023 Absence de selles cet après midi +Note IDE [NOM] [NOM] +20 : 03 +Comportement : +Patient cohérent et orienté sur l'après midi +nous raconte l'épisode de cette nuit : dit "avoir vu des monstres qui lui courraient après, a voulu +s'échapper ce qui explique qu'il a couper la sonde et la VVP".. hallucinations? a surveiller +Douleur : +=> pas de plainte algique +Neuro/comportement : +=> patient calme et coopérant ce matin +26/02/2023 +Note IDE [NOM] [NOM] +13 : 53 Transit : +=> selles ce matin +Mobilisation : +=> levé au fauteuil ce matin, matelas à air mis en place +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 7 de 20 Infectieux : +=> apyrétique +=> PCR covid prélevé +Alimentation : +=> BCY débuté ce matin comme convenu --> apprécié par le patient +Radiothérapie : +=> à son prochain RDV demain à 11h30 et mardi à 12h --> transport ddé +Comportement : +A 1h30, patient retrouvé avec du sang et des selles +++ dans la chambre (lit, adaptable, salle de +bain, sol...). Poche de recueil d'urines retrouvée par terre dans la SDB, rampe et pied à perf par +terre. +Le patient tient un petit ciseau dans les mains, qui lui a sans doute permis de sectionner la +tubulure de la SV et de la VVP. +26/02/2023 +Note IDE [NOM] [NOM] Dit avoir eu un moment de panique où il ne savait plus où il se trouvait. +00 : 16 +Patient très virulent dans ses propos, agressif. +Lors de mon arrivée dans la chambre, patient orienté dans l'espace et dans le temps. +Calme le reste de la nuit. +Douleur : +Pas de plainte algique +Digestif : +Pas de nausées ni de vomissement sur l'après midi +25/02/2023 +Note IDE [NOM] [NOM] +19 : 18 +Transit : +Absence de selles cet après midi, laxatif per os administrés +Etat général : +Patient toujours asthénique, a dormi toute l'après midi +Douleur : +=> pas de plainte algique +Digestif : +=> SNG en place et fonctionnelle --> 500cc de résidus ce matin soit 2500cc depuis la pose de la +SNG (moins de 24h) +=> patient gêné +++ par al SNG, demande à boire --> signalé au médecin --> ok pour un jus ce +matin +=> suite scan abdo en urgence --> CAT de retirer la SNG et ok pour liquide ajd puis passage en +BCY demain +Examen : +25/02/2023 +Note IDE [NOM] [NOM] => scan abdo en urgence ce matin --> "Syndrome occlusif grêlique fonctionnel en amont d'une +14 : 10 +iléite (radique ?). Pas de zone transitionnelle franche. Progression osseuse avec apparition de +tassements pathologiques en T11 T12" +Elimination : +=> SV en place et fonctionnelle +Etat général : +=> patient asthénique en fin de matinée, dort en rentrant du scan +TTT : +=> ajout hydrat ce matin car déshydratation +Elimination : +SV en place et fonctionnelle. +Digestif : +SNG fonctionnelle, en aspi, poche changée à 23h, liquide fécaloïde. +500 CC dans la poche à 6h30. +Thymie/comportement : +25/02/2023 +Note IDE [NOM] [NOM] Patient très agacé d'avoir la SNG, dit qu'elle le dérange, se l'est retiré jusqu'au repère 35.. +00 : 23 +Demande à plusieurs reprises à ce qu'on lui serve un café au lait avec ton autoritaire, explications +sur l'impossibilité de lui en servir un, patient en colère. +SNG remise jusqu'au repère 55, fonctionnelle. +Douleur : +Pas de plainte algique. +Entourage : +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 8 de 20 Fille présente en chambre cette nuit. +Motif d'hospitalisation : +Patient entré ce jour pour AEG dans un contexte d'ADK de prostate suivi a Bergonié +Voie d'abord : +VVP posée (capital veineux précaire) +Alimentation : +Patient qui mange très peu au domicile depuis plusieurs jours --> diet ddé +Elimination : +Dysurie importante, déshydratation? --> bladder 62cc +SV ch 16 posée sur consignes médicales + ECBU réalisé +Digestif : +Patient qui dit ne pas avoir eu de selles depuis au moins 5 jours --> lavement réalisé cet après +midi non efficace +--> dlr abdo + Vomissement fécaloïde à 20h --> SNG posée repère 65 en aspi --> 600cc fécaloïde +24/02/2023 +Note IDE [NOM] [NOM] évacué d'emblé +20 : 49 +Cardio : +ECG réalisé cet après midi --> FA --> avis cardio introduction d'ATC +Etat général : +Patient asthénique ++, ne se mobilise plus depuis 3 jours --> matelas air ddé +Douleur : +Douleurs abdo ce soir, soulagées par la pose de la SNG +porteur d'un patch d'ATG3 retiré à 16h selon consignes médicales +Suivi onco : +2 dernières séances de radiothérapie prévues le 27 et 28/02 (horaire à récupérer auprès des +enfants) +Risque infectieux : +PCR refusé par le patient ce soir.. à faire demain matin svp +Traitements médicamenteux +Date de dernière +Prescription Dose Fréquence Date de début Note Docteur +administration +Voie d`administration : INTRAVEINEUSE +Statut des prescriptions : Arrêté +Le débit a été +EUPANTOL 40MG PDR INJ modifié. Le débit +40 mg - Soir [19h] Normal 24/02/2023 16 : 02 27/02/2023 19:28 [NOM] [NOM] +[1] Flacon(s) en cours est : 60 +par . +Le débit a été +METHYLPREDNISOLONE +modifié. Le débit +MYL 40MG PDR INJ [10] 40 mg - Matin midi Normal 25/02/2023 06 : 00 28/02/2023 08:41 [NOM] [NOM] +en cours est : 3 +Flacon(s) +par . +METOCLOPRAMIDE CHL +REN 10MG/2ML INJ [100] 1 AMP - Normal 24/02/2023 16 : 02 [NOM] [NOM] +Ampoule(s) +Le débit a été +POLYIONIQUE 1A G5 modifié. Le débit +BAX POC VFO 500ML [1] - Normal 24/02/2023 16 : 09 01/03/2023 08:45 en cours est : [NOM] [NOM] +POCHE(S) 41.666666666666664 +ML par 1 hrs. +Le débit a été +SODIUM CHL MACO modifié. Le débit +DR. [NOM] +0,9% INJ PP 500ML [1] - Normal 25/02/2023 12 : 31 27/02/2023 00:28 en cours est : +[NOM] +POCHE(S) 41.666666666666664 +ML par 1 hrs. +Statut des prescriptions : Réalisé +Le débit a été +METHYLPREDNISOLONE +- 1 seule fois 1 seule modifié. Le débit +MYL 120MG PDR INJ [10] 80 mg 24/02/2023 16 : 02 24/02/2023 16:49 [NOM] [NOM] +fois en cours est : 2 +Flacon(s) +par . +Voie d`administration : ORALE +Statut des prescriptions : Signé +ACTISKENAN 10MG +1 GEL - Normal 24/02/2023 16 : 02 [NOM] [NOM] +GELULE [14] Gelule(s) +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 9 de 20 ACTISKENAN 10MG +1 GEL - Presc. de Sortie 02/03/2023 14 : 00 [NOM] [NOM] +GELULE [14] Gelule(s) +EZETIMIBE MYL 10MG +1 CPR - Soir [19h] Normal 24/02/2023 16 : 09 01/03/2023 19:31 [NOM] [NOM] +CPR [90] CPR(s) +EZETIMIBE MYL 10MG - Soir [19h] Presc. de +1 CPR 02/03/2023 14 : 00 [NOM] [NOM] +CPR [90] CPR(s) Sortie +FORLAX 10G PDR [NOM] - Matin midi soir +2 SACHET 24/02/2023 16 : 02 02/03/2023 08:11 [NOM] [NOM] +SACHET [20] Sachet(s) Normal +FORLAX 10G PDR [NOM] - Matin midi soir +2 SACHET 02/03/2023 14 : 00 [NOM] [NOM] +SACHET [20] Sachet(s) Presc. de Sortie +GABAPENTINE ARW +- Matin soir (8h - +300MG GELULE [90] 1 GEL 02/03/2023 14 : 00 [NOM] [NOM] +19h) Presc. de Sortie +Gelule(s) +LANSOPRAZOLE BGA 30 - Prise unique à 19h +1 CPR 28/02/2023 11 : 19 01/03/2023 19:31 [NOM] [NOM] +MG CPR OROD [14] CPR(s) Normal +LANSOPRAZOLE BGA 30 - Prise unique à 19h +1 CPR 02/03/2023 14 : 00 [NOM] [NOM] +MG CPR OROD [14] CPR(s) Presc. de Sortie +LANSOYL FRAMBOISE +GEL ORAL UNIDOSE 1 REC. DR. [NOM] +- Matin [8h] Normal 25/02/2023 12 : 47 02/03/2023 08:11 +[9] RECIPIENT(S) UNIDOSE [NOM] +UNIDOSE(S) +LANSOYL FRAMBOISE +GEL ORAL UNIDOSE 1 REC. - Matin [8h] Presc. de +02/03/2023 14 : 00 [NOM] [NOM] +[9] RECIPIENT(S) UNIDOSE Sortie +UNIDOSE(S) +PRIMPERAN 10MG CPR +1 CPR - Normal 28/02/2023 11 : 19 [NOM] [NOM] +[40] COMPRIME(S) +PRIMPERAN 10MG CPR +1 CPR - Presc. de Sortie 02/03/2023 14 : 00 [NOM] [NOM] +[40] COMPRIME(S) +SIMVASTATINE +AHL 20MG CPR [28] 2 CPR - Soir [19h] Normal 24/02/2023 16 : 09 01/03/2023 19:31 [NOM] [NOM] +COMPRIME(S) +SIMVASTATINE +- Soir [19h] Presc. de +AHL 20MG CPR [28] 2 CPR 02/03/2023 14 : 00 [NOM] [NOM] +Sortie +COMPRIME(S) +SOLUPRED 20MG +CPR ORODISP [20] 2 CPR - Matin midi Normal 28/02/2023 11 : 19 02/03/2023 08:11 [NOM] [NOM] +COMPRIME(S) +SOLUPRED 20MG +- Matin midi Presc. +CPR ORODISP [20] 2 CPR 02/03/2023 14 : 00 [NOM] [NOM] +de Sortie +COMPRIME(S) +XATRAL 2,5MG CPR [30] - Matin midi soir +1 CPR 27/02/2023 11 : 18 02/03/2023 08:11 [NOM] [NOM] +COMPRIME(S) Normal +XATRAL 2,5MG CPR [30] - Matin midi soir +1 CPR 01/03/2023 14 : 17 [NOM] [NOM] +COMPRIME(S) Presc. de Sortie +Statut des prescriptions : En cours +GABAPENTINE ARW +- Matin soir (8h - +300MG GELULE [90] 1 GEL 24/02/2023 16 : 02 02/03/2023 08:11 [NOM] [NOM] +19h) Normal +Gelule(s) +Voie d`administration : RECTALE +Statut des prescriptions : Réalisé +NORMACOL LAVEMENT +AD SOL RECTALE 1 REC. - 1 seule fois 1 seule +24/02/2023 16 : 02 24/02/2023 16:49 [NOM] [NOM] +[1] RECIPIENT(S) UNIDOSE fois +UNIDOSE(S) +Voie d`administration : SOUS-CUTANEE +Statut des prescriptions : Signé +INNOHEP 14 000UI +AXa/0,7ML SOL INJ 13000 UI +- Soir [19h] Normal 24/02/2023 16 : 50 01/03/2023 19:31 [NOM] [NOM] +[2] SERINGUE(S) AXa +PREREMPLIE(S) +INNOHEP 14 000UI +AXa/0,7ML SOL INJ 13000 UI - Soir [19h] Presc. de +02/03/2023 14 : 00 [NOM] [NOM] +[2] SERINGUE(S) AXa Sortie +PREREMPLIE(S) +Statut des prescriptions : Arrêté +LOVENOX 4000UI +1 +AXa/0,4ML INJ SER +SERINGUE(S) - Soir [19h] Normal 24/02/2023 16 : 06 [NOM] [NOM] ++S [2] SERINGUE(S) +PREREMPLIE(S) +PREREMPLIE(S) +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 10 de 20 Prescriptions de radiologie +Heure Date Heure +Date début Prescription Statut Docteur [NOM] +début exécution exécution +Scanner Thoraco Abdomino +25/02/2023 10 : 38 25/02/2023 11:15 Réalisé DR. [NOM] +Pelvien +Scintigraphie osseuse pour +01/03/2023 10 : 21 01/03/2023 13:42 Réalisé DR. [NOM] +bilan osseux +Prescriptions de laboratoire +Date de +Date Heure Prescription Docteur [NOM] +collection +24/02/2023 +24/02/2023 16 : 02 Ionogramme ( Na, K, CL ) [NOM] [NOM] +17 : 10 +26/02/2023 +24/02/2023 18 : 07 Grippe recherche directe [NOM] [NOM] +09 : 44 +28/02/2023 +28/02/2023 07 : 00 Ionogramme ( Na, K, CL ) [NOM] [NOM] +08 : 55 +Prescriptions de soins +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +[NOM] +1 Semaine - Matin 24/02/2023 [NOM] +ENVIRONNEMENT Signé +[8h] Normal 17 : 46 [NOM] +PATIENT +1 Semaine - Matin 24/02/2023 [NOM] +REPAS : AIDE PARTIELLE Signé +[8h] Normal 17 : 46 [NOM] +- 3x/Nuit (22h 2h 6h) 28/02/2023 Marie [NOM] +SOMMEIL : SURV. Signé +Normal 06 : 36 [NOM] +TOILETTE : AIDE - 3X/J (horaires du 24/02/2023 [NOM] +Signé +COMPLETE cycle) Normal 17 : 46 [NOM] +Prescriptions de sortie +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +[NOM] 10MG 1 GEL 02/03/2023 0/120 : Non [NOM] +Signé - Presc. de Sortie +GELULE [14] Gelule(s) ORALE 14 : 00 administré A valider [NOM] +EZETIMIBE MYL 10MG 1 CPR - Soir [19h] Presc. de 02/03/2023 0/30 : Non administré [NOM] +Signé +CPR [90] CPR(s) ORALE Sortie 14 : 00 A valider [NOM] +FORLAX 10G PDR [NOM] 2 SACHET - Matin midi soir 02/03/2023 0/180 : Non [NOM] +Signé +SACHET [20] Sachet(s) ORALE Presc. de Sortie 14 : 00 administré A valider [NOM] +GABAPENTINE ARW +1 GEL - Matin soir (8h - 02/03/2023 0/60 : Non administré [NOM] +300MG GELULE [90] Signé +ORALE 19h) Presc. de Sortie 14 : 00 A valider [NOM] +Gelule(s) +INNOHEP 14 000UI +13000 UI +AXa/0,7ML SOL INJ - Soir [19h] Presc. de 02/03/2023 0/28 : Non administré [NOM] +AXa SOUS- Signé +[2] SERINGUE(S) Sortie 14 : 00 A valider [NOM] +CUTANEE +PREREMPLIE(S) +LANSOPRAZOLE BGA 30 1 CPR - Prise unique à 19h 02/03/2023 0/30 : Non administré [NOM] +Signé +MG CPR OROD [14] CPR(s) ORALE Presc. de Sortie 14 : 00 A valider [NOM] +LANSOYL FRAMBOISE +1 REC. +GEL ORAL UNIDOSE - Matin [8h] Presc. de 02/03/2023 0/30 : Non administré [NOM] +UNIDOSE Signé +[9] RECIPIENT(S) Sortie 14 : 00 A valider [NOM] +ORALE +UNIDOSE(S) +PRIMPERAN 10MG CPR 1 CPR 02/03/2023 0/90 : Non administré [NOM] +Signé - Presc. de Sortie +[40] COMPRIME(S) ORALE 14 : 00 A valider [NOM] +SIMVASTATINE +2 CPR - Soir [19h] Presc. de 02/03/2023 0/60 : Non administré [NOM] +AHL 20MG CPR [28] Signé +ORALE Sortie 14 : 00 A valider [NOM] +COMPRIME(S) +SOLUPRED 20MG +2 CPR - Matin midi Presc. 02/03/2023 0/120 : Non [NOM] +CPR ORODISP [20] Signé +ORALE de Sortie 14 : 00 administré A valider [NOM] +COMPRIME(S) +XATRAL 2,5MG CPR [30] 1 CPR - Matin midi soir 01/03/2023 0/7 : Non administré [NOM] +Signé +COMPRIME(S) ORALE Presc. de Sortie 14 : 17 A valider [NOM] +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 11 de 20 Plan de soins Jour J du 02/03/2023 07h00 au 03/03/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ Début le 24/02/2023 à 10:02 * 1 +16 : 02 16:02 GEL +"Si douleurs " Fin le 26/03/2023 à +10 : 02 +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ Début le 24/02/2023 à 16:02 * 1 +16 : 02 16:02 GEL +"Si douleurs " Fin le 26/03/2023 à +10 : 02 +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ Début le 24/02/2023 à 22:02 * 1 +16 : 02 16:02 GEL +"Si douleurs " Fin le 26/03/2023 à +10 : 02 +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ Début le 24/02/2023 à 04:02 * 1 +16 : 02 16:02 GEL +"Si douleurs " Fin le 26/03/2023 à +10 : 02 +[NOM] [NOM] +Signé — EZETIMIBE MYL 10MG CPR - 10MG Début le 24/02/2023 à +comprime - Dose 1 CPR - ORALE - Soir [19h] - 16 : 09 19:00 * 1 +1ère dose : 24/02/2023 @ 19:00 Fin le 25/03/2023 à CPR +19 : 00 +Admin le 01/03/2023 à +19 : 31 +[NOM] [NOM] +Signé — FORLAX 10G PDR [NOM] - Début le 24/02/2023 à +10G poudre - Dose 2 SACHET - ORALE - Matin 16 : 02 12:00 * 2 +midi soir - 1ère dose : 25/02/2023 @ 08:00 Fin le 26/03/2023 à SACHET +12 : 00 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +Signé — FORLAX 10G PDR [NOM] - Début le 24/02/2023 à +10G poudre - Dose 2 SACHET - ORALE - Matin 16 : 02 19:00 * 2 +midi soir - 1ère dose : 25/02/2023 @ 08:00 Fin le 26/03/2023 à SACHET +12 : 00 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +Signé — FORLAX 10G PDR [NOM] - Début le 24/02/2023 à +10G poudre - Dose 2 SACHET - ORALE - Matin 16 : 02 08:11 * 2 +midi soir - 1ère dose : 25/02/2023 @ 08:00 Fin le 26/03/2023 à SACHET +12 : 00 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +En cours — GABAPENTINE ARW 300MG Début le 24/02/2023 à +GELULE - 300MG gelule - Dose 1 GEL - 16 : 02 +O 24 R /0 A 2 L /2 E 0 2 - 3 M @ at i 1 n 9 s : o 0 i 0 r (8h - 19h) - 1ère dose: F 08 in :0 l 0 e 26/03/2023 à 1 G 9 E :0 L 0 * 1 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +En cours — GABAPENTINE ARW 300MG Début le 24/02/2023 à +GELULE - 300MG gelule - Dose 1 GEL - 16 : 02 +O 24 R /0 A 2 L /2 E 0 2 - 3 M @ at i 1 n 9 s : o 0 i 0 r (8h - 19h) - 1ère dose: F 08 in :0 l 0 e 26/03/2023 à 0 G 8 E :1 L 1 * 1 +Admin le 02/03/2023 à +08 : 11 +Signé — LANSOPRAZOLE BGA 30 MG [NOM] [NOM] 19 : 00 * 1 +CPR OROD - 30MG comprime - Dose 1 CPR CPR +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 12 de 20 Début le 28/02/2023 à +- ORALE - Prise unique à 19h - 1ère dose : 11:19 +28/02/2023 @ 19 : 00 Fin le 29/03/2023 à +19 : 00 +Admin le 01/03/2023 à +19 : 31 +[NOM] [NOM] +Signé — LANSOYL FRAMBOISE GEL ORAL Début le 25/02/2023 à +UNIDOSE - 11,734G/15G gel - Dose 1 REC. 12 : 47 08:11 * +UNIDOSE - ORALE - Matin [8h] - 1ère dose : Fin le 27/03/2023 à 1 REC. +26/02/2023 @ 08 : 00 08:00 UNIDOSE +Admin le 02/03/2023 à +08 : 11 +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 [NOM] [NOM] +Heure(s) Si besoin - Début presc. : 28/02/2023 @ Début le 28/02/2023 à 11:19 * 1 +11 : 19 11:19 CPR +"Si nausées et/ou vomissements " Fin le 30/03/2023 à +03 : 19 +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 [NOM] [NOM] +Heure(s) Si besoin - Début presc. : 28/02/2023 @ Début le 28/02/2023 à 19:19 * 1 +11 : 19 11:19 CPR +"Si nausées et/ou vomissements " Fin le 30/03/2023 à +03 : 19 +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 [NOM] [NOM] +Heure(s) Si besoin - Début presc. : 28/02/2023 @ Début le 28/02/2023 à 03:19 * 1 +11 : 19 11:19 CPR +"Si nausées et/ou vomissements " Fin le 30/03/2023 à +03 : 19 +[NOM] [NOM] +Signé — SIMVASTATINE AHL 20MG CPR - Début le 24/02/2023 à +20MG comprime - Dose 2 CPR - ORALE - Soir 16 : 09 19:00 * 2 +[19h] - 1ère dose : 24/02/2023 @ 19:00 Fin le 25/03/2023 à CPR +19 : 00 +Admin le 01/03/2023 à +19 : 31 +[NOM] [NOM] +Signé — SOLUPRED 20MG CPR ORODISP - Début le 28/02/2023 à +20MG comprime - Dose 2 CPR - ORALE - Matin 11 : 19 12:00 * 2 +midi - 1ère dose : 28/02/2023 @ 12:00 Fin le 30/03/2023 à CPR +08 : 00 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +Signé — SOLUPRED 20MG CPR ORODISP - Début le 28/02/2023 à +20MG comprime - Dose 2 CPR - ORALE - Matin 11 : 19 08:11 * 2 +midi - 1ère dose : 28/02/2023 @ 12:00 Fin le 30/03/2023 à CPR +08 : 00 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +Signé — XATRAL 2,5 MG CPR - 2,5MG Début le 27/02/2023 à +comprime - Dose 1 CPR - ORALE - Matin midi 11 : 18 12:00 * 1 +soir - 1ère dose : 27/02/2023 @ 12:00 Fin le 09/03/2023 à CPR +08 : 00 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +Signé — XATRAL 2,5 MG CPR - 2,5MG Début le 27/02/2023 à +comprime - Dose 1 CPR - ORALE - Matin midi 11 : 18 19:00 * 1 +soir - 1ère dose : 27/02/2023 @ 12:00 Fin le 09/03/2023 à CPR +08 : 00 +Admin le 02/03/2023 à +08 : 11 +Signé — XATRAL 2,5 MG CPR - 2,5MG [NOM] [NOM] +comprime - Dose 1 CPR - ORALE - Matin midi Début le 27/02/2023 à 08 : 11 * 1 +soir - 1ère dose : 27/02/2023 @ 12:00 11:18 CPR +Fin le 09/03/2023 à +08 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 13 de 20 Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +Signé — INNOHEP 14 000UI AXA SOL INJ - Début le 24/02/2023 à +14000UI AXa solution (0,7 mL) - Dose 13000 UI 16 : 50 19:00 * +A +1è +X +re +a +d +- +o +S +s +O +e : +U +2 +S +4 +- +/0 +C +2 +U +/2 +T +0 +A +2 +N +3 +E +@ +E +1 +D +9 +i + : +r +0 +e +0 +cte - Soir [19h] - F +19 +in + : 0 +l +0 +e 25/03/2023 à 1 +A +3 +X +0 +a +00 UI +Admin le 01/03/2023 à +19 : 31 +Signé — DESINFECTION ENVIRONNEMENT [NOM] [NOM] +PATIENT - Matin [8h] - 1 Semaine- Date Début : Début le 24/02/2023 à +24/02/2023 @ 17 : 46 17:46 08:00 * 1 +Fin le 03/03/2023 à +08 : 00 +Signé — REPAS : AIDE PARTIELLE - Matin [NOM] [NOM] +[8h] - 1 Semaine- Date Début : 24/02/2023 @ Début le 24/02/2023 à +17 : 46 17:46 08:00 * 1 +Fin le 03/03/2023 à +08 : 00 +Marie [NOM] [NOM] +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 28/02/2023 à +6h) - pendant 7 Jour(s)- Date Début : 28/02/2023 06:36 +@ 06 : 36 Fin le 07/03/2023 à 22:00 * 1 +06 : 00 +Admin le 01/03/2023 à +23 : 44 +Marie [NOM] [NOM] +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 28/02/2023 à +6h) - pendant 7 Jour(s)- Date Début : 28/02/2023 06:36 +@ 06 : 36 Fin le 07/03/2023 à 02:00 * 1 +06 : 00 +Admin le 01/03/2023 à +23 : 44 +Marie [NOM] [NOM] +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 28/02/2023 à +6h) - pendant 7 Jour(s)- Date Début : 28/02/2023 06:36 +@ 06 : 36 Fin le 07/03/2023 à 06:00 * 1 +06 : 00 +Admin le 01/03/2023 à +23 : 44 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 14 de 20 Plan de soins Jour J + 1 du 03/03/2023 07h00 au 04/03/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ Début le 24/02/2023 à 10:02 * 1 +16 : 02 16:02 GEL +"Si douleurs " Fin le 26/03/2023 à +10 : 02 +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ Début le 24/02/2023 à 16:02 * 1 +16 : 02 16:02 GEL +"Si douleurs " Fin le 26/03/2023 à +10 : 02 +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ Début le 24/02/2023 à 22:02 * 1 +16 : 02 16:02 GEL +"Si douleurs " Fin le 26/03/2023 à +10 : 02 +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ Début le 24/02/2023 à 04:02 * 1 +16 : 02 16:02 GEL +"Si douleurs " Fin le 26/03/2023 à +10 : 02 +[NOM] [NOM] +Signé — EZETIMIBE MYL 10MG CPR - 10MG Début le 24/02/2023 à +comprime - Dose 1 CPR - ORALE - Soir [19h] - 16 : 09 19:00 * 1 +1ère dose : 24/02/2023 @ 19:00 Fin le 25/03/2023 à CPR +19 : 00 +Admin le 01/03/2023 à +19 : 31 +[NOM] [NOM] +Signé — FORLAX 10G PDR [NOM] - Début le 24/02/2023 à +10G poudre - Dose 2 SACHET - ORALE - Matin 16 : 02 08:00 * 2 +midi soir - 1ère dose : 25/02/2023 @ 08:00 Fin le 26/03/2023 à SACHET +12 : 00 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +Signé — FORLAX 10G PDR [NOM] - Début le 24/02/2023 à +10G poudre - Dose 2 SACHET - ORALE - Matin 16 : 02 12:00 * 2 +midi soir - 1ère dose : 25/02/2023 @ 08:00 Fin le 26/03/2023 à SACHET +12 : 00 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +Signé — FORLAX 10G PDR [NOM] - Début le 24/02/2023 à +10G poudre - Dose 2 SACHET - ORALE - Matin 16 : 02 19:00 * 2 +midi soir - 1ère dose : 25/02/2023 @ 08:00 Fin le 26/03/2023 à SACHET +12 : 00 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +En cours — GABAPENTINE ARW 300MG Début le 24/02/2023 à +GELULE - 300MG gelule - Dose 1 GEL - 16 : 02 +O 24 R /0 A 2 L /2 E 0 2 - 3 M @ at i 1 n 9 s : o 0 i 0 r (8h - 19h) - 1ère dose: F 08 in :0 l 0 e 26/03/2023 à 0 G 8 E :0 L 0 * 1 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +En cours — GABAPENTINE ARW 300MG Début le 24/02/2023 à +GELULE - 300MG gelule - Dose 1 GEL - 16 : 02 +O 24 R /0 A 2 L /2 E 0 2 - 3 M @ at i 1 n 9 s : o 0 i 0 r (8h - 19h) - 1ère dose: F 08 in :0 l 0 e 26/03/2023 à 1 G 9 E :0 L 0 * 1 +Admin le 02/03/2023 à +08 : 11 +Signé — LANSOPRAZOLE BGA 30 MG [NOM] [NOM] 19 : 00 * 1 +CPR OROD - 30MG comprime - Dose 1 CPR CPR +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 15 de 20 Début le 28/02/2023 à +- ORALE - Prise unique à 19h - 1ère dose : 11:19 +28/02/2023 @ 19 : 00 Fin le 29/03/2023 à +19 : 00 +Admin le 01/03/2023 à +19 : 31 +[NOM] [NOM] +Signé — LANSOYL FRAMBOISE GEL ORAL Début le 25/02/2023 à +UNIDOSE - 11,734G/15G gel - Dose 1 REC. 12 : 47 08:00 * +UNIDOSE - ORALE - Matin [8h] - 1ère dose : Fin le 27/03/2023 à 1 REC. +26/02/2023 @ 08 : 00 08:00 UNIDOSE +Admin le 02/03/2023 à +08 : 11 +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 [NOM] [NOM] +Heure(s) Si besoin - Début presc. : 28/02/2023 @ Début le 28/02/2023 à 11:19 * 1 +11 : 19 11:19 CPR +"Si nausées et/ou vomissements " Fin le 30/03/2023 à +03 : 19 +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 [NOM] [NOM] +Heure(s) Si besoin - Début presc. : 28/02/2023 @ Début le 28/02/2023 à 19:19 * 1 +11 : 19 11:19 CPR +"Si nausées et/ou vomissements " Fin le 30/03/2023 à +03 : 19 +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 [NOM] [NOM] +Heure(s) Si besoin - Début presc. : 28/02/2023 @ Début le 28/02/2023 à 03:19 * 1 +11 : 19 11:19 CPR +"Si nausées et/ou vomissements " Fin le 30/03/2023 à +03 : 19 +[NOM] [NOM] +Signé — SIMVASTATINE AHL 20MG CPR - Début le 24/02/2023 à +20MG comprime - Dose 2 CPR - ORALE - Soir 16 : 09 19:00 * 2 +[19h] - 1ère dose : 24/02/2023 @ 19:00 Fin le 25/03/2023 à CPR +19 : 00 +Admin le 01/03/2023 à +19 : 31 +[NOM] [NOM] +Signé — SOLUPRED 20MG CPR ORODISP - Début le 28/02/2023 à +20MG comprime - Dose 2 CPR - ORALE - Matin 11 : 19 08:00 * 2 +midi - 1ère dose : 28/02/2023 @ 12:00 Fin le 30/03/2023 à CPR +08 : 00 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +Signé — SOLUPRED 20MG CPR ORODISP - Début le 28/02/2023 à +20MG comprime - Dose 2 CPR - ORALE - Matin 11 : 19 12:00 * 2 +midi - 1ère dose : 28/02/2023 @ 12:00 Fin le 30/03/2023 à CPR +08 : 00 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +Signé — XATRAL 2,5 MG CPR - 2,5MG Début le 27/02/2023 à +comprime - Dose 1 CPR - ORALE - Matin midi 11 : 18 08:00 * 1 +soir - 1ère dose : 27/02/2023 @ 12:00 Fin le 09/03/2023 à CPR +08 : 00 +Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +Signé — XATRAL 2,5 MG CPR - 2,5MG Début le 27/02/2023 à +comprime - Dose 1 CPR - ORALE - Matin midi 11 : 18 12:00 * 1 +soir - 1ère dose : 27/02/2023 @ 12:00 Fin le 09/03/2023 à CPR +08 : 00 +Admin le 02/03/2023 à +08 : 11 +Signé — XATRAL 2,5 MG CPR - 2,5MG [NOM] [NOM] +comprime - Dose 1 CPR - ORALE - Matin midi Début le 27/02/2023 à 19 : 00 * 1 +soir - 1ère dose : 27/02/2023 @ 12:00 11:18 CPR +Fin le 09/03/2023 à +08 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 16 de 20 Admin le 02/03/2023 à +08 : 11 +[NOM] [NOM] +Signé — INNOHEP 14 000UI AXA SOL INJ - Début le 24/02/2023 à +14000UI AXa solution (0,7 mL) - Dose 13000 UI 16 : 50 19:00 * +A +1è +X +re +a +d +- +o +S +s +O +e : +U +2 +S +4 +- +/0 +C +2 +U +/2 +T +0 +A +2 +N +3 +E +@ +E +1 +D +9 +i + : +r +0 +e +0 +cte - Soir [19h] - F +19 +in + : 0 +l +0 +e 25/03/2023 à 1 +A +3 +X +0 +a +00 UI +Admin le 01/03/2023 à +19 : 31 +Signé — DESINFECTION ENVIRONNEMENT [NOM] [NOM] +PATIENT - Matin [8h] - 1 Semaine- Date Début : Début le 24/02/2023 à +24/02/2023 @ 17 : 46 17:46 08:00 * 1 +Fin le 03/03/2023 à +08 : 00 +Signé — REPAS : AIDE PARTIELLE - Matin [NOM] [NOM] +[8h] - 1 Semaine- Date Début : 24/02/2023 @ Début le 24/02/2023 à +17 : 46 17:46 08:00 * 1 +Fin le 03/03/2023 à +08 : 00 +Marie [NOM] [NOM] +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 28/02/2023 à +6h) - pendant 7 Jour(s)- Date Début : 28/02/2023 06:36 +@ 06 : 36 Fin le 07/03/2023 à 22:00 * 1 +06 : 00 +Admin le 01/03/2023 à +23 : 44 +Marie [NOM] [NOM] +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 28/02/2023 à +6h) - pendant 7 Jour(s)- Date Début : 28/02/2023 06:36 +@ 06 : 36 Fin le 07/03/2023 à 02:00 * 1 +06 : 00 +Admin le 01/03/2023 à +23 : 44 +Marie [NOM] [NOM] +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 28/02/2023 à +6h) - pendant 7 Jour(s)- Date Début : 28/02/2023 06:36 +@ 06 : 36 Fin le 07/03/2023 à 06:00 * 1 +06 : 00 +Admin le 01/03/2023 à +23 : 44 +Résultats de radiologie +Prescription Date Résultat +Compte rendu au format texte +Bayonne, le 25/02/2023 +Docteur [NOM] +Nom de naissance : [NOM] +Nom utilisé : [NOM] +Prénom de naissance : [NOM] +Prénom utilisé : [NOM] +[DATE_NAISSANCE] +Lieu de naissance : 99350 +Sexe : M +Matricule INS : (NIR) [NIR] +Examen du : 25/02/2023 +Compte-rendu validé électroniquement par Dr [NOM] le 25/02/2023 +25/02/2023 +CR Scanner +10 : 38 +SCANNER THORACO-ABDOMINO-PELVIEN +Indication : +Réévaluation dans un contexte de néoplasie prostatique. Vomissement fécaloïde. +Occlusion ? +Protocole : +Scanner thoraco-abdomino-pelvien après injection au temps portal. +RESULTATS : +Examen confronté à celui du 30 12 2022. +A l'étage thoracique : +Atélectasie partielle lobaire inférieure droite. +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 17 de 20 Micronodule lobaire supérieur droit de 3mm +Pas d'adénomégalie médiastino-hilaire ou axillaire. +Pas d'épanchement pleuro-péricardique. +A l'étage abdomino pelvien : +Distension hydroaérique gastrique et grêlique sans zone transitionnelle franche. +Il existe un rehaussement pariétal iléal pouvant évoquer une iléite : radique ? +Hernie inguinale indirecte gauche au contenu digestif colique non compliquée. +Absence de lésion focale suspecte du foie, du pancréas, de la rate, des reins et des surrénales. +Les voies biliaires intra et extra hépatiques sont fines. +Adénopathies rétropéritonéales stables mesurant en latéro aortique gauche 11 et 13mm de petit axe. +Pas d'épanchement péritonéal. +Epaississement pariétal vésical. +Atteinte athéromateuse sévère de l'aorte abdominale. +Progression osseuse avec visualisation de lésions ostéocondensantes multiples en particulier rachidiennes. +Tassement pathologique de T11 et T12. +Epidurite débutante en T6 +CONCLUSION : +Syndrome occlusif grêlique fonctionnel en amont d'une iléite (radique ?). Pas de zone transitionnelle franche. +Progression osseuse avec apparition de tassements pathologiques en T11 T12. A confronter au dosage des PSA. +Dr [NOM] +Technique : +GE Revolution Frontier CT B225007 +PDL : 613.9 mGy.cm CTDI : 9.11 mGy +Protocole d'acquisition : 5.7 TAP Portal +XENETIX 350 200mL 22wf015c01 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] +Compte rendu au format texte +Bayonne, le 01/03/2023 +Docteur [NOM] +Nom de naissance : [NOM] +Nom utilisé : [NOM] +Prénom de naissance : [NOM] +Prénom utilisé : [NOM] +[DATE_NAISSANCE] +Lieu de naissance : 99350 +Sexe : M +Matricule INS : (NIR) [NIR] +CR +01/03/2023 +Médecine +10 : 21 +nucléaire +Examen du : 01/03/2023 +Compte-rendu validé électroniquement par Dr [NOM] le 01/03/2023 +SCINTIGRAPHIE OSSEUSE +INDICATION : +Cancer de prostate métastatique évolutif. Bilan de baseline. +RESULTAT : Comparatif au TEP-scan du 17/09/2020 +Balayage tomoscinti-TDM thoraco-lombo-pelvienne : +Majoration du nombre de foyers hyperfixants : +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 18 de 20 . Nette extension de l'atteinte de l'arc postérieur de la 6e côte gauche s'étendant désormais au corps vertébral de T6. +. Apparition d'une hyperfixation avec ostéocondensation de l'arc postérieur de la 7e côte droite. +. Apparition d'hyperfixations des corps vertébraux postérieurs de T10-T11-T12 avec tassement vertébraux T11 et T12 sans recul du +mur postérieur. +. Apparition d'une hyperfixation de la scapula gauche au-dessus de l'épine et de la scapula droite en arrière de l'acromion. +. Apparition de fractures hyperfixantes des arcs antérieurs des 5e, 6e, 7e et 8e côtes droites. +Sur le plan TDM : +Adénopathies rétropéritonéales latéro aortique gauches supracentimétriques. +Pas de dilatation des cavités pyélocalicielles. +Pas de macro nodule pulmonaire. +Pas d'hypodensité hépatique suspecte en contraste spontané. +Sur le reste du squelette (balayage corps entier) : +Fixation osseuse normale. +CONCLUSION : +Atteinte secondaire osseuse et condensante du rachis (T6, T10, T11 et T12), K7 droit, scapulas avec tassements vertébraux T11 et +T12. +Apparition de fractures possiblement post-traumatiques des 5e 6e 7e et 8e côtes droites. +Bien confraternellement Dr [NOM] +TECHNIQUE : +Radiopharmaceutique : HMDP (Hydroxy-Méthyl-Diphosphate) ?99m Tc +Dose Administrée : 683 MBq IV (poids patient : 73.0 kg) +Acquisition : sur gamma-caméra SYMBIA (Siemens) +PDL : 615.64 mGy.cm CTDI : 7.9 mGy Protocole d'acquisition : 6.5 CT 1 Lit 2.5 mm +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 : RAD001123105 [DATE_NAISSANCE] +Résultats de laboratoire +28/02/2023 08 : 55 26/02/2023 09:00 24/02/2023 20:23 24/02/2023 17:10 +Résultat de labo +(5895105) (5892957) (5892958) (5892806) +Apparition des symptômes Asymptomatique +Bilirubine conjuguée calculée 8 µmol/l +Bilirubine non conjuguée 12 µmol/l +Bilirubine totale 8 µmol/l 20 µmol/l +ASAT 26 U/l 32 U/l +Bilirubine totale < : +21 µmol/L : dosage des +Commentaire bilirubine totale fractions conjuguée +et non conjugée non +réalisé. +Gamma GT 65 U/l 90 U/l +Phosphatase alcaline 61 U/l 76 U/l +Calcium 1,91 mmol/l 2,30 mmol/l +Chlore 103 mmol/l 93 mmol/l +Créatinine 68 µmol/l 116 µmol/l +CRP 30 mg/l 168 mg/l +Compte rendu Bactériologie Bact230226142435-1.pdf +Compte-rendu laboratoire Labo230228115307-1.pdf Labo230227094415-1.pdf Labo230225133622-1.pdf +Polynucléaires neutrophiles +92,0 % 90,7 % +(%) +Polynucléaires neutrophiles +3,45 10.9/l 2,42 10.9/l +(#) +Polynucléaires éosinophiles +0,0 % 0,0 % +(%) +Polynucléaires éosinophiles +0,00 10.9/l 0,00 10.9/l +(#) +Polynucléaires basophiles (%) 0,0 % 1,1 % +Polynucléaires basophiles (#) 0,00 10.9/l 0,03 10.9/l +Lymphocytes (%) 2,0 % 5,2 % +Lymphocytes (#) 0,07 10.9/l 0,14 10.9/l +Monocytes (%) 2,0 % 3,0 % +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 19 de 20 Monocytes (#) 0,07 10.9/l 0,08 10.9/l +Morphologie des globules Polynucléaires +blancs hyposegmentés ++ +Formule vérifiée par le +Oui Oui +technicien +Myélocytes neutrophiles (%) 4,0 % +Myélocytes neutrophiles (#) 0,15 10.9/l +Glucose 5,7 mmol/l 9,0 mmol/l +ALAT 38 U/l 58 U/l +réalisée sur frottis réalisée sur automate +Formule sanguine +sanguin au microscope XN (Sysmex) +Hématocrite (%) 31,6 % 47,8 % +Indice de distribution des +17,0 % 18,5 % +hématies +Verification sur lame des Absence d'amas Absence d'amas +plaquettes plaquettaires. plaquettaires. +Absence de traitement +Traitement anticoagulant +anticoagulant +Potassium 4,0 mmol/l 4,1 mmol/l +LDH 237 U/l 286 U/l +PCR Grippe A Négative +PCR Grippe B Négative +PCR COVID 19 (prélèvement +Négative +nasal) GeneXpert +PCR Virus respiratoire +Négative +syncitial +Culture ECBU TK Stérile. +Leucocytes 3,75 10.9/l 16 /µL 2,67 10.9/l +Nature du prélèvement Urine Milieu de jet +Hématies 3,74 10.12/l (t/l) 5,64 10.12/l (t/l) +Hémoglobine 10,7 g/dl 15,9 g/dl +VGM 84,5 fl 84,8 fl +TCMH 28,6 pg 28,2 pg +CCMH 33,9 g/dl 33,3 g/dl +Sodium 134 mmol/l 134 mmol/l +Prélèvement non +Non conformité validé initialement par +Service +Osmolarité sang 274 mOSM/l 277 mOSM/l +Plaquettes 96 10.9/l 144 10.9/l +Protéines 48 g/l 72 g/l +Le patient est-il professionel +non +de santé ? +Réserve alcaline 29 mmol/l 31 mmol/l +Validation et diffusion sous la +Dr [NOM] [NOM] [NOM] Dr [NOM] [NOM] [NOM] +responsabilité du biologiste +Trou anionique 6 14 +TCA 21,0 secondes +TCA ratio 0,69 +TP 106 % +Temps de Quick 11,0 secondes +Situation de résidence du +hébergement individuel +patient +Urée 20,3 mmol/l +Volume plaquettaire moyen 10,4 fl 9,6 fl +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le 02/03/2023 09 : 53 Page 20 de 20 + + +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] ENEA Ville de résidence: [VILLE] +Episode No : [EPISODE] +Localisation : ONCOLOGIE HC Médecin courant: DR. [NOM] +Date d'admission : 24/02/2023 Heure d'admission: 14:51 +Date de sortie : Heure de sortie: +Nom : Adresse Téléphone +DR. [NOM] [NOM] : [ADRESSE][CODE_POSTAL] D [NOM] [TEL] +Type de contact : Relation Nom Prénom Adresse Tél. domicile Tél. +professionel Mobile +Personne à prévenir +(Trakcare) : Epouse FRANCE [TEL] +Personne à prévenir +(Trakcare) : Fils [NOM] [NOM] [TEL] +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Item de +surveillance : 02/03/2023 +08:41 01/03/2023 +23:24 01/03/2023 +21:56 01/03/2023 +18:00 01/03/2023 +08:43 01/03/2023 +08:14 28/02/2023 +23:22 28/02/2023 +16:09 28/02/2023 +13:10 28/02/2023 +09:15 28/02/2023 +09:00 28/02/2023 +06:08 28/02/2023 +04:33 +Température : 37,30 37,00 37,40 37,20 37,30 37,50 37,20 37,90 +Pouls : 83,00 80,00 82,00 82,00 78,00 +PA +Systolique : 136,00 138,00 144,00 149,00 116,00 +PA +Diastolique : 71,00 73,00 88,00 72,00 56,00 +PA +Moyenne : 93,00 95,00 107,00 98,00 76,00 +Saturation +O² : 97,00 95,00 95,00 94,00 95,00 +Ventilation : Ventilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant n +Echelle +douleur : EN EN EN EN EN +Score au +repos : 0,00 0,00 0,00 0,00 0,00 +Glycémie +capillaire : 1,12 1,23 0,84 1,42 +Volume +de miction +[ml] : 400,00 0,00 326,00 +Transit : Absence Peu Absence +Item de +surveillance : 01/03/2023 +07:44 28/02/2023 +07:55 27/02/2023 +15:00 27/02/2023 +07:31 26/02/2023 +07:56 25/02/2023 +23:00 25/02/2023 +15:33 25/02/2023 +07:59 +Diurèse : 1000,00 800,00 300,00 900,00 250,00 400,00 400,00 250,00 + +Diurèse +- Cumul +8h/8h : 1000,00 1100,00 300,00 900,00 1050,00 800,00 400,00 250,00 +Pyélo/ +Néphro +drte - +Cumul +8h/8h : 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Pyélo/ +Néphro +gche - +Cumul +8h/8h : 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Diurèse +Totale : 1000,00 800,00 300,00 900,00 250,00 400,00 400,00 250,00 +Diurèse +- Cumul +8h/8h Total : 1000,00 1100,00 300,00 900,00 1050,00 800,00 400,00 250,00 +Compens +° Diurèse +- Cumul +8h/8h : 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Item de +surveillance : 01/03/2023 +07:44 28/02/2023 +07:55 27/02/2023 +15:00 27/02/2023 +07:31 26/02/2023 +07:56 25/02/2023 +23:00 25/02/2023 +15:33 25/02/2023 +07:59 +Balance +hydrique +totale +(cumulée) +[ml] : -4300,00 -3300,00 -2500,00 -2200,00 -1300,00 -1050,00 -650,00 -250,00 +Balance +hydrique +totale +(session) : -1000,00 -800,00 -300,00 -900,00 -250,00 -400,00 -400,00 -250,00 +Entrées +totales des +liquides +(cumulé) : 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Entrées +totales des +liquides +(session) +[ml] : 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Total Pertes +Liquidiennes +(Relevé) : 4300,00 3300,00 2500,00 2200,00 1300,00 1050,00 650,00 250,00 +Total Pertes +liquidiennes +(session) : 1000,00 800,00 300,00 900,00 250,00 400,00 400,00 250,00 +Item de +surveillance : 01/03/2023 +08:44 28/02/2023 +10:39 27/02/2023 +11:09 24/02/2023 +16:12 +Poids [kg] : 76,00 76,00 76,70 73,00 +Taille [cm] : 168,00 168,00 168,00 +Indice +de masse +corporelle : 26.927 26.927 25.865 +Surface +corporelle : 1.86 1.86 1.83 +Item de +surveillance : 02/03/2023 +08:41 01/03/2023 +23:24 01/03/2023 +08:43 28/02/2023 +23:22 28/02/2023 +16:09 28/02/2023 +13:10 28/02/2023 +09:15 28/02/2023 +06:08 28/02/2023 +04:33 27/02/2023 +15:48 27/02/2023 +08:29 26/02/2023 +22:25 26/02/2023 +15:37 +Température : 37,30 37,00 37,40 37,20 37,30 37,50 37,20 37,90 37,40 37,50 37,30 37,00 +Pouls : 83,00 80,00 82,00 82,00 78,00 77,00 72,00 86,00 93,00 +PA +Systolique : 136,00 138,00 144,00 149,00 116,00 166,00 162,00 142,00 116,00 +PA +Diastolique : 71,00 73,00 88,00 72,00 56,00 83,00 80,00 76,00 60,00 +Saturation +O² : 97,00 95,00 95,00 94,00 95,00 96,00 98,00 95,00 +Transit : Absence Peu Absence Absence Absence + +Item de +surveillance : 02/03/2023 +08:41 01/03/2023 +23:24 01/03/2023 +18:00 01/03/2023 +08:43 01/03/2023 +08:14 28/02/2023 +23:22 28/02/2023 +16:09 28/02/2023 +13:10 28/02/2023 +09:15 28/02/2023 +09:00 28/02/2023 +06:08 28/02/2023 +04:33 27/02/2023 +15:48 +Température : 37,30 37,00 37,40 37,20 37,30 37,50 37,20 37,90 37,40 +Pouls : 83,00 80,00 82,00 82,00 78,00 77,00 +PA +Systolique : 136,00 138,00 144,00 149,00 116,00 166,00 +PA +Diastolique : 71,00 73,00 88,00 72,00 56,00 83,00 +Saturation +O² : 97,00 95,00 95,00 94,00 95,00 96,00 +Glycémie +capillaire : 1,12 1,23 0,84 1,42 +Transit : Absence Peu Absence +Type d'observation : Nom Date Commentaires +Note d'évolution : [NOM] [NOM] 01/03/2023 +12:18 Sur le plan symptomatique/oncologique : +Poursuite d'une bonne évolution clinique. +Reprise alimentation normale et arrêt de l'hydratation. +Scintigraphie osseuse ce jour en Baseline avant initiation TAXOTERE. +Pose de PAC en ambulatoire le 03/03 et programmation des HDJ pour TAXOTERE toutes les 3 +semaines à partir du 08/03. +Sur le plan du devenir : +Transfert au [ETABLISSEMENT] demain en fin de matinée. +Sa fille présente en chambre a été informée de l'ensemble de la prise en charge, de la prise +en charge au [ETABLISSEMENT] demain, de la pose de PAC le 03/03 et de l'initiation de la +chimiothérapie semaine prochaine le 08/03. +Note d'évolution : [NOM] [NOM] 28/02/2023 +14:49 Sur le plan symptomatique : +Stabilité clinique, transit ce jour, pas de nausées ni de vomissements. +Poids en diminution -0.7kg (soit +3kg sur l'hyperhydratation depuis le début d'hospitalisation), +sans signe de surcharge pulmonaire. +> Relai traitements per os devant la bonne évolution clinique et biologique avec nette +amélioration de la fonction rénale. +> Poursuite élargissement progressif de l'alimentation sur la bonne tolérance digestive. +> Prescription kinésithérapie de mobilisation. +Sur le plan spécifique: +En attente date pour une scintigraphie osseuse. Pose de PAC maintenue au 03/03. +Sur le plan du devenir : +Patient favorable à une prise en charge en [ETABLISSEMENT] à Grancher, demande faite. +Note d'évolution : [NOM] [NOM] 27/02/2023 +15:36 Sur le plan symptomatique : +Va bien mieux, pas de nausées ni de vomissements. Transit régulier, pas de douleurs +abdominales, abdomen souple, dépressible et indolore. ++3.5kg sans signe de surcharge clinique notamment pulmonaire. +> Elargissement alimentation ce jour, poursuite traitement laxatifs et surveillance transit ++. +> Ajout traitement par XATRAL pour retrait de la sonde urinaire dans 48/72h. +> Diminution hydratation par PG5 à 1L/jour. +Sur le plan oncologique : +Dernière séance de radiothérapie le 28/02. +Scintigraphie osseuse demandée pour cette semaine, sera probablement réalisée le 01/03. +Pose de PAC prévue le 03/03 après midi à 16h pour initiation de la nouvelle ligne de +chimiothérapie par TAXOTERE fin de semaine ou début de semaine prochaine. +> Prévoir suspension anticoagulation curative le 02/03. +Sur le plan du devenir : +Discussion avec le patient et son fils ce jour de l'intérêt d'une prise en charge en [ETABLISSEMENT] dans +les suites immédiates de l'hospitalisation à visée de remobilisation et de réautonomisation +qu'ils semblent comprendre et accepter. Explication donnée quant à la visée suspensive de la +chimiothérapie dont l'objectif n'est pas curatif mais à visée de contrôle le plus longtemps possible +de la maladie. +Note d'évolution : DR. [NOM] +[NOM] 26/02/2023 +12:07 Selles cette nuit en grande quantité avec confusion +nouvelles selles le 26/02 au matin +N'est plus confus, non algique +Essai Fauteuil dans la journée +BCY ce jour +reprise radiothérapie lundi +Est d'accord pour [ETABLISSEMENT] au décours du C1 de TAXOTERE + +Note d'évolution : DR. [NOM] +[NOM] 25/02/2023 +12:39 Effectivement tres altérée +vomissements fécaloïdes à l'arrivée avec SNG productive > 2 Ln pas de selles depuis 8 jours +abdomen souple, pas de fecalome +deshydraté +non douloureux au repos +TDM: Syndrome occlusif grêlique fonctionnel en amont d'une iléite (radique ?). Pas de zone +transitionnelle franche. Progression osseuse avec apparition de tassements pathologiques en T11 +T12 +Poursuite CTC 1mg/kg , hydratation ++, ACTISKENAN ALD, laxatifs +++ +Retrait SNG et alimentation liquide auj avec BCY demain si OK +Discuter IRM rachis avant RCP neuro +Achever radiothérapie en début de semaine pour débuter TAXOTERE sans trop tarder selon +évolution clinique +Note d'évolution : [NOM] [NOM] 24/02/2023 +16:52 ECG : FA à réponse ventriculaire rapide à 160bpm. +> Non connue, pas d'anticoagulation curative en place. +> Avis cardio (Dr [NOM]) : Mise en place d'une anticoagulation curative, pas de bloquant du +fait de la tension artérielle limite, à rediscuter selon évolution. + +Item de +surveillance : 24/02/2023 +16:09 24/02/2023 +22:52 25/02/2023 +09:23 25/02/2023 +15:32 25/02/2023 +22:59 26/02/2023 +02:14 26/02/2023 +08:55 26/02/2023 +15:37 26/02/2023 +22:25 27/02/2023 +08:29 27/02/2023 +15:48 28/02/2023 +04:33 28/02/2023 +06:08 +Température : 36.6 36.5 36.1 36.9 36 36.5 37 37.3 37.5 37.4 37.9 37.2 +PA +Systolique : 91 120 110 130 124 141 116 142 162 166 +PA +Diastolique : 50 57 69 77 80 68 60 76 80 83 +Saturation +O² : 93 94 92 94 99 95 95 98 96 +Transit : Constipati on Absence Absence Molles Diarrhées Absence Absence +Pouls : 107 105 101 102 104 93 86 72 77 +Type de note : Nom Date Note +Note IDE : [NOM] [NOM] 02/03/2023 +02:25 Transit: +Selles sur la nuit. +Note IDE : [NOM] +[NOM] 01/03/2023 +21:26 Elimination : +> Bladder fait à 17 heures car n'a pas uriné de l'après-midi = > 326 cc +> Recontrolé à 18h = > 0 cc +Devenir : +> Transfert à Grancher demain, transport ok et fiche de liaison faite +Note Diététicienne : [NOM] +[NOM] 01/03/2023 +15:16 PEC nutritionnelle : +Retrait SNG (en aspi) le 25/02. +Reprise alimentaire le 26/02 = bonne tolérance. +Elargissement menus avec passage en PO2 le 27/02 = bonne tolérance. +Pas de nausées, ni vomissements. +Appétit présent, conservé. +Transit régulier (cf. trans) +--> Menus NOR dès demain. +Note IDE : [NOM] [NOM] 01/03/2023 +12:56 Elimination : ablation de la sonde vésicale ce matin vers 10h > surveillance reprise miction + +diurèse. +A eu 1 miction par la suite (non constaté car a fait dans les WC). +Alimentation : reprise alimentation en régime normal a partir de ce soir. +Transit : a eu des selles normales en grande quantité ce matin. +Examen : scintigraphie os faite ce matin > à voir. +Devenir : Transfert a Grancher demain a 11h15 > ambu ok. +Note IDE : [NOM] +[NOM] 28/02/2023 +23:29 Infectieux +=> apyrétique + +Note IDE : [NOM] [NOM] 28/02/2023 +16:10 SORTIE GRANCHER jeudi 02/03 à 14h la bas , ambulance commandée +CHIRURGIE POSE PAC vendredi 03/03 à 16h en CHIR AMBULATOIRE , GRANCHER +prevenu sera contacté par secretariat +Note IDE : [NOM] [NOM] 28/02/2023 +14:54 SCINTIGRAPHIE OS : le 01/03 à 10h +Note IDE : [NOM] [NOM] 28/02/2023 +13:32 Alimentation : régime élargi a PO2 à partir de ce jour car a eu des selles le 26/02 + ce jour +également en petite quantité constaté. Transit à surveiller. +Radiothérapie : a eu séance ce jour a 12h, pas d'autres séances prévues. +Examen : scintigraphie os demandée > en attente de date, pas de place ce jour. +Devenir : [ETABLISSEMENT] demandé. +Note IDE : [NOM] +[NOM] 28/02/2023 +04:25 Infectieux +=> fébricule à 37.9°C à 4h30 +=> redescendu spontanément à 37.2°C à 6h +Note IDE : [NOM] +[NOM] 27/02/2023 +21:57 Digestif : +> Pas de selles cet AM +Douleur : +> Pas de plaintes algiques +Note IDE : [NOM] [NOM] 27/02/2023 +14:44 Douleur : +=> pas de plainte algique +Digestif : +=> pas de nausées ni de vomissement +=> alimentation BCY ajd +Risque de surcharge : +=> +3.7kg en quelques jour --> diminution hydrat +Radiothérapie : +=> radiothérapie ce matin à 11h30 +=> RdxTTT demain matin à 12h --> transport ok +Examen : +=> scinti os ddé +Voie d'abord : +=> pose de PAC le 3/03 +Note IDE : [NOM] [NOM] 26/02/2023 +23:40 Neuro: +Patient calme, orienté et coopérant. +Se rend compte, de ses dires, qu'il a "fait des bêtises" la nuit dernière. +Douleur: +Pas de plainte algique. +Transit: +Pas de selles. +Note IDE : [NOM] [NOM] 26/02/2023 +20:03 Douleur: +Pas de plainte algique sur l'après midi +Transit: +Absence de selles cet après midi +Comportement: +Patient cohérent et orienté sur l'après midi +nous raconte l'épisode de cette nuit: dit "avoir vu des monstres qui lui courraient après, a voulu +s'échapper ce qui explique qu'il a couper la sonde et la VVP".. hallucinations? a surveiller + +Note IDE : [NOM] [NOM] 26/02/2023 +00:16 Comportement: +A 1h30, patient retrouvé avec du sang et des selles +++ dans la chambre (lit, adaptable, salle de +bain, sol...). Poche de recueil d'urines retrouvée par terre dans la SDB, rampe et pied à perf par +terre. +Le patient tient un petit ciseau dans les mains, qui lui a sans doute permis de sectionner la +tubulure de la SV et de la VVP. +Dit avoir eu un moment de panique où il ne savait plus où il se trouvait. +Patient très virulent dans ses propos, agressif. +Lors de mon arrivée dans la chambre, patient orienté dans l'espace et dans le temps. +Calme le reste de la nuit. +Note IDE : [NOM] [NOM] 25/02/2023 +19:18 Douleur: +Pas de plainte algique +Digestif: +Pas de nausées ni de vomissement sur l'après midi +Transit: +Absence de selles cet après midi, laxatif per os administrés +Etat général: +Patient toujours asthénique, a dormi toute l'après midi +Note IDE : [NOM] [NOM] 25/02/2023 +14:10 Douleur : +=> pas de plainte algique +Digestif : +=> SNG en place et fonctionnelle --> 500cc de résidus ce matin soit 2500cc depuis la pose de la +SNG (moins de 24h) +=> patient gêné +++ par al SNG, demande à boire --> signalé au médecin --> ok pour un jus ce +matin +=> suite scan abdo en urgence --> CAT de retirer la SNG et ok pour liquide ajd puis passage en +BCY demain +Examen : +=> scan abdo en urgence ce matin --> "Syndrome occlusif grêlique fonctionnel en amont d'une +iléite (radique ?). Pas de zone transitionnelle franche. Progression osseuse avec apparition de +tassements pathologiques en T11 T12" +Elimination : +=> SV en place et fonctionnelle +Etat général : +=> patient asthénique en fin de matinée, dort en rentrant du scan +TTT : +=> ajout hydrat ce matin car déshydratation + +Note IDE : [NOM] [NOM] 24/02/2023 +20:49 Motif d'hospitalisation: +Patient entré ce jour pour AEG dans un contexte d'ADK de prostate suivi a Bergonié +Voie d'abord: +VVP posée (capital veineux précaire) +Alimentation: +Patient qui mange très peu au domicile depuis plusieurs jours --> diet ddé +Elimination: +Dysurie importante, déshydratation? --> bladder 62cc +SV ch 16 posée sur consignes médicales + ECBU réalisé +Digestif: +Patient qui dit ne pas avoir eu de selles depuis au moins 5 jours --> lavement réalisé cet après +midi non efficace +--> dlr abdo + Vomissement fécaloïde à 20h --> SNG posée repère 65 en aspi --> 600cc fécaloïde +évacué d'emblé +Cardio: +ECG réalisé cet après midi --> FA --> avis cardio introduction d'ATC +Etat général: +Patient asthénique ++, ne se mobilise plus depuis 3 jours --> matelas air ddé +Douleur: +Douleurs abdo ce soir, soulagées par la pose de la SNG +porteur d'un patch d'ATG3 retiré à 16h selon consignes médicales +Suivi onco: +2 dernières séances de radiothérapie prévues le 27 et 28/02 (horaire à récupérer auprès des +enfants) +Risque infectieux: +PCR refusé par le patient ce soir.. à faire demain matin svp +Prescription : Dose Fréquence Date de début Date de dernière +administration Note Docteur +EUPANTOL 40MG PDR INJ +[1] Flacon(s) : 40 mg - Soir [19h] Normal 24/02/2023 16:02 27/02/2023 19:28 Le débit a été +modifié. Le débit +en cours est : 60 +par . [NOM] [NOM] +METHYLPREDNISOLONE +MYL 40MG PDR INJ [10] +Flacon(s) : 40 mg - Matin midi Normal 25/02/2023 06:00 28/02/2023 08:41 Le débit a été +modifié. Le débit +en cours est : 3 +par . [NOM] [NOM] +METOCLOPRAMIDE CHL +REN 10MG/2ML INJ [100] +Ampoule(s) : 1 AMP - Normal 24/02/2023 16:02 [NOM] [NOM] +POLYIONIQUE 1A G5 +BAX POC VFO 500ML [1] +POCHE(S) : - Normal 24/02/2023 16:09 01/03/2023 08:45 Le débit a été +modifié. Le débit +en cours est : +41.66666666666666 +ML par 1 hrs. [NOM] [NOM] +4 +SODIUM CHL MACO +0,9% INJ PP 500ML [1] +POCHE(S) : - Normal 25/02/2023 12:31 27/02/2023 00:28 Le débit a été +modifié. Le débit +en cours est : +41.66666666666666 +ML par 1 hrs. DR. [NOM] +[NOM] +4 +METHYLPREDNISOLONE +MYL 120MG PDR INJ [10] +Flacon(s) : 80 mg - 1 seule fois 1 seule +fois 24/02/2023 16:02 24/02/2023 16:49 Le débit a été +modifié. Le débit +en cours est : 2 +par . [NOM] [NOM] +ACTISKENAN 10MG +GELULE [14] Gelule(s) : 1 GEL - Normal 24/02/2023 16:02 [NOM] [NOM] + +ACTISKENAN 10MG +GELULE [14] Gelule(s) : 1 GEL - Presc. de Sortie 02/03/2023 14:00 [NOM] [NOM] +EZETIMIBE MYL 10MG +CPR [90] CPR(s) : 1 CPR - Soir [19h] Normal 24/02/2023 16:09 01/03/2023 19:31 [NOM] [NOM] +EZETIMIBE MYL 10MG +CPR [90] CPR(s) : 1 CPR - Soir [19h] Presc. de +Sortie 02/03/2023 14:00 [NOM] [NOM] +FORLAX 10G PDR ORALE +SACHET [20] Sachet(s) : 2 SACHET - Matin midi soir +Normal 24/02/2023 16:02 02/03/2023 08:11 [NOM] [NOM] +FORLAX 10G PDR ORALE +SACHET [20] Sachet(s) : 2 SACHET - Matin midi soir +Presc. de Sortie 02/03/2023 14:00 [NOM] [NOM] +GABAPENTINE ARW +300MG GELULE [90] +Gelule(s) : 1 GEL - Matin soir (8h - +19h) Presc. de Sortie 02/03/2023 14:00 [NOM] [NOM] +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR - Prise unique à 19h +Normal 28/02/2023 11:19 01/03/2023 19:31 [NOM] [NOM] +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR - Prise unique à 19h +Presc. de Sortie 02/03/2023 14:00 [NOM] [NOM] +LANSOYL FRAMBOISE +GEL ORAL UNIDOSE +[9] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - Matin [8h] Normal 25/02/2023 12:47 02/03/2023 08:11 DR. [NOM] +[NOM] +LANSOYL FRAMBOISE +GEL ORAL UNIDOSE +[9] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - Matin [8h] Presc. de +Sortie 02/03/2023 14:00 [NOM] [NOM] +PRIMPERAN 10MG CPR +[40] COMPRIME(S) : 1 CPR - Normal 28/02/2023 11:19 [NOM] [NOM] +PRIMPERAN 10MG CPR +[40] COMPRIME(S) : 1 CPR - Presc. de Sortie 02/03/2023 14:00 [NOM] [NOM] +SIMVASTATINE +AHL 20MG CPR [28] +COMPRIME(S) : 2 CPR - Soir [19h] Normal 24/02/2023 16:09 01/03/2023 19:31 [NOM] [NOM] +SIMVASTATINE +AHL 20MG CPR [28] +COMPRIME(S) : 2 CPR - Soir [19h] Presc. de +Sortie 02/03/2023 14:00 [NOM] [NOM] +SOLUPRED 20MG +CPR ORODISP [20] +COMPRIME(S) : 2 CPR - Matin midi Normal 28/02/2023 11:19 02/03/2023 08:11 [NOM] [NOM] +SOLUPRED 20MG +CPR ORODISP [20] +COMPRIME(S) : 2 CPR - Matin midi Presc. +de Sortie 02/03/2023 14:00 [NOM] [NOM] +XATRAL 2,5MG CPR [30] +COMPRIME(S) : 1 CPR - Matin midi soir +Normal 27/02/2023 11:18 02/03/2023 08:11 [NOM] [NOM] +XATRAL 2,5MG CPR [30] +COMPRIME(S) : 1 CPR - Matin midi soir +Presc. de Sortie 01/03/2023 14:17 [NOM] [NOM] +GABAPENTINE ARW +300MG GELULE [90] +Gelule(s) : 1 GEL - Matin soir (8h - +19h) Normal 24/02/2023 16:02 02/03/2023 08:11 [NOM] [NOM] +NORMACOL LAVEMENT +AD SOL RECTALE +[1] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - 1 seule fois 1 seule +fois 24/02/2023 16:02 24/02/2023 16:49 [NOM] [NOM] +INNOHEP 14 000UI +AXa/0,7ML SOL INJ +[2] SERINGUE(S) +PREREMPLIE(S) : 13000 UI +AXa - Soir [19h] Normal 24/02/2023 16:50 01/03/2023 19:31 [NOM] [NOM] +INNOHEP 14 000UI +AXa/0,7ML SOL INJ +[2] SERINGUE(S) +PREREMPLIE(S) : 13000 UI +AXa - Soir [19h] Presc. de +Sortie 02/03/2023 14:00 [NOM] [NOM] +LOVENOX 4000UI +AXa/0,4ML INJ SER ++S [2] SERINGUE(S) +PREREMPLIE(S) : 1 +SERINGUE(S) +PREREMPLIE - Soir [19h] Normal +(S) 24/02/2023 16:06 [NOM] [NOM] + +Date début : Heure +début Prescription Date +exécution Heure +exécution Statut Docteur Note +25/02/2023 : 10:38 Scanner Thoraco Abdomino +Pelvien 25/02/2023 11:15 Réalisé DR. [NOM] +01/03/2023 : 10:21 Scintigraphie osseuse pour +bilan osseux 01/03/2023 13:42 Réalisé DR. [NOM] +Date : Heure Prescription Docteur Date de +collection Note +24/02/2023 : 16:02 Ionogramme ( Na, K, CL ) [NOM] [NOM] 24/02/2023 +17:10 +24/02/2023 : 18:07 Grippe recherche directe [NOM] [NOM] 26/02/2023 +09:44 +28/02/2023 : 07:00 Ionogramme ( Na, K, CL ) [NOM] [NOM] 28/02/2023 +08:55 +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +DESINFECTION +ENVIRONNEMENT +PATIENT : Signé 1 Semaine - Matin +[8h] Normal 24/02/2023 +17:46 [NOM] +[NOM] +REPAS : AIDE PARTIELLE Signé 1 Semaine - Matin +[8h] Normal 24/02/2023 +17:46 [NOM] +[NOM] +SOMMEIL : SURV. Signé - 3x/Nuit (22h 2h 6h) +Normal 28/02/2023 +06:36 Marie [NOM] +[NOM] +TOILETTE : AIDE +COMPLETE Signé - 3X/J (horaires du +cycle) Normal 24/02/2023 +17:46 [NOM] +[NOM] +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +ACTISKENAN 10MG +GELULE [14] Gelule(s) : 1 GEL +ORALE Signé - Presc. de Sortie 02/03/2023 +14:00 0/120 : Non +administré A valider [NOM] +[NOM] +EZETIMIBE MYL 10MG +CPR [90] CPR(s) : 1 CPR +ORALE Signé - Soir [19h] Presc. de +Sortie 02/03/2023 +14:00 0/30 : Non administré +A valider [NOM] +[NOM] +FORLAX 10G PDR ORALE +SACHET [20] Sachet(s) : 2 SACHET +ORALE Signé - Matin midi soir +Presc. de Sortie 02/03/2023 +14:00 0/180 : Non +administré A valider [NOM] +[NOM] +GABAPENTINE ARW +300MG GELULE [90] +Gelule(s) : 1 GEL +ORALE Signé - Matin soir (8h - +19h) Presc. de Sortie 02/03/2023 +14:00 0/60 : Non administré +A valider [NOM] +[NOM] +INNOHEP 14 000UI +AXa/0,7ML SOL INJ +[2] SERINGUE(S) +PREREMPLIE(S) : 13000 UI +AXa SOUS- +CUTANEE Signé - Soir [19h] Presc. de +Sortie 02/03/2023 +14:00 0/28 : Non administré +A valider [NOM] +[NOM] +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR +ORALE Signé - Prise unique à 19h +Presc. de Sortie 02/03/2023 +14:00 0/30 : Non administré +A valider [NOM] +[NOM] +LANSOYL FRAMBOISE +GEL ORAL UNIDOSE +[9] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE +ORALE Signé - Matin [8h] Presc. de +Sortie 02/03/2023 +14:00 0/30 : Non administré +A valider [NOM] +[NOM] +PRIMPERAN 10MG CPR +[40] COMPRIME(S) : 1 CPR +ORALE Signé - Presc. de Sortie 02/03/2023 +14:00 0/90 : Non administré +A valider [NOM] +[NOM] +SIMVASTATINE +AHL 20MG CPR [28] +COMPRIME(S) : 2 CPR +ORALE Signé - Soir [19h] Presc. de +Sortie 02/03/2023 +14:00 0/60 : Non administré +A valider [NOM] +[NOM] +SOLUPRED 20MG +CPR ORODISP [20] +COMPRIME(S) : 2 CPR +ORALE Signé - Matin midi Presc. +de Sortie 02/03/2023 +14:00 0/120 : Non +administré A valider [NOM] +[NOM] +XATRAL 2,5MG CPR [30] +COMPRIME(S) : 1 CPR +ORALE Signé - Matin midi soir +Presc. de Sortie 01/03/2023 +14:17 0/7 : Non administré +A valider [NOM] +[NOM] + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 10:02 * 1 +GEL +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 16:02 * 1 +GEL +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 22:02 * 1 +GEL +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 04:02 * 1 +GEL +Signé — EZETIMIBE MYL 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Soir [19h] - +1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:09 +Fin le 25/03/2023 à +19:00 +Admin le 01/03/2023 à +19:31 19:00 * 1 +CPR +Signé — FORLAX 10G PDR ORALE SACHET - +10G poudre - Dose 2 SACHET - ORALE - Matin +midi soir - 1ère dose : 25/02/2023 @ 08:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +12:00 +Admin le 02/03/2023 à +08:11 12:00 * 2 +SACHET +Signé — FORLAX 10G PDR ORALE SACHET - +10G poudre - Dose 2 SACHET - ORALE - Matin +midi soir - 1ère dose : 25/02/2023 @ 08:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +12:00 +Admin le 02/03/2023 à +08:11 19:00 * 2 +SACHET +Signé — FORLAX 10G PDR ORALE SACHET - +10G poudre - Dose 2 SACHET - ORALE - Matin +midi soir - 1ère dose : 25/02/2023 @ 08:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +12:00 +Admin le 02/03/2023 à +08:11 08:11 * 2 +SACHET +En cours — GABAPENTINE ARW 300MG +GELULE - 300MG gelule - Dose 1 GEL - +ORALE - Matin soir (8h - 19h) - 1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 19:00 * 1 +GEL +En cours — GABAPENTINE ARW 300MG +GELULE - 300MG gelule - Dose 1 GEL - +ORALE - Matin soir (8h - 19h) - 1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:11 * 1 +GEL + +Signé — LANSOYL FRAMBOISE GEL ORAL +UNIDOSE - 11,734G/15G gel - Dose 1 REC. +UNIDOSE - ORALE - Matin [8h] - 1ère dose : 26/02/2023 @ 08:00 [NOM] [NOM] +Début le 25/02/2023 à +12:47 +Fin le 27/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:11 * +1 REC. +UNIDOSE +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) Si besoin - Début presc. : 28/02/2023 @ +11:19 +"Si nausées et/ou vomissements " [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +03:19 11:19 * 1 +CPR +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) Si besoin - Début presc. : 28/02/2023 @ +11:19 +"Si nausées et/ou vomissements " [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +03:19 19:19 * 1 +CPR +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) Si besoin - Début presc. : 28/02/2023 @ +11:19 +"Si nausées et/ou vomissements " [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +03:19 03:19 * 1 +CPR +Signé — SIMVASTATINE AHL 20MG CPR - +20MG comprime - Dose 2 CPR - ORALE - Soir +[19h] - 1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:09 +Fin le 25/03/2023 à +19:00 +Admin le 01/03/2023 à +19:31 19:00 * 2 +CPR +Signé — SOLUPRED 20MG CPR ORODISP - +20MG comprime - Dose 2 CPR - ORALE - Matin +midi - 1ère dose : 28/02/2023 @ 12:00 [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 12:00 * 2 +CPR +Signé — SOLUPRED 20MG CPR ORODISP - +20MG comprime - Dose 2 CPR - ORALE - Matin +midi - 1ère dose : 28/02/2023 @ 12:00 [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:11 * 2 +CPR +Signé — XATRAL 2,5 MG CPR - 2,5MG +comprime - Dose 1 CPR - ORALE - Matin midi +soir - 1ère dose : 27/02/2023 @ 12:00 [NOM] [NOM] +Début le 27/02/2023 à +11:18 +Fin le 09/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 12:00 * 1 +CPR +Signé — XATRAL 2,5 MG CPR - 2,5MG +comprime - Dose 1 CPR - ORALE - Matin midi +soir - 1ère dose : 27/02/2023 @ 12:00 [NOM] [NOM] +Début le 27/02/2023 à +11:18 +Fin le 09/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 19:00 * 1 +CPR + +Signé — INNOHEP 14 000UI AXA SOL INJ - +14000UI AXa solution (0,7 mL) - Dose 13000 UI +AXa - SOUS-CUTANEE Directe - Soir [19h] - +1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:50 +Fin le 25/03/2023 à +19:00 +Admin le 01/03/2023 à +19:31 19:00 * +13000 UI +AXa +Signé — DESINFECTION ENVIRONNEMENT +PATIENT - Matin [8h] - 1 Semaine- Date Début : 24/02/2023 @ 17:46 [NOM] [NOM] +Début le 24/02/2023 à +17:46 +Fin le 03/03/2023 à +08:00 08:00 * 1 +Signé — REPAS : AIDE PARTIELLE - Matin +[8h] - 1 Semaine- Date Début: 24/02/2023 @ +17:46 [NOM] [NOM] +Début le 24/02/2023 à +17:46 +Fin le 03/03/2023 à +08:00 08:00 * 1 +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 28/02/2023 +@ 06:36 Marie [NOM] [NOM] +Début le 28/02/2023 à +06:36 +Fin le 07/03/2023 à +06:00 +Admin le 01/03/2023 à +23:44 22:00 * 1 +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 28/02/2023 +@ 06:36 Marie [NOM] [NOM] +Début le 28/02/2023 à +06:36 +Fin le 07/03/2023 à +06:00 +Admin le 01/03/2023 à +23:44 02:00 * 1 +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 28/02/2023 +@ 06:36 Marie [NOM] [NOM] +Début le 28/02/2023 à +06:36 +Fin le 07/03/2023 à +06:00 +Admin le 01/03/2023 à +23:44 06:00 * 1 + + + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 10:02 * 1 +GEL +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 16:02 * 1 +GEL +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 22:02 * 1 +GEL +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 04:02 * 1 +GEL +Signé — EZETIMIBE MYL 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Soir [19h] - +1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:09 +Fin le 25/03/2023 à +19:00 +Admin le 01/03/2023 à +19:31 19:00 * 1 +CPR +Signé — FORLAX 10G PDR ORALE SACHET - +10G poudre - Dose 2 SACHET - ORALE - Matin +midi soir - 1ère dose : 25/02/2023 @ 08:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +12:00 +Admin le 02/03/2023 à +08:11 08:00 * 2 +SACHET +Signé — FORLAX 10G PDR ORALE SACHET - +10G poudre - Dose 2 SACHET - ORALE - Matin +midi soir - 1ère dose : 25/02/2023 @ 08:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +12:00 +Admin le 02/03/2023 à +08:11 12:00 * 2 +SACHET +Signé — FORLAX 10G PDR ORALE SACHET - +10G poudre - Dose 2 SACHET - ORALE - Matin +midi soir - 1ère dose : 25/02/2023 @ 08:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +12:00 +Admin le 02/03/2023 à +08:11 19:00 * 2 +SACHET +En cours — GABAPENTINE ARW 300MG +GELULE - 300MG gelule - Dose 1 GEL - +ORALE - Matin soir (8h - 19h) - 1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:00 * 1 +GEL +En cours — GABAPENTINE ARW 300MG +GELULE - 300MG gelule - Dose 1 GEL - +ORALE - Matin soir (8h - 19h) - 1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 19:00 * 1 +GEL + +Signé — LANSOYL FRAMBOISE GEL ORAL +UNIDOSE - 11,734G/15G gel - Dose 1 REC. +UNIDOSE - ORALE - Matin [8h] - 1ère dose : 26/02/2023 @ 08:00 [NOM] [NOM] +Début le 25/02/2023 à +12:47 +Fin le 27/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:00 * +1 REC. +UNIDOSE +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) Si besoin - Début presc. : 28/02/2023 @ +11:19 +"Si nausées et/ou vomissements " [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +03:19 11:19 * 1 +CPR +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) Si besoin - Début presc. : 28/02/2023 @ +11:19 +"Si nausées et/ou vomissements " [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +03:19 19:19 * 1 +CPR +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) Si besoin - Début presc. : 28/02/2023 @ +11:19 +"Si nausées et/ou vomissements " [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +03:19 03:19 * 1 +CPR +Signé — SIMVASTATINE AHL 20MG CPR - +20MG comprime - Dose 2 CPR - ORALE - Soir +[19h] - 1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:09 +Fin le 25/03/2023 à +19:00 +Admin le 01/03/2023 à +19:31 19:00 * 2 +CPR +Signé — SOLUPRED 20MG CPR ORODISP - +20MG comprime - Dose 2 CPR - ORALE - Matin +midi - 1ère dose : 28/02/2023 @ 12:00 [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:00 * 2 +CPR +Signé — SOLUPRED 20MG CPR ORODISP - +20MG comprime - Dose 2 CPR - ORALE - Matin +midi - 1ère dose : 28/02/2023 @ 12:00 [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 12:00 * 2 +CPR +Signé — XATRAL 2,5 MG CPR - 2,5MG +comprime - Dose 1 CPR - ORALE - Matin midi +soir - 1ère dose : 27/02/2023 @ 12:00 [NOM] [NOM] +Début le 27/02/2023 à +11:18 +Fin le 09/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:00 * 1 +CPR +Signé — XATRAL 2,5 MG CPR - 2,5MG +comprime - Dose 1 CPR - ORALE - Matin midi +soir - 1ère dose : 27/02/2023 @ 12:00 [NOM] [NOM] +Début le 27/02/2023 à +11:18 +Fin le 09/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 12:00 * 1 +CPR + +Signé — INNOHEP 14 000UI AXA SOL INJ - +14000UI AXa solution (0,7 mL) - Dose 13000 UI +AXa - SOUS-CUTANEE Directe - Soir [19h] - +1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:50 +Fin le 25/03/2023 à +19:00 +Admin le 01/03/2023 à +19:31 19:00 * +13000 UI +AXa +Signé — DESINFECTION ENVIRONNEMENT +PATIENT - Matin [8h] - 1 Semaine- Date Début : 24/02/2023 @ 17:46 [NOM] [NOM] +Début le 24/02/2023 à +17:46 +Fin le 03/03/2023 à +08:00 08:00 * 1 +Signé — REPAS : AIDE PARTIELLE - Matin +[8h] - 1 Semaine- Date Début: 24/02/2023 @ +17:46 [NOM] [NOM] +Début le 24/02/2023 à +17:46 +Fin le 03/03/2023 à +08:00 08:00 * 1 +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 28/02/2023 +@ 06:36 Marie [NOM] [NOM] +Début le 28/02/2023 à +06:36 +Fin le 07/03/2023 à +06:00 +Admin le 01/03/2023 à +23:44 22:00 * 1 +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 28/02/2023 +@ 06:36 Marie [NOM] [NOM] +Début le 28/02/2023 à +06:36 +Fin le 07/03/2023 à +06:00 +Admin le 01/03/2023 à +23:44 02:00 * 1 +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 28/02/2023 +@ 06:36 Marie [NOM] [NOM] +Début le 28/02/2023 à +06:36 +Fin le 07/03/2023 à +06:00 +Admin le 01/03/2023 à +23:44 06:00 * 1 + + +Prescription : Date Résultat + +Résultat de labo : 28/02/2023 08:55 +(5895105) 26/02/2023 09:00 +(5892957) 24/02/2023 20:23 +(5892958) 24/02/2023 17:10 +(5892806) +Apparition des symptômes : Asymptomatique +Bilirubine conjuguée calculée : 8 µmol/l +Bilirubine non conjuguée : 12 µmol/l +Bilirubine totale : 8 µmol/l 20 µmol/l +ASAT : 26 U/l 32 U/l +Commentaire bilirubine totale : Bilirubine totale < +21 µmol/L : dosage des +fractions conjuguée +et non conjugée non +réalisé. +Gamma GT : 65 U/l 90 U/l +Phosphatase alcaline : 61 U/l 76 U/l +Calcium : 1,91 mmol/l 2,30 mmol/l +Chlore : 103 mmol/l 93 mmol/l +Créatinine : 68 µmol/l 116 µmol/l +CRP : 30 mg/l 168 mg/l +Compte rendu Bactériologie : Bact230226142435-1.pdf +Compte-rendu laboratoire : Labo230228115307-1.pd fLabo230227094415-1.pd f Labo230225133622-1.pd f +Polynucléaires neutrophiles +(%) : 92,0 % 90,7 % +Polynucléaires neutrophiles +(#) : 3,45 10.9/l 2,42 10.9/l +Polynucléaires éosinophiles +(%) : 0,0 % 0,0 % +Polynucléaires éosinophiles +(#) : 0,00 10.9/l 0,00 10.9/l +Polynucléaires basophiles (%) : 0,0 % 1,1 % +Polynucléaires basophiles (#) : 0,00 10.9/l 0,03 10.9/l +Lymphocytes (%) : 2,0 % 5,2 % +Lymphocytes (#) : 0,07 10.9/l 0,14 10.9/l +Monocytes (%) : 2,0 % 3,0 % + +Monocytes (#) : 0,07 10.9/l 0,08 10.9/l +Morphologie des globules +blancs : Polynucléaires +hyposegmentés ++ +Formule vérifiée par le +technicien : Oui Oui +Myélocytes neutrophiles (%) : 4,0 % +Myélocytes neutrophiles (#) : 0,15 10.9/l +Glucose : 5,7 mmol/l 9,0 mmol/l +ALAT : 38 U/l 58 U/l +Formule sanguine : réalisée sur frottis +sanguin au microscope réalisée sur automate +XN (Sysmex) +Hématocrite (%) : 31,6 % 47,8 % +Indice de distribution des +hématies : 17,0 % 18,5 % +Verification sur lame des +plaquettes : Absence d'amas +plaquettaires. Absence d'amas +plaquettaires. +Traitement anticoagulant : Absence de traitement +anticoagulant +Potassium : 4,0 mmol/l 4,1 mmol/l +LDH : 237 U/l 286 U/l +PCR Grippe A : Négative +PCR Grippe B : Négative +PCR COVID 19 (prélèvement +nasal) GeneXpert : Négative +PCR Virus respiratoire +syncitial : Négative +Culture ECBU TK : Stérile. +Leucocytes : 3,75 10.9/l 16 /µL 2,67 10.9/l +Nature du prélèvement : Urine Milieu de jet +Hématies : 3,74 10.12/l (t/l) 5,64 10.12/l (t/l) +Hémoglobine : 10,7 g/dl 15,9 g/dl +VGM : 84,5 fl 84,8 fl +TCMH : 28,6 pg 28,2 pg +CCMH : 33,9 g/dl 33,3 g/dl +Sodium : 134 mmol/l 134 mmol/l +Non conformité : Prélèvement non +validé initialement par +Service +Osmolarité sang : 274 mOSM/l 277 mOSM/l +Plaquettes : 96 10.9/l 144 10.9/l +Protéines : 48 g/l 72 g/l +Le patient est-il professionel +de santé ? : non +Réserve alcaline : 29 mmol/l 31 mmol/l +Validation et diffusion sous la +responsabilité du biologiste : Dr [NOM] [NOM] Dr [NOM] [NOM] Dr [NOM] [NOM] Dr [NOM] [NOM] +Trou anionique : 6 14 +TCA : 21,0 secondes +TCA ratio : 0,69 +TP : 106 % +Temps de Quick : 11,0 secondes +Situation de résidence du +patient : hébergement individuel +Urée : 20,3 mmol/l +Volume plaquettaire moyen : 10,4 fl 9,6 fl diff --git a/test_3ogc/anonymise/trackare-01285757-23042510_01285757_23042510.redacted_raster.pdf b/test_3ogc/anonymise/trackare-01285757-23042510_01285757_23042510.redacted_raster.pdf new file mode 100644 index 0000000..e6eda05 Binary files /dev/null and b/test_3ogc/anonymise/trackare-01285757-23042510_01285757_23042510.redacted_raster.pdf differ diff --git a/test_3ogc/anonymise/trackare-01285757-23042510_01285757_23042510.redacted_vector.pdf b/test_3ogc/anonymise/trackare-01285757-23042510_01285757_23042510.redacted_vector.pdf new file mode 100644 index 0000000..1663f9b Binary files /dev/null and b/test_3ogc/anonymise/trackare-01285757-23042510_01285757_23042510.redacted_vector.pdf differ diff --git a/test_3ogc/anonymise/trackare-02004744-23116460_02004744_23116460.audit.jsonl b/test_3ogc/anonymise/trackare-02004744-23116460_02004744_23116460.audit.jsonl new file mode 100644 index 0000000..0db391a --- /dev/null +++ b/test_3ogc/anonymise/trackare-02004744-23116460_02004744_23116460.audit.jsonl @@ -0,0 +1,528 @@ +{"page": -1, "kind": "VILLE", "original": "URRUGNE", "placeholder": "[VILLE]", "bbox_hint": null} +{"page": -1, "kind": "VILLE", "original": "URRUGNE", "placeholder": "[VILLE]", "bbox_hint": null} +{"page": -1, "kind": "VILLE", "original": "URRUGNE", "placeholder": "[VILLE]", "bbox_hint": null} +{"page": -1, "kind": "VILLE", "original": "URRUGNE", "placeholder": "[VILLE]", "bbox_hint": null} +{"page": -1, "kind": "CODE_POSTAL", "original": "64122", "placeholder": "[CODE_POSTAL]", "bbox_hint": null} +{"page": -1, "kind": "CODE_POSTAL", "original": "64122", "placeholder": "[CODE_POSTAL]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "ADRESSE", "original": "300 CH. 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[ADRESSE], [CODE_POSTAL] +640000162 +POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine +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 de résidence: [VILLE] +[ADRESSE] +Détails épisode +Episode No : [EPISODE] +Localisation : Pôle Méd. interne : H semaine Médecin courant: DR. [NOM] +Date d'admission : 19/06/2023 Heure d'admission: 07:34 +Date de sortie : 23/06/2023 Heure de sortie: 12:05 +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 +Fils X FRANCE [TEL] +(Clinicom) +Personne à prévenir [NOM] +Epouse [NOM] [TEL] [TEL] +(Trakcare) gabrielle +Personne à prévenir +Fils [NOM] gerard [TEL] +(Trakcare) +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 23/06/2023 23/06/2023 22/06/2023 22/06/2023 22/06/2023 22/06/2023 22/06/2023 21/06/2023 21/06/2023 21/06/2023 21/06/2023 21/06/2023 21/06/2023 +surveillance 07 : 59 07:48 22:48 18:43 14:21 12:24 07:55 22:55 18:37 17:23 14:31 13:31 12:05 +Pouls 77 77 95 87 71 79 +PA +115 137 156 146 145 121 +Systolique +PA +69 78 90 86 72 67 +Diastolique +Glycémie +1,10 1,16 1,15 1,24 1,39 1,22 1,23 1,09 1,46 1,76 1,47 +capillaire +Température 36,50 +Saturation +97 +O² +Ventilation +spontanée +Ventilation +Air +ambiant +Echelle +EN +douleur +Score au +0 +repos +Poids/Taille +Item de 23/06/2023 19/06/2023 16/06/2023 +surveillance 07 : 54 08:10 00:28 +Poids [kg] 97,10 98,90 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le 23/06/2023 14 : 55 Page 1 de 12 Taille [cm] 172 172 172 +Indice +de masse 32,82 33,43 +corporelle +Surface +2,10 2,11 +corporelle +Surv. Isolement et Contention +Item de 23/06/2023 23/06/2023 22/06/2023 21/06/2023 21/06/2023 21/06/2023 21/06/2023 21/06/2023 20/06/2023 19/06/2023 +surveillance 07 : 59 07:48 07:55 22:55 17:23 13:31 08:05 07:59 07:51 08:06 +Pouls 77 77 95 87 71 79 111 72 73 82 +PA +115 137 156 146 145 121 123 148 145 137 +Systolique +PA +69 78 90 86 72 67 64 72 73 79 +Diastolique +Température 36,50 36,60 36,40 +Saturation +97 96 97 +O² +Surv. Contention +Item de 23/06/2023 23/06/2023 22/06/2023 22/06/2023 22/06/2023 22/06/2023 22/06/2023 21/06/2023 21/06/2023 21/06/2023 21/06/2023 21/06/2023 21/06/2023 +surveillance 07 : 59 07:48 22:48 18:43 14:21 12:24 07:55 22:55 18:37 17:23 14:31 13:31 12:05 +Pouls 77 77 95 87 71 79 +PA +115 137 156 146 145 121 +Systolique +PA +69 78 90 86 72 67 +Diastolique +Glycémie +1,10 1,16 1,15 1,24 1,39 1,22 1,23 1,09 1,46 1,76 1,47 +capillaire +Température 36,50 +Saturation +97 +O² +Observations médicales +Type d'observation Nom Date Commentaires +HDS/ETP/Atelier de groupe +A participé à une séance collective de l’atelier « Mieux Connaitre mes Médicaments » +A partir de l’ordonnance de ce jour, les principaux points abordés : +- Savoir distinguer les médicaments du diabète des médicaments des autres pathologies +- Mieux connaitre les indications de chaque médicament +- Principaux effets indésirables survenus ou à « prévenir » : Metformine notamment +- Horaires de prise : notamments quels médicaments ne pas prendre si repas sauté +Avis spécialisés DR. [NOM] 22/06/2023 - Pilulier : principe & modalités d’utilisation pratique d’un pilulier semainier +recueillis [NOM] 17 : 49 - Automédication responsable : Attention aux AINS en vente sans ordonnances +- Informer les différents professionnels de santé de toutes les prises de médicaments ou de +phytothérapie (Tisanes, Huiles essentielles…) Jus de pamplemousse, Millepertuis & Interactions +médicamenteuses +- S’assurer d’avoir l’ensemble des ordonnances et qu’elles soient à jour +- Ne pas hésiter à solliciter les pharmaciens pour info sur médicaments surtout lors du switch vers +les génériques +Motif entrée : +Première éducation dans le cadre d'un diabète de type 2 +Introduction de GLP1 en en neurologie lors de son AVC en mai 2023 (HbA1c 7,9%) +Antécédents +FA +SAOS appareillé +diabete +HTA +Histoire de la DR. [NOM] 19/06/2023 +AVC fin mai +maladie [NOM] 10 : 16 +Suivi retentissement : +Ophtalmo Dr [NOM], dernière cs 4/05/2023 : rétinopathie minime et maculopathie. IVT OD +prévue +cardio : dernière évaluation Dr [NOM] en juillet 2021 +Traitements habituels +Nebivolol 5 mg 1-0-0 +Pravastatine 40 mg 1 le soir +Eliquis 5 : 1 cp matin et soir +Perindopril 10mg 1-0-0 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le 23/06/2023 14 : 55 Page 2 de 12 Amlodipine 5 le matin +Velmetia 50/1000mg 1-0-1 (alors que je l'avais arrêté en neurologie et j'avais prescrit metformine +seule) +Gliclazide 30mg 2-0-0 +Trulicity 1,5 les mardis +Vaccination ne sait pas pour covid et tétanos, n'a jamais été vacciné contre la grippe +Mode de vie : +Vit avec son épouse +n'a jamais fumé +EC : +Ralentisement idéomoteur +Poids 98,9 IMC 33,4 kg/m² +Onychomycose, pallesthésie OK, pouls OK pieds grade 0 +Biologie : +HbA1C 7,1% +TSH 0,72 +LDL 0,55 Tg 0,92 HDL 0,31 g/l +iono NFS bilan hépatique sans anomalies +Créatinémie 65 µmol/l +RAC 2,6 mg/mmol +Albuminémie 39,4 g/L +Carence modérée en vitamine D +Pas de carence en vitamine B12 et folates +PRISE EN CHARGE DANS LE SERVICE : +Pas de modification du traitement antidiabétique +avis EMOG (cf CR). Introduction de seroplex +Supplémentation par une ampoule d'uvedose +Suivi : +Pas de cs diabéto +HbA1C tous les 3 mois, objectif 7,5% +Cs cardio à reprévoir +CS cardio pour IVT à organiser avec le Dr [NOM] +Conclusion : diabète type 2 compliqué sur le plan vasculaire, bien équilibré depuis +l'introduction de GLP1 +Syndrome dépressif, introduction de seroplex après avis EMOG +Surveillance Psychiatrie +Item de 23/06/2023 23/06/2023 22/06/2023 21/06/2023 21/06/2023 21/06/2023 21/06/2023 21/06/2023 20/06/2023 19/06/2023 +surveillance 07 : 59 07:48 07:55 22:55 17:23 13:31 08:05 07:59 07:51 08:06 +Pouls 77 77 95 87 71 79 111 72 73 82 +PA +115 137 156 146 145 121 123 148 145 137 +Systolique +PA +69 78 90 86 72 67 64 72 73 79 +Diastolique +Température 36,50 36,60 36,40 +Saturation +97 96 97 +O² +Notes paramédicales +Type de note Nom Date Note +HDS ETP DIET +Patient DT2 sous AGLP1, Metformine et Glibenclamide +contexte d'AVC récent, troubles de l'élocution, a du mal à s'exprimer. +HbA1C : 7,1 % +obésité : 98,9 kg, 1,72m, IMC:33,4. +Marié, retraité ouvrier. +Activité physique : un peu de marche. +22/06/2023 +Note Diététicienne Armelle LOUBERE +11 : 43 +Alimentation +Depuis l'AVC, l'épouse de Monsieur a beaucoup diminué les charcuteries, +le fromage et le pain dans les repas. +Monsieur mangeait charcuteries tous les jours, midi et soir. +Les repas sont structurés avec VPO, Féculent et légumes, un peu de pain, fromage 1x/jour, +1 fruit ou 1 compote. +PEC diététique : +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le 23/06/2023 14 : 55 Page 3 de 12 - a assisté aux ateliers diététiques, à l'écoute, +- entretien avec son épouse et sa fille : patient qui était gros mangeur et surtout tachyphage +--> nous faisons le point sur les RHD : modération des quantités mais sans interdits stricts, +fromage 1x/jour, charcuterie permis en qt modérée 2 à 3/semaine, pain à chaque repas +avec équivalence pain/féculent, équivalence fruit/dessert sucré +--> notion de manger plus lentement, pour mieux gérer les quantités, abordé aussi en atelier, +--> notion de plaisir alimentaire donc ne pas supprimer les aliments qu'il aime +mais être plus modéré sur les quantités et/ou les fréquences, +--> support écrit pour le RAD. +- a perdu 1,8 kg. +21/06/2023 Risque podologique : Grade 0 +Note IDE [NOM] [NOM] +11 : 05 A participé à l'atelier +20/06/2023 +Note IDE [NOM] [NOM] Psy : souhaite l'EMOG, patient triste +21 : 14 +Mr B admet avoir perdu de ses connaissances sur le diabète. Désireux de participer aux ateliers +19/06/2023 pour obtenir les informations en lien avec la pathologie, en vue de mieux la réguler. +Note IDE [NOM] [NOM] +17 : 45 Je lui propose de l'éduquer à l'utilisation de son lecteur de glycémie, n'est pas demandeur il dit +que son épouse le fait pour lui. Elle sera là demain matin→ prévoir de l'éduquer? +Traitements médicamenteux +Date de dernière +Prescription Dose Fréquence Date de début Note Docteur +administration +Voie d`administration : ORALE +Statut des prescriptions : Signé +AMLODIPINE ARG 5MG DR. [NOM] +1 GEL - Matin [8h] Normal 19/06/2023 10 : 34 23/06/2023 07:55 +GELULE [30] Gelule(s) [NOM] +ELIQUIS 5MG CPR [60] - Matin soir (8h - DR. [NOM] +1 CPR 19/06/2023 10 : 34 23/06/2023 07:55 +COMPRIME(S) 19h) Normal [NOM] +GLICLAZIDE ARW +DR. [NOM] +LM 30MG CPR [30] 2 CPR - Matin [8h] Normal 19/06/2023 10 : 34 23/06/2023 07:55 +[NOM] +COMPRIME(S) +METFORMINE MYP +- Matin soir (8h - DR. [NOM] +1000MG CPR [30] 1 CPR 19/06/2023 10 : 34 23/06/2023 07:55 +19h) Normal [NOM] +COMPRIME(S) +NEBIVOLOL ARW 5MG DR. [NOM] +1 CPR - Matin [8h] Normal 19/06/2023 10 : 34 23/06/2023 07:55 +CPR [90] COMPRIME(S) [NOM] +PERINDOPRIL ARW 4MG DR. [NOM] +2 CPR - Matin [8h] Normal 19/06/2023 10 : 34 23/06/2023 07:55 +CPR [30] COMPRIME(S) [NOM] +PRAVASTATINE +DR. [NOM] +MYL 40MG CPR [28] 1 CPR - Soir [19h] Normal 19/06/2023 10 : 34 22/06/2023 18:37 +[NOM] +COMPRIME(S) +Statut des prescriptions : Réalisé +AMLODIPINE ARG 5MG - Matin [8h] Presc. de DR. [NOM] +1 GEL 23/06/2023 09 : 30 +GELULE [30] Gelule(s) Sortie [NOM] +ELIQUIS 5MG CPR [60] - Matin soir (8h - DR. [NOM] +1 CPR 23/06/2023 09 : 30 +COMPRIME(S) 19h) Presc. de Sortie [NOM] +GLICLAZIDE ARW +- Matin [8h] Presc. de DR. [NOM] +LM 30MG CPR [30] 2 CPR 23/06/2023 09 : 30 +Sortie [NOM] +COMPRIME(S) +METFORMINE MYP +- Matin soir (8h - DR. [NOM] +1000MG CPR [30] 1 CPR 23/06/2023 09 : 30 +19h) Presc. de Sortie [NOM] +COMPRIME(S) +NEBIVOLOL ARW 5MG - Matin [8h] Presc. de DR. [NOM] +1 CPR 23/06/2023 09 : 30 +CPR [90] COMPRIME(S) Sortie [NOM] +PERINDOPRIL ARW 4MG - Matin [8h] Presc. de DR. [NOM] +2 CPR 23/06/2023 09 : 30 +CPR [30] COMPRIME(S) Sortie [NOM] +PRAVASTATINE +- Soir [19h] Presc. de DR. [NOM] +MYL 40MG CPR [28] 1 CPR 23/06/2023 09 : 30 +Sortie [NOM] +COMPRIME(S) +ZYMAD 80000UI SOL BUV - 1 seule fois 1 seule DR. [NOM] +1 AMP 22/06/2023 09 : 29 22/06/2023 12:22 +AMP [1] Ampoule(s) fois [NOM] +Voie d`administration : SOUS-CUTANEE +Statut des prescriptions : Signé +TRULICITY 1,5 MG SOL +- 1xSemaine [8h] DR. [NOM] +INJ STYLO [4] Stylo(s) 1,5 mg 19/06/2023 10 : 34 +Normal [NOM] +Prerempli(s) +TRULICITY 1,5 MG SOL +- 1xSemaine [8h] DR. [NOM] +INJ STYLO [4] Stylo(s) 1,5 mg 23/06/2023 09 : 30 +Presc. de Sortie [NOM] +Prerempli(s) +Prescriptions de laboratoire +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le 23/06/2023 14 : 55 Page 4 de 12 Date de +Date Heure Prescription Docteur [NOM] +collection +19/06/2023 +19/06/2023 08 : 00 Ionogramme ( Na, K, CL ) Camille [NOM] [NOM] +09 : 22 +Prescriptions de soins +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +19/06/2023 [NOM] +REGIME DIABÉTIQUE Signé - à 08h Normal +07 : 00 [NOM] +19/06/2023 [NOM] +DIAGNOSTIC EDUCATIF Signé - à 08h Normal +07 : 00 [NOM] +DESINFECTION +19/06/2023 [NOM] +ENVIRONNEMENT Réalisé - Matin [8h] Normal +07 : 00 [NOM] +PATIENT +LIT : REFECTION 19/06/2023 [NOM] +Réalisé - Matin [8h] Normal +PARTIELLE 07 : 00 [NOM] +- Matin midi soir 19/06/2023 [NOM] +REPAS : INSTALLATION Réalisé +Normal 07 : 00 [NOM] +- 3x/Nuit (22h 2h 6h) 21/06/2023 [NOM] +SOMMEIL : SURV. Réalisé +Normal 21 : 00 [NOM] +19/06/2023 [NOM] +EDUCATION DIABETIQUE Réalisé - Matin [8h] Normal +07 : 00 [NOM] +- 7x/jour (8h 12h +GLYCEMIE CAPILLAIRE x 19/06/2023 [NOM] +Réalisé 14h 19h 22h 0h 4h) +7 07 : 00 [NOM] +Normal +SIGNES VITAUX (Pls, +- 2X /jour (8h 16h) 19/06/2023 [NOM] +TA, FR, T°, Glyc, Miction, Réalisé +Normal 07 : 00 [NOM] +Transit) +Prescriptions de sortie +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +DR. +AMLODIPINE ARG 5MG 1 GEL - Matin [8h] Presc. de 23/06/2023 0/30 : Non administré +Réalisé [NOM] +GELULE [30] Gelule(s) ORALE Sortie 09 : 30 Révisé/Traité +[NOM] +DR. +[NOM] 5MG CPR [60] 1 CPR - Matin soir (8h - 23/06/2023 0/60 : Non administré +Réalisé [NOM] +COMPRIME(S) ORALE 19h) Presc. de Sortie 09 : 30 Révisé/Traité +[NOM] +GLICLAZIDE ARW DR. +2 CPR - Matin [8h] Presc. de 23/06/2023 0/60 : Non administré +LM 30MG CPR [30] Réalisé [NOM] +ORALE Sortie 09 : 30 Révisé/Traité +COMPRIME(S) [NOM] +METFORMINE MYP DR. +1 CPR - Matin soir (8h - 23/06/2023 0/60 : Non administré +1000MG CPR [30] Réalisé [NOM] +ORALE 19h) Presc. de Sortie 09 : 30 Révisé/Traité +COMPRIME(S) [NOM] +DR. +[NOM] 5MG 1 CPR - Matin [8h] Presc. de 23/06/2023 0/30 : Non administré +Réalisé [NOM] +CPR [90] COMPRIME(S) ORALE Sortie 09 : 30 Révisé/Traité +[NOM] +DR. +[NOM] 4MG 2 CPR - Matin [8h] Presc. de 23/06/2023 0/60 : Non administré +Réalisé [NOM] +CPR [30] COMPRIME(S) ORALE Sortie 09 : 30 Révisé/Traité +[NOM] +PRAVASTATINE DR. +1 CPR - Soir [19h] Presc. de 23/06/2023 0/30 : Non administré +MYL 40MG CPR [28] Réalisé [NOM] +ORALE Sortie 09 : 30 Révisé/Traité +COMPRIME(S) [NOM] +TRULICITY 1,5 MG SOL 1,5 mg DR. +- 1xSemaine [8h] 23/06/2023 0/4 : Non administré +INJ STYLO [4] Stylo(s) SOUS- Signé [NOM] +Presc. de Sortie 09 : 30 A valider +Prerempli(s) CUTANEE [NOM] +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le 23/06/2023 14 : 55 Page 5 de 12 Plan de soins Jour J du 23/06/2023 07h00 au 24/06/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +Signé — REGIME DIABÉTIQUE - à 08h - Début le 19/06/2023 à +pendant 5 Jour(s)- Date Début : 19/06/2023 @ 07:00 +07 : 00 Fin le 23/06/2023 à 07:55 * 1 +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — AMLODIPINE ARG 5MG GELULE - Début le 19/06/2023 à +5MG gelule - Dose 1 GEL - ORALE - Matin [8h] 10 : 34 07:55 * 1 +- 1ère dose : 20/06/2023 @ 08:00 Fin le 19/07/2023 à GEL +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — ELIQUIS 5MG CPR - 5MG comprime Début le 19/06/2023 à +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - 10 : 34 19:00 * 1 +1ère dose : 19/06/2023 @ 19:00 Fin le 19/07/2023 à CPR +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — ELIQUIS 5MG CPR - 5MG comprime Début le 19/06/2023 à +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - 10 : 34 07:55 * 1 +1ère dose : 19/06/2023 @ 19:00 Fin le 19/07/2023 à CPR +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — GLICLAZIDE ARW LM 30MG CPR - Début le 19/06/2023 à +30MG comprime - Dose 2 CPR - ORALE - Matin 10 : 34 07:55 * 2 +[8h] - 1ère dose : 20/06/2023 @ 08:00 Fin le 19/07/2023 à CPR +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — METFORMINE VIATRIS 1 000 Début le 19/06/2023 à +MG CPR - 1000MG comprime - Dose 1 CPR 10 : 34 +- 1 9 O /0 R 6 A /2 L 0 E 2 3 - M @ a 1 ti 9 n : 0 s 0 oir (8h - 19h) - 1ère dose: F 08 in :0 l 0 e 19/07/2023 à 1 C 9 P : R 00 * 1 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — METFORMINE VIATRIS 1 000 Début le 19/06/2023 à +MG CPR - 1000MG comprime - Dose 1 CPR 10 : 34 +- 1 9 O /0 R 6 A /2 L 0 E 2 3 - M @ a 1 ti 9 n : 0 s 0 oir (8h - 19h) - 1ère dose: F 08 in :0 l 0 e 19/07/2023 à 0 C 7 P : R 55 * 1 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — NEBIVOLOL ARW 5MG CPR - 5MG Début le 19/06/2023 à +comprime - Dose 1 CPR - ORALE - Matin [8h] - 10 : 34 07:55 * 1 +1ère dose : 20/06/2023 @ 08:00 Fin le 19/07/2023 à CPR +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — PERINDOPRIL ARW 4MG CPR - 4MG Début le 19/06/2023 à +comprime - Dose 2 CPR - ORALE - Matin [8h] - 10 : 34 07:55 * 2 +1ère dose : 20/06/2023 @ 08:00 Fin le 19/07/2023 à CPR +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — PRAVASTATINE MYL 40MG CPR - Début le 19/06/2023 à +40MG comprime - Dose 1 CPR - ORALE - Soir 10 : 34 19:00 * 1 +[19h] - 1ère dose : 19/06/2023 @ 19:00 Fin le 18/07/2023 à CPR +19 : 00 +Admin le 22/06/2023 à +18 : 37 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le 23/06/2023 14 : 55 Page 6 de 12 [NOM] [NOM] +Réalisé — DESINFECTION Début le 19/06/2023 à +ENVIRONNEMENT PATIENT - Matin [8h] - 07 : 00 +pendant 7 Jour(s)- Date Début : 19/06/2023 @ Fin le 25/06/2023 à 08:00 * 1 +07 : 00 08:00 +Admin le 23/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — LIT : REFECTION PARTIELLE Début le 19/06/2023 à +- Matin [8h] - pendant 7 Jour(s)- Date Début : 07:00 +19/06/2023 @ 07 : 00 Fin le 25/06/2023 à 08:00 * 1 +08 : 00 +Admin le 23/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — REPAS : INSTALLATION - Matin Début le 19/06/2023 à +midi soir - pendant 7 Jour(s)- Date Début : 07:00 +19/06/2023 @ 07 : 00 Fin le 25/06/2023 à 19:00 * 1 +19 : 00 +Admin le 23/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — REPAS : INSTALLATION - Matin Début le 19/06/2023 à +midi soir - pendant 7 Jour(s)- Date Début : 07:00 +19/06/2023 @ 07 : 00 Fin le 25/06/2023 à 08:00 * 1 +19 : 00 +Admin le 23/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — REPAS : INSTALLATION - Matin Début le 19/06/2023 à +midi soir - pendant 7 Jour(s)- Date Début : 07:00 +19/06/2023 @ 07 : 00 Fin le 25/06/2023 à 12:00 * 1 +19 : 00 +Admin le 23/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 21/06/2023 à +6h) - pendant 7 Jour(s)- Date Début : 21/06/2023 21:00 +@ 21 : 00 Fin le 28/06/2023 à 06:00 * 1 +06 : 00 +Admin le 23/06/2023 à +06 : 37 +[NOM] [NOM] +Réalisé — EDUCATION DIABETIQUE - Matin Début le 19/06/2023 à +[8h] - pendant 7 Jour(s)- Date Début : 19/06/2023 07:00 +@ 07 : 00 Fin le 25/06/2023 à 07:55 * 1 +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le 19/06/2023 à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 07 : 00 +Jour(s)- Date Début : 19/06/2023 @ 07:00 Fin le 24/06/2023 à 14:00 * 1 +04 : 00 +Admin le 23/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le 19/06/2023 à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 07 : 00 +Jour(s)- Date Début : 19/06/2023 @ 07:00 Fin le 24/06/2023 à 19:00 * 1 +04 : 00 +Admin le 23/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le 19/06/2023 à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 07 : 00 +Jour(s)- Date Début : 19/06/2023 @ 07:00 Fin le 24/06/2023 à 22:00 * 1 +04 : 00 +Admin le 23/06/2023 à +12 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le 23/06/2023 14 : 55 Page 7 de 12 [NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le 19/06/2023 à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 07 : 00 +Jour(s)- Date Début : 19/06/2023 @ 07:00 Fin le 24/06/2023 à 00:00 * 1 +04 : 00 +Admin le 23/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le 19/06/2023 à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 07 : 00 +Jour(s)- Date Début : 19/06/2023 @ 07:00 Fin le 24/06/2023 à 04:00 * 1 +04 : 00 +Admin le 23/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le 19/06/2023 à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 07 : 00 +Jour(s)- Date Début : 19/06/2023 @ 07:00 Fin le 24/06/2023 à 08:00 * 1 +04 : 00 +Admin le 23/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le 19/06/2023 à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 07 : 00 +Jour(s)- Date Début : 19/06/2023 @ 07:00 Fin le 24/06/2023 à 12:00 * 1 +04 : 00 +Admin le 23/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T Début le 19/06/2023 à +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - 07 : 00 +pendant 7 Jour(s)- Date Début : 19/06/2023 @ Fin le 25/06/2023 à 16:00 * 1 +07 : 00 16:00 +Admin le 23/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T Début le 19/06/2023 à +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - 07 : 00 +pendant 7 Jour(s)- Date Début : 19/06/2023 @ Fin le 25/06/2023 à 08:00 * 1 +07 : 00 16:00 +Admin le 23/06/2023 à +08 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le 23/06/2023 14 : 55 Page 8 de 12 Plan de soins Jour J + 1 du 24/06/2023 07h00 au 25/06/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +Signé — AMLODIPINE ARG 5MG GELULE - Début le 19/06/2023 à +5MG gelule - Dose 1 GEL - ORALE - Matin [8h] 10 : 34 08:00 * 1 +- 1ère dose : 20/06/2023 @ 08:00 Fin le 19/07/2023 à GEL +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — ELIQUIS 5MG CPR - 5MG comprime Début le 19/06/2023 à +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - 10 : 34 08:00 * 1 +1ère dose : 19/06/2023 @ 19:00 Fin le 19/07/2023 à CPR +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — ELIQUIS 5MG CPR - 5MG comprime Début le 19/06/2023 à +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - 10 : 34 19:00 * 1 +1ère dose : 19/06/2023 @ 19:00 Fin le 19/07/2023 à CPR +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — GLICLAZIDE ARW LM 30MG CPR - Début le 19/06/2023 à +30MG comprime - Dose 2 CPR - ORALE - Matin 10 : 34 08:00 * 2 +[8h] - 1ère dose : 20/06/2023 @ 08:00 Fin le 19/07/2023 à CPR +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — METFORMINE VIATRIS 1 000 Début le 19/06/2023 à +MG CPR - 1000MG comprime - Dose 1 CPR 10 : 34 +- 1 9 O /0 R 6 A /2 L 0 E 2 3 - M @ a 1 ti 9 n : 0 s 0 oir (8h - 19h) - 1ère dose: F 08 in :0 l 0 e 19/07/2023 à 0 C 8 P : R 00 * 1 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — METFORMINE VIATRIS 1 000 Début le 19/06/2023 à +MG CPR - 1000MG comprime - Dose 1 CPR 10 : 34 +- 1 9 O /0 R 6 A /2 L 0 E 2 3 - M @ a 1 ti 9 n : 0 s 0 oir (8h - 19h) - 1ère dose: F 08 in :0 l 0 e 19/07/2023 à 1 C 9 P : R 00 * 1 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — NEBIVOLOL ARW 5MG CPR - 5MG Début le 19/06/2023 à +comprime - Dose 1 CPR - ORALE - Matin [8h] - 10 : 34 08:00 * 1 +1ère dose : 20/06/2023 @ 08:00 Fin le 19/07/2023 à CPR +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — PERINDOPRIL ARW 4MG CPR - 4MG Début le 19/06/2023 à +comprime - Dose 2 CPR - ORALE - Matin [8h] - 10 : 34 08:00 * 2 +1ère dose : 20/06/2023 @ 08:00 Fin le 19/07/2023 à CPR +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Signé — PRAVASTATINE MYL 40MG CPR - Début le 19/06/2023 à +40MG comprime - Dose 1 CPR - ORALE - Soir 10 : 34 19:00 * 1 +[19h] - 1ère dose : 19/06/2023 @ 19:00 Fin le 18/07/2023 à CPR +19 : 00 +Admin le 22/06/2023 à +18 : 37 +[NOM] [NOM] +Réalisé — DESINFECTION Début le 19/06/2023 à +ENVIRONNEMENT PATIENT - Matin [8h] - 07 : 00 +pendant 7 Jour(s)- Date Début : 19/06/2023 @ Fin le 25/06/2023 à 08:00 * 1 +07 : 00 08:00 +Admin le 23/06/2023 à +08 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le 23/06/2023 14 : 55 Page 9 de 12 [NOM] [NOM] +Réalisé — LIT : REFECTION PARTIELLE Début le 19/06/2023 à +- Matin [8h] - pendant 7 Jour(s)- Date Début : 07:00 +19/06/2023 @ 07 : 00 Fin le 25/06/2023 à 08:00 * 1 +08 : 00 +Admin le 23/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — REPAS : INSTALLATION - Matin Début le 19/06/2023 à +midi soir - pendant 7 Jour(s)- Date Début : 07:00 +19/06/2023 @ 07 : 00 Fin le 25/06/2023 à 08:00 * 1 +19 : 00 +Admin le 23/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — REPAS : INSTALLATION - Matin Début le 19/06/2023 à +midi soir - pendant 7 Jour(s)- Date Début : 07:00 +19/06/2023 @ 07 : 00 Fin le 25/06/2023 à 12:00 * 1 +19 : 00 +Admin le 23/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — REPAS : INSTALLATION - Matin Début le 19/06/2023 à +midi soir - pendant 7 Jour(s)- Date Début : 07:00 +19/06/2023 @ 07 : 00 Fin le 25/06/2023 à 19:00 * 1 +19 : 00 +Admin le 23/06/2023 à +12 : 00 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 21/06/2023 à +6h) - pendant 7 Jour(s)- Date Début : 21/06/2023 21:00 +@ 21 : 00 Fin le 28/06/2023 à 22:00 * 1 +06 : 00 +Admin le 23/06/2023 à +06 : 37 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 21/06/2023 à +6h) - pendant 7 Jour(s)- Date Début : 21/06/2023 21:00 +@ 21 : 00 Fin le 28/06/2023 à 02:00 * 1 +06 : 00 +Admin le 23/06/2023 à +06 : 37 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 21/06/2023 à +6h) - pendant 7 Jour(s)- Date Début : 21/06/2023 21:00 +@ 21 : 00 Fin le 28/06/2023 à 06:00 * 1 +06 : 00 +Admin le 23/06/2023 à +06 : 37 +[NOM] [NOM] +Réalisé — EDUCATION DIABETIQUE - Matin Début le 19/06/2023 à +[8h] - pendant 7 Jour(s)- Date Début : 19/06/2023 07:00 +@ 07 : 00 Fin le 25/06/2023 à 08:00 * 1 +08 : 00 +Admin le 23/06/2023 à +07 : 55 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T Début le 19/06/2023 à +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - 07 : 00 +pendant 7 Jour(s)- Date Début : 19/06/2023 @ Fin le 25/06/2023 à 08:00 * 1 +07 : 00 16:00 +Admin le 23/06/2023 à +08 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T Début le 19/06/2023 à +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - 07 : 00 +pendant 7 Jour(s)- Date Début : 19/06/2023 @ Fin le 25/06/2023 à 16:00 * 1 +07 : 00 16:00 +Admin le 23/06/2023 à +08 : 00 +Résultats de laboratoire +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le 23/06/2023 14 : 55 Page 10 de 12 22/06/2023 06 : 38 19/06/2023 11:27 19/06/2023 09:22 +Résultat de labo +(5984891) (5980669) (5980670) +Hémoglobine A1c 7,1 % +Albumine 39,4 g/l +Acide urique 372 µmol/l +Les valeurs de +références de 25- +hydroxyvitamine D +se situent entre 30 +et 60 ng/mL pour la +prise en charge de +patients porteurs d'une +pathologie osseuse, +phosphocalcique ou +rénale, à l'exception +des patients dialysés +pour lesquels la zone +cible est réduite (30 à +45-50 ng/mL). Pour +les patients ayant une +granulomatose, la 25- +hydroxyvitamine D +doit être comprise +entre 15 et 20 ng/ +mL. Concernant la +population générale, +le dosage de 25- +hydroxyvitamine D +n'est pas indiqué et il +n'existe pas de valeurs +de références, sachant +Commentaire 25 +qu'environ 50 % de la +hydroxyvitamine D +population générale +en bonne santé a une +concentration de 25- +hydroxyvitamine D +inférieure à 20 ng/ +mL. Pour rappel, les +indications du dosage +de 25-hydroxyvitamine +D validées par la +HAS sont la suspicion +de rachitisme ou +d'ostéomalacie, le +suivi des patients +transplantés rénaux +3 mois après +transplantation, +la surveillance de +patients avant et après +chirurgie bariatrique, +les personnes âgées +faisant des chutes à +répétition et le suivi +des traitements pour +lesquels le dosage de +25-hydroxyvitamine D +est préconisé. +ASAT 32 U/l +Ferritine 295,13 µg/l +Gamma GT 17 U/l +Objectifs +thérapeutiques pour +les patients présentant +un risque cardio- +vasculaire (HAS +2017) : Risque cardio- +Commentaire LDL +vasculaire faible : +< : 4,9 mmol/L (1,9 +g/L) Risque cardio- +vasculaire modéré : +< : 3,4 mmol/L (1,3 +g/L) Risque cardio- +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le 23/06/2023 14 : 55 Page 11 de 12 vasculaire élevé : +< : 2,6 mmol/L (1 +g/L) Risque cardio- +vasculaire très élevé : +< : 1,8 mmol/L (0,7 g/ +L) +TSH 3ème génération 0,72 mUI/L +25-hydroxyvitamine D 17 ng/ml +Rapport Albuminurie / +2,6 mg/mmol +Créatininurie +Cholestérol total 2,58 mmol/l +HDL cholestérol 0,81 mmol/l +Chlore 105 mmol/l +LDL cholestérol 1,42 mmol/l +Créatinine 65 µmol/l +CRP 9 mg/l 1 mg/l +Créatinine urinaire 10,72 mmol/l +Compte-rendu laboratoire Labo230622102021-1.pdfLabo230619163045-1.pdfLabo230619130416-1.pdf +Folates 8,79 nmol/l +Polynucléaires neutrophiles +76,6 % +(%) +Polynucléaires neutrophiles +5,77 10.9/l +(#) +Polynucléaires éosinophiles +2,5 % +(%) +Polynucléaires éosinophiles +0,19 10.9/l +(#) +Polynucléaires basophiles (%) 0,5 % +Polynucléaires basophiles (#) 0,04 10.9/l +Lymphocytes (%) 11,8 % +Lymphocytes (#) 0,89 10.9/l +Monocytes (%) 8,6 % +Monocytes (#) 0,65 10.9/l +Glucose 5,5 mmol/l +ALAT 28 U/l +réalisée sur automate +Formule sanguine +XN (Sysmex) +Hématocrite (%) 42,2 % +Indice de distribution des +12,4 % +hématies +Traitement anticoagulant Inconnu +Potassium 3,7 mmol/l +Albumine urinaire 28 mg/l +Leucocytes 7,53 10.9/l +Hématies 4,54 10.12/l (t/l) +Hémoglobine 14,5 g/dl +VGM 93,0 fl +TCMH 31,9 pg +CCMH 34,4 g/dl +Sodium 137 mmol/l +Osmolarité sang 280 mOSM/l +Plaquettes 184 10.9/l +Protéines 73 g/l +Validation et diffusion sous la +"" Dr [NOM] [NOM] [NOM] +responsabilité du biologiste +TCA 35,0 secondes +TCA ratio 1,16 +TP 88 % +Temps de Quick 12,4 secondes +Triglycérides 1,04 mmol/l +Vitamine B12 436 pmol/l +Volume plaquettaire moyen 12,3 fl +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le 23/06/2023 14 : 55 Page 12 de 12 + + +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 : [ADRESSE] Ville de résidence: [VILLE] +Episode No : [EPISODE] +Localisation : Pôle Méd. interne : H semaine Médecin courant: DR. [NOM] +Date d'admission : 19/06/2023 Heure d'admission: 07:34 +Date de sortie : 23/06/2023 Heure de sortie: 12:05 +Nom : Adresse Téléphone +DR. [NOM] [NOM] : [ADRESSE][CODE_POSTAL] +Type de contact : Relation Nom Prénom Adresse Tél. domicile Tél. +professionel Mobile +Personne à prévenir +(Clinicom) : Fils X FRANCE [TEL] +Personne à prévenir +(Trakcare) : Epouse [NOM] [NOM] +gabrielle [TEL] [TEL] +Personne à prévenir +(Trakcare) : Fils [NOM] gerard [TEL] +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Item de +surveillance : 23/06/2023 +07:59 23/06/2023 +07:48 22/06/2023 +22:48 22/06/2023 +18:43 22/06/2023 +14:21 22/06/2023 +12:24 22/06/2023 +07:55 21/06/2023 +22:55 21/06/2023 +18:37 21/06/2023 +17:23 21/06/2023 +14:31 21/06/2023 +13:31 21/06/2023 +12:05 +Pouls : 77 77 95 87 71 79 +PA +Systolique : 115 137 156 146 145 121 +PA +Diastolique : 69 78 90 86 72 67 +Glycémie +capillaire : 1,10 1,16 1,15 1,24 1,39 1,22 1,23 1,09 1,46 1,76 1,47 +Température : 36,50 +Saturation +O² : 97 +Ventilation : Ventilatio +spontanée +Air +ambiant n +Echelle +douleur : EN +Score au +repos : 0 +Item de +surveillance : 23/06/2023 +07:54 19/06/2023 +08:10 16/06/2023 +00:28 +Poids [kg] : 97,10 98,90 + +Taille [cm] : 172 172 172 +Indice +de masse +corporelle : 32,82 33,43 +Surface +corporelle : 2,10 2,11 +Item de +surveillance : 23/06/2023 +07:59 23/06/2023 +07:48 22/06/2023 +07:55 21/06/2023 +22:55 21/06/2023 +17:23 21/06/2023 +13:31 21/06/2023 +08:05 21/06/2023 +07:59 20/06/2023 +07:51 19/06/2023 +08:06 +Pouls : 77 77 95 87 71 79 111 72 73 82 +PA +Systolique : 115 137 156 146 145 121 123 148 145 137 +PA +Diastolique : 69 78 90 86 72 67 64 72 73 79 +Température : 36,50 36,60 36,40 +Saturation +O² : 97 96 97 +Item de +surveillance : 23/06/2023 +07:59 23/06/2023 +07:48 22/06/2023 +22:48 22/06/2023 +18:43 22/06/2023 +14:21 22/06/2023 +12:24 22/06/2023 +07:55 21/06/2023 +22:55 21/06/2023 +18:37 21/06/2023 +17:23 21/06/2023 +14:31 21/06/2023 +13:31 21/06/2023 +12:05 +Pouls : 77 77 95 87 71 79 +PA +Systolique : 115 137 156 146 145 121 +PA +Diastolique : 69 78 90 86 72 67 +Glycémie +capillaire : 1,10 1,16 1,15 1,24 1,39 1,22 1,23 1,09 1,46 1,76 1,47 +Température : 36,50 +Saturation +O² : 97 +Type d'observation : Nom Date Commentaires +Avis spécialisés +recueillis : DR. [NOM] +[NOM] 22/06/2023 +17:49 HDS/ETP/Atelier de groupe +A participé à une séance collective de l’atelier « Mieux Connaitre mes Médicaments » +A partir de l’ordonnance de ce jour, les principaux points abordés : +- Savoir distinguer les médicaments du diabète des médicaments des autres pathologies +- Mieux connaitre les indications de chaque médicament +- Principaux effets indésirables survenus ou à « prévenir » : Metformine notamment +- Horaires de prise :notamments quels médicaments ne pas prendre si repas sauté +- Pilulier : principe & modalités d’utilisation pratique d’un pilulier semainier +- Automédication responsable : Attention aux AINS en vente sans ordonnances +- Informer les différents professionnels de santé de toutes les prises de médicaments ou de +phytothérapie (Tisanes, Huiles essentielles…) Jus de pamplemousse, Millepertuis & Interactions +médicamenteuses +- S’assurer d’avoir l’ensemble des ordonnances et qu’elles soient à jour +- Ne pas hésiter à solliciter les pharmaciens pour info sur médicaments surtout lors du switch vers +les génériques + +Item de +surveillance : 23/06/2023 +07:59 23/06/2023 +07:48 22/06/2023 +07:55 21/06/2023 +22:55 21/06/2023 +17:23 21/06/2023 +13:31 21/06/2023 +08:05 21/06/2023 +07:59 20/06/2023 +07:51 19/06/2023 +08:06 +Pouls : 77 77 95 87 71 79 111 72 73 82 +PA +Systolique : 115 137 156 146 145 121 123 148 145 137 +PA +Diastolique : 69 78 90 86 72 67 64 72 73 79 +Température : 36,50 36,60 36,40 +Saturation +O² : 97 96 97 +Type de note : Nom Date Note + +Note IDE : [NOM] [NOM] 21/06/2023 +11:05 Risque podologique : Grade 0 +A participé à l'atelier +Note IDE : [NOM] [NOM] 20/06/2023 +21:14 Psy : souhaite l'EMOG, patient triste +Note IDE : [NOM] [NOM] 19/06/2023 +17:45 Mr B admet avoir perdu de ses connaissances sur le diabète. Désireux de participer aux ateliers +pour obtenir les informations en lien avec la pathologie, en vue de mieux la réguler. +Je lui propose de l'éduquer à l'utilisation de son lecteur de glycémie, n'est pas demandeur il dit +que son épouse le fait pour lui. Elle sera là demain matin→ prévoir de l'éduquer? +Prescription : Dose Fréquence Date de début Date de dernière +administration Note Docteur +AMLODIPINE ARG 5MG +GELULE [30] Gelule(s) : 1 GEL - Matin [8h] Normal 19/06/2023 10:34 23/06/2023 07:55 DR. [NOM] +[NOM] +ELIQUIS 5MG CPR [60] +COMPRIME(S) : 1 CPR - Matin soir (8h - +19h) Normal 19/06/2023 10:34 23/06/2023 07:55 DR. [NOM] +[NOM] +GLICLAZIDE ARW +LM 30MG CPR [30] +COMPRIME(S) : 2 CPR - Matin [8h] Normal 19/06/2023 10:34 23/06/2023 07:55 DR. [NOM] +[NOM] +METFORMINE MYP +1000MG CPR [30] +COMPRIME(S) : 1 CPR - Matin soir (8h - +19h) Normal 19/06/2023 10:34 23/06/2023 07:55 DR. [NOM] +[NOM] +NEBIVOLOL ARW 5MG +CPR [90] COMPRIME(S) : 1 CPR - Matin [8h] Normal 19/06/2023 10:34 23/06/2023 07:55 DR. [NOM] +[NOM] +PERINDOPRIL ARW 4MG +CPR [30] COMPRIME(S) : 2 CPR - Matin [8h] Normal 19/06/2023 10:34 23/06/2023 07:55 DR. [NOM] +[NOM] +PRAVASTATINE +MYL 40MG CPR [28] +COMPRIME(S) : 1 CPR - Soir [19h] Normal 19/06/2023 10:34 22/06/2023 18:37 DR. [NOM] +[NOM] +AMLODIPINE ARG 5MG +GELULE [30] Gelule(s) : 1 GEL - Matin [8h] Presc. de +Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +ELIQUIS 5MG CPR [60] +COMPRIME(S) : 1 CPR - Matin soir (8h - +19h) Presc. de Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +GLICLAZIDE ARW +LM 30MG CPR [30] +COMPRIME(S) : 2 CPR - Matin [8h] Presc. de +Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +METFORMINE MYP +1000MG CPR [30] +COMPRIME(S) : 1 CPR - Matin soir (8h - +19h) Presc. de Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +NEBIVOLOL ARW 5MG +CPR [90] COMPRIME(S) : 1 CPR - Matin [8h] Presc. de +Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +PERINDOPRIL ARW 4MG +CPR [30] COMPRIME(S) : 2 CPR - Matin [8h] Presc. de +Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +PRAVASTATINE +MYL 40MG CPR [28] +COMPRIME(S) : 1 CPR - Soir [19h] Presc. de +Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +ZYMAD 80000UI SOL BUV +AMP [1] Ampoule(s) : 1 AMP - 1 seule fois 1 seule +fois 22/06/2023 09:29 22/06/2023 12:22 DR. [NOM] +[NOM] +TRULICITY 1,5 MG SOL +INJ STYLO [4] Stylo(s) +Prerempli(s) : 1,5 mg - 1xSemaine [8h] +Normal 19/06/2023 10:34 DR. [NOM] +[NOM] +TRULICITY 1,5 MG SOL +INJ STYLO [4] Stylo(s) +Prerempli(s) : 1,5 mg - 1xSemaine [8h] +Presc. de Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] + +Date : Heure Prescription Docteur Date de +collection Note +19/06/2023 : 08:00 Ionogramme ( Na, K, CL ) Camille [NOM] [NOM] 19/06/2023 +09:22 +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +REGIME DIABÉTIQUE : Signé - à 08h Normal 19/06/2023 +07:00 [NOM] +[NOM] +DIAGNOSTIC EDUCATIF : Signé - à 08h Normal 19/06/2023 +07:00 [NOM] +[NOM] +DESINFECTION +ENVIRONNEMENT +PATIENT : Réalisé - Matin [8h] Normal 19/06/2023 +07:00 [NOM] +[NOM] +LIT : REFECTION +PARTIELLE Réalisé - Matin [8h] Normal 19/06/2023 +07:00 [NOM] +[NOM] +REPAS : INSTALLATION Réalisé - Matin midi soir +Normal 19/06/2023 +07:00 [NOM] +[NOM] +SOMMEIL : SURV. Réalisé - 3x/Nuit (22h 2h 6h) +Normal 21/06/2023 +21:00 [NOM] +[NOM] +EDUCATION DIABETIQUE : Réalisé - Matin [8h] Normal 19/06/2023 +07:00 [NOM] +[NOM] +GLYCEMIE CAPILLAIRE x +7 : Réalisé - 7x/jour (8h 12h +14h 19h 22h 0h 4h) +Normal 19/06/2023 +07:00 [NOM] +[NOM] +SIGNES VITAUX (Pls, +TA, FR, T°, Glyc, Miction, +Transit) : Réalisé - 2X /jour (8h 16h) +Normal 19/06/2023 +07:00 [NOM] +[NOM] +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +AMLODIPINE ARG 5MG +GELULE [30] Gelule(s) : 1 GEL +ORALE Réalisé - Matin [8h] Presc. de +Sortie 23/06/2023 +09:30 0/30 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +ELIQUIS 5MG CPR [60] +COMPRIME(S) : 1 CPR +ORALE Réalisé - Matin soir (8h - +19h) Presc. de Sortie 23/06/2023 +09:30 0/60 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +GLICLAZIDE ARW +LM 30MG CPR [30] +COMPRIME(S) : 2 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 23/06/2023 +09:30 0/60 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +METFORMINE MYP +1000MG CPR [30] +COMPRIME(S) : 1 CPR +ORALE Réalisé - Matin soir (8h - +19h) Presc. de Sortie 23/06/2023 +09:30 0/60 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +NEBIVOLOL ARW 5MG +CPR [90] COMPRIME(S) : 1 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 23/06/2023 +09:30 0/30 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +PERINDOPRIL ARW 4MG +CPR [30] COMPRIME(S) : 2 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 23/06/2023 +09:30 0/60 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +PRAVASTATINE +MYL 40MG CPR [28] +COMPRIME(S) : 1 CPR +ORALE Réalisé - Soir [19h] Presc. de +Sortie 23/06/2023 +09:30 0/30 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +TRULICITY 1,5 MG SOL +INJ STYLO [4] Stylo(s) +Prerempli(s) : 1,5 mg +SOUS- +CUTANEE Signé - 1xSemaine [8h] +Presc. de Sortie 23/06/2023 +09:30 0/4 : Non administré +A valider DR. +[NOM] +[NOM] + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — REGIME DIABÉTIQUE - à 08h - +pendant 5 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 23/06/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 1 +Signé — AMLODIPINE ARG 5MG GELULE - +5MG gelule - Dose 1 GEL - ORALE - Matin [8h] +- 1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 1 +GEL +Signé — ELIQUIS 5MG CPR - 5MG comprime +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - +1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 19:00 * 1 +CPR +Signé — ELIQUIS 5MG CPR - 5MG comprime +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - +1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 1 +CPR +Signé — GLICLAZIDE ARW LM 30MG CPR - +30MG comprime - Dose 2 CPR - ORALE - Matin +[8h] - 1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 2 +CPR +Signé — METFORMINE VIATRIS 1 000 +MG CPR - 1000MG comprime - Dose 1 CPR +- ORALE - Matin soir (8h - 19h) - 1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 19:00 * 1 +CPR +Signé — METFORMINE VIATRIS 1 000 +MG CPR - 1000MG comprime - Dose 1 CPR +- ORALE - Matin soir (8h - 19h) - 1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 1 +CPR +Signé — NEBIVOLOL ARW 5MG CPR - 5MG +comprime - Dose 1 CPR - ORALE - Matin [8h] - +1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 1 +CPR +Signé — PERINDOPRIL ARW 4MG CPR - 4MG +comprime - Dose 2 CPR - ORALE - Matin [8h] - +1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 2 +CPR +Signé — PRAVASTATINE MYL 40MG CPR - +40MG comprime - Dose 1 CPR - ORALE - Soir +[19h] - 1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 18/07/2023 à +19:00 +Admin le 22/06/2023 à +18:37 19:00 * 1 +CPR + +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - +pendant 7 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +08:00 +Admin le 23/06/2023 à +08:00 08:00 * 1 +Réalisé — LIT : REFECTION PARTIELLE +- Matin [8h] - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +08:00 +Admin le 23/06/2023 à +08:00 08:00 * 1 +Réalisé — REPAS : INSTALLATION - Matin +midi soir - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +19:00 +Admin le 23/06/2023 à +12:00 19:00 * 1 +Réalisé — REPAS : INSTALLATION - Matin +midi soir - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +19:00 +Admin le 23/06/2023 à +12:00 08:00 * 1 +Réalisé — REPAS : INSTALLATION - Matin +midi soir - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +19:00 +Admin le 23/06/2023 à +12:00 12:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 21/06/2023 +@ 21:00 [NOM] [NOM] +Début le 21/06/2023 à +21:00 +Fin le 28/06/2023 à +06:00 +Admin le 23/06/2023 à +06:37 06:00 * 1 +Réalisé — EDUCATION DIABETIQUE - Matin +[8h] - pendant 7 Jour(s)- Date Début : 19/06/2023 +@ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 14:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 19:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 22:00 * 1 + +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 00:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 04:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 08:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 12:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - +pendant 7 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +16:00 +Admin le 23/06/2023 à +08:00 16:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - +pendant 7 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +16:00 +Admin le 23/06/2023 à +08:00 08:00 * 1 + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — AMLODIPINE ARG 5MG GELULE - +5MG gelule - Dose 1 GEL - ORALE - Matin [8h] +- 1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 1 +GEL +Signé — ELIQUIS 5MG CPR - 5MG comprime +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - +1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 1 +CPR +Signé — ELIQUIS 5MG CPR - 5MG comprime +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - +1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 19:00 * 1 +CPR +Signé — GLICLAZIDE ARW LM 30MG CPR - +30MG comprime - Dose 2 CPR - ORALE - Matin +[8h] - 1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 2 +CPR +Signé — METFORMINE VIATRIS 1 000 +MG CPR - 1000MG comprime - Dose 1 CPR +- ORALE - Matin soir (8h - 19h) - 1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 1 +CPR +Signé — METFORMINE VIATRIS 1 000 +MG CPR - 1000MG comprime - Dose 1 CPR +- ORALE - Matin soir (8h - 19h) - 1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 19:00 * 1 +CPR +Signé — NEBIVOLOL ARW 5MG CPR - 5MG +comprime - Dose 1 CPR - ORALE - Matin [8h] - +1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 1 +CPR +Signé — PERINDOPRIL ARW 4MG CPR - 4MG +comprime - Dose 2 CPR - ORALE - Matin [8h] - +1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 2 +CPR +Signé — PRAVASTATINE MYL 40MG CPR - +40MG comprime - Dose 1 CPR - ORALE - Soir +[19h] - 1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 18/07/2023 à +19:00 +Admin le 22/06/2023 à +18:37 19:00 * 1 +CPR +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - +pendant 7 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +08:00 +Admin le 23/06/2023 à +08:00 08:00 * 1 + +Réalisé — LIT : REFECTION PARTIELLE +- Matin [8h] - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +08:00 +Admin le 23/06/2023 à +08:00 08:00 * 1 +Réalisé — REPAS : INSTALLATION - Matin +midi soir - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +19:00 +Admin le 23/06/2023 à +12:00 08:00 * 1 +Réalisé — REPAS : INSTALLATION - Matin +midi soir - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +19:00 +Admin le 23/06/2023 à +12:00 12:00 * 1 +Réalisé — REPAS : INSTALLATION - Matin +midi soir - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +19:00 +Admin le 23/06/2023 à +12:00 19:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 21/06/2023 +@ 21:00 [NOM] [NOM] +Début le 21/06/2023 à +21:00 +Fin le 28/06/2023 à +06:00 +Admin le 23/06/2023 à +06:37 22:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 21/06/2023 +@ 21:00 [NOM] [NOM] +Début le 21/06/2023 à +21:00 +Fin le 28/06/2023 à +06:00 +Admin le 23/06/2023 à +06:37 02:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 21/06/2023 +@ 21:00 [NOM] [NOM] +Début le 21/06/2023 à +21:00 +Fin le 28/06/2023 à +06:00 +Admin le 23/06/2023 à +06:37 06:00 * 1 +Réalisé — EDUCATION DIABETIQUE - Matin +[8h] - pendant 7 Jour(s)- Date Début : 19/06/2023 +@ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - +pendant 7 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +16:00 +Admin le 23/06/2023 à +08:00 08:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - +pendant 7 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +16:00 +Admin le 23/06/2023 à +08:00 16:00 * 1 + +Résultat de labo : 22/06/2023 06:38 +(5984891) 19/06/2023 11:27 +(5980669) 19/06/2023 09:22 +(5980670) +Hémoglobine A1c : 7,1 % +Albumine : 39,4 g/l +Acide urique : 372 µmol/l +Commentaire 25 +hydroxyvitamine D : Les valeurs de +références de 25- +hydroxyvitamine D +se situent entre 30 +et 60 ng/mL pour la +prise en charge de +patients porteurs d'une +pathologie osseuse, +phosphocalcique ou +rénale, à l'exception +des patients dialysés +pour lesquels la zone +cible est réduite (30 à +45-50 ng/mL). Pour +les patients ayant une +granulomatose, la 25- +hydroxyvitamine D +doit être comprise +entre 15 et 20 ng/ +mL. Concernant la +population générale, +le dosage de 25- +hydroxyvitamine D +n'est pas indiqué et il +n'existe pas de valeurs +de références, sachant +qu'environ 50 % de la +population générale +en bonne santé a une +concentration de 25- +hydroxyvitamine D +inférieure à 20 ng/ +mL. Pour rappel, les +indications du dosage +de 25-hydroxyvitamine +D validées par la +HAS sont la suspicion +de rachitisme ou +d'ostéomalacie, le +suivi des patients +transplantés rénaux +3 mois après +transplantation, +la surveillance de +patients avant et après +chirurgie bariatrique, +les personnes âgées +faisant des chutes à +répétition et le suivi +des traitements pour +lesquels le dosage de +25-hydroxyvitamine D +est préconisé. +ASAT : 32 U/l +Ferritine : 295,13 µg/l +Gamma GT : 17 U/l + +TSH 3ème génération : 0,72 mUI/L +25-hydroxyvitamine D : 17 ng/ml +Rapport Albuminurie / +Créatininurie : 2,6 mg/mmol +Cholestérol total : 2,58 mmol/l +HDL cholestérol : 0,81 mmol/l +Chlore : 105 mmol/l +LDL cholestérol : 1,42 mmol/l +Créatinine : 65 µmol/l +CRP : 9 mg/l 1 mg/l +Créatinine urinaire : 10,72 mmol/l +Compte-rendu laboratoire : Labo230622102021-1.pd fLabo230619163045-1.pd fLabo230619130416-1.pd f +Folates : 8,79 nmol/l +Polynucléaires neutrophiles +(%) : 76,6 % +Polynucléaires neutrophiles +(#) : 5,77 10.9/l +Polynucléaires éosinophiles +(%) : 2,5 % +Polynucléaires éosinophiles +(#) : 0,19 10.9/l +Polynucléaires basophiles (%) : 0,5 % +Polynucléaires basophiles (#) : 0,04 10.9/l +Lymphocytes (%) : 11,8 % +Lymphocytes (#) : 0,89 10.9/l +Monocytes (%) : 8,6 % +Monocytes (#) : 0,65 10.9/l +Glucose : 5,5 mmol/l +ALAT : 28 U/l +Formule sanguine : réalisée sur automate +XN (Sysmex) +Hématocrite (%) : 42,2 % +Indice de distribution des +hématies : 12,4 % +Traitement anticoagulant : Inconnu +Potassium : 3,7 mmol/l +Albumine urinaire : 28 mg/l +Leucocytes : 7,53 10.9/l +Hématies : 4,54 10.12/l (t/l) +Hémoglobine : 14,5 g/dl +VGM : 93,0 fl +TCMH : 31,9 pg +CCMH : 34,4 g/dl +Sodium : 137 mmol/l +Osmolarité sang : 280 mOSM/l +Plaquettes : 184 10.9/l +Protéines : 73 g/l +Validation et diffusion sous la +responsabilité du biologiste : "" Dr [NOM] [NOM] Dr [NOM] [NOM] +TCA : 35,0 secondes +TCA ratio : 1,16 +TP : 88 % +Temps de Quick : 12,4 secondes +Triglycérides : 1,04 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+{"page": -1, "kind": "ETAB_GLOBAL", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null} diff --git a/test_3ogc/anonymise/trackare-BA165196-23061393_BA165196_23061393.pseudonymise.txt b/test_3ogc/anonymise/trackare-BA165196-23061393_BA165196_23061393.pseudonymise.txt new file mode 100644 index 0000000..538f4b7 --- /dev/null +++ b/test_3ogc/anonymise/trackare-BA165196-23061393_BA165196_23061393.pseudonymise.txt @@ -0,0 +1,4338 @@ +[MASK] +*640N0° F0in0ess162* +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +640000162 +MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC +Dossier Patient +Détails des patients +Nom de naissance : DE [NOM] [NOM] [NOM] IPP : [IPP] +Nom et Prénom : DE [NOM] [NOM] [NOM] REGINA [DATE_NAISSANCE] +Sexe : Féminin Lieu de naissance: [VILLE] +Nationalité : PORTUGAL [CODE_POSTAL] +Adresse : [ADRESSE]: [NOM] +Détails épisode +Episode No : [EPISODE] +Localisation : PNEUMOLOGIE PHTISIOLOGIE HC Médecin courant: DR. [NOM] +Date d'admission : 25/03/2023 Heure d'admission: 00:51 +Date de sortie : 03/04/2023 Heure de sortie: 14:04 +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 +Epoux [NOM] [CODE_POSTAL] [TEL] +(Trakcare) +Personne à prévenir [TEL] +Fille [NOM] [NOM] X [CODE_POSTAL] +(Clinicom) 66 +Personne de [TEL] +Fille [NOM] [NOM] +confiance [ADRESSE]25/03/2023 +Episode - Heure 00 : 51 +Mode de transport à l'arrivée Ambulance +Médicalisation du transport Prise en charge paramédicale +Mode d'entrée Autres admissions urgentes +Date d'orientation 25/03/2023 +Heure d'orientation 00 : 56 +IAO [NOM] +Priorité Priorité 2 +Sous-type épisode URG - Circuit Long +Motif de prise en charge Dyspnée +adressée par SOS pour décompensation cardio respi +hyperthermie cet am,non retrouvé au SAU +Observ. IDE Urg arrive sous 3L O2 aux lunettes : 97%,baissé à 2litres +BI verifié et posé +test antigen covid : neg +Médecin de la prise en charge médicale [NOM] [NOM] +Date de prise en charge médicale 25/03/2023 +Heure de prise en charge médicale 00 : 51 +Médecin de la décision médicale [NOM] [NOM] +Date de décision médicale 25/03/2023 +Heure de décision médicale 04 : 58 +Décision médicale Hospitalisation MCO +Orientation du patient hospitalisation dans une unité de Médecine hors SC, SI, REA +Destination du patient REED TOKI EDER CAMBO +Date de sortie des urgences 25/03/2023 +Heure de sortie des Urgences 05 : 10 +US de destination US PNEUMOLOGIE +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 1 de 27 UF de destination PNEUMOLOGIE PHTISIOLOGIE HC +Diagnostic aux urgences +Type Etat Code Date +Principal actif J12.9 Pneumopathie virale, sans précision 25/03/2023 04 : 57 +Alertes +Date +Catégorie Alerte Date début Message +expiration +Accompagnants 27/04/2022 fille +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 03/04/2023 03/04/2023 03/04/2023 03/04/2023 03/04/2023 02/04/2023 02/04/2023 02/04/2023 02/04/2023 02/04/2023 02/04/2023 01/04/2023 01/04/2023 +surveillance 12 : 01 09:17 07:57 06:19 00:19 18:53 15:16 12:04 07:48 06:15 00:14 18:29 16:16 +Glycémie +1,45 2,90 0,65 0,88 2,51 1,43 1,73 1,51 1,88 1,68 1,66 +capillaire +Température 37,10 37,40 37 36,50 37,30 36,50 +Pouls 84 100 93 83 95 92 +PA +138 113 125 121 +Systolique +PA +66 76 68 67 +Diastolique +Saturation +96 96 97 95 95 96 +O² +Débit O² +2 2 2 2 2 2 +[L/mn] +Ventilation Ventilation Ventilation Ventilation Ventilation +Ventilation +Ventilation spontanée spontanée spontanée spontanée spontanée +assistée +Oxygène Oxygène Oxygène Oxygène Oxygène +Echelle +EN EN EN EN EN +douleur +Score au +5 0 0 0 0 +repos +Transit Normal Absence Absence Absence Normal Normal Absence Absence Absence Absence Absence +Fréq. +respiratoire +Poids/Taille +Item de 31/03/2023 27/03/2023 +surveillance 08 : 39 12:23 +Poids [kg] 88 88,80 +Taille [cm] 152 152 +Indice +de masse 38,09 38,44 +corporelle +Surface +1,84 1,85 +corporelle +Surv. Isolement et Contention +Item de 03/04/2023 03/04/2023 02/04/2023 02/04/2023 02/04/2023 01/04/2023 01/04/2023 01/04/2023 31/03/2023 31/03/2023 31/03/2023 31/03/2023 30/03/2023 +surveillance 07 : 57 00:19 15:16 07:48 00:14 16:16 08:58 00:34 18:38 15:55 08:17 05:55 22:12 +Température 37,10 37,40 37 36,50 37,30 36,50 37 37,20 36,50 37 37 +Pouls 84 100 93 83 95 92 88 100 91 90 90 96 +PA +138 113 125 121 131 134 134 105 +Systolique +PA +66 76 68 67 65 58 55 55 +Diastolique +Saturation +96 96 97 95 95 96 96 95 96 94 92 95 +O² +Transit Normal Absence Absence Absence Normal Normal +Fréq. +respiratoire +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 2 de 27 Surv. Contention +Item de 03/04/2023 03/04/2023 03/04/2023 03/04/2023 03/04/2023 02/04/2023 02/04/2023 02/04/2023 02/04/2023 02/04/2023 02/04/2023 01/04/2023 01/04/2023 +surveillance 12 : 01 09:17 07:57 06:19 00:19 18:53 15:16 12:04 07:48 06:15 00:14 18:29 16:16 +Glycémie +1,45 2,90 0,65 0,88 2,51 1,43 1,73 1,51 1,88 1,68 1,66 +capillaire +Température 37,10 37,40 37 36,50 37,30 36,50 +Pouls 84 100 93 83 95 92 +PA +138 113 125 121 +Systolique +PA +66 76 68 67 +Diastolique +Saturation +96 96 97 95 95 96 +O² +Transit Normal Absence Absence +Observations médicales +Type d'observation Nom Date Commentaires +nouvelle hospitalisation pour nouvelle décompensation cardio-respiratoire sans aucun critère de +DR. [NOM] 03/04/2023 gravité +Conclusion Clinique +[NOM] 13 : 27 bonne évolution sous antibiotiques et diurétiques (hypokaliémie à recontrôlée) +transfert à Toki ce jour +DR. [NOM] 01/04/2023 01/04/23 CNE +Note d'évolution +[NOM] 14 : 20 pas d'hypoglycémie, nuit de bonne qualité +DR. [NOM] 31/03/2023 adaptation doses insuline +Note d'évolution +[NOM] 14 : 54 je suis là demain matin on peut me rappeler si elle fait encore des hypos cette nuit +31/03/23 : CNE +persistance d'OMI +DR. [NOM] 31/03/2023 +Note d'évolution a dormi un peu au lit cette nuit +[NOM] 12 : [ADRESSE][NOM] pour la tendance aux hypoglycémies +30/03/23 : +Apyretique +Diabete : HGT ce matin à 0.71 +Cardio : +ETT : FEVG à 60% +VG non dilaté +Pression de remplissage VG normales, pas de signe de surcharge +OG de taille normale +Absence de valvulopathie +CD non dilatées +fonction VD normale +Pression droites normales, minime épanchement péricardique de 4/5mm sans retentissement +VCI non dilatée compliante +DR. [NOM] 30/03/2023 +Note d'évolution +[NOM] 12 : 29 +bio : K=3.3 +nouvlle seringue K=2g sur 6h +avis gastro sur cette anémie ferriprive +FERINJECT fait le 29/03 +dernier colo Fogd en 2020 Dr [NOM] : proposition de consult RDV le 25/07 11h40, il +jugera en fonction de la réhab si FOGD sous AL ou en hospit +CAT : +- diminution LASILIX spécial 1 le matin (dose usuelle) +- supplémentation K +- surveillance glycémie +- avis cardio : possible majoration NTproBNP sur intro FORXIGA ? +- FERINJECT 500 ce jour (totalité de 1g) puis à nouveau 500mg ds 15j +29/03 +APyretique +DR. [NOM] 29/03/2023 HGT tjrs > à 2g : majoration insuline lente à 66ui vs 62ui +Note d'évolution +[NOM] 10 : [ADRESSE][ETABLISSEMENT] lundi +Bio : K=2.7n, Na=136 +CRP plate +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 3 de 27 NtproBNP 507 +anémie microcytaire à 10g avec VGM=75 +bilan martial carence avec ferritine et CS abaissé +ECG sur hypoK : FA +pas d'onde U +pas de sus decalage ST +onde T plate mais deja present sur ECG du 25 +Ccl : ascension NTproBNP sans douleur thoracique Sans modification ECG +CAT : +- supplémentation potassique +- FERINJECT et avis gastro (indication à colo fibro ? colo virtuelle ?) +- demande d'ETT +- recuperer courrier carido Dr [NOM] car patient en'ayant pas de beta bloquant ni d'IEC +(nécessité d'optimiser ttt cardio ?) +28/03/23 : +Patiente apyretique +discrete amélioration d ela toux +kine ce matin sans expectoration +ausuclt : ronchi bilateraux +DR. [NOM] 28/03/2023 +Note d'évolution +[NOM] 14 : 44 +echo pleurale : pas d'pénachement pleural gauche ou droit +OMI peristants +patiente m'explique ne pas supporter les bas de contentions +glycémies encore hautes : majoration insuline rapide. +27/03 +Avis diabeto sur indication GLICLAZIDE ? place du FORXIGA ? +DR. [NOM] 27/03/2023 +Note d'évolution Dr [NOM] : +[NOM] 16 : 47 +- arret GLICLAZIDE (HbA1c à 9% donc on considère que c'est inefficace) +- maintien basal/bolus +- introduction FORXIGA 10mg/j +L'objectif est de pouvoir equilibré le basal/bolus en [ETABLISSEMENT] +27/03 +Apyretique +amélioration de la toux +demangeaison sur tout le corps probablement lié à la prise de codeine +pas d'améloioratino des OMI +DR. [NOM] 27/03/2023 bio : decroissance sd inflam +Note d'évolution +[NOM] 15 : 03 stabilité NTproBNP +CAT : +- poursuite ABT +- avis diabeto sur ttt FORXIGA ? insuline ? +- attente [ETABLISSEMENT] +- arret codeine ca rmauvaise tolérance +- kine +- tjrs sous diffuK 9/j, iono OK ce jour : ajout ESIDREX 25 +- bio ds 48h +26/03 +DR. [NOM] 26/03/2023 +Note d'évolution +[NOM] 11 : 35 +Apyretique +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 4 de 27 HGT >1.5g +HbA1c à 9 fin fevrier +amélioration d ela toux +a doemi au fauteil cette nuit +--> codeine si beosin pour la nuit +peristiance OMI blanc mous des jambes +CAT : +- bio demain +- ajout codeine le soir +- ajout insuline rapide, avis endoc demain +- patiente en accord pour [ETABLISSEMENT] +Patiente admise le24/03 aux urgences pour majoration de la dyspnée et de la toux +Correspondants : +- Pneumo : Dr [NOM] +ATCD : +- Insuffisance respiratoire chronique mixte sur obésité et BPCO post-tabagique VEMS 44% en +octobre 2022 --> Sous OLD 2L, VNI nocturne +- Dyskinésie trachéale +- FA paroxystique en 2022 +- DT2 insulino dépendant +- HTA +- Trouble bipolaire +ATCD chir : +- Anneau gastrique +TTT : +-ROSUVASTATINE 10MG 1 le matin +-ESOMEPRAZOLE 20MG soir +-BUSPIRONE 10MG soir +-DEPAKOTE 500MG matin soir +-TERCIAN 4% 15 goutte le soir +-DUROGESIC 12,5µg toutes les 72h +-VERSATIS 5% EMPLATRE +-XARELTO 20MG +-LASILIX [NOM] 500MG 1 le matin +-LOXEN LP 50MG matin +Histoire de la DR. [NOM] 25/03/2023 -POTASSIUM 600MG GELULE 2 GELULE matin midi et soir +maladie [NOM] 14 : 08 -TRIMBOW 2 BOUFFEE matin et soir +-DIFICLIR 100 mg matin et soir jusqu'au 06/03 +-ABASAGLAR 62 UI à 19h +-OZEMPIC 2 MG toutes les semaines +-GLICLAZIDE 30MG 1 COMPRIME +-TIORFAN 100mg matin midi et soir SI DIARRHEES +-SMECTA matin midi et soir SI DIARRHEES +Allergies : Nc +Toxiques : +- Tabac sevré, 30PA +HDM : +Multiples hospitalisation en 2022 dans le cadre de décompensation cardiorespiratoire avec +épanchement pleuraux notamment gauche lymphocytaire sans cellules maligne après 2 +prélèvements, pas d'anomalie décelé lors d'une fibroscopie bronchique réalisé en aout 2022. +Hospitalisée en pneumologie après passage en USC fin janvier 2023 sur une décompensation +cardio respiratoire sans trigger évident retrouvé, traitée par Céfépime 7jours et déplétion par +Lasilix devant un ATCD de colonisation par Klebsiella Pneumoniae. +Hospitalisée en pneumologie du 20/02/23 au 04/03/23 pour décompensation respiratoire sur +colite à Clostridium difficile traitée par 10 jours de DIFFICLIR. +Ce jour adressée par SOS médecin pour décompensation cardio respi avec majoration des +besoins en O2 + hyperthermie dans l'après-midi, OMI et crépitants bilatéraux. +Contexte de possible contage chez petite fille de 4ans qui lui a rendu visité wend dernier +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 5 de 27 Cliniquement : +Apyrétique, tachycarde +G15, orientée dans le temps et l'espace +Toux grasse +eupnéique sous 3L +crépitants bilatéraux aux 2 bases +OMI bilatéraux prenant le godet avec sensibilité cheville gauche dérite depuis s3 jour environ, +pas de rougeur +BDC irréguliers sans souffle perçu +pas de DT +Abdo souple dépressible et indolore +Bio : +GDS sous 2L : ph=7.46, pO2=81, pCO2=50 +K=3.1, CRP=19 +Hb=9.4, VGM=78 +GB=8900 +antigenuries négatives +PCR grippe et covid négatives +CAT : +- majoration LASILIX +- poursuite VNI +- poursuite ABT probabiliste +- bain de bouche +- kine +- ECBC +- surviellance poids diurese +Bio : pro BNP 400, CRP 30 pas d'hyperleucocytose +K+ 3.1, Na 132 +25/03/2023 +Note d'évolution [NOM] [NOM] --> décompensation cardio-respi sans trigger identifié +04 : 57 +a eu 125 mg lasilix IVD + 80 mg CTC +devant hyperthermie dans l'après-midi et devant atcd début augmentin +hospitalisation en pneumo +RADIOGRAPHIE PULMONAIRE +Indication : +Bilan de dyspnée. +RESULTATS : +Sous réserve de la faible ampliation thoracique : +Diminution de la transparence parenchymateuse aux bases apparaissant être liée notamment +à la projection des parties molles. Absence de foyer circonscrit au niveau des apex pulmonaires. +Augmentation de l'index cardiothoracique.. +25/03/2023 +Note d'évolution [NOM] [NOM] +03 : 16 +Dr [NOM] +Technique : +PDS : 0.426 dGy.cm² +A l'entrée : 0.065 mGy +Protocole d'acquisition : Thorax +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] +25/03/2023 GDS : pH 7.46, pO2 86mmHg, pCO2 50mmHg, bicar 35 +Note d'évolution [NOM] [NOM] +02 : 25 --> hypercapnie compensée métabolique +Motif de cs : décompensation cardio-respi +Correspondants : +Histoire de la 25/03/2023 - Pneumo : Dr [NOM] +[NOM] [NOM] +maladie 01 : 29 +ATCD : +- Insuffisance respiratoire chronique mixte sur obésité et BPCO post-tabagique VEMS 44% en +octobre 2022 --> Sous OLD 2L, VNI nocturne +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 6 de 27 - Dyskinésie trachéale +- FA paroxystique en 2022 +- DT2 insulino dépendant +- HTA +- Trouble bipolaire +ATCD chir : +- Anneau gastrique +TTT : +-ROSUVASTATINE 10MG 1 le matin +-ESOMEPRAZOLE 20MG soir +-BUSPIRONE 10MG soir +-DEPAKOTE 500MG matin soir +-TERCIAN 4% 15 goutte le soir +-DUROGESIC 12,5µg toutes les 72h +-VERSATIS 5% EMPLATRE +-XARELTO 20MG +-LASILIX [NOM] 500MG 1 le matin +-LOXEN LP 50MG matin +-POTASSIUM 600MG GELULE 2 GELULE matin midi et soir +-TRIMBOW 2 BOUFFEE matin et soir +-DIFICLIR 100 mg matin et soir jusqu'au 06/03 +-ABASAGLAR 62 UI à 19h +-OZEMPIC 2 MG toutes les semaines +-GLICLAZIDE 30MG 1 COMPRIME +-TIORFAN 100mg matin midi et soir SI DIARRHEES +-SMECTA matin midi et soir SI DIARRHEES +Allergies : Nc +Toxiques : +- Tabac sevré, 30PA +Vaccins : +- Covid*3 +MDV : +Vit en maison plein pied avec son époux à [NOM] +Aide ménagère 1 fois par semaine, IDE 3 fois par jours +Époux aidant pour les courses, la toilette +3 enfants dans la région +HDM : +Multiples hospitalisation en 2022 dans le cadre de décompensation cardiorespiratoire avec +épanchement pleuraux lymphocytaire sans cellules maligne après 2 prélèvements, pas d'anomalie +décelé lors d'une fibroscopie bronchique réalisé en aout 2022. +Hospitalisée en pneumologie après passage en USC fin janvier 2023 sur une décompensation +cardio respiratoire sans trigger évident retrouvé, traitée par Céfépime 7jours et déplétion par +lasilix devant un ATCD de colonisation par Klebsiella Pneumoniae. +Hospitalisée en pneumologie du 20/02/23 au 04/03/23 pour décompensation respiratoire sur +colite à Clostridium difficile traitée par 10 jours de DIFFICLIR. +Ce jour adressée par SOS médecin pour décompensation cardio respi avec majoration des +besoins en O2 + hyperthermie dans l'après-midi, OMI et crépitants bilatéraux. +Cliniquement : +Apyrétique, tachycarde +G15, orientée dans le temps et l'espace +Toux grasse +eupnéique sous 3L +crépitants bilatéraux aux 2 bases +OMI bilatéraux prenant le godet +BDC irréguliers sans souffle perçu +pas de DT +Abdo souple dépressible et indolore +CAT : +Bio + GDS +RP +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 7 de 27 Surveillance Psychiatrie +Item de 03/04/2023 03/04/2023 02/04/2023 02/04/2023 02/04/2023 01/04/2023 01/04/2023 01/04/2023 31/03/2023 31/03/2023 31/03/2023 31/03/2023 30/03/2023 +surveillance 07 : 57 00:19 15:16 07:48 00:14 16:16 08:58 00:34 18:38 15:55 08:17 05:55 22:12 +Température 37,10 37,40 37 36,50 37,30 36,50 37 37,20 36,50 37 37 +Pouls 84 100 93 83 95 92 88 100 91 90 90 96 +PA +138 113 125 121 131 134 134 105 +Systolique +PA +66 76 68 67 65 58 55 55 +Diastolique +Saturation +96 96 97 95 95 96 96 95 96 94 92 95 +O² +Transit Normal Absence Absence Absence Normal Normal Absence Absence Absence Absence Absence Normal +Fréq. +respiratoire +Notes paramédicales +Type de note Nom Date Note +Hypoglycémie : +0.65g ce matin. Ressentie car se sent fatiguée --> Re sucrée : OK pour la fin de journée. +Hypoglycémie : +03/04/2023 ECG OK +Note IDE [NOM] [NOM] +14 : 04 4 gel potassium donné à 10h30. +Sortie prévue ce jour pour Toki EDER -> Papiers de sortie donnés. +02/04/2023 +Note IDE [NOM] [NOM] / +19 : 53 +01/04/2023 +Note IDE [NOM] [NOM] / +21 : 56 +Glycémie : +- ce matin : 1.05 g/L --> insuline non donné +01/04/2023 - ce midi : 1.2 g/L --> insuline non donné +Note IDE [NOM] [NOM] +13 : 12 +Persistance OMI +01/04/2023 +Note IDE [NOM] [NOM] ENDOC : glycémie stable +07 : 46 +Endocrinologie +- avis diabéto pris pour hypoglycémie +-> diminution insuline lente. +31/03/2023 +Note IDE [NOM] [NOM] -> ce soir, Hgt 1.71, lente + humalog faites. +19 : 18 +Kaliémie +- contrôle kaliémie après PSE hier lundi +Devenir => départ à Toki Eder lundi, patiente OK +[NOM] 31/03/2023 +Note IDE HGT => 1.07 G/L ce matin => rapide faite 10 UI au lieu de 14 UI +[NOM] 13 : 49 +Hypo => 0.54 G/L à midi => pas d'insuline faite, a mangé le repas, avis diabeto ddé +Respiratoire : dyspnée à la mobilisation, bonne sat sous O2 2L +31/03/2023 +Note IDE [NOM] [NOM] +01 : 10 +Glycémie : 0.74 à 6h, la patiente se dit asténique. Ressucrée po +Hypoglycémie +- 16h : Hgt 0.77 -> collation donnée +- 18h : Hgt 2.11 -> insuline lente et rapide +30/03/2023 Hypokaliémie +Note IDE [NOM] [NOM] +22 : 29 - K+ 3.3 -> PSE potassium passé sur l'après-midi, RAS +Elimination +- pas de nouvelles diarrhées +Transit => pas de diarrhées ce matin +HGT => 0.71g/L ce midi => raide faite mais moitié dose +[NOM] 30/03/2023 +Note IDE Thermo => 37.7° ce matin => apyrétique ce midi +[NOM] 14 : 31 +BS => manque de fer => pose VVP puis pose de perfusion ce midi +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 8 de 27 manque de K => SE cet a m +ETT ce jour => diminution diurétique +Respiratoire : patiente eupneique sous O2 2L au repos +30/03/2023 +Note IDE [NOM] [NOM] +00 : 37 +Transit : deux selles diarrhéique cette nuit, instructions données pour copro +Respiratoire +- stable sous 2L, encombré -> aérosols productifs. +29/03/2023 Hypokaliémie +Note IDE [NOM] [NOM] +18 : 57 - PSE posé cet après-midi -> contrôle demain matin +Endocrinologie +- Hgt : 1.62 15h : lente et humalog faites +glycémie : 1,83g/l ce midi. +majoration de l'insuline lente. +HypoKCL : 2,7, ECG. +supplémentation per os + IVSE en cours =) BS de control a faire ce soir. +cardio : ecg fait sur hypokcl, FA =) ETT demandée +29/03/2023 +Note IDE [NOM] [NOM] +13 : 23 bilan martial : carence avec ferritine =) ferinject fait. +avis gastro. +douleur : algique au niveau de son dos et d'écrit des douleurs neuropathique au niveau des +jambes. +changement patch atg 3 ce jour. +transit : absence de selle =) cocktail fait, efficace. +29/03/2023 +Note IDE [NOM] [NOM] Endoc : glycémie toujours élevée ce matin +06 : 52 +Respiratoire : clinique stable sous 2l . +Endocrino : HGT élevé ce soir . +28/03/2023 +Note IDE [NOM] [NOM] --> Insuline faite selon protocole +21 : 32 +Cardio : OMI toujours présents +RESPI=> 96% sous 2L O2 : patiente dort au fauteuil; VNI enlevé cette nuit vers 3h. +Glycémie=> hyperglycémie ce matin => 2.41 à 8H : 2.81 à 12h +après avis du diabeto=> augmentation de la rapide à 14 unités. +28/03/2023 +Note IDE [NOM] [NOM] +14 : 04 +RESPI=> 96% sous 2L O2 : patiente dort au fauteuil; VNI enlevé cette nuit vers 3h. +Glycémie=> hyperglycémie ce matin => 2.41 à 8H : 2.81 à 12h +après avis du diabeto=> augmentation de la rapide à 14 unités et Forxiga +28/03/2023 +Note IDE [NOM] DA [NOM] +13 : 53 +début de prise en charge pour ce nouvel épisode d'hospitalisation +Note [NOM] 28/03/2023 toux présente lors de la ventilation dirigée +Kinésithérapeute [NOM] 12 : 56 toux non productive +ventilation dirigée peu dyspneique +dort au fauteuil +28/03/2023 RESPI : VNI enlevé vers 03h +Note IDE [NOM] [NOM] +00 : 57 +ENDOC : HGT +Respiratoire : clinique et saturation stable sous 2l. +27/03/2023 Endocrino : Hypoglycémiants oraux modifiés . +Note IDE [NOM] [NOM] +20 : 03 Etat cutanée : OMI présents +respi : +27/03/2023 +Note IDE [NOM] [NOM] pas de problème au niveau du masque de la VNI +13 : 55 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 9 de 27 Respi=) bonne sat mais problème de masque de VNI cette nuit vu avec la patiente non mise ce +27/03/2023 soir car le masque se désadapte régulièrement laissée aux lunettes allo prestataire demain svp +Note IDE [NOM] [NOM] +00 : 05 orkyn +infectieux=) patiente apyrétique +RESPI : quintes de toux moins gênantes avec toux moins rauque , ATG2 pris pour la nuit +HYPERHGT : > à 3g ce soir (a bu du coca) => protocole d'insuline fait +26/03/2023 +Note IDE [NOM] [NOM] +19 : 06 DEVENIR : VT fait +OMI bilat prenant le godet +diab : 2.27 à 12h, vu avec med pour reprise insuline rapide +26/03/2023 patch ATG3 : changement patch ATG 3 mais me dit avoir deux patch ATG3, un de 25µg et un de +Note IDE [NOM] [NOM] +14 : 50 12µg, vu avec med +respi : toux seche, atg codéiné mis et aérosol fait +TTT : patiente signale qu'elle prend de l'aérius et du singulair le soir => à revoir SVP +DESEQUILIBRE DIABETE : hyperHGT ce soir > à 2g f signes vitaux , patient me signale +qu'elle a un protocole de rattrapage si HGT > 1.5g => à revoir aussi SVP +25/03/2023 +Note IDE [NOM] [NOM] +19 : 27 TOUX : sèche +++ => aérosol de serum phy fait X2 qui la soulage un peu +PATCH ATG3 : à changer demain midi svp , information donnée par sa fille +TTT INHALES : a l'habitude d'utiliser une chambre d'inhalation => commandée +respi : +dyspnée sous 2L/min, sous CTC +25/03/2023 +Note IDE [NOM] [NOM] +15 : 02 diab : hyperglycémie à 2.49 à midi +patch ATG : patiente doit s'informer de la date de pose du patch pour poursuite ttt antalgique +MDA : Adressée pour décompensation cardio-respi. Sortie récemment d'Hospit +Examens : +ECG12D fait et montré +GDS prélevés et envoyés +BS prélevé pdt pose VVP 20GA main D et envoyé +PCR prélevée et envoyée +ECBU envoyé +25/03/2023 +Note IDE [NOM] [NOM] +01 : 35 Cardio-respi : +Diurétiques admin IVL selon PM. [NOM] bonne réponse +CorticoTT + ATBTT débutés avant transfert. +Administratif : +Inventaire réalisé +Devenir : Pneumologie +Traitements médicamenteux +Date de dernière +Prescription Dose Fréquence Date de début Note Docteur +administration +Voie d`administration : INTRAVEINEUSE +Statut des prescriptions : Réalisé +Le débit a été +FERINJECT 500MG/10ML - 1 seule fois 1 seule modifié. Le débit DR. [NOM] +500 mg 29/03/2023 11 : 07 29/03/2023 11:44 +SOL INJ [2] Flacon(s) fois en cours est : 20 [NOM] +par . +Le débit a été +FERINJECT 500MG/10ML - 1 seule fois 1 seule modifié. Le débit DR. [NOM] +500 mg 30/03/2023 12 : 38 30/03/2023 14:28 +SOL INJ [2] Flacon(s) fois en cours est : 20 [NOM] +par . +FUROSEMIDE REN +- 1 seule fois 1 seule +20MG/2ML SOL INJ [100] 125 mg 25/03/2023 02 : 00 25/03/2023 02:12 [NOM] [NOM] +fois +Ampoule(s) +Statut des prescriptions : En cours +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 10 de 27 Le débit a été +Potassium PSE 2G/50ML modifié. Le débit DR. [NOM] +- Normal 29/03/2023 10 : 51 29/03/2023 12:22 +(2AMP) - BSFP en cours est : 8.3 [NOM] +ML par 1 hrs. +Le débit a été +Potassium PSE 2G/50ML modifié. Le débit DR. [NOM] +- Normal 30/03/2023 12 : 38 30/03/2023 15:34 +(2AMP) - BSFP en cours est : 8.3 [NOM] +ML par 1 hrs. +Voie d`administration : ORALE +Statut des prescriptions : Signé +BUSPIRONE MYL 10MG - Prise unique à 19h +1 CPR 25/03/2023 04 : 49 02/04/2023 20:40 [NOM] [NOM] +CPR [20] COMPRIME(S) Normal +CETIRIZINE ARW 10MG DR. [NOM] +1 CPR - Soir [19h] Normal 26/03/2023 15 : 41 02/04/2023 18:44 +CPR [60] COMPRIME(S) [NOM] +DEPAKOTE 500MG CPR - Matin soir (8h - La posologie est DR. [NOM] +750 mg 25/03/2023 14 : 08 03/04/2023 07:49 +[90] COMPRIME(S) 20h) Normal variable. [NOM] +FORXIGA 10MG CPR [30] DR. [NOM] +1 CPR - Matin [8h] Normal 27/03/2023 16 : 14 03/04/2023 07:49 +CPR(s) [NOM] +FUROSEMIDE ZEN 500MG +1 CPR - Matin [8h] Normal 25/03/2023 04 : 49 03/04/2023 07:49 [NOM] [NOM] +CPR [30] CPR(s) +HYDROCHLOROTHIAZIDE +DR. [NOM] +ARW 25 MG CPR [90] 1 CPR - Matin [8h] Normal 27/03/2023 18 : 00 03/04/2023 07:49 +[NOM] +CPR(s) +LANSOPRAZOLE BGA 30 - Prise unique à 19h +1 CPR 25/03/2023 04 : 49 02/04/2023 18:44 [NOM] [NOM] +MG CPR OROD [14] CPR(s) Normal +LOXEN LP 50MG GELULE +1 GEL - 1xJour [8h] Normal 25/03/2023 04 : 49 03/04/2023 07:49 [NOM] [NOM] +[60] Gelule(s) +MONTELUKAST +DR. [NOM] +ARW 10MG CPR [28] 1 CPR - Soir [19h] Normal 26/03/2023 15 : 41 02/04/2023 18:44 +[NOM] +COMPRIME(S) +POTASSIUM 600MG - Matin midi soir +3 GEL 25/03/2023 04 : 49 03/04/2023 12:16 [NOM] [NOM] +GELULE Normal +ROSUVASTATINE ARW +0,5 CPR - 1xJour [8h] Normal 25/03/2023 04 : 49 03/04/2023 07:49 [NOM] [NOM] +20MG CPR [90] CPR(s) +TERCIAN 4% SOL BUV FL +15 GTT - à 21h Normal 25/03/2023 04 : 49 02/04/2023 20:40 [NOM] [NOM] +30ML [1200] Flacon(s) +XARELTO 20MG CPR [14] +1 CPR - 1xJour [8h] Normal 25/03/2023 04 : 49 03/04/2023 07:49 [NOM] [NOM] +COMPRIME(S) +Statut des prescriptions : Arrêté +DEPAKOTE 500MG CPR - Matin soir (8h - +1 CPR 25/03/2023 04 : 49 26/03/2023 08:00 [NOM] [NOM] +[90] COMPRIME(S) 19h) Normal +GLICLAZIDE ARW +LM 30MG CPR [30] 2 CPR - 1xJour [8h] Normal 25/03/2023 04 : 49 29/03/2023 08:00 [NOM] [NOM] +COMPRIME(S) +PARACETAMOL COD +DR. [NOM] +ARW 500/30MG CPR EFF 2 CPR - Nuit [21h] Normal 26/03/2023 12 : 58 26/03/2023 18:24 +[NOM] +[16] COMPRIME(S) +Statut des prescriptions : Réalisé +AMOX/AC CLAV SDZ +- Matin midi soir +1G/125MG AD SACH [12] 1 G 25/03/2023 04 : 49 30/03/2023 19:07 [NOM] [NOM] +Normal +Sachet(s) +DR. [NOM] +BUSPIRONE MYL 10MG - Prise unique à 19h +1 CPR 03/04/2023 13 : 27 NOCENT- +CPR [20] COMPRIME(S) Presc. de Sortie +EJNAINI +DR. [NOM] +CETIRIZINE ARW 10MG - Soir [19h] Presc. de +1 CPR 03/04/2023 13 : 27 NOCENT- +CPR [60] COMPRIME(S) Sortie +EJNAINI +DR. [NOM] +DEPAKOTE 500MG CPR - Matin soir (8h - La posologie est +750 mg 03/04/2023 13 : 27 NOCENT- +[90] COMPRIME(S) 20h) Presc. de Sortie variable. +EJNAINI +DR. [NOM] +FORXIGA 10MG CPR [30] - Matin [8h] Presc. de +1 CPR 03/04/2023 13 : 27 NOCENT- +CPR(s) Sortie +EJNAINI +DR. [NOM] +FUROSEMIDE ZEN 500MG - Matin [8h] Presc. de +1 CPR 03/04/2023 13 : 27 NOCENT- +CPR [30] CPR(s) Sortie +EJNAINI +HYDROCHLOROTHIAZIDE DR. [NOM] +- Matin [8h] Presc. de +ARW 25 MG CPR [90] 1 CPR 03/04/2023 13 : 27 NOCENT- +Sortie +CPR(s) EJNAINI +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 11 de 27 DR. [NOM] +LANSOPRAZOLE BGA 30 - Prise unique à 19h +1 CPR 03/04/2023 13 : 27 NOCENT- +MG CPR OROD [14] CPR(s) Presc. de Sortie +EJNAINI +DR. [NOM] +LOXEN LP 50MG GELULE - 1xJour [8h] Presc. +1 GEL 03/04/2023 13 : 27 NOCENT- +[60] Gelule(s) de Sortie +EJNAINI +MONTELUKAST DR. [NOM] +- Soir [19h] Presc. de +ARW 10MG CPR [28] 1 CPR 03/04/2023 13 : 27 NOCENT- +Sortie +COMPRIME(S) EJNAINI +DR. [NOM] +POTASSIUM 600MG +4 GEL - URGENT Urgent 03/04/2023 11 : 21 03/04/2023 11:22 NOCENT- +GELULE +EJNAINI +DR. [NOM] +POTASSIUM 600MG - Matin midi soir +3 GEL 03/04/2023 13 : 27 NOCENT- +GELULE Presc. de Sortie +EJNAINI +DR. [NOM] +ROSUVASTATINE ARW - 1xJour [8h] Presc. +0,5 CPR 03/04/2023 13 : 27 NOCENT- +20MG CPR [90] CPR(s) de Sortie +EJNAINI +SOLUPRED 20MG +DR. [NOM] +CPR ORODISP [20] 3 CPR - 1xJour [8h] Normal 25/03/2023 04 : 23 27/03/2023 08:28 +[NOM] +COMPRIME(S) +DR. [NOM] +TERCIAN 4% SOL BUV FL - à 21h Presc. de +15 GTT 03/04/2023 13 : 27 NOCENT- +30ML [1200] Flacon(s) Sortie +EJNAINI +DR. [NOM] +XARELTO 20MG CPR [14] - 1xJour [8h] Presc. +1 CPR 03/04/2023 13 : 27 NOCENT- +COMPRIME(S) de Sortie +EJNAINI +Voie d`administration : SOUS-CUTANEE +Statut des prescriptions : Signé +ABASAGLAR 300 U SOL - Prise unique à 19h +60 UI 25/03/2023 04 : 49 02/04/2023 18:54 [NOM] [NOM] +INJ CART [5] Cartouche(s) Normal +DR. [NOM] +ABASAGLAR 300 U SOL - Prise unique à 19h +60 UI 03/04/2023 13 : 27 NOCENT- +INJ CART [5] Cartouche(s) Presc. de Sortie +EJNAINI +HUMALOG 300UI/3ML +- Matin midi soir DR. [NOM] +KWIKPEN SOL INJ [5] 14 UI 26/03/2023 10 : 07 03/04/2023 12:17 +Normal [NOM] +Stylo(s) Prerempli(s) +HUMALOG 300UI/3ML DR. [NOM] +- Matin midi soir +KWIKPEN SOL INJ [5] 14 UI 03/04/2023 13 : 27 NOCENT- +Presc. de Sortie +Stylo(s) Prerempli(s) EJNAINI +OZEMPIC 1 MG SOL INJ +- 1xSemaine [8h] +STYLO 3ML [1] Stylo(s) 1 mg 25/03/2023 04 : 49 01/04/2023 08:00 [NOM] [NOM] +Normal +Prerempli(s) +OZEMPIC 1 MG SOL INJ DR. [NOM] +- 1xSemaine [8h] +STYLO 3ML [1] Stylo(s) 1 mg 03/04/2023 13 : 27 NOCENT- +Presc. de Sortie +Prerempli(s) EJNAINI +Voie d`administration : TRANSDERMIQUE +Statut des prescriptions : Signé +DUROGESIC 12MICROG/ +H DISP TRANSDERM - Ttes les 72H (1j /3) DR. [NOM] +1 PATCH 26/03/2023 15 : 01 02/04/2023 14:16 +[5] DISPOSITIF(S) Normal [NOM] +TRANSDERMIQUE(S) +DUROGESIC 25MICROG/ +H DISP TRANSDERM +1 PATCH - Normal 25/03/2023 04 : 49 02/04/2023 14:16 [NOM] [NOM] +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) +Statut des prescriptions : Réalisé +DUROGESIC 12MICROG/ +DR. [NOM] +H DISP TRANSDERM - Ttes les 72H (1j /3) +1 PATCH 03/04/2023 13 : 27 NOCENT- +[5] DISPOSITIF(S) Presc. de Sortie +EJNAINI +TRANSDERMIQUE(S) +DUROGESIC 25MICROG/ +DR. [NOM] +H DISP TRANSDERM +1 PATCH - Presc. de Sortie 03/04/2023 13 : 27 NOCENT- +[5] DISPOSITIF(S) +EJNAINI +TRANSDERMIQUE(S) +Voie d`administration : INHALEE +Statut des prescriptions : Signé +IPRATROPIUM AGT +Le débit en cours +0,5MG/2ML AD INHAL 1 REC. DR. [NOM] +- Normal 26/03/2023 12 : 58 03/04/2023 12:18 est : 8 ML par 1 +[10] RECIPIENT(S) UNIDOSE [NOM] +hrs. +UNIDOSE(S) +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 12 de 27 IPRATROPIUM AGT +DR. [NOM] +0,5MG/2ML AD INHAL 1 REC. +- Presc. de Sortie 03/04/2023 13 : 27 NOCENT- +[10] RECIPIENT(S) UNIDOSE +EJNAINI +UNIDOSE(S) +TERBUTALINE ARW +Le débit en cours +5MG/2ML SOL INHAL 1 REC. DR. [NOM] +- Normal 26/03/2023 12 : 58 03/04/2023 12:18 est : 8 ML par 1 +[50] RECIPIENT(S) UNIDOSE [NOM] +hrs. +UNIDOSE(S) +TERBUTALINE ARW +DR. [NOM] +5MG/2ML SOL INHAL 1 REC. +- Presc. de Sortie 03/04/2023 13 : 27 NOCENT- +[50] RECIPIENT(S) UNIDOSE +EJNAINI +UNIDOSE(S) +TRIMBOW 87/5/9 +MCG SOL INH 60 - Matin soir (8h - +2 BOUFFEE 25/03/2023 04 : 49 03/04/2023 07:49 [NOM] [NOM] +D [1] FLACON(S) 19h) Normal +PRESSURISE(S) +TRIMBOW 87/5/9 +DR. [NOM] +MCG SOL INH 60 - Matin soir (8h - +2 BOUFFEE 03/04/2023 13 : 27 NOCENT- +D [1] FLACON(S) 19h) Presc. de Sortie +EJNAINI +PRESSURISE(S) +Voie d`administration : BUCCALE +Statut des prescriptions : Signé +SODIUM BIC BAX 1,4% +- Matin midi soir DR. [NOM] +POC CFX 500ML V1 [1] 10 ml 26/03/2023 12 : 58 03/04/2023 12:00 +Normal [NOM] +POCHE(S) +Voie d`administration : CUTANEE +Statut des prescriptions : Signé +VERSATIS 5% EMPLATRE 1 - Prise unique à 19h +25/03/2023 04 : 49 02/04/2023 20:39 [NOM] [NOM] +[30] Emplatre(s) Emplatre(s) Normal +Statut des prescriptions : Réalisé +DR. [NOM] +VERSATIS 5% EMPLATRE 1 - Prise unique à 19h +03/04/2023 13 : 27 NOCENT- +[30] Emplatre(s) Emplatre(s) Presc. de Sortie +EJNAINI +Prescriptions de radiologie +Heure Date Heure +Date début Prescription Statut Docteur [NOM] +début exécution exécution +25/03/2023 02 : 19 Thorax F P 25/03/2023 02:36 Réalisé [NOM] [NOM] +Prescriptions de laboratoire +Date de +Date Heure Prescription Docteur [NOM] +collection +25/03/2023 +25/03/2023 01 : 08 Ionogramme ( Na, K, CL ) DR. [NOM] +01 : 10 +27/03/2023 +27/03/2023 08 : 00 Clairance à la creatinine MDRD DR. [NOM] +08 : 26 +29/03/2023 +29/03/2023 08 : 00 Clairance à la creatinine MDRD DR. [NOM] +08 : 11 +03/04/2023 +03/04/2023 07 : 00 Ionogramme ( Na, K, CL ) DR. [NOM] +09 : 07 +03/04/2023 +03/04/2023 07 : 00 Créatinine sang ( dosage ) DR. [NOM] +09 : 07 +Bilirubine ( totale + conjuguée + 03/04/2023 +03/04/2023 07 : 00 DR. [NOM] +non conjuguée ) sang ( dosage ) 09 : 07 +Prescriptions de soins +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +[NOM] +25/03/2023 [NOM] +ENVIRONNEMENT Signé - Matin [8h] Normal +13 : 41 [NOM] +PATIENT +LIT : REFECTION 25/03/2023 [NOM] +Signé - Matin [8h] Normal +COMPLETE 13 : 41 [NOM] +TOILETTE DOUCHE : 25/03/2023 [NOM] +Signé - Matin [8h] Normal +AIDE PARTIELLE 13 : 41 [NOM] +ACCOMPAGNER Jean- +1 Semaine - Matin 28/03/2023 +INSTALLER AUX Réalisé [NOM] +[8h] Normal 10 : 24 +TOILETTES [NOM] +DESINFECTION Jean- +1 Semaine - Matin 28/03/2023 +ENVIRONNEMENT Réalisé [NOM] +[8h] Normal 10 : 24 +PATIENT [NOM] +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 13 de 27 [NOM] +1 Semaine - Nuit 28/03/2023 +SOMMEIL : SURV. Réalisé ESTOMBA- +[21h] Normal 06 : 46 +[NOM] +Jean- +1 Semaine - Matin 28/03/2023 +TOILETTE : AUTONOME Réalisé [NOM] +[8h] Normal 10 : 24 +[NOM] +Notes du +professionel +de santé : +- 7x/jour (8h 12h bien noter DR. +[NOM] x 31/03/2023 +Réalisé 14h 19h 22h 0h 4h) toutes les [NOM] +7 14 : 52 +Normal glycémies [NOM] +sur trakcare +notamment +celles de 22h +Prescriptions de sortie +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +60 UI DR. [NOM] +ABASAGLAR 300 U SOL - Prise unique à 19h 03/04/2023 0/6 : Non administré +SOUS- Signé NOCENT- +INJ CART [5] Cartouche(s) Presc. de Sortie 13 : 27 A valider +CUTANEE EJNAINI +DR. [NOM] +BUSPIRONE MYL 10MG 1 CPR - Prise unique à 19h 03/04/2023 0/30 : Non administré +Réalisé NOCENT- +CPR [20] COMPRIME(S) ORALE Presc. de Sortie 13 : 27 Révisé/Traité +EJNAINI +DR. [NOM] +CETIRIZINE ARW 10MG 1 CPR - Soir [19h] Presc. de 03/04/2023 0/30 : Non administré +Réalisé NOCENT- +CPR [60] COMPRIME(S) ORALE Sortie 13 : 27 Révisé/Traité +EJNAINI +0/105 : Non DR. [NOM] +DEPAKOTE 500MG CPR 750 mg - Matin soir (8h - 03/04/2023 +Réalisé administré Révisé/ NOCENT- +[90] COMPRIME(S) ORALE 20h) Presc. de Sortie 13 : 27 +Traité EJNAINI +DUROGESIC 12MICROG/ +DR. [NOM] +H DISP TRANSDERM 1 PATCH - Ttes les 72H (1j /3) 03/04/2023 0/10 : Non administré +Réalisé NOCENT- +[5] DISPOSITIF(S) TRANSDERMIQUE Presc. de Sortie 13 : 27 Révisé/Traité +EJNAINI +TRANSDERMIQUE(S) +DUROGESIC 25MICROG/ +DR. [NOM] +H DISP TRANSDERM 1 PATCH 03/04/2023 0/10 : Non administré +Réalisé - Presc. de Sortie NOCENT- +[5] DISPOSITIF(S) TRANSDERMIQUE 13 : 27 Révisé/Traité +EJNAINI +TRANSDERMIQUE(S) +DR. [NOM] +FORXIGA 10MG CPR [30] 1 CPR - Matin [8h] Presc. de 03/04/2023 0/30 : Non administré +Réalisé NOCENT- +CPR(s) ORALE Sortie 13 : 27 Révisé/Traité +EJNAINI +DR. [NOM] +FUROSEMIDE ZEN 500MG 1 CPR - Matin [8h] Presc. de 03/04/2023 0/30 : Non administré +Réalisé NOCENT- +CPR [30] CPR(s) ORALE Sortie 13 : 27 Révisé/Traité +EJNAINI +HUMALOG 300UI/3ML 14 UI DR. [NOM] +- Matin midi soir 03/04/2023 0/5 : Non administré +KWIKPEN SOL INJ [5] SOUS- Signé NOCENT- +Presc. de Sortie 13 : 27 A valider +Stylo(s) Prerempli(s) CUTANEE EJNAINI +HYDROCHLOROTHIAZIDE DR. [NOM] +1 CPR - Matin [8h] Presc. de 03/04/2023 0/30 : Non administré +ARW 25 MG CPR [90] Réalisé NOCENT- +ORALE Sortie 13 : 27 Révisé/Traité +CPR(s) EJNAINI +IPRATROPIUM AGT +1 REC. DR. [NOM] +0,5MG/2ML AD INHAL 03/04/2023 0/90 : Non administré +UNIDOSE Signé - Presc. de Sortie NOCENT- +[10] RECIPIENT(S) 13 : 27 A valider +INHALEE EJNAINI +UNIDOSE(S) +DR. [NOM] +LANSOPRAZOLE BGA 30 1 CPR - Prise unique à 19h 03/04/2023 0/30 : Non administré +Réalisé NOCENT- +MG CPR OROD [14] CPR(s) ORALE Presc. de Sortie 13 : 27 Révisé/Traité +EJNAINI +DR. [NOM] +LOXEN LP 50MG GELULE 1 GEL - 1xJour [8h] Presc. 03/04/2023 0/30 : Non administré +Réalisé NOCENT- +[60] Gelule(s) ORALE de Sortie 13 : 27 Révisé/Traité +EJNAINI +MONTELUKAST DR. [NOM] +1 CPR - Soir [19h] Presc. de 03/04/2023 0/30 : Non administré +ARW 10MG CPR [28] Réalisé NOCENT- +ORALE Sortie 13 : 27 Révisé/Traité +COMPRIME(S) EJNAINI +OZEMPIC 1 MG SOL INJ DR. [NOM] +1 mg SOUS- - 1xSemaine [8h] 03/04/2023 0/1 : Non administré +STYLO 3ML [1] Stylo(s) Signé NOCENT- +CUTANEE Presc. de Sortie 13 : 27 A valider +Prerempli(s) EJNAINI +0/270 : Non DR. [NOM] +POTASSIUM 600MG 3 GEL - Matin midi soir 03/04/2023 +Réalisé administré Révisé/ NOCENT- +GELULE ORALE Presc. de Sortie 13 : 27 +Traité EJNAINI +DR. [NOM] +ROSUVASTATINE ARW 0,5 CPR - 1xJour [8h] Presc. 03/04/2023 0/15 : Non administré +Réalisé NOCENT- +20MG CPR [90] CPR(s) ORALE de Sortie 13 : 27 Révisé/Traité +EJNAINI +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 14 de 27 TERBUTALINE ARW +1 REC. DR. [NOM] +5MG/2ML SOL INHAL 03/04/2023 0/90 : Non administré +UNIDOSE Signé - Presc. de Sortie NOCENT- +[50] RECIPIENT(S) 13 : 27 A valider +INHALEE EJNAINI +UNIDOSE(S) +DR. [NOM] +TERCIAN 4% SOL BUV FL 15 GTT - à 21h Presc. de 03/04/2023 0/1 : Non administré +Réalisé NOCENT- +30ML [1200] Flacon(s) ORALE Sortie 13 : 27 Révisé/Traité +EJNAINI +TRIMBOW 87/5/9 +DR. [NOM] +MCG SOL INH 60 2 BOUFFEE - Matin soir (8h - 03/04/2023 0/120 : Non +Signé NOCENT- +D [1] FLACON(S) INHALEE 19h) Presc. de Sortie 13 : 27 administré A valider +EJNAINI +PRESSURISE(S) +1 DR. [NOM] +VERSATIS 5% EMPLATRE - Prise unique à 19h 03/04/2023 0/30 : Non administré +Emplatre(s) Réalisé NOCENT- +[30] Emplatre(s) Presc. de Sortie 13 : 27 Révisé/Traité +CUTANEE EJNAINI +DR. [NOM] +XARELTO 20MG CPR [14] 1 CPR - 1xJour [8h] Presc. 03/04/2023 0/30 : Non administré +Réalisé NOCENT- +COMPRIME(S) ORALE de Sortie 13 : 27 Révisé/Traité +EJNAINI +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 15 de 27 Plan de soins Jour J du 03/04/2023 07h00 au 04/04/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le 26/03/2023 à +500ML V1 - 1,4G/100ML solution (500 mL) - 12 : 58 +Dose 10 ml - BUCCALE - Matin midi soir - 1ère Fin le 05/04/2023 à 19 : 00 * 10 ml +dose : 26/03/2023 @ 19:00 12:00 +Admin le 03/04/2023 à +12 : 00 +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le 26/03/2023 à +500ML V1 - 1,4G/100ML solution (500 mL) - 12 : 58 +Dose 10 ml - BUCCALE - Matin midi soir - 1ère Fin le 05/04/2023 à 07 : 49 * 10 ml +dose : 26/03/2023 @ 19:00 12:00 +Admin le 03/04/2023 à +12 : 00 +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le 26/03/2023 à +500ML V1 - 1,4G/100ML solution (500 mL) - 12 : 58 +Dose 10 ml - BUCCALE - Matin midi soir - 1ère Fin le 05/04/2023 à 12 : 00 * 10 ml +dose : 26/03/2023 @ 19:00 12:00 +Admin le 03/04/2023 à +12 : 00 +[NOM] [NOM] +Signé — VERSATIS 700MG EMPLATRE Début le 25/03/2023 à +- 700MG emplatre - Dose 1 Emplatre(s) - 04 : 49 +C 25 U /0 T 3 A /2 N 0 E 2 E 3 @ - P r 1 i 9 se : 0 u 0 nique à 19h - 1ère dose: F 19 in :0 l 0 e 23/04/2023 à 1 E 9 m :0 p 0 la * tr e 1 (s) +Admin le 02/04/2023 à +20 : 39 +Signé — IPRATROPIUM AGT 0,5MG/2ML AD [NOM] [NOM] +INHAL - 0,5MG/2ML solution (2 mL) - Dose Début le 26/03/2023 à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 20:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le 25/04/2023 à 1 REC. +26/03/2023 @ 12 : 58 04:58 UNIDOSE +Admin le 03/04/2023 à +12 : 18 +Signé — IPRATROPIUM AGT 0,5MG/2ML AD [NOM] [NOM] +INHAL - 0,5MG/2ML solution (2 mL) - Dose Début le 26/03/2023 à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 04:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le 25/04/2023 à 1 REC. +26/03/2023 @ 12 : 58 04:58 UNIDOSE +Admin le 03/04/2023 à +12 : 18 +Signé — IPRATROPIUM AGT 0,5MG/2ML AD [NOM] [NOM] +INHAL - 0,5MG/2ML solution (2 mL) - Dose Début le 26/03/2023 à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 12:18 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le 25/04/2023 à 1 REC. +26/03/2023 @ 12 : 58 04:58 UNIDOSE +Admin le 03/04/2023 à +12 : 18 +Signé — TERBUTALINE ARW 5MG/2ML [NOM] [NOM] +SOL INHAL - 5MG/2ML solution (2 mL) - Dose Début le 26/03/2023 à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 20:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le 25/04/2023 à 1 REC. +26/03/2023 @ 12 : 58 04:58 UNIDOSE +Admin le 03/04/2023 à +12 : 18 +Signé — TERBUTALINE ARW 5MG/2ML [NOM] [NOM] +SOL INHAL - 5MG/2ML solution (2 mL) - Dose Début le 26/03/2023 à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 04:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le 25/04/2023 à 1 REC. +26/03/2023 @ 12 : 58 04:58 UNIDOSE +Admin le 03/04/2023 à +12 : 18 +Signé — TERBUTALINE ARW 5MG/2ML [NOM] [NOM] +SOL INHAL - 5MG/2ML solution (2 mL) - Dose Début le 26/03/2023 à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 12:18 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le 25/04/2023 à 1 REC. +26/03/2023 @ 12 : 58 04:58 UNIDOSE +Admin le 03/04/2023 à +12 : 18 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 16 de 27 [NOM] [NOM] +Signé — TRIMBOW 87/5/9 MCG SOL INH Début le 25/03/2023 à +60 D - 87/5/9 solution - Dose 2 BOUFFEE - 04 : 49 +I d N os H e A : 2 L 5 E /0 E 3 D /2 i 0 re 2 c 3 t e @ - 0 M 8 a :0 ti 0 n soir (8h - 19h) - 1ère F 19 in :0 l 0 e 23/04/2023 à 1 B 9 O :0 U 0 F * F E 2 E +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — TRIMBOW 87/5/9 MCG SOL INH Début le 25/03/2023 à +60 D - 87/5/9 solution - Dose 2 BOUFFEE - 04 : 49 +I d N os H e A : 2 L 5 E /0 E 3 D /2 i 0 re 2 c 3 t e @ - 0 M 8 a :0 ti 0 n soir (8h - 19h) - 1ère F 19 in :0 l 0 e 23/04/2023 à 0 B 7 O :4 U 9 F * F E 2 E +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — BUSPIRONE MYL 10MG CPR - 10MG Début le 25/03/2023 à +comprime - Dose 1 CPR - ORALE - Prise unique 04 : 49 19:00 * 1 +à 19h - 1ère dose : 25/03/2023 @ 19:00 Fin le 23/04/2023 à CPR +19 : 00 +Admin le 02/04/2023 à +20 : 40 +[NOM] [NOM] +Signé — CETIRIZINE ARW 10MG CPR - 10MG Début le 26/03/2023 à +comprime - Dose 1 CPR - ORALE - Soir [19h] - 15 : 41 19:00 * 1 +1ère dose : 26/03/2023 @ 19:00 Fin le 05/04/2023 à CPR +19 : 00 +Admin le 02/04/2023 à +18 : 44 +[NOM] [NOM] +Signé — DEPAKOTE 500MG CPR - 500MG Début le 25/03/2023 à +comprime - Dose Variable - ORALE - Matin soir 14 : 08 +(8h - 20h) - 1ère dose : 25/03/2023 @ 20:00 Fin le 09/04/2023 à 2 m 0 g :00 * 1000 +08 : 00 +! Plan de dosage variable Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — DEPAKOTE 500MG CPR - 500MG Début le 25/03/2023 à +comprime - Dose Variable - ORALE - Matin soir 14 : 08 +(8h - 20h) - 1ère dose : 25/03/2023 @ 20:00 Fin le 09/04/2023 à 0 m 7 g :49 * 750 +08 : 00 +! Plan de dosage variable Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — FORXIGA 10MG CPR - 10MG Début le 27/03/2023 à +comprime - Dose 1 CPR - ORALE - Matin [8h] - 16 : 14 07:49 * 1 +1ère dose : 28/03/2023 @ 08:00 Fin le 26/04/2023 à CPR +08 : 00 +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — FUROSEMIDE ZEN 500MG CPR - Début le 25/03/2023 à +500MG comprime - Dose 1 CPR - ORALE - 04 : 49 07:49 * 1 +Matin [8h] - 1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à CPR +08 : 00 +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — HYDROCHLOROTHIAZIDE ARW Début le 27/03/2023 à +25 MG CPR - 25MG comprime - Dose 1 CPR - 18 : 00 +O 08 R : 0 A 0 LE - Matin [8h] - 1ère dose: 28/03/2023 @ F 08 in :0 l 0 e 26/04/2023 à 0 C 7 P : R 49 * 1 +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — LANSOPRAZOLE BGA 30 MG Début le 25/03/2023 à +CPR OROD - 30MG comprime - Dose 1 CPR 04 : 49 +- 2 5 O /0 R 3 A /2 L 0 E 2 3 - P @ ri s 1 e 9 : u 0 n 0 ique à 19h - 1ère dose: F 19 in :0 l 0 e 23/04/2023 à 1 C 9 P : R 00 * 1 +Admin le 02/04/2023 à +18 : 44 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 17 de 27 [NOM] [NOM] +Signé — LOXEN LP 50MG GELULE - 50MG Début le 25/03/2023 à +gelule - Dose 1 GEL - ORALE - 1xJour [8h] - 04 : 49 07:49 * 1 +1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à GEL +08 : 00 +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — MONTELUKAST ARW 10MG CPR - Début le 26/03/2023 à +10MG comprime - Dose 1 CPR - ORALE - Soir 15 : 41 19:00 * 1 +[19h] - 1ère dose : 26/03/2023 @ 19:00 Fin le 09/04/2023 à CPR +19 : 00 +Admin le 02/04/2023 à +18 : 44 +[NOM] [NOM] +Signé — POTASSIUM 600MG GELULE - Début le 25/03/2023 à +600MG gelule - Dose 3 GEL - ORALE - Matin 04 : 49 19:00 * 3 +midi soir - 1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à GEL +19 : 00 +Admin le 03/04/2023 à +12 : 16 +[NOM] [NOM] +Signé — POTASSIUM 600MG GELULE - Début le 25/03/2023 à +600MG gelule - Dose 3 GEL - ORALE - Matin 04 : 49 07:49 * 3 +midi soir - 1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à GEL +19 : 00 +Admin le 03/04/2023 à +12 : 16 +[NOM] [NOM] +Signé — POTASSIUM 600MG GELULE - Début le 25/03/2023 à +600MG gelule - Dose 3 GEL - ORALE - Matin 04 : 49 12:16 * 3 +midi soir - 1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à GEL +19 : 00 +Admin le 03/04/2023 à +12 : 16 +[NOM] +[NOM] +Réalisé — POTASSIUM 600MG GELULE Début le 03/04/2023 à +- 600MG gelule - Dose 4 GEL - ORALE - 11 : 21 11:22 * 4 +URGENT - Début presc. : 03/04/2023 @ 11:21 Fin le 03/04/2023 à GEL +11 : 21 +Admin le 03/04/2023 à +11 : 22 +[NOM] [NOM] +Signé — ROSUVASTATINE ARW 20MG CPR Début le 25/03/2023 à +- 20MG comprime - Dose 0,5 CPR - ORALE - 04 : 49 07:49 * 0.5 +1xJour [8h] - 1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à CPR +08 : 00 +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — TERCIAN 40 MG/ML SOL BUV 30ML Début le 25/03/2023 à +- 0,04G/ML solution (30 mL) - Dose 15 GTT - 04 : 49 21:00 * 15 +ORALE - à 21h - 1ère dose : 25/03/2023 @ 21:00 Fin le 23/04/2023 à GTT +21 : 00 +Admin le 02/04/2023 à +20 : 40 +[NOM] [NOM] +Signé — XARELTO 20 MG CPR - 20MG Début le 25/03/2023 à +comprime - Dose 1 CPR - ORALE - 1xJour [8h] - 04 : 49 07:49 * 1 +1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à CPR +08 : 00 +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — ABASAGLAR 300 U SOL INJ CART - Début le 25/03/2023 à +100UI/ML solution (3 mL) - Dose 60 UI - SOUS- 04 : 49 +C +do +U +s +T +e : +A +2 +N +5/ +E +0 +E +3 / +D +20 +ir +2 +e +3 +c t +@ +e - +1 +P +9 +r + : +i +0 +s +0 +e unique à 19h - 1ère F +19 +in + : 0 +l +0 +e 23/04/2023 à 19 : 00 * 60 UI +Admin le 02/04/2023 à +18 : 54 +Signé — HUMALOG 300UI KWIKPEN SOL +[NOM] [NOM] 19 : 00 * 14 UI +INJ - 300UI solution (3 mL) - Dose 14 UI - +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 18 de 27 Début le 26/03/2023 à +SOUS-CUTANEE Directe - Matin midi soir - 1ère 10 : 07 +dose : 26/03/2023 @ 12:00 Fin le 25/04/2023 à +08 : 00 +Admin le 03/04/2023 à +12 : 17 +[NOM] [NOM] +Signé — HUMALOG 300UI KWIKPEN SOL Début le 26/03/2023 à +INJ - 300UI solution (3 mL) - Dose 14 UI - 10 : 07 +S +do +O +s +U +e : +S +2 +- +6 +C +/ +U +03 +T +/ +A +20 +N +2 +E +3 +E +@ +D +1 +ir +2 +e + : +c +0 +t +0 +e - Matin midi soir - 1ère F +08 +in + : 0 +l +0 +e 25/04/2023 à 08 : 00 * 14 UI +Admin le 03/04/2023 à +12 : 17 +[NOM] [NOM] +Signé — HUMALOG 300UI KWIKPEN SOL Début le 26/03/2023 à +INJ - 300UI solution (3 mL) - Dose 14 UI - 10 : 07 +S +do +O +s +U +e : +S +2 +- +6 +C +/ +U +03 +T +/ +A +20 +N +2 +E +3 +E +@ +D +1 +ir +2 +e + : +c +0 +t +0 +e - Matin midi soir - 1ère F +08 +in + : 0 +l +0 +e 25/04/2023 à 12 : 17 * 14 UI +Admin le 03/04/2023 à +12 : 17 +[NOM] Jean- +[NOM] +Réalisé — ACCOMPAGNER INSTALLER AUX Début le 28/03/2023 à +TOILETTES - Matin [8h] - 1 Semaine- Date 10 : 24 +Début : 28/03/2023 @ 10:24 Fin le 04/04/2023 à 08:00 * 1 +08 : 00 +Admin le 03/04/2023 à +08 : 00 +[NOM] Jean- +[NOM] +Réalisé — DESINFECTION Début le 28/03/2023 à +ENVIRONNEMENT PATIENT - Matin [8h] - 1 10 : 24 +Semaine- Date Début : 28/03/2023 @ 10:24 Fin le 04/04/2023 à 08:00 * 1 +08 : 00 +Admin le 03/04/2023 à +08 : 00 +ESTOMBA- +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - Nuit [21h] - 1 Début le 28/03/2023 à +Semaine- Date Début : 28/03/2023 @ 06:46 06:46 21:00 * 1 +Fin le 03/04/2023 à +21 : 00 +Admin le 02/04/2023 à +21 : 00 +[NOM] Jean- +[NOM] +Réalisé — TOILETTE : AUTONOME - Matin Début le 28/03/2023 à +[8h] - 1 Semaine- Date Début : 28/03/2023 @ 10:24 +10 : 24 Fin le 04/04/2023 à 08:00 * 1 +08 : 00 +Admin le 03/04/2023 à +08 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 19:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 22:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 00:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 19 de 27 Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 04:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 08:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 12:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 14:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 20 de 27 Plan de soins Jour J + 1 du 04/04/2023 07h00 au 05/04/2023 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le 26/03/2023 à +500ML V1 - 1,4G/100ML solution (500 mL) - 12 : 58 +Dose 10 ml - BUCCALE - Matin midi soir - 1ère Fin le 05/04/2023 à 08 : 00 * 10 ml +dose : 26/03/2023 @ 19:00 12:00 +Admin le 03/04/2023 à +12 : 00 +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le 26/03/2023 à +500ML V1 - 1,4G/100ML solution (500 mL) - 12 : 58 +Dose 10 ml - BUCCALE - Matin midi soir - 1ère Fin le 05/04/2023 à 12 : 00 * 10 ml +dose : 26/03/2023 @ 19:00 12:00 +Admin le 03/04/2023 à +12 : 00 +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le 26/03/2023 à +500ML V1 - 1,4G/100ML solution (500 mL) - 12 : 58 +Dose 10 ml - BUCCALE - Matin midi soir - 1ère Fin le 05/04/2023 à 19 : 00 * 10 ml +dose : 26/03/2023 @ 19:00 12:00 +Admin le 03/04/2023 à +12 : 00 +[NOM] [NOM] +Signé — VERSATIS 700MG EMPLATRE Début le 25/03/2023 à +- 700MG emplatre - Dose 1 Emplatre(s) - 04 : 49 +C 25 U /0 T 3 A /2 N 0 E 2 E 3 @ - P r 1 i 9 se : 0 u 0 nique à 19h - 1ère dose: F 19 in :0 l 0 e 23/04/2023 à 1 E 9 m :0 p 0 la * tr e 1 (s) +Admin le 02/04/2023 à +20 : 39 +Signé — IPRATROPIUM AGT 0,5MG/2ML AD [NOM] [NOM] +INHAL - 0,5MG/2ML solution (2 mL) - Dose Début le 26/03/2023 à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 12:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le 25/04/2023 à 1 REC. +26/03/2023 @ 12 : 58 04:58 UNIDOSE +Admin le 03/04/2023 à +12 : 18 +Signé — IPRATROPIUM AGT 0,5MG/2ML AD [NOM] [NOM] +INHAL - 0,5MG/2ML solution (2 mL) - Dose Début le 26/03/2023 à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 20:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le 25/04/2023 à 1 REC. +26/03/2023 @ 12 : 58 04:58 UNIDOSE +Admin le 03/04/2023 à +12 : 18 +Signé — IPRATROPIUM AGT 0,5MG/2ML AD [NOM] [NOM] +INHAL - 0,5MG/2ML solution (2 mL) - Dose Début le 26/03/2023 à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 04:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le 25/04/2023 à 1 REC. +26/03/2023 @ 12 : 58 04:58 UNIDOSE +Admin le 03/04/2023 à +12 : 18 +Signé — TERBUTALINE ARW 5MG/2ML [NOM] [NOM] +SOL INHAL - 5MG/2ML solution (2 mL) - Dose Début le 26/03/2023 à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 12:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le 25/04/2023 à 1 REC. +26/03/2023 @ 12 : 58 04:58 UNIDOSE +Admin le 03/04/2023 à +12 : 18 +Signé — TERBUTALINE ARW 5MG/2ML [NOM] [NOM] +SOL INHAL - 5MG/2ML solution (2 mL) - Dose Début le 26/03/2023 à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 20:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le 25/04/2023 à 1 REC. +26/03/2023 @ 12 : 58 04:58 UNIDOSE +Admin le 03/04/2023 à +12 : 18 +Signé — TERBUTALINE ARW 5MG/2ML [NOM] [NOM] +SOL INHAL - 5MG/2ML solution (2 mL) - Dose Début le 26/03/2023 à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 04:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le 25/04/2023 à 1 REC. +26/03/2023 @ 12 : 58 04:58 UNIDOSE +Admin le 03/04/2023 à +12 : 18 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 21 de 27 [NOM] [NOM] +Signé — TRIMBOW 87/5/9 MCG SOL INH Début le 25/03/2023 à +60 D - 87/5/9 solution - Dose 2 BOUFFEE - 04 : 49 +I d N os H e A : 2 L 5 E /0 E 3 D /2 i 0 re 2 c 3 t e @ - 0 M 8 a :0 ti 0 n soir (8h - 19h) - 1ère F 19 in :0 l 0 e 23/04/2023 à 0 B 8 O :0 U 0 F * F E 2 E +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — TRIMBOW 87/5/9 MCG SOL INH Début le 25/03/2023 à +60 D - 87/5/9 solution - Dose 2 BOUFFEE - 04 : 49 +I d N os H e A : 2 L 5 E /0 E 3 D /2 i 0 re 2 c 3 t e @ - 0 M 8 a :0 ti 0 n soir (8h - 19h) - 1ère F 19 in :0 l 0 e 23/04/2023 à 1 B 9 O :0 U 0 F * F E 2 E +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — BUSPIRONE MYL 10MG CPR - 10MG Début le 25/03/2023 à +comprime - Dose 1 CPR - ORALE - Prise unique 04 : 49 19:00 * 1 +à 19h - 1ère dose : 25/03/2023 @ 19:00 Fin le 23/04/2023 à CPR +19 : 00 +Admin le 02/04/2023 à +20 : 40 +[NOM] [NOM] +Signé — CETIRIZINE ARW 10MG CPR - 10MG Début le 26/03/2023 à +comprime - Dose 1 CPR - ORALE - Soir [19h] - 15 : 41 19:00 * 1 +1ère dose : 26/03/2023 @ 19:00 Fin le 05/04/2023 à CPR +19 : 00 +Admin le 02/04/2023 à +18 : 44 +[NOM] [NOM] +Signé — DEPAKOTE 500MG CPR - 500MG Début le 25/03/2023 à +comprime - Dose Variable - ORALE - Matin soir 14 : 08 +(8h - 20h) - 1ère dose : 25/03/2023 @ 20:00 Fin le 09/04/2023 à 0 m 8 g :00 * 750 +08 : 00 +! Plan de dosage variable Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — DEPAKOTE 500MG CPR - 500MG Début le 25/03/2023 à +comprime - Dose Variable - ORALE - Matin soir 14 : 08 +(8h - 20h) - 1ère dose : 25/03/2023 @ 20:00 Fin le 09/04/2023 à 2 m 0 g :00 * 1000 +08 : 00 +! Plan de dosage variable Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — FORXIGA 10MG CPR - 10MG Début le 27/03/2023 à +comprime - Dose 1 CPR - ORALE - Matin [8h] - 16 : 14 08:00 * 1 +1ère dose : 28/03/2023 @ 08:00 Fin le 26/04/2023 à CPR +08 : 00 +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — FUROSEMIDE ZEN 500MG CPR - Début le 25/03/2023 à +500MG comprime - Dose 1 CPR - ORALE - 04 : 49 08:00 * 1 +Matin [8h] - 1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à CPR +08 : 00 +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — HYDROCHLOROTHIAZIDE ARW Début le 27/03/2023 à +25 MG CPR - 25MG comprime - Dose 1 CPR - 18 : 00 +O 08 R : 0 A 0 LE - Matin [8h] - 1ère dose: 28/03/2023 @ F 08 in :0 l 0 e 26/04/2023 à 0 C 8 P : R 00 * 1 +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — LANSOPRAZOLE BGA 30 MG Début le 25/03/2023 à +CPR OROD - 30MG comprime - Dose 1 CPR 04 : 49 +- 2 5 O /0 R 3 A /2 L 0 E 2 3 - P @ ri s 1 e 9 : u 0 n 0 ique à 19h - 1ère dose: F 19 in :0 l 0 e 23/04/2023 à 1 C 9 P : R 00 * 1 +Admin le 02/04/2023 à +18 : 44 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 22 de 27 [NOM] [NOM] +Signé — LOXEN LP 50MG GELULE - 50MG Début le 25/03/2023 à +gelule - Dose 1 GEL - ORALE - 1xJour [8h] - 04 : 49 08:00 * 1 +1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à GEL +08 : 00 +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — MONTELUKAST ARW 10MG CPR - Début le 26/03/2023 à +10MG comprime - Dose 1 CPR - ORALE - Soir 15 : 41 19:00 * 1 +[19h] - 1ère dose : 26/03/2023 @ 19:00 Fin le 09/04/2023 à CPR +19 : 00 +Admin le 02/04/2023 à +18 : 44 +[NOM] [NOM] +Signé — POTASSIUM 600MG GELULE - Début le 25/03/2023 à +600MG gelule - Dose 3 GEL - ORALE - Matin 04 : 49 08:00 * 3 +midi soir - 1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à GEL +19 : 00 +Admin le 03/04/2023 à +12 : 16 +[NOM] [NOM] +Signé — POTASSIUM 600MG GELULE - Début le 25/03/2023 à +600MG gelule - Dose 3 GEL - ORALE - Matin 04 : 49 12:00 * 3 +midi soir - 1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à GEL +19 : 00 +Admin le 03/04/2023 à +12 : 16 +[NOM] [NOM] +Signé — POTASSIUM 600MG GELULE - Début le 25/03/2023 à +600MG gelule - Dose 3 GEL - ORALE - Matin 04 : 49 19:00 * 3 +midi soir - 1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à GEL +19 : 00 +Admin le 03/04/2023 à +12 : 16 +[NOM] [NOM] +Signé — ROSUVASTATINE ARW 20MG CPR Début le 25/03/2023 à +- 20MG comprime - Dose 0,5 CPR - ORALE - 04 : 49 08:00 * 0.5 +1xJour [8h] - 1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à CPR +08 : 00 +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — TERCIAN 40 MG/ML SOL BUV 30ML Début le 25/03/2023 à +- 0,04G/ML solution (30 mL) - Dose 15 GTT - 04 : 49 21:00 * 15 +ORALE - à 21h - 1ère dose : 25/03/2023 @ 21:00 Fin le 23/04/2023 à GTT +21 : 00 +Admin le 02/04/2023 à +20 : 40 +[NOM] [NOM] +Signé — XARELTO 20 MG CPR - 20MG Début le 25/03/2023 à +comprime - Dose 1 CPR - ORALE - 1xJour [8h] - 04 : 49 08:00 * 1 +1ère dose : 25/03/2023 @ 08:00 Fin le 23/04/2023 à CPR +08 : 00 +Admin le 03/04/2023 à +07 : 49 +[NOM] [NOM] +Signé — ABASAGLAR 300 U SOL INJ CART - Début le 25/03/2023 à +100UI/ML solution (3 mL) - Dose 60 UI - SOUS- 04 : 49 +C +do +U +s +T +e : +A +2 +N +5/ +E +0 +E +3 / +D +20 +ir +2 +e +3 +c t +@ +e - +1 +P +9 +r + : +i +0 +s +0 +e unique à 19h - 1ère F +19 +in + : 0 +l +0 +e 23/04/2023 à 19 : 00 * 60 UI +Admin le 02/04/2023 à +18 : 54 +[NOM] [NOM] +Signé — HUMALOG 300UI KWIKPEN SOL Début le 26/03/2023 à +INJ - 300UI solution (3 mL) - Dose 14 UI - 10 : 07 +S +do +O +s +U +e : +S +2 +- +6 +C +/ +U +03 +T +/ +A +20 +N +2 +E +3 +E +@ +D +1 +ir +2 +e + : +c +0 +t +0 +e - Matin midi soir - 1ère F +08 +in + : 0 +l +0 +e 25/04/2023 à 08 : 00 * 14 UI +Admin le 03/04/2023 à +12 : 17 +Signé — HUMALOG 300UI KWIKPEN SOL +[NOM] [NOM] 12 : 00 * 14 UI +INJ - 300UI solution (3 mL) - Dose 14 UI - +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 23 de 27 Début le 26/03/2023 à +SOUS-CUTANEE Directe - Matin midi soir - 1ère 10 : 07 +dose : 26/03/2023 @ 12:00 Fin le 25/04/2023 à +08 : 00 +Admin le 03/04/2023 à +12 : 17 +[NOM] [NOM] +Signé — HUMALOG 300UI KWIKPEN SOL Début le 26/03/2023 à +INJ - 300UI solution (3 mL) - Dose 14 UI - 10 : 07 +S +do +O +s +U +e : +S +2 +- +6 +C +/ +U +03 +T +/ +A +20 +N +2 +E +3 +E +@ +D +1 +ir +2 +e + : +c +0 +t +0 +e - Matin midi soir - 1ère F +08 +in + : 0 +l +0 +e 25/04/2023 à 19 : 00 * 14 UI +Admin le 03/04/2023 à +12 : 17 +[NOM] [NOM] +Signé — DUROGESIC 12 MICROG/H DISP Début le 26/03/2023 à +TRANSDERM - 0.012MG/HEURE dispositif - 15 : 01 +D 72 o H se ( 1 1 j P / A 3) T - C 1 H è r - e T d R o A se N : 2 S 9 D /0 E 3 R /2 M 0 I 2 Q 3 U @ E 0 - 8 T :0 te 0 s les F 08 in :0 l 0 e 10/04/2023 à 0 PA 8: T 0 C 0 H * 1 +Admin le 02/04/2023 à +14 : 16 +[NOM] Jean- +[NOM] +Réalisé — ACCOMPAGNER INSTALLER AUX Début le 28/03/2023 à +TOILETTES - Matin [8h] - 1 Semaine- Date 10 : 24 +Début : 28/03/2023 @ 10:24 Fin le 04/04/2023 à 08:00 * 1 +08 : 00 +Admin le 03/04/2023 à +08 : 00 +[NOM] Jean- +[NOM] +Réalisé — DESINFECTION Début le 28/03/2023 à +ENVIRONNEMENT PATIENT - Matin [8h] - 1 10 : 24 +Semaine- Date Début : 28/03/2023 @ 10:24 Fin le 04/04/2023 à 08:00 * 1 +08 : 00 +Admin le 03/04/2023 à +08 : 00 +[NOM] Jean- +[NOM] +Réalisé — TOILETTE : AUTONOME - Matin Début le 28/03/2023 à +[8h] - 1 Semaine- Date Début : 28/03/2023 @ 10:24 +10 : 24 Fin le 04/04/2023 à 08:00 * 1 +08 : 00 +Admin le 03/04/2023 à +08 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 08:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 12:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 14:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 19:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 24 de 27 Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 22:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 00:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le 31/03/2023 à +Jour(s)- Date Début : 31/03/2023 @ 14:52 14:52 +Notes de professionel de santé : Fin le 14/04/2023 à 04:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le 03/04/2023 à +notamment celles de 22h +14 : 00 +Résultats de radiologie +Prescription Date Résultat +Compte rendu au format texte +Bayonne, le 25/03/2023 +Docteur +Nom de naissance : DE [NOM] [NOM] [NOM] +Nom utilisé : DE [NOM] [NOM] [NOM] +Prénom de naissance : REGINA +Prénom utilisé : REGINA +[DATE_NAISSANCE] +Lieu de naissance : 99999 +Sexe : F +Matricule INS : +Examen du : 25/03/2023 +Compte-rendu validé électroniquement par Dr [NOM] le 25/03/2023 +RADIOGRAPHIE PULMONAIRE +Indication : +Bilan de dyspnée. +RESULTATS : +25/03/2023 +CR RX-Echo +02 : 19 +Sous réserve de la faible ampliation thoracique : +Diminution de la transparence parenchymateuse aux bases apparaissant être liée notamment à la projection des parties molles. +Absence de foyer circonscrit au niveau des apex pulmonaires. Augmentation de l'index cardiothoracique.. +Dr [NOM] +Technique : +PDS : 0.426 dGy.cm² +A l'entrée : 0.065 mGy +Protocole d'acquisition : Thorax +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 +03/04/2023 09 : 17 03/04/2023 09:07 30/03/2023 08:44 29/03/2023 08:11 29/03/2023 08:11 +Résultat de labo +(5920658) (5920659) (5918673) (5917252) (5917251) +Bilirubine totale 5 µmol/l +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 25 de 27 Score Fibrosis-4 (FIB4) 1,60 +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) % Non renseigné(e) % +Bicarbonates 38,0 mmol/l 37,7 mmol/l +Origine Artériel Artériel +Non renseigné(e) L/ Non renseigné(e) L/ +Débit +min min +Non renseignée (rendu Non renseignée (rendu +Température pour une température pour une température +de 37°C) °C de 37°C) °C +ASAT 27 U/l +Bilirubine totale < : +21 µmol/L : dosage des +Commentaire bilirubine totale fractions conjuguée +et non conjugée non +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 +masse musculaire - masse musculaire - masse 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 39 U/l +NT-proBNP 229 ng/l 507 ng/l +Zone grise : +insuffisance cardiaque +Négatif : Insuffisance moins plausible. +Interprétation NT-proBNP +cardiaque peu probable Envisager d?autres +causes d?augmentation +du NT-proBNP. +Phosphatase alcaline 80 U/l +Calcium 2,10 mmol/l +Estimation du DFG (CKD- +97 ml/mn/1.73 m2 71 ml/mn/1.73 m2 92 ml/mn/1.73 m2 +EPI) +Chlore 90 mmol/l 88 mmol/l 89 mmol/l +Créatinine 52 µmol/l 76 µmol/l 60 µmol/l +CRP 34 mg/l 2 mg/l +Compte-rendu laboratoire Labo230403105652-1.pdfLabo230403104835-1.pdfLabo230330101823-1.pdfLabo230329103002-1.pdfLabo230329102552-1.pdf +Polynucléaires neutrophiles +65,1 % 70,3 % +(%) +Polynucléaires neutrophiles +6,89 10.9/l 6,21 10.9/l +(#) +Polynucléaires éosinophiles +1,1 % 0,1 % +(%) +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 26 de 27 Polynucléaires éosinophiles +0,12 10.9/l 0,01 10.9/l +(#) +Polynucléaires basophiles (%) 0,4 % 0,3 % +Polynucléaires basophiles (#) 0,04 10.9/l 0,03 10.9/l +Lymphocytes (%) 24,3 % 19,3 % +Lymphocytes (#) 2,57 10.9/l 1,70 10.9/l +Monocytes (%) 9,1 % 10,0 % +Monocytes (#) 0,96 10.9/l 0,88 10.9/l +Glucose 13,4 mmol/l 9,7 mmol/l 15,0 mmol/l +pH 7,50 7,48 +pO2 100 mmHg 103 mmHg +Saturation O2 96,0 % 96,5 % +pCO2 49 mmHg 51 mmHg +ALAT 19 U/l +réalisée sur automate réalisée sur automate +Formule sanguine +XN (Sysmex) XN (Sysmex) +Hématocrite (%) 35,5 % 33,9 % +Indice de distribution des +20,3 % 18,2 % +hématies +Potassium 2,6 mmol/l 3,3 mmol/l 2,7 mmol/l +Leucocytes 10,59 10.9/l 8,83 10.9/l +Hématies 4,57 10.12/l (t/l) 4,48 10.12/l (t/l) +Hémoglobine 10,6 g/dl 10,1 g/dl +VGM 77,7 fl 75,7 fl +TCMH 23,2 pg 22,5 pg +CCMH 29,9 g/dl 29,8 g/dl +Sodium 137 mmol/l 136 mmol/l 136 mmol/l +Osmolarité sang 287 mOSM/l 282 mOSM/l 287 mOSM/l +Plaquettes 252 10.9/l 290 10.9/l +Validation et diffusion sous la Dr. [NOM] +Dr [NOM] "" Dr [NOM] [NOM] [NOM] +responsabilité du biologiste [NOM] +Volume plaquettaire moyen 9,0 fl 9,1 fl +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le 03/04/2023 14 : 23 Page 27 de 27 + + +Nom de naissance : DE [NOM] [NOM] [NOM] IPP : [IPP] +Nom et Prénom : DE [NOM] [NOM] [NOM] REGINA [DATE_NAISSANCE] +Sexe : Féminin Lieu de naissance: [VILLE] +Nationalité : PORTUGAL [CODE_POSTAL] +Adresse : [ADRESSE]: [NOM] +Episode No : [EPISODE] +Localisation : PNEUMOLOGIE PHTISIOLOGIE HC Médecin courant: DR. [NOM] +Date d'admission : 25/03/2023 Heure d'admission: 00:51 +Date de sortie : 03/04/2023 Heure de sortie: 14:04 +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) : Epoux [NOM] [CODE_POSTAL] [TEL] +Personne à prévenir +(Clinicom) : Fille [NOM] [NOM] X [CODE_POSTAL] [TEL] + +Personne de +confiance : Fille [NOM] [NOM] [TEL] + +Episode - Date : 25/03/2023 +Episode - Heure : 00:51 +Mode de transport à l'arrivée : Ambulance +Médicalisation du transport : Prise en charge paramédicale +Mode d'entrée : Autres admissions urgentes +Date d'orientation : 25/03/2023 +Heure d'orientation : 00:56 +IAO : [NOM] +Priorité : Priorité 2 +Sous-type épisode : URG - Circuit Long +Motif de prise en charge : Dyspnée +Observ. IDE Urg : adressée par SOS pour décompensation cardio respi +hyperthermie cet am,non retrouvé au SAU +arrive sous 3L O2 aux lunettes:97%,baissé à 2litres +BI verifié et posé +test antigen covid:neg +Médecin de la prise en charge médicale : [NOM] [NOM] +Date de prise en charge médicale : 25/03/2023 +Heure de prise en charge médicale : 00:51 +Médecin de la décision médicale : [NOM] [NOM] +Date de décision médicale : 25/03/2023 +Heure de décision médicale : 04:58 +Décision médicale : Hospitalisation MCO +Orientation du patient : hospitalisation dans une unité de Médecine hors SC, SI, REA +Destination du patient : REED TOKI EDER CAMBO +Date de sortie des urgences : 25/03/2023 +Heure de sortie des Urgences : 05:10 +US de destination : US PNEUMOLOGIE + +UF de destination : PNEUMOLOGIE PHTISIOLOGIE HC +Type : Etat Code Date +Principal : actif J12.9 Pneumopathie virale, sans précision 25/03/2023 04:57 +Catégorie : Alerte Date début Date +expiration Message +Accompagnants : 27/04/2022 fille +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Item de +surveillance : 03/04/2023 +12:01 03/04/2023 +09:17 03/04/2023 +07:57 03/04/2023 +06:19 03/04/2023 +00:19 02/04/2023 +18:53 02/04/2023 +15:16 02/04/2023 +12:04 02/04/2023 +07:48 02/04/2023 +06:15 02/04/2023 +00:14 01/04/2023 +18:29 01/04/2023 +16:16 +Glycémie +capillaire : 1,45 2,90 0,65 0,88 2,51 1,43 1,73 1,51 1,88 1,68 1,66 +Température : 37,10 37,40 37 36,50 37,30 36,50 +Pouls : 84 100 93 83 95 92 +PA +Systolique : 138 113 125 121 +PA +Diastolique : 66 76 68 67 +Saturation +O² : 96 96 97 95 95 96 +Débit O² +[L/mn] : 2 2 2 2 2 2 +Ventilation : Ventilatio +spontanée +Oxygène n Ventilatio +assistée n Ventilatio +spontanée +Oxygène n Ventilatio +spontanée +Oxygène n Ventilatio +spontanée +Oxygène n Ventilatio +spontanée +Oxygène +Echelle +douleur : EN EN EN EN EN +Score au +repos : 5 0 0 0 0 +Transit : Normal Absence Absence Absence Normal Normal Absence Absence Absence Absence Absence +Fréq. +respiratoire +Item de +surveillance : 31/03/2023 +08:39 27/03/2023 +12:23 +Poids [kg] : 88 88,80 +Taille [cm] : 152 152 +Indice +de masse +corporelle : 38,09 38,44 +Surface +corporelle : 1,84 1,85 +Item de +surveillance : 03/04/2023 +07:57 03/04/2023 +00:19 02/04/2023 +15:16 02/04/2023 +07:48 02/04/2023 +00:14 01/04/2023 +16:16 01/04/2023 +08:58 01/04/2023 +00:34 31/03/2023 +18:38 31/03/2023 +15:55 31/03/2023 +08:17 31/03/2023 +05:55 30/03/2023 +22:12 +Température : 37,10 37,40 37 36,50 37,30 36,50 37 37,20 36,50 37 37 +Pouls : 84 100 93 83 95 92 88 100 91 90 90 96 +PA +Systolique : 138 113 125 121 131 134 134 105 +PA +Diastolique : 66 76 68 67 65 58 55 55 +Saturation +O² : 96 96 97 95 95 96 96 95 96 94 92 95 +Transit : Normal Absence Absence Absence Normal Normal +Fréq. +respiratoire + +Item de +surveillance : 03/04/2023 +12:01 03/04/2023 +09:17 03/04/2023 +07:57 03/04/2023 +06:19 03/04/2023 +00:19 02/04/2023 +18:53 02/04/2023 +15:16 02/04/2023 +12:04 02/04/2023 +07:48 02/04/2023 +06:15 02/04/2023 +00:14 01/04/2023 +18:29 01/04/2023 +16:16 +Glycémie +capillaire : 1,45 2,90 0,65 0,88 2,51 1,43 1,73 1,51 1,88 1,68 1,66 +Température : 37,10 37,40 37 36,50 37,30 36,50 +Pouls : 84 100 93 83 95 92 +PA +Systolique : 138 113 125 121 +PA +Diastolique : 66 76 68 67 +Saturation +O² : 96 96 97 95 95 96 +Transit : Normal Absence Absence +Type d'observation : Nom Date Commentaires +Conclusion Clinique : DR. [NOM] +[NOM] 03/04/2023 +13:27 nouvelle hospitalisation pour nouvelle décompensation cardio-respiratoire sans aucun critère de +gravité +bonne évolution sous antibiotiques et diurétiques (hypokaliémie à recontrôlée) +transfert à Toki ce jour +Note d'évolution : DR. [NOM] +[NOM] 01/04/2023 +14:20 01/04/23 CNE +pas d'hypoglycémie, nuit de bonne qualité +Note d'évolution : DR. [NOM] +[NOM] 31/03/2023 +14:54 adaptation doses insuline +je suis là demain matin on peut me rappeler si elle fait encore des hypos cette nuit +Note d'évolution : DR. [NOM] +[NOM] 31/03/2023 +12:56 31/03/23 : CNE +persistance d'OMI +a dormi un peu au lit cette nuit +place à Toki Eder lundi +appel Dr [NOM] pour la tendance aux hypoglycémies +Note d'évolution : DR. [NOM] +[NOM] 30/03/2023 +12:29 30/03/23 : +Apyretique +Diabete : HGT ce matin à 0.71 +Cardio : +ETT : FEVG à 60% +VG non dilaté +Pression de remplissage VG normales, pas de signe de surcharge +OG de taille normale +Absence de valvulopathie +CD non dilatées +fonction VD normale +Pression droites normales, minime épanchement péricardique de 4/5mm sans retentissement +VCI non dilatée compliante +bio : K=3.3 +nouvlle seringue K=2g sur 6h +avis gastro sur cette anémie ferriprive +FERINJECT fait le 29/03 +dernier colo Fogd en 2020 Dr [NOM] : proposition de consult RDV le 25/07 11h40, il +jugera en fonction de la réhab si FOGD sous AL ou en hospit +CAT : +- diminution LASILIX spécial 1 le matin (dose usuelle) +- supplémentation K +- surveillance glycémie +- avis cardio : possible majoration NTproBNP sur intro FORXIGA ? +- FERINJECT 500 ce jour (totalité de 1g) puis à nouveau 500mg ds 15j + +Note d'évolution : DR. [NOM] +[NOM] 28/03/2023 +14:44 28/03/23 : +Patiente apyretique +discrete amélioration d ela toux +kine ce matin sans expectoration +ausuclt : ronchi bilateraux +echo pleurale : pas d'pénachement pleural gauche ou droit +OMI peristants +patiente m'explique ne pas supporter les bas de contentions +glycémies encore hautes : majoration insuline rapide. +Note d'évolution : DR. [NOM] +[NOM] 27/03/2023 +16:47 27/03 +Avis diabeto sur indication GLICLAZIDE ? place du FORXIGA ? +Dr [NOM] : +- arret GLICLAZIDE (HbA1c à 9% donc on considère que c'est inefficace) +- maintien basal/bolus +- introduction FORXIGA 10mg/j +L'objectif est de pouvoir equilibré le basal/bolus en [ETABLISSEMENT] +Note d'évolution : DR. [NOM] +[NOM] 27/03/2023 +15:03 27/03 +Apyretique +amélioration de la toux +demangeaison sur tout le corps probablement lié à la prise de codeine +pas d'améloioratino des OMI +bio : decroissance sd inflam +stabilité NTproBNP +CAT : +- poursuite ABT +- avis diabeto sur ttt FORXIGA ? insuline ? +- attente [ETABLISSEMENT] +- arret codeine ca rmauvaise tolérance +- kine +- tjrs sous diffuK 9/j, iono OK ce jour : ajout ESIDREX 25 +- bio ds 48h + +Note d'évolution : [NOM] [NOM] 25/03/2023 +04:57 Bio : pro BNP 400, CRP 30 pas d'hyperleucocytose +K+ 3.1, Na 132 +--> décompensation cardio-respi sans trigger identifié +a eu 125 mg lasilix IVD + 80 mg CTC +devant hyperthermie dans l'après-midi et devant atcd début augmentin +hospitalisation en pneumo +Note d'évolution : [NOM] [NOM] 25/03/2023 +03:16 RADIOGRAPHIE PULMONAIRE +Indication : +Bilan de dyspnée. +RESULTATS : +Sous réserve de la faible ampliation thoracique : +Diminution de la transparence parenchymateuse aux bases apparaissant être liée notamment +à la projection des parties molles. Absence de foyer circonscrit au niveau des apex pulmonaires. +Augmentation de l'index cardiothoracique.. +Dr [NOM] +Technique : +PDS : 0.426 dGy.cm² +A l'entrée : 0.065 mGy +Protocole d'acquisition : Thorax +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] +Note d'évolution : [NOM] [NOM] 25/03/2023 +02:25 GDS : pH 7.46, pO2 86mmHg, pCO2 50mmHg, bicar 35 +--> hypercapnie compensée métabolique + +Item de +surveillance : 03/04/2023 +07:57 03/04/2023 +00:19 02/04/2023 +15:16 02/04/2023 +07:48 02/04/2023 +00:14 01/04/2023 +16:16 01/04/2023 +08:58 01/04/2023 +00:34 31/03/2023 +18:38 31/03/2023 +15:55 31/03/2023 +08:17 31/03/2023 +05:55 30/03/2023 +22:12 +Température : 37,10 37,40 37 36,50 37,30 36,50 37 37,20 36,50 37 37 +Pouls : 84 100 93 83 95 92 88 100 91 90 90 96 +PA +Systolique : 138 113 125 121 131 134 134 105 +PA +Diastolique : 66 76 68 67 65 58 55 55 +Saturation +O² : 96 96 97 95 95 96 96 95 96 94 92 95 +Transit : Normal Absence Absence Absence Normal Normal Absence Absence Absence Absence Absence Normal +Fréq. +respiratoire +Type de note : Nom Date Note +Note IDE : [NOM] [NOM] 03/04/2023 +14:04 Hypoglycémie : +0.65g ce matin. Ressentie car se sent fatiguée --> Re sucrée : OK pour la fin de journée. +Hypoglycémie : +ECG OK +4 gel potassium donné à 10h30. +Sortie prévue ce jour pour Toki EDER -> Papiers de sortie donnés. +Note IDE : [NOM] [NOM] 02/04/2023 +19:53 / +Note IDE : [NOM] [NOM] 01/04/2023 +21:56 / +Note IDE : [NOM] [NOM] 01/04/2023 +13:12 Glycémie : +- ce matin : 1.05 g/L --> insuline non donné +- ce midi : 1.2 g/L --> insuline non donné +Persistance OMI +Note IDE : [NOM] [NOM] 01/04/2023 +07:46 ENDOC: glycémie stable +Note IDE : [NOM] [NOM] 31/03/2023 +19:18 Endocrinologie +- avis diabéto pris pour hypoglycémie +-> diminution insuline lente. +-> ce soir, Hgt 1.71, lente + humalog faites. +Kaliémie +- contrôle kaliémie après PSE hier lundi +Note IDE : [NOM] +[NOM] 31/03/2023 +13:49 Devenir => départ à Toki Eder lundi, patiente OK +HGT => 1.07 G/L ce matin => rapide faite 10 UI au lieu de 14 UI +Hypo => 0.54 G/L à midi => pas d'insuline faite, a mangé le repas, avis diabeto ddé +Note IDE : [NOM] [NOM] 31/03/2023 +01:10 Respiratoire: dyspnée à la mobilisation, bonne sat sous O2 2L +Glycémie: 0.74 à 6h, la patiente se dit asténique. Ressucrée po +Note IDE : [NOM] [NOM] 30/03/2023 +22:29 Hypoglycémie +- 16h : Hgt 0.77 -> collation donnée +- 18h : Hgt 2.11 -> insuline lente et rapide +Hypokaliémie +- K+ 3.3 -> PSE potassium passé sur l'après-midi, RAS +Elimination +- pas de nouvelles diarrhées + +Note IDE : [NOM] [NOM] 30/03/2023 +00:37 Respiratoire: patiente eupneique sous O2 2L au repos +Transit: deux selles diarrhéique cette nuit, instructions données pour copro +Note IDE : [NOM] [NOM] 29/03/2023 +18:57 Respiratoire +- stable sous 2L, encombré -> aérosols productifs. +Hypokaliémie +- PSE posé cet après-midi -> contrôle demain matin +Endocrinologie +- Hgt : 1.62 15h : lente et humalog faites +Note IDE : [NOM] [NOM] 29/03/2023 +13:23 glycémie : 1,83g/l ce midi. +majoration de l'insuline lente. +HypoKCL : 2,7, ECG. +supplémentation per os + IVSE en cours =) BS de control a faire ce soir. +cardio : ecg fait sur hypokcl, FA =) ETT demandée +bilan martial : carence avec ferritine =) ferinject fait. +avis gastro. +douleur : algique au niveau de son dos et d'écrit des douleurs neuropathique au niveau des +jambes. +changement patch atg 3 ce jour. +transit : absence de selle =) cocktail fait, efficace. +Note IDE : [NOM] [NOM] 29/03/2023 +06:52 Endoc: glycémie toujours élevée ce matin +Note IDE : [NOM] [NOM] 28/03/2023 +21:32 Respiratoire : clinique stable sous 2l . +Endocrino : HGT élevé ce soir . +--> Insuline faite selon protocole +Cardio : OMI toujours présents +Note IDE : [NOM] [NOM] 28/03/2023 +14:04 RESPI=> 96% sous 2L O2 ; patiente dort au fauteuil; VNI enlevé cette nuit vers 3h. +Glycémie=> hyperglycémie ce matin => 2.41 à 8H; 2.81 à 12h +après avis du diabeto=> augmentation de la rapide à 14 unités. +Note IDE : [NOM] DA [NOM] 28/03/2023 +13:53 RESPI=> 96% sous 2L O2 ; patiente dort au fauteuil; VNI enlevé cette nuit vers 3h. +Glycémie=> hyperglycémie ce matin => 2.41 à 8H; 2.81 à 12h +après avis du diabeto=> augmentation de la rapide à 14 unités et Forxiga +Note +Kinésithérapeute : [NOM] +[NOM] 28/03/2023 +12:56 début de prise en charge pour ce nouvel épisode d'hospitalisation +toux présente lors de la ventilation dirigée +toux non productive +ventilation dirigée peu dyspneique +Note IDE : [NOM] [NOM] 28/03/2023 +00:57 dort au fauteuil +RESPI: VNI enlevé vers 03h +ENDOC: HGT +Note IDE : [NOM] [NOM] 27/03/2023 +20:03 Respiratoire : clinique et saturation stable sous 2l. +Endocrino : Hypoglycémiants oraux modifiés . +Etat cutanée : OMI présents +Note IDE : [NOM] [NOM] 27/03/2023 +13:55 respi : +pas de problème au niveau du masque de la VNI + +Note IDE : [NOM] [NOM] 27/03/2023 +00:05 Respi=) bonne sat mais problème de masque de VNI cette nuit vu avec la patiente non mise ce +soir car le masque se désadapte régulièrement laissée aux lunettes allo prestataire demain svp +orkyn +infectieux=) patiente apyrétique +Note IDE : [NOM] [NOM] 26/03/2023 +19:06 RESPI : quintes de toux moins gênantes avec toux moins rauque , ATG2 pris pour la nuit +HYPERHGT : > à 3g ce soir (a bu du coca) => protocole d'insuline fait +DEVENIR : VT fait +OMI bilat prenant le godet +Note IDE : [NOM] [NOM] 26/03/2023 +14:50 diab : 2.27 à 12h, vu avec med pour reprise insuline rapide +patch ATG3 : changement patch ATG 3 mais me dit avoir deux patch ATG3, un de 25µg et un de +12µg, vu avec med +respi : toux seche, atg codéiné mis et aérosol fait +Note IDE : [NOM] [NOM] 25/03/2023 +19:27 TTT : patiente signale qu'elle prend de l'aérius et du singulair le soir => à revoir SVP +DESEQUILIBRE DIABETE : hyperHGT ce soir > à 2g f signes vitaux , patient me signale +qu'elle a un protocole de rattrapage si HGT > 1.5g => à revoir aussi SVP +TOUX : sèche +++ => aérosol de serum phy fait X2 qui la soulage un peu +PATCH ATG3 : à changer demain midi svp , information donnée par sa fille +TTT INHALES : a l'habitude d'utiliser une chambre d'inhalation => commandée +Note IDE : [NOM] [NOM] 25/03/2023 +15:02 respi : +dyspnée sous 2L/min, sous CTC +diab : hyperglycémie à 2.49 à midi +patch ATG : patiente doit s'informer de la date de pose du patch pour poursuite ttt antalgique +Note IDE : [NOM] [NOM] 25/03/2023 +01:35 MDA : Adressée pour décompensation cardio-respi. Sortie récemment d'Hospit +Examens : +ECG12D fait et montré +GDS prélevés et envoyés +BS prélevé pdt pose VVP 20GA main D et envoyé +PCR prélevée et envoyée +ECBU envoyé +Cardio-respi : +Diurétiques admin IVL selon PM. Très bonne réponse +CorticoTT + ATBTT débutés avant transfert. +Administratif : +Inventaire réalisé +Devenir : Pneumologie +Prescription : Dose Fréquence Date de début Date de dernière +administration Note Docteur +FERINJECT 500MG/10ML +SOL INJ [2] Flacon(s) : 500 mg - 1 seule fois 1 seule +fois 29/03/2023 11:07 29/03/2023 11:44 Le débit a été +modifié. Le débit +en cours est : 20 +par . DR. [NOM] +[NOM] +FERINJECT 500MG/10ML +SOL INJ [2] Flacon(s) : 500 mg - 1 seule fois 1 seule +fois 30/03/2023 12:38 30/03/2023 14:28 Le débit a été +modifié. Le débit +en cours est : 20 +par . DR. [NOM] +[NOM] +FUROSEMIDE REN +20MG/2ML SOL INJ [100] +Ampoule(s) : 125 mg - 1 seule fois 1 seule +fois 25/03/2023 02:00 25/03/2023 02:12 [NOM] [NOM] + +Potassium PSE 2G/50ML +(2AMP) - BSFP : - Normal 29/03/2023 10:51 29/03/2023 12:22 Le débit a été +modifié. Le débit +en cours est : 8.3 +ML par 1 hrs. DR. [NOM] +[NOM] +Potassium PSE 2G/50ML +(2AMP) - BSFP : - Normal 30/03/2023 12:38 30/03/2023 15:34 Le débit a été +modifié. Le débit +en cours est : 8.3 +ML par 1 hrs. DR. [NOM] +[NOM] +BUSPIRONE MYL 10MG +CPR [20] COMPRIME(S) : 1 CPR - Prise unique à 19h +Normal 25/03/2023 04:49 02/04/2023 20:40 [NOM] [NOM] +CETIRIZINE ARW 10MG +CPR [60] COMPRIME(S) : 1 CPR - Soir [19h] Normal 26/03/2023 15:41 02/04/2023 18:44 DR. [NOM] +[NOM] +DEPAKOTE 500MG CPR +[90] COMPRIME(S) : 750 mg - Matin soir (8h - +20h) Normal 25/03/2023 14:08 03/04/2023 07:49 La posologie est +variable. DR. [NOM] +[NOM] +FORXIGA 10MG CPR [30] +CPR(s) : 1 CPR - Matin [8h] Normal 27/03/2023 16:14 03/04/2023 07:49 DR. [NOM] +[NOM] +FUROSEMIDE ZEN 500MG +CPR [30] CPR(s) : 1 CPR - Matin [8h] Normal 25/03/2023 04:49 03/04/2023 07:49 [NOM] [NOM] +HYDROCHLOROTHIAZIDE +ARW 25 MG CPR [90] +CPR(s) : 1 CPR - Matin [8h] Normal 27/03/2023 18:00 03/04/2023 07:49 DR. [NOM] +[NOM] +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR - Prise unique à 19h +Normal 25/03/2023 04:49 02/04/2023 18:44 [NOM] [NOM] +LOXEN LP 50MG GELULE +[60] Gelule(s) : 1 GEL - 1xJour [8h] Normal 25/03/2023 04:49 03/04/2023 07:49 [NOM] [NOM] +MONTELUKAST +ARW 10MG CPR [28] +COMPRIME(S) : 1 CPR - Soir [19h] Normal 26/03/2023 15:41 02/04/2023 18:44 DR. [NOM] +[NOM] +POTASSIUM 600MG +GELULE : 3 GEL - Matin midi soir +Normal 25/03/2023 04:49 03/04/2023 12:16 [NOM] [NOM] +ROSUVASTATINE ARW +20MG CPR [90] CPR(s) : 0,5 CPR - 1xJour [8h] Normal 25/03/2023 04:49 03/04/2023 07:49 [NOM] [NOM] +TERCIAN 4% SOL BUV FL +30ML [1200] Flacon(s) : 15 GTT - à 21h Normal 25/03/2023 04:49 02/04/2023 20:40 [NOM] [NOM] +XARELTO 20MG CPR [14] +COMPRIME(S) : 1 CPR - 1xJour [8h] Normal 25/03/2023 04:49 03/04/2023 07:49 [NOM] [NOM] +DEPAKOTE 500MG CPR +[90] COMPRIME(S) : 1 CPR - Matin soir (8h - +19h) Normal 25/03/2023 04:49 26/03/2023 08:00 [NOM] [NOM] +GLICLAZIDE ARW +LM 30MG CPR [30] +COMPRIME(S) : 2 CPR - 1xJour [8h] Normal 25/03/2023 04:49 29/03/2023 08:00 [NOM] [NOM] +PARACETAMOL COD +ARW 500/30MG CPR EFF +[16] COMPRIME(S) : 2 CPR - Nuit [21h] Normal 26/03/2023 12:58 26/03/2023 18:24 DR. [NOM] +[NOM] +AMOX/AC CLAV SDZ +1G/125MG AD SACH [12] +Sachet(s) : 1 G - Matin midi soir +Normal 25/03/2023 04:49 30/03/2023 19:07 [NOM] [NOM] +BUSPIRONE MYL 10MG +CPR [20] COMPRIME(S) : 1 CPR - Prise unique à 19h +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +CETIRIZINE ARW 10MG +CPR [60] COMPRIME(S) : 1 CPR - Soir [19h] Presc. de +Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +DEPAKOTE 500MG CPR +[90] COMPRIME(S) : 750 mg - Matin soir (8h - +20h) Presc. de Sortie 03/04/2023 13:27 La posologie est +variable. DR. [NOM] +NOCENT- +EJNAINI +FORXIGA 10MG CPR [30] +CPR(s) : 1 CPR - Matin [8h] Presc. de +Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +FUROSEMIDE ZEN 500MG +CPR [30] CPR(s) : 1 CPR - Matin [8h] Presc. de +Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +HYDROCHLOROTHIAZIDE +ARW 25 MG CPR [90] +CPR(s) : 1 CPR - Matin [8h] Presc. de +Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI + +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR - Prise unique à 19h +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +LOXEN LP 50MG GELULE +[60] Gelule(s) : 1 GEL - 1xJour [8h] Presc. +de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +MONTELUKAST +ARW 10MG CPR [28] +COMPRIME(S) : 1 CPR - Soir [19h] Presc. de +Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +POTASSIUM 600MG +GELULE : 4 GEL - URGENT Urgent 03/04/2023 11:21 03/04/2023 11:22 DR. [NOM] +NOCENT- +EJNAINI +POTASSIUM 600MG +GELULE : 3 GEL - Matin midi soir +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +ROSUVASTATINE ARW +20MG CPR [90] CPR(s) : 0,5 CPR - 1xJour [8h] Presc. +de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +SOLUPRED 20MG +CPR ORODISP [20] +COMPRIME(S) : 3 CPR - 1xJour [8h] Normal 25/03/2023 04:23 27/03/2023 08:28 DR. [NOM] +[NOM] +TERCIAN 4% SOL BUV FL +30ML [1200] Flacon(s) : 15 GTT - à 21h Presc. de +Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +XARELTO 20MG CPR [14] +COMPRIME(S) : 1 CPR - 1xJour [8h] Presc. +de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +ABASAGLAR 300 U SOL +INJ CART [5] Cartouche(s) : 60 UI - Prise unique à 19h +Normal 25/03/2023 04:49 02/04/2023 18:54 [NOM] [NOM] +ABASAGLAR 300 U SOL +INJ CART [5] Cartouche(s) : 60 UI - Prise unique à 19h +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +HUMALOG 300UI/3ML +KWIKPEN SOL INJ [5] +Stylo(s) Prerempli(s) : 14 UI - Matin midi soir +Normal 26/03/2023 10:07 03/04/2023 12:17 DR. [NOM] +[NOM] +HUMALOG 300UI/3ML +KWIKPEN SOL INJ [5] +Stylo(s) Prerempli(s) : 14 UI - Matin midi soir +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +OZEMPIC 1 MG SOL INJ +STYLO 3ML [1] Stylo(s) +Prerempli(s) : 1 mg - 1xSemaine [8h] +Normal 25/03/2023 04:49 01/04/2023 08:00 [NOM] [NOM] +OZEMPIC 1 MG SOL INJ +STYLO 3ML [1] Stylo(s) +Prerempli(s) : 1 mg - 1xSemaine [8h] +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +DUROGESIC 12MICROG/ +H DISP TRANSDERM +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) : 1 PATCH - Ttes les 72H (1j /3) +Normal 26/03/2023 15:01 02/04/2023 14:16 DR. [NOM] +[NOM] +DUROGESIC 25MICROG/ +H DISP TRANSDERM +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) : 1 PATCH - Normal 25/03/2023 04:49 02/04/2023 14:16 [NOM] [NOM] +DUROGESIC 12MICROG/ +H DISP TRANSDERM +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) : 1 PATCH - Ttes les 72H (1j /3) +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +DUROGESIC 25MICROG/ +H DISP TRANSDERM +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) : 1 PATCH - Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +IPRATROPIUM AGT +0,5MG/2ML AD INHAL +[10] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - Normal 26/03/2023 12:58 03/04/2023 12:18 Le débit en cours +est : 8 ML par 1 +hrs. DR. [NOM] +[NOM] + +IPRATROPIUM AGT +0,5MG/2ML AD INHAL +[10] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +TERBUTALINE ARW +5MG/2ML SOL INHAL +[50] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - Normal 26/03/2023 12:58 03/04/2023 12:18 Le débit en cours +est : 8 ML par 1 +hrs. DR. [NOM] +[NOM] +TERBUTALINE ARW +5MG/2ML SOL INHAL +[50] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +TRIMBOW 87/5/9 +MCG SOL INH 60 +D [1] FLACON(S) +PRESSURISE(S) : 2 BOUFFEE - Matin soir (8h - +19h) Normal 25/03/2023 04:49 03/04/2023 07:49 [NOM] [NOM] +TRIMBOW 87/5/9 +MCG SOL INH 60 +D [1] FLACON(S) +PRESSURISE(S) : 2 BOUFFEE - Matin soir (8h - +19h) Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +SODIUM BIC BAX 1,4% +POC CFX 500ML V1 [1] +POCHE(S) : 10 ml - Matin midi soir +Normal 26/03/2023 12:58 03/04/2023 12:00 DR. [NOM] +[NOM] +VERSATIS 5% EMPLATRE +[30] Emplatre(s) : 1 +Emplatre(s) - Prise unique à 19h +Normal 25/03/2023 04:49 02/04/2023 20:39 [NOM] [NOM] +VERSATIS 5% EMPLATRE +[30] Emplatre(s) : 1 +Emplatre(s) - Prise unique à 19h +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +Date début : Heure +début Prescription Date +exécution Heure +exécution Statut Docteur Note +25/03/2023 : 02:19 Thorax F P 25/03/2023 02:36 Réalisé [NOM] [NOM] +Date : Heure Prescription Docteur Date de +collection Note +25/03/2023 : 01:08 Ionogramme ( Na, K, CL ) DR. [NOM] 25/03/2023 +01:10 +27/03/2023 : 08:00 Clairance à la creatinine MDRD DR. [NOM] 27/03/2023 +08:26 +29/03/2023 : 08:00 Clairance à la creatinine MDRD DR. [NOM] 29/03/2023 +08:11 +03/04/2023 : 07:00 Ionogramme ( Na, K, CL ) DR. [NOM] 03/04/2023 +09:07 +03/04/2023 : 07:00 Créatinine sang ( dosage ) DR. [NOM] 03/04/2023 +09:07 +03/04/2023 : 07:00 Bilirubine ( totale + conjuguée + +non conjuguée ) sang ( dosage ) DR. [NOM] 03/04/2023 +09:07 +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +DESINFECTION +ENVIRONNEMENT +PATIENT : Signé - Matin [8h] Normal 25/03/2023 +13:41 [NOM] +[NOM] +LIT : REFECTION +COMPLETE Signé - Matin [8h] Normal 25/03/2023 +13:41 [NOM] +[NOM] +TOILETTE DOUCHE : AIDE PARTIELLE Signé - Matin [8h] Normal 25/03/2023 +13:41 [NOM] +[NOM] +ACCOMPAGNER +INSTALLER AUX +TOILETTES : Réalisé 1 Semaine - Matin +[8h] Normal 28/03/2023 +10:24 Jean- +[NOM] +[NOM] +DESINFECTION +ENVIRONNEMENT +PATIENT : Réalisé 1 Semaine - Matin +[8h] Normal 28/03/2023 +10:24 Jean- +[NOM] +[NOM] + +SOMMEIL : SURV. Réalisé 1 Semaine - Nuit +[21h] Normal 28/03/2023 +06:46 [NOM] +ESTOMBA- +[NOM] +TOILETTE : AUTONOME Réalisé 1 Semaine - Matin +[8h] Normal 28/03/2023 +10:24 Jean- +[NOM] +[NOM] +GLYCEMIE CAPILLAIRE x +7 : Réalisé - 7x/jour (8h 12h +14h 19h 22h 0h 4h) +Normal 31/03/2023 +14:52 Notes du +professionel +de santé: +bien noter +toutes les +glycémies +sur trakcare +notamment +celles de 22h DR. +[NOM] +[NOM] +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +ABASAGLAR 300 U SOL +INJ CART [5] Cartouche(s) : 60 UI +SOUS- +CUTANEE Signé - Prise unique à 19h +Presc. de Sortie 03/04/2023 +13:27 0/6 : Non administré +A valider DR. [NOM] +NOCENT- +EJNAINI +BUSPIRONE MYL 10MG +CPR [20] COMPRIME(S) : 1 CPR +ORALE Réalisé - Prise unique à 19h +Presc. de Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +CETIRIZINE ARW 10MG +CPR [60] COMPRIME(S) : 1 CPR +ORALE Réalisé - Soir [19h] Presc. de +Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +DEPAKOTE 500MG CPR +[90] COMPRIME(S) : 750 mg +ORALE Réalisé - Matin soir (8h - +20h) Presc. de Sortie 03/04/2023 +13:27 0/105 : Non +administré Révisé/ +Traité DR. [NOM] +NOCENT- +EJNAINI +DUROGESIC 12MICROG/ +H DISP TRANSDERM +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) : 1 PATCH +TRANSDERM Réalisé +IQUE - Ttes les 72H (1j /3) +Presc. de Sortie 03/04/2023 +13:27 0/10 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +DUROGESIC 25MICROG/ +H DISP TRANSDERM +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) : 1 PATCH +TRANSDERM Réalisé +IQUE - Presc. de Sortie 03/04/2023 +13:27 0/10 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +FORXIGA 10MG CPR [30] +CPR(s) : 1 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +FUROSEMIDE ZEN 500MG +CPR [30] CPR(s) : 1 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +HUMALOG 300UI/3ML +KWIKPEN SOL INJ [5] +Stylo(s) Prerempli(s) : 14 UI +SOUS- +CUTANEE Signé - Matin midi soir +Presc. de Sortie 03/04/2023 +13:27 0/5 : Non administré +A valider DR. [NOM] +NOCENT- +EJNAINI +HYDROCHLOROTHIAZIDE +ARW 25 MG CPR [90] +CPR(s) : 1 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +IPRATROPIUM AGT +0,5MG/2ML AD INHAL +[10] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE +INHALEE Signé - Presc. de Sortie 03/04/2023 +13:27 0/90 : Non administré +A valider DR. [NOM] +NOCENT- +EJNAINI +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR +ORALE Réalisé - Prise unique à 19h +Presc. de Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +LOXEN LP 50MG GELULE +[60] Gelule(s) : 1 GEL +ORALE Réalisé - 1xJour [8h] Presc. +de Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +MONTELUKAST +ARW 10MG CPR [28] +COMPRIME(S) : 1 CPR +ORALE Réalisé - Soir [19h] Presc. de +Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +OZEMPIC 1 MG SOL INJ +STYLO 3ML [1] Stylo(s) +Prerempli(s) : 1 mg SOUS- +CUTANEE Signé - 1xSemaine [8h] +Presc. de Sortie 03/04/2023 +13:27 0/1 : Non administré +A valider DR. [NOM] +NOCENT- +EJNAINI +POTASSIUM 600MG +GELULE : 3 GEL +ORALE Réalisé - Matin midi soir +Presc. de Sortie 03/04/2023 +13:27 0/270 : Non +administré Révisé/ +Traité DR. [NOM] +NOCENT- +EJNAINI +ROSUVASTATINE ARW +20MG CPR [90] CPR(s) : 0,5 CPR +ORALE Réalisé - 1xJour [8h] Presc. +de Sortie 03/04/2023 +13:27 0/15 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI + +TERBUTALINE ARW +5MG/2ML SOL INHAL +[50] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE +INHALEE Signé - Presc. de Sortie 03/04/2023 +13:27 0/90 : Non administré +A valider DR. [NOM] +NOCENT- +EJNAINI +TERCIAN 4% SOL BUV FL +30ML [1200] Flacon(s) : 15 GTT +ORALE Réalisé - à 21h Presc. de +Sortie 03/04/2023 +13:27 0/1 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +TRIMBOW 87/5/9 +MCG SOL INH 60 +D [1] FLACON(S) +PRESSURISE(S) : 2 BOUFFEE +INHALEE Signé - Matin soir (8h - +19h) Presc. de Sortie 03/04/2023 +13:27 0/120 : Non +administré A valider DR. [NOM] +NOCENT- +EJNAINI +VERSATIS 5% EMPLATRE +[30] Emplatre(s) : 1 +Emplatre(s) +CUTANEE Réalisé - Prise unique à 19h +Presc. de Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +XARELTO 20MG CPR [14] +COMPRIME(S) : 1 CPR +ORALE Réalisé - 1xJour [8h] Presc. +de Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - BUCCALE - Matin midi soir - 1ère +dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 05/04/2023 à +12:00 +Admin le 03/04/2023 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 - BUCCALE - Matin midi soir - 1ère +dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 05/04/2023 à +12:00 +Admin le 03/04/2023 à +12:00 07:49 * 10 ml +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - BUCCALE - Matin midi soir - 1ère +dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 05/04/2023 à +12:00 +Admin le 03/04/2023 à +12:00 12:00 * 10 ml +Signé — VERSATIS 700MG EMPLATRE +- 700MG emplatre - Dose 1 Emplatre(s) - +CUTANEE - Prise unique à 19h - 1ère dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +20:39 19:00 * 1 +Emplatre(s) +Signé — IPRATROPIUM AGT 0,5MG/2ML AD +INHAL - 0,5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 20:58 * +1 REC. +UNIDOSE +Signé — IPRATROPIUM AGT 0,5MG/2ML AD +INHAL - 0,5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 04:58 * +1 REC. +UNIDOSE +Signé — IPRATROPIUM AGT 0,5MG/2ML AD +INHAL - 0,5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 12:18 * +1 REC. +UNIDOSE +Signé — TERBUTALINE ARW 5MG/2ML +SOL INHAL - 5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 20:58 * +1 REC. +UNIDOSE +Signé — TERBUTALINE ARW 5MG/2ML +SOL INHAL - 5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 04:58 * +1 REC. +UNIDOSE +Signé — TERBUTALINE ARW 5MG/2ML +SOL INHAL - 5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 12:18 * +1 REC. +UNIDOSE + + + + + + + + + + + + + +Signé — TRIMBOW 87/5/9 MCG SOL INH +60 D - 87/5/9 solution - Dose 2 BOUFFEE - +INHALEE Directe - Matin soir (8h - 19h) - 1ère +dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +07:49 19:00 * 2 +BOUFFEE +Signé — TRIMBOW 87/5/9 MCG SOL INH +60 D - 87/5/9 solution - Dose 2 BOUFFEE - +INHALEE Directe - Matin soir (8h - 19h) - 1ère +dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +07:49 07:49 * 2 +BOUFFEE +Signé — BUSPIRONE MYL 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Prise unique +à 19h - 1ère dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +20:40 19:00 * 1 +CPR +Signé — CETIRIZINE ARW 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Soir [19h] - +1ère dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +15:41 +Fin le 05/04/2023 à +19:00 +Admin le 02/04/2023 à +18:44 19:00 * 1 +CPR +Signé — DEPAKOTE 500MG CPR - 500MG +comprime - Dose Variable - ORALE - Matin soir +(8h - 20h) - 1ère dose : 25/03/2023 @ 20:00 +! Plan de dosage variable [NOM] [NOM] +Début le 25/03/2023 à +14:08 +Fin le 09/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 20:00 * 1000 +mg +Signé — DEPAKOTE 500MG CPR - 500MG +comprime - Dose Variable - ORALE - Matin soir +(8h - 20h) - 1ère dose : 25/03/2023 @ 20:00 +! Plan de dosage variable [NOM] [NOM] +Début le 25/03/2023 à +14:08 +Fin le 09/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 750 +mg +Signé — FORXIGA 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Matin [8h] - +1ère dose : 28/03/2023 @ 08:00 [NOM] [NOM] +Début le 27/03/2023 à +16:14 +Fin le 26/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 1 +CPR +Signé — FUROSEMIDE ZEN 500MG CPR - +500MG comprime - Dose 1 CPR - ORALE - +Matin [8h] - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 1 +CPR +Signé — HYDROCHLOROTHIAZIDE ARW +25 MG CPR - 25MG comprime - Dose 1 CPR - +ORALE - Matin [8h] - 1ère dose : 28/03/2023 @ +08:00 [NOM] [NOM] +Début le 27/03/2023 à +18:00 +Fin le 26/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 1 +CPR +Signé — LANSOPRAZOLE BGA 30 MG +CPR OROD - 30MG comprime - Dose 1 CPR +- ORALE - Prise unique à 19h - 1ère dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +18:44 19:00 * 1 +CPR + + + + + +Signé — LOXEN LP 50MG GELULE - 50MG +gelule - Dose 1 GEL - ORALE - 1xJour [8h] - +1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 1 +GEL +Signé — MONTELUKAST ARW 10MG CPR - +10MG comprime - Dose 1 CPR - ORALE - Soir +[19h] - 1ère dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +15:41 +Fin le 09/04/2023 à +19:00 +Admin le 02/04/2023 à +18:44 19:00 * 1 +CPR +Signé — POTASSIUM 600MG GELULE - +600MG gelule - Dose 3 GEL - ORALE - Matin +midi soir - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +12:16 19:00 * 3 +GEL +Signé — POTASSIUM 600MG GELULE - +600MG gelule - Dose 3 GEL - ORALE - Matin +midi soir - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +12:16 07:49 * 3 +GEL +Signé — POTASSIUM 600MG GELULE - +600MG gelule - Dose 3 GEL - ORALE - Matin +midi soir - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +12:16 12:16 * 3 +GEL +Réalisé — POTASSIUM 600MG GELULE +- 600MG gelule - Dose 4 GEL - ORALE - +URGENT - Début presc. : 03/04/2023 @ 11:21 [NOM] +[NOM] +Début le 03/04/2023 à +11:21 +Fin le 03/04/2023 à +11:21 +Admin le 03/04/2023 à +11:22 11:22 * 4 +GEL +Signé — ROSUVASTATINE ARW 20MG CPR +- 20MG comprime - Dose 0,5 CPR - ORALE - +1xJour [8h] - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 0.5 +CPR +Signé — TERCIAN 40 MG/ML SOL BUV 30ML +- 0,04G/ML solution (30 mL) - Dose 15 GTT - +ORALE - à 21h - 1ère dose : 25/03/2023 @ 21:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +21:00 +Admin le 02/04/2023 à +20:40 21:00 * 15 +GTT +Signé — XARELTO 20 MG CPR - 20MG +comprime - Dose 1 CPR - ORALE - 1xJour [8h] - +1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 1 +CPR +Signé — ABASAGLAR 300 U SOL INJ CART - +100UI/ML solution (3 mL) - Dose 60 UI - SOUS- +CUTANEE Directe - Prise unique à 19h - 1ère +dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +18:54 19:00 * 60 UI + + + + + +Signé — HUMALOG 300UI KWIKPEN SOL +INJ - 300UI solution (3 mL) - Dose 14 UI - +SOUS-CUTANEE Directe - Matin midi soir - 1ère +dose : 26/03/2023 @ 12:00 [NOM] [NOM] +Début le 26/03/2023 à +10:07 +Fin le 25/04/2023 à +08:00 +Admin le 03/04/2023 à +12:17 08:00 * 14 UI +Signé — HUMALOG 300UI KWIKPEN SOL +INJ - 300UI solution (3 mL) - Dose 14 UI - +SOUS-CUTANEE Directe - Matin midi soir - 1ère +dose : 26/03/2023 @ 12:00 [NOM] [NOM] +Début le 26/03/2023 à +10:07 +Fin le 25/04/2023 à +08:00 +Admin le 03/04/2023 à +12:17 12:17 * 14 UI +Réalisé — ACCOMPAGNER INSTALLER AUX +TOILETTES - Matin [8h] - 1 Semaine- Date +Début : 28/03/2023 @ 10:24 [NOM] Jean- +[NOM] +Début le 28/03/2023 à +10:24 +Fin le 04/04/2023 à +08:00 +Admin le 03/04/2023 à +08:00 08:00 * 1 +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - 1 +Semaine- Date Début : 28/03/2023 @ 10:24 [NOM] Jean- +[NOM] +Début le 28/03/2023 à +10:24 +Fin le 04/04/2023 à +08:00 +Admin le 03/04/2023 à +08:00 08:00 * 1 +Réalisé — SOMMEIL : SURV. - Nuit [21h] - 1 +Semaine- Date Début: 28/03/2023 @ 06:46 ESTOMBA- +[NOM] [NOM] +Début le 28/03/2023 à +06:46 +Fin le 03/04/2023 à +21:00 +Admin le 02/04/2023 à +21:00 21:00 * 1 +Réalisé — TOILETTE : AUTONOME - Matin +[8h] - 1 Semaine- Date Début: 28/03/2023 @ +10:24 [NOM] Jean- +[NOM] +Début le 28/03/2023 à +10:24 +Fin le 04/04/2023 à +08:00 +Admin le 03/04/2023 à +08:00 08:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 19:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 22:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 00:00 * 1 + + + + + +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 04:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 08:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 12:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 14:00 * 1 + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - BUCCALE - Matin midi soir - 1ère +dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 05/04/2023 à +12:00 +Admin le 03/04/2023 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 - BUCCALE - Matin midi soir - 1ère +dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 05/04/2023 à +12:00 +Admin le 03/04/2023 à +12:00 12:00 * 10 ml +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - BUCCALE - Matin midi soir - 1ère +dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 05/04/2023 à +12:00 +Admin le 03/04/2023 à +12:00 19:00 * 10 ml +Signé — VERSATIS 700MG EMPLATRE +- 700MG emplatre - Dose 1 Emplatre(s) - +CUTANEE - Prise unique à 19h - 1ère dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +20:39 19:00 * 1 +Emplatre(s) +Signé — IPRATROPIUM AGT 0,5MG/2ML AD +INHAL - 0,5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 12:58 * +1 REC. +UNIDOSE +Signé — IPRATROPIUM AGT 0,5MG/2ML AD +INHAL - 0,5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 20:58 * +1 REC. +UNIDOSE +Signé — IPRATROPIUM AGT 0,5MG/2ML AD +INHAL - 0,5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 04:58 * +1 REC. +UNIDOSE +Signé — TERBUTALINE ARW 5MG/2ML +SOL INHAL - 5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 12:58 * +1 REC. +UNIDOSE +Signé — TERBUTALINE ARW 5MG/2ML +SOL INHAL - 5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 20:58 * +1 REC. +UNIDOSE +Signé — TERBUTALINE ARW 5MG/2ML +SOL INHAL - 5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 04:58 * +1 REC. +UNIDOSE + + + + + + + + + + + + + +Signé — TRIMBOW 87/5/9 MCG SOL INH +60 D - 87/5/9 solution - Dose 2 BOUFFEE - +INHALEE Directe - Matin soir (8h - 19h) - 1ère +dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +07:49 08:00 * 2 +BOUFFEE +Signé — TRIMBOW 87/5/9 MCG SOL INH +60 D - 87/5/9 solution - Dose 2 BOUFFEE - +INHALEE Directe - Matin soir (8h - 19h) - 1ère +dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +07:49 19:00 * 2 +BOUFFEE +Signé — BUSPIRONE MYL 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Prise unique +à 19h - 1ère dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +20:40 19:00 * 1 +CPR +Signé — CETIRIZINE ARW 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Soir [19h] - +1ère dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +15:41 +Fin le 05/04/2023 à +19:00 +Admin le 02/04/2023 à +18:44 19:00 * 1 +CPR +Signé — DEPAKOTE 500MG CPR - 500MG +comprime - Dose Variable - ORALE - Matin soir +(8h - 20h) - 1ère dose : 25/03/2023 @ 20:00 +! Plan de dosage variable [NOM] [NOM] +Début le 25/03/2023 à +14:08 +Fin le 09/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 750 +mg +Signé — DEPAKOTE 500MG CPR - 500MG +comprime - Dose Variable - ORALE - Matin soir +(8h - 20h) - 1ère dose : 25/03/2023 @ 20:00 +! Plan de dosage variable [NOM] [NOM] +Début le 25/03/2023 à +14:08 +Fin le 09/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 20:00 * 1000 +mg +Signé — FORXIGA 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Matin [8h] - +1ère dose : 28/03/2023 @ 08:00 [NOM] [NOM] +Début le 27/03/2023 à +16:14 +Fin le 26/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 1 +CPR +Signé — FUROSEMIDE ZEN 500MG CPR - +500MG comprime - Dose 1 CPR - ORALE - +Matin [8h] - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 1 +CPR +Signé — HYDROCHLOROTHIAZIDE ARW +25 MG CPR - 25MG comprime - Dose 1 CPR - +ORALE - Matin [8h] - 1ère dose : 28/03/2023 @ +08:00 [NOM] [NOM] +Début le 27/03/2023 à +18:00 +Fin le 26/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 1 +CPR +Signé — LANSOPRAZOLE BGA 30 MG +CPR OROD - 30MG comprime - Dose 1 CPR +- ORALE - Prise unique à 19h - 1ère dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +18:44 19:00 * 1 +CPR + + + + + +Signé — LOXEN LP 50MG GELULE - 50MG +gelule - Dose 1 GEL - ORALE - 1xJour [8h] - +1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 1 +GEL +Signé — MONTELUKAST ARW 10MG CPR - +10MG comprime - Dose 1 CPR - ORALE - Soir +[19h] - 1ère dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +15:41 +Fin le 09/04/2023 à +19:00 +Admin le 02/04/2023 à +18:44 19:00 * 1 +CPR +Signé — POTASSIUM 600MG GELULE - +600MG gelule - Dose 3 GEL - ORALE - Matin +midi soir - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +12:16 08:00 * 3 +GEL +Signé — POTASSIUM 600MG GELULE - +600MG gelule - Dose 3 GEL - ORALE - Matin +midi soir - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +12:16 12:00 * 3 +GEL +Signé — POTASSIUM 600MG GELULE - +600MG gelule - Dose 3 GEL - ORALE - Matin +midi soir - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +12:16 19:00 * 3 +GEL +Signé — ROSUVASTATINE ARW 20MG CPR +- 20MG comprime - Dose 0,5 CPR - ORALE - +1xJour [8h] - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 0.5 +CPR +Signé — TERCIAN 40 MG/ML SOL BUV 30ML +- 0,04G/ML solution (30 mL) - Dose 15 GTT - +ORALE - à 21h - 1ère dose : 25/03/2023 @ 21:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +21:00 +Admin le 02/04/2023 à +20:40 21:00 * 15 +GTT +Signé — XARELTO 20 MG CPR - 20MG +comprime - Dose 1 CPR - ORALE - 1xJour [8h] - +1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 1 +CPR +Signé — ABASAGLAR 300 U SOL INJ CART - +100UI/ML solution (3 mL) - Dose 60 UI - SOUS- +CUTANEE Directe - Prise unique à 19h - 1ère +dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +18:54 19:00 * 60 UI +Signé — HUMALOG 300UI KWIKPEN SOL +INJ - 300UI solution (3 mL) - Dose 14 UI - +SOUS-CUTANEE Directe - Matin midi soir - 1ère +dose : 26/03/2023 @ 12:00 [NOM] [NOM] +Début le 26/03/2023 à +10:07 +Fin le 25/04/2023 à +08:00 +Admin le 03/04/2023 à +12:17 08:00 * 14 UI + + + + + + + +Signé — HUMALOG 300UI KWIKPEN SOL +INJ - 300UI solution (3 mL) - Dose 14 UI - +SOUS-CUTANEE Directe - Matin midi soir - 1ère +dose : 26/03/2023 @ 12:00 [NOM] [NOM] +Début le 26/03/2023 à +10:07 +Fin le 25/04/2023 à +08:00 +Admin le 03/04/2023 à +12:17 19:00 * 14 UI +Signé — DUROGESIC 12 MICROG/H DISP +TRANSDERM - 0.012MG/HEURE dispositif - +Dose 1 PATCH - TRANSDERMIQUE - Ttes les +72H (1j /3) - 1ère dose : 29/03/2023 @ 08:00 [NOM] [NOM] +Début le 26/03/2023 à +15:01 +Fin le 10/04/2023 à +08:00 +Admin le 02/04/2023 à +14:16 08:00 * 1 +PATCH +Réalisé — ACCOMPAGNER INSTALLER AUX +TOILETTES - Matin [8h] - 1 Semaine- Date +Début : 28/03/2023 @ 10:24 [NOM] Jean- +[NOM] +Début le 28/03/2023 à +10:24 +Fin le 04/04/2023 à +08:00 +Admin le 03/04/2023 à +08:00 08:00 * 1 +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - 1 +Semaine- Date Début : 28/03/2023 @ 10:24 [NOM] Jean- +[NOM] +Début le 28/03/2023 à +10:24 +Fin le 04/04/2023 à +08:00 +Admin le 03/04/2023 à +08:00 08:00 * 1 +Réalisé — TOILETTE : AUTONOME - Matin +[8h] - 1 Semaine- Date Début: 28/03/2023 @ +10:24 [NOM] Jean- +[NOM] +Début le 28/03/2023 à +10:24 +Fin le 04/04/2023 à +08:00 +Admin le 03/04/2023 à +08:00 08:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 08:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 12:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 14:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 19:00 * 1 + + + +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 22:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 00:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 04:00 * 1 +Prescription : Date Résultat +CR RX-Echo : 25/03/2023 +02:19 Compte rendu au format texte +Bayonne, le 25/03/2023 +Docteur +Nom de naissance : DE [NOM] [NOM] [NOM] +Nom utilisé : DE [NOM] [NOM] [NOM] +Prénom de naissance : REGINA +Prénom utilisé : REGINA +[DATE_NAISSANCE] +Lieu de naissance : 99999 +Sexe : F +Matricule INS : +Examen du : 25/03/2023 +Compte-rendu validé électroniquement par Dr [NOM] le 25/03/2023 +RADIOGRAPHIE PULMONAIRE +Indication : +Bilan de dyspnée. +RESULTATS : +Sous réserve de la faible ampliation thoracique : +Diminution de la transparence parenchymateuse aux bases apparaissant être liée notamment à la projection des parties molles. +Absence de foyer circonscrit au niveau des apex pulmonaires. Augmentation de l'index cardiothoracique.. +Dr [NOM] +Technique : +PDS : 0.426 dGy.cm² +A l'entrée : 0.065 mGy +Protocole d'acquisition : Thorax +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 : 03/04/2023 09:17 +(5920658) 03/04/2023 09:07 +(5920659) 30/03/2023 08:44 +(5918673) 29/03/2023 08:11 +(5917252) 29/03/2023 08:11 +(5917251) +Bilirubine totale : 5 µmol/l + +Score Fibrosis-4 (FIB4) : 1,60 +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) % Non renseigné(e) % +Bicarbonates : 38,0 mmol/l 37,7 mmol/l +Origine : Artériel Artériel +Débit : Non renseigné(e) L/ +min Non renseigné(e) L/ +min +Température : Non renseignée (rendu +pour une température +de 37°C) °C Non renseignée (rendu +pour une température +de 37°C) °C +ASAT : 27 U/l +Commentaire bilirubine totale : 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 +masse 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 +masse 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 +masse musculaire - +alimentation pauvre +en protéines animales +et patients dénutris - +patients d'origine non +caucasienne +Gamma GT : 39 U/l +NT-proBNP : 229 ng/l 507 ng/l +Interprétation NT-proBNP : Négatif : Insuffisance +cardiaque peu probable Zone grise : +insuffisance cardiaque +moins plausible. +Envisager d?autres +causes d?augmentation +du NT-proBNP. +Phosphatase alcaline : 80 U/l +Calcium : 2,10 mmol/l +Estimation du DFG (CKD- +EPI) : 97 ml/mn/1.73 m2 71 ml/mn/1.73 m2 92 ml/mn/1.73 m2 +Chlore : 90 mmol/l 88 mmol/l 89 mmol/l +Créatinine : 52 µmol/l 76 µmol/l 60 µmol/l +CRP : 34 mg/l 2 mg/l +Compte-rendu laboratoire : Labo230403105652-1.pd fLabo230403104835-1.pd fLabo230330101823-1.pd fLabo230329103002-1.pd fLabo230329102552-1.pd +Polynucléaires neutrophiles +(%) : 65,1 % 70,3 % +Polynucléaires neutrophiles +(#) : 6,89 10.9/l 6,21 10.9/l +Polynucléaires éosinophiles +(%) : 1,1 % 0,1 % + +Polynucléaires éosinophiles +(#) : 0,12 10.9/l 0,01 10.9/l +Polynucléaires basophiles (%) : 0,4 % 0,3 % +Polynucléaires basophiles (#) : 0,04 10.9/l 0,03 10.9/l +Lymphocytes (%) : 24,3 % 19,3 % +Lymphocytes (#) : 2,57 10.9/l 1,70 10.9/l +Monocytes (%) : 9,1 % 10,0 % +Monocytes (#) : 0,96 10.9/l 0,88 10.9/l +Glucose : 13,4 mmol/l 9,7 mmol/l 15,0 mmol/l +pH : 7,50 7,48 +pO2 : 100 mmHg 103 mmHg +Saturation O2 : 96,0 % 96,5 % +pCO2 : 49 mmHg 51 mmHg +ALAT : 19 U/l +Formule sanguine : réalisée sur automate +XN (Sysmex) réalisée sur automate +XN (Sysmex) +Hématocrite (%) : 35,5 % 33,9 % +Indice de distribution des +hématies : 20,3 % 18,2 % +Potassium : 2,6 mmol/l 3,3 mmol/l 2,7 mmol/l +Leucocytes : 10,59 10.9/l 8,83 10.9/l +Hématies : 4,57 10.12/l (t/l) 4,48 10.12/l (t/l) +Hémoglobine : 10,6 g/dl 10,1 g/dl +VGM : 77,7 fl 75,7 fl +TCMH : 23,2 pg 22,5 pg +CCMH : 29,9 g/dl 29,8 g/dl +Sodium : 137 mmol/l 136 mmol/l 136 mmol/l +Osmolarité sang : 287 mOSM/l 282 mOSM/l 287 mOSM/l +Plaquettes : 252 10.9/l 290 10.9/l +Validation et diffusion sous la +responsabilité du biologiste : Dr [NOM] "" Dr. [NOM] [NOM] +[NOM] Dr [NOM] [NOM] Dr [NOM] [NOM] +Volume plaquettaire moyen : 9,0 fl 9,1 fl diff --git a/test_3ogc/anonymise/trackare-BA165196-23061393_BA165196_23061393.redacted_raster.pdf b/test_3ogc/anonymise/trackare-BA165196-23061393_BA165196_23061393.redacted_raster.pdf new file mode 100644 index 0000000..825a240 Binary files /dev/null and b/test_3ogc/anonymise/trackare-BA165196-23061393_BA165196_23061393.redacted_raster.pdf differ diff --git a/test_3ogc/anonymise/trackare-BA165196-23061393_BA165196_23061393.redacted_vector.pdf b/test_3ogc/anonymise/trackare-BA165196-23061393_BA165196_23061393.redacted_vector.pdf new file mode 100644 index 0000000..777b4bc --- /dev/null +++ b/test_3ogc/anonymise/trackare-BA165196-23061393_BA165196_23061393.redacted_vector.pdf @@ -0,0 +1,1976 @@ +%PDF-1.4 +%µ¶ +% Written by MuPDF 1.27.1 + +1 0 obj 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[ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +[TEL] +Pôle Médecine Interne +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Bayonne, le [DATE] +CHEF DE PÔLE +Dr [NOM] +M [NOM] [NOM] +DERMATOLOGIE [ADRESSE] +Dr [NOM] MAISON [NOM] [NOM] +Chef de Service +Dr [NOM] [CODE_POSTAL] +Dr [NOM] +Secrétariat : +[TEL] Mon cher confrère, +ENDOCRINOLOGIE +Dr [NOM] Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du [DATE] au [DATE] pour le motif +C D h r e f E d l e i s S a e r M vic A e URY suivant : +Dr [NOM] +D D r r M M a a r th io ie n u G A S U C Z H I WIND - Motif entrée : +Secrétariat : +[TEL] Première éducation dans le cadre d'un diabète de type 2 +MAL. INFECTIEUSES Introduction de GLP1 en en neurologie lors de son AVC en [DATE] (HbA1c 7,9%) +Dr [NOM] +Chef de Service Antécédents +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] SAOS appareillé +Secrétariat : +[TEL] diabete +HTA +NEPHROLOGIE AVC fin [DATE] +Dr [NOM] +Chef de Service +Dr [NOM] [NOM] Suivi retentissement : +Dr [NOM] [NOM] Ophtalmo Dr [NOM], dernière cs [DATE] : rétinopathie minime et maculopathie. IVT OD prévue +Dr [NOM] +Dr [NOM] [NOM] cardio : dernière évaluation Dr [NOM] en [DATE] +Secrétariat : +[TEL] Traitements habituels +RHUMATOLOGIE Nebivolol 5 mg 1-0-0 +Dr [NOM] Pravastatine 40 mg 1 le soir +Chef de Service Eliquis 5 : 1 cp matin et soir +Dr [NOM] +Dr [NOM] Perindopril 10mg 1-0-0 +Secrétariat : Amlodipine 5 le matin +[TEL] Velmetia 50/1000mg 1-0-1 (alors que je l'avais arrêté en neurologie et j'avais prescrit metformine seule) +MÉDECINE INTERNE Gliclazide 30mg 2-0-0 +Dr [NOM] Trulicity 1,5 les mardis +Chef de Service +Dr [NOM] +Dr [NOM] Vaccination ne sait pas pour covid et tétanos, n'a jamais été vacciné contre la grippe +Secrétariat : +[TEL] Mode de vie : +Vit avec son épouse +n'a jamais fumé +EC : +Ralentisement idéomoteur +Poids 98,9 IMC 33,4 kg/m² +Onychomycose, pallesthésie OK, pouls OK pieds grade 0 +Biologie : +HbA1C 7,1% +TSH 0,72 +LDL 0,55 Tg 0,92 HDL 0,31 g/l +iono NFS bilan hépatique sans anomalies +Créatinémie 65 µmol/l +RAC 2,6 mg/mmol +Albuminémie 39,4 g/L +Carence modérée en vitamine D +Pas de carence en vitamine B12 et folates +PRISE EN CHARGE DANS LE SERVICE : +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE] +IPP : [IPP] / [EPISODE] (Pôle Méd. interne : H semaine) +V1 - Imprimé le [DATE] à 14 : 34 par Page(s): 1 sur 3 N° Finess [MASK] +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +[TEL] +Pôle Médecine Interne +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Pas de modification du traitement antidiabétique +CHEF DE PÔLE avis EMOG (cf CR). Introduction de seroplex +Dr [NOM] Supplémentation par une ampoule d'uvedose +DERMATOLOGIE +Dr [NOM] [NOM] Suivi : +Chef de Service Pas de cs diabéto +Dr [NOM] +Dr [NOM] HbA1C tous les 3 mois, objectif 7,5% +Secrétariat : Cs cardio à reprévoir +[TEL] CS cardio pour IVT à organiser avec le Dr [NOM] +ENDOCRINOLOGIE +Dr [NOM] [NOM] Conclusion : diabète type 2 compliqué sur le plan vasculaire, bien équilibré depuis l'introduction de GLP1 +Chef de Service Syndrome dépressif, introduction de seroplex après avis EMOG +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +Avis spécialisés : +MAL. INFECTIEUSES +Dr [NOM] [NOM] [NOM] [DATE] 17 : 49 DR. [NOM]: HDS/ETP/Atelier de groupe +Chef de Service A participé à une séance collective de l’atelier « Mieux Connaitre mes Médicaments » +Dr [NOM] [NOM] A partir de l’ordonnance de ce jour, les principaux points abordés : +Dr [NOM] +Dr [NOM] - Savoir distinguer les médicaments du diabète des médicaments des autres pathologies +Dr [NOM] - Mieux connaitre les indications de chaque médicament +Secrétariat : - Principaux effets indésirables survenus ou à « prévenir » : Metformine notamment +[TEL] +- Horaires de prise : notamments quels médicaments ne pas prendre si repas sauté +NEPHROLOGIE - Pilulier : principe & modalités d’utilisation pratique d’un pilulier semainier +Dr [NOM] [NOM] - Automédication responsable : Attention aux AINS en vente sans ordonnances +Chef de Service +Dr [NOM] - Informer les différents professionnels de santé de toutes les prises de médicaments ou de phytothérapie (Tisanes, Huiles +Dr [NOM] essentielles…) Jus de pamplemousse, Millepertuis & Interactions médicamenteuses +Dr [NOM] - S’assurer d’avoir l’ensemble des ordonnances et qu’elles soient à jour +Dr [NOM] +Secrétariat : - Ne pas hésiter à solliciter les pharmaciens pour info sur médicaments surtout lors du switch vers les génériques +[TEL] +RHUMATOLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] [NOM] Votre patient(e) quitte le service avec : +Dr [NOM] +Secrétariat : - Pharmacie : +[TEL] PRAVASTATINE MYL 40MG CPR [28] COMPRIME(S) 1 COMPRIME (ORALE) soir [19h] +MÉDECINE INTERNE GLICLAZIDE ARW LM 30MG CPR [30] COMPRIME(S) 2 COMPRIME (ORALE) matin [8h] +Dr [NOM] METFORMINE MYP 1000MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 19h) +Chef de Service NEBIVOLOL ARW 5MG CPR [90] COMPRIME(S) 1 COMPRIME (ORALE) matin [8h] +Dr [NOM] +Dr [NOM] PERINDOPRIL ARW 4MG CPR [30] COMPRIME(S) 2 COMPRIME (ORALE) matin [8h] +Secrétariat : ELIQUIS 5MG CPR [60] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 19h) +[TEL] AMLODIPINE ARG 5MG GELULE [30] Gelule(s) 1 GELULE (ORALE) matin [8h] +TRULICITY 1,5 MG SOL INJ STYLO [4] Stylo(s) Prerempli(s) 1.5 MG (SOUS-CUTANEE) en direct 1xsemaine [8h] +Les consignes d'usage ont été remises. +Bien confraternellement, +Docteur [NOM] +*10004401716* +10004401716 +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE] +IPP : [IPP] / [EPISODE] (Pôle Méd. interne : H semaine) +V1 - Imprimé le [DATE] à 14 : 34 par Page(s): 2 sur 3 N° Finess [MASK] +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +[TEL] +Pôle Médecine Interne +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Liste des destinataires : +CHEF DE PÔLE +Dr [NOM] Monsieur [NOM] +DERMATOLOGIE DR. [NOM] +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +ENDOCRINOLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MAL. INFECTIEUSES +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +NEPHROLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +RHUMATOLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MÉDECINE INTERNE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE] +IPP : [IPP] / [EPISODE] (Pôle Méd. interne : H semaine) +V1 - Imprimé le [DATE] à 14 : 34 par Page(s): 3 sur 3 N° Finess [MASK] +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +[TEL] +Pôle Médecine Interne +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Bayonne, le [DATE] +CHEF DE PÔLE +Dr [NOM] +DR [NOM] +DERMATOLOGIE [ADRESSE] +Dr [NOM] [CODE_POSTAL] +Chef de Service +Dr [NOM] +Dr [NOM] +Secrétariat : Mon cher confrère, +[TEL] +ENDOCRINOLOGIE Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du [DATE] au [DATE] pour le motif +Dr [NOM] [NOM] suivant : +Chef de Service +Dr [NOM] +Dr [NOM] [NOM] - Motif entrée : +Dr [NOM] +Dr [NOM] +Secrétariat : Première éducation dans le cadre d'un diabète de type 2 +[TEL] Introduction de GLP1 en en neurologie lors de son AVC en [DATE] (HbA1c 7,9%) +MAL. INFECTIEUSES +Dr [NOM] Antécédents +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] SAOS appareillé +Dr [NOM] diabete +Secrétariat : +[TEL] HTA +AVC fin [DATE] +NEPHROLOGIE +Dr [NOM] +Chef de Service Suivi retentissement : +Dr [NOM] [NOM] Ophtalmo Dr [NOM], dernière cs [DATE] : rétinopathie minime et maculopathie. IVT OD prévue +Dr [NOM] [NOM] cardio : dernière évaluation Dr [NOM] en [DATE] +Dr [NOM] +Dr [NOM] +Secrétariat : Traitements habituels +[TEL] Nebivolol 5 mg 1-0-0 +RHUMATOLOGIE Pravastatine 40 mg 1 le soir +Dr [NOM] [NOM] [NOM] Eliquis 5 : 1 cp matin et soir +Chef de Service Perindopril 10mg 1-0-0 +Dr [NOM] +Dr [NOM] Amlodipine 5 le matin +Secrétariat : Velmetia 50/1000mg 1-0-1 (alors que je l'avais arrêté en neurologie et j'avais prescrit metformine seule) +[TEL] Gliclazide 30mg 2-0-0 +MÉDECINE INTERNE Trulicity 1,5 les mardis +Dr [NOM] +Chef de Service Vaccination ne sait pas pour covid et tétanos, n'a jamais été vacciné contre la grippe +Dr [NOM] +Dr [NOM] +Secrétariat : Mode de vie : +[TEL] Vit avec son épouse +n'a jamais fumé +EC : +Ralentisement idéomoteur +Poids 98,9 IMC 33,4 kg/m² +Onychomycose, pallesthésie OK, pouls OK pieds grade 0 +Biologie : +HbA1C 7,1% +TSH 0,72 +LDL 0,55 Tg 0,92 HDL 0,31 g/l +iono NFS bilan hépatique sans anomalies +Créatinémie 65 µmol/l +RAC 2,6 mg/mmol +Albuminémie 39,4 g/L +Carence modérée en vitamine D +Pas de carence en vitamine B12 et folates +PRISE EN CHARGE DANS LE SERVICE : +Pas de modification du traitement antidiabétique +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE] +IPP : [IPP] / [EPISODE] (Pôle Méd. interne : H semaine) +V1 - Imprimé le [DATE] à 14 : 34 par Page(s): 1 sur 3 N° Finess [MASK] +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +[TEL] +Pôle Médecine Interne +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +avis EMOG (cf CR). Introduction de seroplex +CHEF DE PÔLE Supplémentation par une ampoule d'uvedose +Dr [NOM] +DERMATOLOGIE Suivi : +Dr [NOM] Pas de cs diabéto +Chef de Service HbA1C tous les 3 mois, objectif 7,5% +Dr [NOM] +Dr [NOM] cardio à reprévoir +Secrétariat : CS cardio pour IVT à organiser avec le Dr [NOM] +[TEL] +ENDOCRINOLOGIE Conclusion : diabète type 2 compliqué sur le plan vasculaire, bien équilibré depuis l'introduction de GLP1 +Dr [NOM] Syndrome dépressif, introduction de seroplex après avis EMOG +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] Avis spécialisés : +[DATE] 17 : 49 DR. [NOM]: HDS/ETP/Atelier de groupe +MAL. INFECTIEUSES +Dr [NOM] A participé à une séance collective de l’atelier « Mieux Connaitre mes Médicaments » +Chef de Service A partir de l’ordonnance de ce jour, les principaux points abordés : +Dr [NOM] - Savoir distinguer les médicaments du diabète des médicaments des autres pathologies +Dr [NOM] +Dr [NOM] - Mieux connaitre les indications de chaque médicament +Dr [NOM] [NOM] - Principaux effets indésirables survenus ou à « prévenir » : Metformine notamment +Secrétariat : - Horaires de prise :notamments quels médicaments ne pas prendre si repas sauté +[TEL] +- Pilulier : principe & modalités d’utilisation pratique d’un pilulier semainier +NEPHROLOGIE - Automédication responsable : Attention aux AINS en vente sans ordonnances +Dr [NOM] - Informer les différents professionnels de santé de toutes les prises de médicaments ou de phytothérapie (Tisanes, Huiles +Chef de Service +Dr [NOM] essentielles…) Jus de pamplemousse, Millepertuis & Interactions médicamenteuses +Dr [NOM] - S’assurer d’avoir l’ensemble des ordonnances et qu’elles soient à jour +Dr [NOM] - Ne pas hésiter à solliciter les pharmaciens pour info sur médicaments surtout lors du switch vers les génériques +Dr [NOM] +Secrétariat : +[TEL] +RHUMATOLOGIE +Dr [NOM] +Chef de Service Votre patient(e) quitte le service avec : +Dr [NOM] +Dr [NOM] [NOM] - Pharmacie : +Secrétariat : PRAVASTATINE MYL 40MG CPR [28] COMPRIME(S) 1 COMPRIME (ORALE) soir [19h] +[TEL] GLICLAZIDE ARW LM 30MG CPR [30] COMPRIME(S) 2 COMPRIME (ORALE) matin [8h] +MÉDECINE INTERNE METFORMINE MYP 1000MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 19h) +Dr [NOM] NEBIVOLOL ARW 5MG CPR [90] COMPRIME(S) 1 COMPRIME (ORALE) matin [8h] +Chef de Service PERINDOPRIL ARW 4MG CPR [30] COMPRIME(S) 2 COMPRIME (ORALE) matin [8h] +Dr [NOM] +Dr [NOM] ELIQUIS 5MG CPR [60] COMPRIME(S) 1 COMPRIME (ORALE) matin soir (8h - 19h) +Secrétariat : AMLODIPINE ARG 5MG GELULE [30] Gelule(s) 1 GELULE (ORALE) matin [8h] +[TEL] TRULICITY 1,5 MG SOL INJ STYLO [4] Stylo(s) Prerempli(s) 1.5 MG (SOUS-CUTANEE) en direct 1xsemaine [8h] +Les consignes d'usage ont été remises. +Bien confraternellement, +Docteur [NOM] +*10004401716* +10004401716 +Liste des destinataires : +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE] +IPP : [IPP] / [EPISODE] (Pôle Méd. interne : H semaine) +V1 - Imprimé le [DATE] à 14 : 34 par Page(s): 2 sur 3 N° Finess [MASK] +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +[TEL] +Pôle Médecine Interne +Services de Dermatologie - Endocrinologie - Maladies Infectieuses +- Néphrologie - Rhumatologie - Médecine Polyvalente +Monsieur [NOM] +CHEF DE PÔLE +Dr [NOM] DR. [NOM] +DERMATOLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +ENDOCRINOLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MAL. INFECTIEUSES +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +NEPHROLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +RHUMATOLOGIE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +MÉDECINE INTERNE +Dr [NOM] +Chef de Service +Dr [NOM] +Dr [NOM] +Secrétariat : +[TEL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE] +IPP : [IPP] / [EPISODE] (Pôle Méd. interne : H semaine) +V1 - Imprimé le [DATE] à 14 : 34 par Page(s): 3 sur 3 \ No newline at end of file diff --git a/test_3ogc/anonymise_old/407 crh.redacted_raster.pdf b/test_3ogc/anonymise_old/407 crh.redacted_raster.pdf new file mode 100644 index 0000000..e782113 Binary files /dev/null and b/test_3ogc/anonymise_old/407 crh.redacted_raster.pdf differ diff --git a/test_3ogc/anonymise_old/qc_rapport.csv b/test_3ogc/anonymise_old/qc_rapport.csv new file mode 100644 index 0000000..a8d2c4d --- /dev/null +++ b/test_3ogc/anonymise_old/qc_rapport.csv @@ -0,0 +1,5 @@ +fichier,total_hits,residual_pii,density_pct,nom_density_pct,alert_overmasking,fp_count,fn_count +407 crh.audit.jsonl,407,0,14.93,9.32,True,0,4 +trackare-01285757-23042510_01285757_23042510.audit.jsonl,1316,0,7.57,4.03,False,0,10 +trackare-02004744-23116460_02004744_23116460.audit.jsonl,876,0,8.57,4.35,False,0,4 +trackare-BA165196-23061393_BA165196_23061393.audit.jsonl,2018,0,8.18,4.81,False,0,25 diff --git a/test_3ogc/anonymise_old/trackare-01285757-23042510_01285757_23042510.audit.jsonl b/test_3ogc/anonymise_old/trackare-01285757-23042510_01285757_23042510.audit.jsonl new file mode 100644 index 0000000..99a9a8b --- /dev/null +++ b/test_3ogc/anonymise_old/trackare-01285757-23042510_01285757_23042510.audit.jsonl @@ -0,0 +1,1316 @@ +{"page": -1, "kind": "VILLE", "original": "CASABLANCA", "placeholder": "[VILLE]", "bbox_hint": null} +{"page": -1, "kind": "VILLE", "original": "CASABLANCA", "placeholder": "[VILLE]", "bbox_hint": 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null} +{"page": -1, "kind": "TEL_GLOBAL", "original": "001122586", "placeholder": "[TEL]", "bbox_hint": null} +{"page": -1, "kind": "ETAB_GLOBAL", "original": "SSR Grancher", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null} +{"page": -1, "kind": "ETAB_GLOBAL", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null} +{"page": -1, "kind": "ETAB_GLOBAL", "original": "SSR de Grancher", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null} diff --git a/test_3ogc/anonymise_old/trackare-01285757-23042510_01285757_23042510.pseudonymise.txt b/test_3ogc/anonymise_old/trackare-01285757-23042510_01285757_23042510.pseudonymise.txt new file mode 100644 index 0000000..bd9882f --- /dev/null +++ b/test_3ogc/anonymise_old/trackare-01285757-23042510_01285757_23042510.pseudonymise.txt @@ -0,0 +1,2859 @@ +[MASK] +*640N0° F0in0ess162* +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +640000162 +ONCOLOGIE - [VILLE] +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] +[NOM] [NOM] +Détails épisode +Episode No : [NDA] +Localisation : [VILLE] Médecin courant: DR. [NOM] +Date d'admission : [DATE] Heure d'admission: 14:51 +Date de sortie : Heure de sortie: +Médecin traitant +Nom Adresse Téléphone +DR. [NOM] [ADRESSE][CODE_POSTAL] D [NOM] [TEL] +Liste des contacts +Tél. +Type de contact Relation Nom Prénom Adresse Tél. domicile Mobile +professionel +Personne à prévenir +Epouse FRANCE [TEL] +(Trakcare) +Personne à prévenir +Fils [NOM] [NOM] [TEL] +(Trakcare) +Antécédents et habitudes de vie (texte libre) +Type de note Nom Date Heure Note +Aucune donnée +renseignée +Signes Vitaux +Item de [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance 08 : 41 23:24 21:56 18:00 08:43 08:14 23:22 16:09 13:10 09:15 09:00 06:08 04:33 +Température 37,30 37,00 37,40 37,20 37,30 37,50 37,20 37,90 +Pouls 83,00 80,00 82,00 82,00 78,00 +PA +136,00 138,00 144,00 149,00 116,00 +Systolique +PA +71,00 73,00 88,00 72,00 56,00 +Diastolique +PA +93,00 95,00 107,00 98,00 76,00 +Moyenne +Saturation +97,00 95,00 95,00 94,00 95,00 +O² +Ventilation Ventilation Ventilation Ventilation Ventilation +spontanée spontanée spontanée spontanée spontanée +Ventilation +Air Air Air Air Air +ambiant ambiant ambiant ambiant ambiant +Echelle +EN EN EN EN EN +douleur +Score au +0,00 0,00 0,00 0,00 0,00 +repos +Glycémie +1,12 1,23 0,84 1,42 +capillaire +Volume +de miction 400,00 0,00 326,00 +[ml] +Transit Absence Peu Absence +Diurèse +Item de [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance 07 : 44 07:55 15:00 07:31 07:56 23:00 15:33 07:59 +Diurèse 1000,00 800,00 300,00 900,00 250,00 400,00 400,00 250,00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [NDA] ( ONCOLOGIE - [VILLE] ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 1 de 20 Diurèse +- Cumul 1000,00 1100,00 300,00 900,00 1050,00 800,00 400,00 250,00 +8h/8h +Pyélo/ +Néphro +drte - 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Cumul +8h/8h +Pyélo/ +Néphro +gche - 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Cumul +8h/8h +Diurèse +1000,00 800,00 300,00 900,00 250,00 400,00 400,00 250,00 +Totale +Diurèse +- Cumul 1000,00 1100,00 300,00 900,00 1050,00 800,00 400,00 250,00 +8h/8h Total +Compens +° Diurèse +0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +- Cumul +8h/8h +Balance des entrées - Sorties +Item de [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance 07 : 44 07:55 15:00 07:31 07:56 23:00 15:33 07:59 +Balance +hydrique +totale -4300,00 -3300,00 -2500,00 -2200,00 -1300,00 -1050,00 -650,00 -250,00 +(cumulée) +[ml] +Balance +hydrique +-1000,00 -800,00 -300,00 -900,00 -250,00 -400,00 -400,00 -250,00 +totale +(session) +Entrées +totales des +0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +liquides +(cumulé) +Entrées +totales des +liquides 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +(session) +[ml] +Total Pertes +Liquidiennes 4300,00 3300,00 2500,00 2200,00 1300,00 1050,00 650,00 250,00 +(Relevé) +Total Pertes +liquidiennes 1000,00 800,00 300,00 900,00 250,00 400,00 400,00 250,00 +(session) +Poids/Taille +Item de [DATE] [DATE] [DATE] [DATE] +surveillance 08 : 44 10:39 11:09 16:12 +Poids [kg] 76,00 76,00 76,70 73,00 +Taille [cm] 168,00 168,00 168,00 +Indice +de masse 26.927 26.927 25.865 +corporelle +Surface +1.86 1.86 1.83 +corporelle +Surv. Isolement et Contention +Item de [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance 08 : 41 23:24 08:43 23:22 16:09 13:10 09:15 06:08 04:33 15:48 08:29 22:25 15:37 +Température 37,30 37,00 37,40 37,20 37,30 37,50 37,20 37,90 37,40 37,50 37,30 37,00 +Pouls 83,00 80,00 82,00 82,00 78,00 77,00 72,00 86,00 93,00 +PA +136,00 138,00 144,00 149,00 116,00 166,00 162,00 142,00 116,00 +Systolique +PA +71,00 73,00 88,00 72,00 56,00 83,00 80,00 76,00 60,00 +Diastolique +Saturation +97,00 95,00 95,00 94,00 95,00 96,00 98,00 95,00 +O² +Transit Absence Peu Absence Absence Absence +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 2 de 20 Surv. Contention +Item de [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance 08 : 41 23:24 18:00 08:43 08:14 23:22 16:09 13:10 09:15 09:00 06:08 04:33 15:48 +Température 37,30 37,00 37,40 37,20 37,30 37,50 37,20 37,90 37,40 +Pouls 83,00 80,00 82,00 82,00 78,00 77,00 +PA +136,00 138,00 144,00 149,00 116,00 166,00 +Systolique +PA +71,00 73,00 88,00 72,00 56,00 83,00 +Diastolique +Saturation +97,00 95,00 95,00 94,00 95,00 96,00 +O² +Glycémie +1,12 1,23 0,84 1,42 +capillaire +Transit Absence Peu Absence +Observations médicales +Type d'observation Nom Date Commentaires +Sur le plan symptomatique/oncologique : +Poursuite d'une bonne évolution clinique. +Reprise alimentation normale et arrêt de l'hydratation. +Scintigraphie osseuse ce jour en Baseline avant initiation TAXOTERE. +Pose de PAC en ambulatoire le [DATE] et programmation des HDJ pour TAXOTERE toutes les 3 +semaines à partir du [DATE]. +[DATE] +Note d'évolution [NOM] [NOM] +12 : 18 +Sur le plan du devenir : +Transfert au [ETABLISSEMENT] demain en fin de matinée. +Sa fille présente en chambre a été informée de l'ensemble de la prise en charge, de la prise +en charge au [ETABLISSEMENT] demain, de la pose de PAC le [DATE] et de l'initiation de la +chimiothérapie semaine prochaine le [DATE]. +Sur le plan symptomatique : +Stabilité clinique, transit ce jour, pas de nausées ni de vomissements. +Poids en diminution -0.7kg (soit +3kg sur l'hyperhydratation depuis le début d'hospitalisation), +sans signe de surcharge pulmonaire. +> Relai traitements per os devant la bonne évolution clinique et biologique avec nette +amélioration de la fonction rénale. +[DATE] > Poursuite élargissement progressif de l'alimentation sur la bonne tolérance digestive. +Note d'évolution [NOM] [NOM] +14 : 49 > Prescription kinésithérapie de mobilisation. +Sur le plan spécifique : +En attente date pour une scintigraphie osseuse. Pose de PAC maintenue au [DATE]. +Sur le plan du devenir : +Patient favorable à une prise en charge en [ETABLISSEMENT] à [ETABLISSEMENT], demande faite. +Sur le plan symptomatique : +Va bien mieux, pas de nausées ni de vomissements. Transit régulier, pas de douleurs +abdominales, abdomen souple, dépressible et indolore. ++3.5kg sans signe de surcharge clinique notamment pulmonaire. +> Elargissement alimentation ce jour, poursuite traitement laxatifs et surveillance transit ++. +> Ajout traitement par XATRAL pour retrait de la sonde urinaire dans 48/72h. +> Diminution hydratation par PG5 à 1L/jour. +Sur le plan oncologique : +Dernière séance de radiothérapie le [DATE]. +[DATE] +Note d'évolution [NOM] [NOM] Scintigraphie osseuse demandée pour cette semaine, sera probablement réalisée le [DATE]. +15 : 36 +Pose de PAC prévue le [DATE] après midi à 16h pour initiation de la nouvelle ligne de +chimiothérapie par TAXOTERE fin de semaine ou début de semaine prochaine. +> Prévoir suspension anticoagulation curative le [DATE]. +Sur le plan du devenir : +Discussion avec le patient et son fils ce jour de l'intérêt d'une prise en charge en [ETABLISSEMENT] dans +les suites immédiates de l'hospitalisation à visée de remobilisation et de réautonomisation +qu'ils semblent comprendre et accepter. Explication donnée quant à la visée suspensive de la +chimiothérapie dont l'objectif n'est pas curatif mais à visée de contrôle le plus longtemps possible +de la maladie. +Selles cette nuit en grande quantité avec confusion +nouvelles selles le [DATE] au matin +N'est plus confus, non algique +DR. [NOM] [DATE]/2023 +Note d'évolution Essai Fauteuil dans la journée +[NOM] 12 : 07 +BCY ce jour +reprise radiothérapie lundi +Est d'accord pour [ETABLISSEMENT] au décours du C1 de TAXOTERE +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 3 de 20 Effectivement tres altérée +vomissements fécaloïdes à l'arrivée avec SNG productive > 2 Ln pas de selles depuis 8 jours +abdomen souple, pas de fecalome +deshydraté +non douloureux au repos +TDM : Syndrome occlusif grêlique fonctionnel en amont d'une iléite (radique ?). Pas de zone +transitionnelle franche. Progression osseuse avec apparition de tassements pathologiques en T11 +T12 +DR. [NOM] [DATE] +Note d'évolution +[NOM] 12 : 39 +Poursuite CTC 1mg/kg , hydratation ++, ACTISKENAN ALD, laxatifs +++ +Retrait SNG et alimentation liquide auj avec BCY demain si OK +Discuter IRM rachis avant RCP neuro +Achever radiothérapie en début de semaine pour débuter TAXOTERE sans trop tarder selon +évolution [ETABLISSEMENT] : FA à réponse ventriculaire rapide à 160bpm. +[DATE] > Non connue, pas d'anticoagulation curative en place. +Note d'évolution [NOM] [NOM] +16 : 52 > Avis cardio (Dr [NOM]) : Mise en place d'une anticoagulation curative, pas de bloquant du +fait de la tension artérielle limite, à rediscuter selon évolution. +Motif d'hospitalisation : +Altération de l’état général chez un patient pris en charge pour un adénocarcinome prostatique +résistant à la castration en progression osseuse. +Antécédents : +- Familiaux : +3-4 cancers de prostate chez les frères, cancer digestif d’étiologie non connue chez la mère, +cancer du sein chez la sœur vers 50 ans. +- Médicaux : +Au plan personnel, HTA sous bithérapie. +Dyslipidémie. +Zona. +Amygdalectomie. +- Chirurgicaux : +* +- Allergies : +Pas d’allergie. +- Traitement en cours : +ENANTONE 30 / 1 sous cut par 6 mois. +DUROGESIC 25. +ACTISKENAN 10 à la demande. +GABAPENTINE 300mg matin et soir. +CORTANCYL 40 mg matin, 40 mg midi. +Histoire de la [DATE] COAPROVEL 300/12.5 : suspendu ? +[NOM] [NOM] +maladie 16 : 20 INNEGY 10/20 : suspendu ? +- Mode de vie : +Marié, 3 enfants de 55, 53, 50 ans, 6 petits-enfants. +Habite [NOM] [NOM] D’[NOM]. +Chef d’entreprise dans l’industrie du self-service. +Histoire de la maladie : +[DATE] : diagnostic de cancer de prostate localisé sur PSA augmenté, traité par prostatectomie +radicale : adénocarcinome moyennement différencié Gleason 6(3+3). +[DATE] : rechute de la loge de prostatectomie : radiothérapie de rattrapage. +[DATE] : progression métastatique osseuse : ENANTONE. +[DATE] : progression biologique et morphologique stade CRPC ENZALUTAMIDE. +[DATE] : progression biologique. Proposition d’une chimiothérapie par TAXOTERE déclinée. +[DATE] : inclusion dans un protocole avec antagoniste du récepteur de l’adénosine à l’Institut +[ETABLISSEMENT]. +[DATE] : progression symptomatique avec atteinte de T11 sur lésion lytique, PSA à 143 : +radiothérapie 30 Gy en 10 par Docteur [NOM], puis chimiothérapie par TAXOTERE 75, +proposée par Docteur [NOM], médecin référent jusque-là, qui propose une prise en +charge à proximité, à BAYONNE. +Histoire récente : +Radiothérapie à visée antalgique en regard de T11 initiée le [DATE] pour un total de 10 séances +interrompue à la 8ème séance (le [DATE]) pour dégradation clinique. +Altération majeure de l’état général depuis le début de la semaine avec asthénie, anorexie et +ralentissement psycho-moteur. A présenté un épisode de chute il y a 3 jours sans TC. +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 4 de 20 Tolérance moyenne de la morphine sous patch de DUROGESIC sans hallucination visuelle/ +auditive. J5 sans selles et dysurie avec 1 miction seulement par 24h sans autre SFU. +RGO sous corticothérapie forte dose et quelques nausées. +Pas de syndrome infectieux récent. +Deux dernières séances de radiothérapie prévues le [DATE] et le [DATE] sous réserve d’une bonne +amélioration clinique. +Examen clinique : +OMS3, asthénie majeure ++. Poids à 76kg. +Conscient et orienté, plutôt G14 (Y3V5M6), pupilles IRS. Pas de déficit moteur notamment des +membres inférieurs. +Bruits du cœur irréguliers, sans souffle perçu. Pas d’OMI. +Auscultation pulmonaire [NOM] et symétrique, pas de bruits surajoutés. FR 12/min, limite. +Pas de douleur au repos, ni reproduite à la palpation du rachis. +Bouche propre, pas de mucite. +TR : Pas de fécalome +Biologie à l'entrée : +Hémoglobine à 15.9g/dL, leucocytes à 2.6G/L dont 2.4 de PNN, plaquettes à 144G/L +Natrémie à 134mmol/L, pas d’autres troubles ioniques +Créatinine à 116umol/L avec urée à 20.3mmol/L +Pas de perturbation significative du bilan hépatique +CRP à 168mg/L +TP à 106%, ratio TCA 0.7 +Bladder négatif. +Au total : +-Altération majeure de l’état général multi factorielle : iatrogénique (mauvaise tolérance +morphinique) et absence de transit. +-Réadaptation des traitements symptomatiques avec poursuite de la corticothérapie, mise en place +d’une sonde urinaire avec hydratation, régularisation du transit et relai IV de ses traitements avec +retrait du DUROGESIC et ACTISKENAN ALD. +Examens complémentaires : +Scanner AP [DATE] : Syndrome occlusif grêlique fonctionnel en amont d'une iléite (radique ?). Pas +de zone transitionnelle franche. Progression osseuse avec apparition de tassements pathologiques +en T11 T12. A confronter au dosage des PSA. +Evolution dans le service : +Sur le plan digestif : +Apparition de vomissements faecaloïdes le [DATE] pour lesquels un scanner AP est réalisé mettant +en évidence un syndrome occlusif grêlique fonctionnel en amont d'une iléite (radique ?), sans +zone transitionnelle franche. +Mise en place d’une sonde naso gastrique productive à 2L retirée le jour même devant une +levée rapide d’occlusion avec la reprise d’un transit normal dès le [DATE]. Bonne évolution +clinique en parallèle avec récupération de son état général ayant permis une reprise d’une +alimentation normale et de ses traitements per os dès le [DATE]. La sonde urinaire mise en place +dans le contexte de syndrome confusionnel a été retirée le [DATE] sous couvert d’un traitement par +XATRAL. +Sur le plan antalgique : +Reprise de la radiothérapie à visée antalgique le [DATE] en regard de T11 avec une dernière +séance le [DATE]. Absence de recrudescence des douleurs après le retrait du DUROGESIC patch, +maintien d’un traitement par ACTISKENAN 10mg à la demande. +Sur le plan spécifique : +Réalisation d’une scintigraphie osseuse de baseline le [DATE] retrouvant ***. +Programmation d’une pose de PAC le [DATE] qui sera réalisée en chirurgie ambulatoire. +Initiation de la nouvelle ligne thérapeutique par TAXOTERE en hôpital de jour le [DATE]. +Sur le plan du devenir : +Nous convenons avec le patient d’une prise en charge dans un premier temps en [ETABLISSEMENT] dans les +suites immédiates de l’hospitalisation à visée de mobilisation et de ré autonomisation. +Le patient et sa famille ont été informés du projet thérapeutique et des prochains rendez-vous. +Traitements de sortie : +ENANTONE 30 / 1 sous cut par 6 mois.. +ACTISKENAN 10 à la demande. +GABAPENTINE 300mg matin et soir. +SOLUPRED 40 mg matin, 40 mg midi. +LANSOPRAZOLE 30mg : 1 le soir +PRIMPERAN si nausées +XATRAL 2.5mg : 1 matin, midi et soir jusqu’au [DATE]. +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 5 de 20 FORLAX : 2 sachets matin, midi et soir +LANSOYL : 1 le matin +ACTISKENAN 10mg à la demande +SIMVASTATINE 40mg le soir +EZETIMIBE 10mg le soir +INNOHEP 13000UI le soir : à suspendre le [DATE] et à reprendre le [DATE] (pour la pose de PAC) +COAPROVEL 300/12.5 : non reconduit pendant l’hospitalisation, à réévaluer selon évolution +tensionnelle. +Conclusion : +Altération de l’état général avec syndrome confusionnel multi factoriels sur iatrogénie en +lien avec un traitement morphinique et sur un syndrome occlusif grêlique fonctionnel sur une +iléite radique. Evolution rapidement favorable avec l’arrêt du DUROGESIC patch et la levée +d’occlusion sous corticothérapie avec une bonne récupération de l’état général. +Pose de PAC prévue pour le [DATE] en chirurgie ambulatoire pour initiation d'une nouvelle ligne +de traitement pat TAXOTERE prévue le [DATE] en hôpital de jour. L'anticoagulation curative sera +à suspendre le [DATE] et à reprendre le lendemain. +Prochains rendez-vous : +Pose de PAC le [DATE] +Hôpital de jour le [DATE] à 12h30 pour C1J1 de TAXOTERE. +Surveillance Psychiatrie +Item de [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance 16 : 09 22:52 09:23 15:32 22:59 02:14 08:55 15:37 22:25 08:29 15:48 04:33 06:08 +Température 36.6 36.5 36.1 36.9 36 36.5 37 37.3 37.5 37.4 37.9 37.2 +PA +91 120 110 130 124 141 116 142 162 166 +Systolique +PA +50 57 69 77 80 68 60 76 80 83 +Diastolique +Saturation +93 94 92 94 99 95 95 98 96 +O² +Transit Constipation Absence Absence Molles Diarrhées Absence Absence +Pouls [NIR] +Notes paramédicales +Type de note Nom Date Note +[DATE]/2023 Transit : +Note IDE [NOM] [NOM] +02 : 25 Selles sur la nuit. +Elimination : +> Bladder fait à 17 heures car n'a pas uriné de l'après-midi = > 326 cc +> Recontrolé à 18h = > 0 cc +[NOM] [DATE_NAISSANCE] +Note IDE +[NOM] 21 : 26 Devenir : +> Transfert à [ETABLISSEMENT] demain, transport ok et fiche de liaison faite +PEC nutritionnelle : +Retrait SNG (en aspi) le [DATE]. +Reprise alimentaire le [DATE] = bonne tolérance. +[NOM] [DATE_NAISSANCE] Elargissement menus avec passage en PO2 le [DATE] = bonne tolérance. +Note Diététicienne +[NOM] 15 : 16 Pas de nausées, ni vomissements. +Appétit présent, conservé. +Transit régulier (cf. trans) +--> Menus NOR dès demain. +Elimination : ablation de la sonde vésicale ce matin vers 10h > surveillance reprise miction + +diurèse. +A eu 1 miction par la suite (non constaté car a fait dans les WC). +Alimentation : reprise alimentation en régime normal a partir de ce soir. +[DATE_NAISSANCE] +Note IDE [NOM] [NOM] +12 : 56 +Transit : a eu des selles normales en grande quantité ce matin. +Examen : scintigraphie os faite ce matin > à voir. +Devenir : Transfert a [ETABLISSEMENT] demain a 11h15 > ambu ok. +[NOM] [DATE] Infectieux +Note IDE +[NOM] 23 : 29 => apyrétique +Examen : +> Scintigraphie osseuse demain à 10h50 +[NOM] [DATE] > Pose de PAC le [DATE] en chirurgie ambu +Note IDE +[NOM] 21 : 41 +Devenir : +> [ETABLISSEMENT] le [DATE] +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE]/2023 09 : 53 Page 6 de 20 SORTIE [NOM] [DATE] à 14h la bas , ambulance commandée +[DATE] +Note IDE [NOM] [NOM] +16 : 10 CHIRURGIE POSE PAC [DATE] à 16h en [ETABLISSEMENT] , [NOM] +prevenu sera contacté par secretariat +[DATE] +Note IDE [NOM] [NOM] SCINTIGRAPHIE OS : le [DATE] à 10h +14 : 54 +Alimentation : régime élargi a PO2 à partir de ce jour car a eu des selles le [DATE] + ce jour +également en petite quantité constaté. Transit à surveiller. +Radiothérapie : a eu séance ce jour a 12h, pas d'autres séances prévues. +[DATE] +Note IDE [NOM] [NOM] +13 : 32 Examen : scintigraphie os demandée > en attente de date, pas de place ce jour. +Devenir : [ETABLISSEMENT] demandé. +Infectieux +[NOM] [DATE] +Note IDE => fébricule à 37.9°C à 4h30 +[NOM] 04 : 25 +=> redescendu spontanément à 37.2°C à 6h +Digestif : +> Pas de selles cet AM +[NOM] [DATE_NAISSANCE] +Note IDE +[NOM] 21 : 57 +Douleur : +> Pas de plaintes algiques +Douleur : +=> pas de plainte algique +Digestif : +=> pas de nausées ni de vomissement +=> alimentation BCY ajd +Risque de surcharge : +=> +3.7kg en quelques jour --> diminution hydrat +[DATE_NAISSANCE] +Note IDE [NOM] [NOM] +14 : 44 +Radiothérapie : +=> radiothérapie ce matin à 11h30 +=> RdxTTT demain matin à 12h --> transport ok +Examen : +=> scinti os ddé +Voie d'abord : +=> pose de PAC le [DATE] +Neuro : +Patient calme, orienté et coopérant. +Se rend compte, de ses dires, qu'il a "fait des bêtises" la nuit dernière. +[DATE]/2023 +Note IDE [NOM] [NOM] Douleur : +23 : 40 +Pas de plainte algique. +Transit : +Pas de selles. +Douleur : +Pas de plainte algique sur l'après midi +Transit : +[DATE]/2023 Absence de selles cet après midi +Note IDE [NOM] [NOM] +20 : 03 +Comportement : +Patient cohérent et orienté sur l'après midi +nous raconte l'épisode de cette nuit : dit "avoir vu des monstres qui lui courraient après, a voulu +s'échapper ce qui explique qu'il a couper la sonde et la VVP".. hallucinations? a surveiller +Douleur : +=> pas de plainte algique +Neuro/comportement : +=> patient calme et coopérant ce matin +[DATE]/2023 +Note IDE [NOM] [NOM] +13 : 53 Transit : +=> selles ce matin +Mobilisation : +=> levé au fauteuil ce matin, matelas à air mis en place +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 7 de 20 Infectieux : +=> apyrétique +=> PCR covid prélevé +Alimentation : +=> BCY débuté ce matin comme convenu --> apprécié par le patient +Radiothérapie : +=> à son prochain RDV demain à 11h30 et mardi à 12h --> transport ddé +Comportement : +A 1h30, patient retrouvé avec du sang et des selles +++ dans la chambre (lit, adaptable, salle de +bain, sol...). Poche de recueil d'urines retrouvée par terre dans la SDB, rampe et pied à perf par +terre. +Le patient tient un petit ciseau dans les mains, qui lui a sans doute permis de sectionner la +tubulure de la SV et de la VVP. +[DATE] +Note IDE [NOM] [NOM] Dit avoir eu un moment de panique où il ne savait plus où il se trouvait. +00 : 16 +Patient très virulent dans ses propos, agressif. +Lors de mon arrivée dans la chambre, patient orienté dans l'espace et dans le temps. +Calme le reste de la nuit. +Douleur : +Pas de plainte algique +Digestif : +Pas de nausées ni de vomissement sur l'après midi +[DATE] +Note IDE [NOM] [NOM] +19 : 18 +Transit : +Absence de selles cet après midi, laxatif per os administrés +Etat général : +Patient toujours asthénique, a dormi toute l'après midi +Douleur : +=> pas de plainte algique +Digestif : +=> SNG en place et fonctionnelle --> 500cc de résidus ce matin soit 2500cc depuis la pose de la +SNG (moins de 24h) +=> patient gêné +++ par al SNG, demande à boire --> signalé au médecin --> ok pour un jus ce +matin +=> suite scan abdo en urgence --> CAT de retirer la SNG et ok pour liquide ajd puis passage en +BCY demain +Examen : +[DATE] +Note IDE [NOM] [NOM] => scan abdo en urgence ce matin --> "Syndrome occlusif grêlique fonctionnel en amont d'une +14 : 10 +iléite (radique ?). Pas de zone transitionnelle franche. Progression osseuse avec apparition de +tassements pathologiques en T11 T12" +Elimination : +=> SV en place et fonctionnelle +Etat général : +=> patient asthénique en fin de matinée, dort en rentrant du scan +TTT : +=> ajout hydrat ce matin car déshydratation +Elimination : +SV en place et fonctionnelle. +Digestif : +SNG fonctionnelle, en aspi, poche changée à 23h, liquide fécaloïde. +500 CC dans la poche à 6h30. +Thymie/comportement : +[DATE] +Note IDE [NOM] [NOM] Patient très agacé d'avoir la SNG, dit qu'elle le dérange, se l'est retiré jusqu'au repère 35.. +[DATE] +Demande à plusieurs reprises à ce qu'on lui serve un café au lait avec ton autoritaire, explications +sur l'impossibilité de lui en servir un, patient en colère. +SNG remise jusqu'au repère 55, fonctionnelle. +Douleur : +Pas de plainte algique. +Entourage : +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 8 de 20 Fille présente en chambre cette nuit. +Motif d'hospitalisation : +Patient entré ce jour pour AEG dans un contexte d'ADK de prostate suivi a [ETABLISSEMENT] +Voie d'abord : +VVP posée (capital veineux précaire) +Alimentation : +Patient qui mange très peu au domicile depuis plusieurs jours --> diet ddé +Elimination : +Dysurie importante, déshydratation? --> bladder 62cc +SV ch 16 posée sur consignes médicales + ECBU réalisé +Digestif : +Patient qui dit ne pas avoir eu de selles depuis au moins 5 jours --> lavement réalisé cet après +midi non efficace +--> dlr abdo + Vomissement fécaloïde à 20h --> SNG posée repère 65 en aspi --> 600cc fécaloïde +[DATE] +Note IDE [NOM] [NOM] évacué d'emblé +20 : 49 +Cardio : +ECG réalisé cet après midi --> FA --> avis cardio introduction d'ATC +Etat général : +Patient asthénique ++, ne se mobilise plus depuis 3 jours --> matelas air ddé +Douleur : +Douleurs abdo ce soir, soulagées par la pose de la SNG +porteur d'un patch d'ATG3 retiré à 16h selon consignes médicales +Suivi onco : +2 dernières séances de radiothérapie prévues le 27 et [DATE] (horaire à récupérer auprès des +enfants) +Risque infectieux : +PCR refusé par le patient ce soir.. à faire demain matin svp +Traitements médicamenteux +Date de dernière +Prescription Dose Fréquence Date de début Note Docteur +administration +Voie d`administration : INTRAVEINEUSE +Statut des prescriptions : Arrêté +Le débit a été +EUPANTOL 40MG PDR INJ modifié. Le débit +40 mg - Soir [19h] Normal [DATE] 16 : 02 [DATE] 19:28 [NOM] [NOM] +[1] Flacon(s) en cours est : 60 +par . +Le débit a été +METHYLPREDNISOLONE +modifié. Le débit +MYL 40MG PDR INJ [10] 40 mg - Matin midi Normal [DATE] 06 : 00 [DATE]/2023 08:41 [NOM] [NOM] +en cours est : 3 +Flacon(s) +par . +METOCLOPRAMIDE CHL +REN 10MG/2ML INJ [100] 1 AMP - Normal [DATE] 16 : 02 [NOM] [NOM] +Ampoule(s) +Le débit a été +POLYIONIQUE 1A G5 modifié. Le débit +BAX POC VFO 500ML [1] - Normal [DATE] 16 : 09 [DATE] 08:45 en cours est : [NOM] [NOM] +POCHE(S) 41.666666666666664 +ML par 1 hrs. +Le débit a été +SODIUM CHL [NOM] modifié. Le débit +DR. [NOM] +0,9% INJ PP 500ML [1] - Normal [DATE] 12 : 31 [DATE] 00:28 en cours est : +[NOM] +POCHE(S) 41.666666666666664 +ML par 1 hrs. +Statut des prescriptions : Réalisé +Le débit a été +METHYLPREDNISOLONE +- 1 seule fois 1 seule modifié. Le débit +MYL 120MG PDR INJ [10] 80 mg [DATE] 16 : 02 [DATE] 16:49 [NOM] [NOM] +fois en cours est : 2 +Flacon(s) +par . +Voie d`administration : ORALE +Statut des prescriptions : Signé +ACTISKENAN 10MG +1 GEL - Normal [DATE] 16 : 02 [NOM] [NOM] +GELULE [14] Gelule(s) +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 9 de 20 ACTISKENAN 10MG +1 GEL - Presc. de Sortie [DATE] 14 : 00 [NOM] [NOM] +GELULE [14] Gelule(s) +EZETIMIBE MYL 10MG +1 CPR - Soir [19h] Normal [DATE] 16 : 09 [DATE] 19:31 [NOM] [NOM] +CPR [90] CPR(s) +EZETIMIBE MYL 10MG - Soir [19h] Presc. de +1 CPR [DATE] 14 : 00 [NOM] [NOM] +CPR [90] CPR(s) Sortie +FORLAX 10G PDR [NOM] - Matin midi soir +2 SACHET [DATE] 16 : 02 [DATE] 08:11 [NOM] [NOM] +SACHET [20] Sachet(s) Normal +FORLAX 10G PDR [NOM] - Matin midi soir +2 SACHET [DATE] 14 : 00 [NOM] [NOM] +SACHET [20] Sachet(s) Presc. de Sortie +GABAPENTINE ARW +- Matin soir (8h - +300MG GELULE [90] 1 GEL [DATE] 14 : 00 [NOM] [NOM] +19h) Presc. de Sortie +Gelule(s) +LANSOPRAZOLE BGA 30 - Prise unique à 19h +1 CPR [DATE] 11 : 19 [DATE] 19:31 [NOM] [NOM] +MG CPR OROD [14] CPR(s) Normal +LANSOPRAZOLE BGA 30 - Prise unique à 19h +1 CPR [DATE] 14 : 00 [NOM] [NOM] +MG CPR OROD [14] CPR(s) Presc. de Sortie +LANSOYL FRAMBOISE +GEL ORAL UNIDOSE 1 REC. DR. [NOM] +- Matin [8h] Normal [DATE] 12 : 47 [DATE] 08:11 +[9] RECIPIENT(S) UNIDOSE [NOM] +UNIDOSE(S) +LANSOYL FRAMBOISE +GEL ORAL UNIDOSE 1 REC. - Matin [8h] Presc. de +[DATE] 14 : 00 [NOM] [NOM] +[9] RECIPIENT(S) UNIDOSE Sortie +UNIDOSE(S) +PRIMPERAN 10MG CPR +1 CPR - Normal [DATE] 11 : 19 [NOM] [NOM] +[40] COMPRIME(S) +PRIMPERAN 10MG CPR +1 CPR - Presc. de Sortie [DATE] 14 : 00 [NOM] [NOM] +[40] COMPRIME(S) +SIMVASTATINE +AHL 20MG CPR [28] 2 CPR - Soir [19h] Normal [DATE] 16 : 09 [DATE] 19:31 [NOM] [NOM] +COMPRIME(S) +SIMVASTATINE +- Soir [19h] Presc. de +AHL 20MG CPR [28] 2 CPR [DATE] 14 : 00 [NOM] [NOM] +Sortie +COMPRIME(S) +SOLUPRED 20MG +CPR ORODISP [20] 2 CPR - Matin midi Normal [DATE] 11 : 19 [DATE] 08:11 [NOM] [NOM] +COMPRIME(S) +SOLUPRED 20MG +- Matin midi Presc. +CPR ORODISP [20] 2 CPR [DATE] 14 : 00 [NOM] [NOM] +de Sortie +COMPRIME(S) +XATRAL 2,5MG CPR [30] - Matin midi soir +1 CPR [DATE] 11 : 18 [DATE] 08:11 [NOM] [NOM] +COMPRIME(S) Normal +XATRAL 2,5MG CPR [30] - Matin midi soir +1 CPR [DATE] 14 : 17 [NOM] [NOM] +COMPRIME(S) Presc. de Sortie +Statut des prescriptions : En cours +GABAPENTINE ARW +- Matin soir (8h - +300MG GELULE [90] 1 GEL [DATE] 16 : 02 [DATE] 08:11 [NOM] [NOM] +19h) Normal +Gelule(s) +Voie d`administration : RECTALE +Statut des prescriptions : Réalisé +NORMACOL LAVEMENT +AD SOL RECTALE 1 REC. - 1 seule fois 1 seule +[DATE] 16 : 02 [DATE] 16:49 [NOM] [NOM] +[1] RECIPIENT(S) UNIDOSE fois +UNIDOSE(S) +Voie d`administration : SOUS-CUTANEE +Statut des prescriptions : Signé +INNOHEP 14 000UI +AXa/0,7ML SOL INJ 13000 UI +- Soir [19h] Normal [DATE] 16 : 50 [DATE] 19:31 [NOM] [NOM] +[2] SERINGUE(S) AXa +PREREMPLIE(S) +INNOHEP 14 000UI +AXa/0,7ML SOL INJ 13000 UI - Soir [19h] Presc. de +[DATE] 14 : 00 [NOM] [NOM] +[2] SERINGUE(S) AXa Sortie +PREREMPLIE(S) +Statut des prescriptions : Arrêté +LOVENOX 4000UI +1 +AXa/0,4ML INJ SER +SERINGUE(S) - Soir [19h] Normal [DATE] 16 : 06 [NOM] [NOM] ++S [2] SERINGUE(S) +PREREMPLIE(S) +PREREMPLIE(S) +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 10 de 20 Prescriptions de radiologie +Heure Date Heure +Date début Prescription Statut Docteur [NOM] +début exécution exécution +Scanner Thoraco Abdomino +[DATE] 10 : 38 [DATE] 11:15 Réalisé DR. [NOM] +Pelvien +Scintigraphie osseuse pour +[DATE] 10 : 21 [DATE] 13:42 Réalisé DR. [NOM] +bilan osseux +Prescriptions de laboratoire +Date de +Date Heure Prescription Docteur [NOM] +collection +[DATE] +[DATE] 16 : 02 Ionogramme ( Na, K, CL ) [NOM] [NOM] +17 : 10 +[DATE] +[DATE] 18 : 07 Grippe recherche directe [NOM] [NOM] +09 : 44 +[DATE] +[DATE] 07 : 00 Ionogramme ( Na, K, CL ) [NOM] [NOM] +08 : 55 +Prescriptions de soins +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +[NOM] +1 Semaine - Matin [DATE] [NOM] +ENVIRONNEMENT Signé +[8h] Normal 17 : 46 [NOM] +PATIENT +1 Semaine - Matin [DATE] [NOM] +REPAS : AIDE PARTIELLE Signé +[8h] Normal 17 : 46 [NOM] +- 3x/Nuit (22h 2h 6h) [DATE] [NOM] [NOM] +SOMMEIL : SURV. Signé +Normal 06 : 36 [NOM] +TOILETTE : AIDE - 3X/J (horaires du [DATE] [NOM] +Signé +COMPLETE cycle) Normal 17 : 46 [NOM] +Prescriptions de sortie +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +[NOM] 10MG 1 GEL [DATE] [DATE] : Non [NOM] +Signé - Presc. de Sortie +GELULE [14] Gelule(s) ORALE 14 : 00 administré A valider [NOM] +EZETIMIBE MYL 10MG 1 CPR - Soir [19h] Presc. de [DATE] [DATE] : Non administré [NOM] +Signé +CPR [90] CPR(s) ORALE Sortie 14 : 00 A valider [NOM] +FORLAX 10G PDR [NOM] 2 SACHET - Matin midi soir [DATE] [DATE] : Non [NOM] +Signé +SACHET [20] Sachet(s) ORALE Presc. de Sortie 14 : 00 administré A valider [NOM] +GABAPENTINE ARW +1 GEL - Matin soir (8h - [DATE] [DATE] : Non administré [NOM] +300MG GELULE [90] Signé +ORALE 19h) Presc. de Sortie 14 : 00 A valider [NOM] +Gelule(s) +INNOHEP 14 000UI +13000 UI +AXa/0,7ML SOL INJ - Soir [19h] Presc. de [DATE] [DATE] : Non administré [NOM] +AXa SOUS- Signé +[2] SERINGUE(S) Sortie 14 : 00 A valider [NOM] +CUTANEE +PREREMPLIE(S) +LANSOPRAZOLE BGA 30 1 CPR - Prise unique à 19h [DATE] [DATE] : Non administré [NOM] +Signé +MG CPR OROD [14] CPR(s) ORALE Presc. de Sortie 14 : 00 A valider [NOM] +LANSOYL FRAMBOISE +1 REC. +GEL ORAL UNIDOSE - Matin [8h] Presc. de [DATE] [DATE] : Non administré [NOM] +UNIDOSE Signé +[9] RECIPIENT(S) Sortie 14 : 00 A valider [NOM] +ORALE +UNIDOSE(S) +PRIMPERAN 10MG CPR 1 CPR [DATE] [DATE] : Non administré [NOM] +Signé - Presc. de Sortie +[40] COMPRIME(S) ORALE 14 : 00 A valider [NOM] +SIMVASTATINE +2 CPR - Soir [19h] Presc. de [DATE] [DATE] : Non administré [NOM] +AHL 20MG CPR [28] Signé +ORALE Sortie 14 : 00 A valider [NOM] +COMPRIME(S) +SOLUPRED 20MG +2 CPR - Matin midi Presc. [DATE] [DATE] : Non [NOM] +CPR ORODISP [20] Signé +ORALE de Sortie 14 : 00 administré A valider [NOM] +COMPRIME(S) +XATRAL 2,5MG CPR [30] 1 CPR - Matin midi soir [DATE] [DATE] : Non administré [NOM] +Signé +COMPRIME(S) ORALE Presc. de Sortie 14 : 17 A valider [NOM] +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 11 de 20 Plan de soins Jour J du [DATE] 07h00 au [DATE] 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 10:02 * 1 +[DATE] 16:02 GEL +"Si douleurs " Fin le [DATE] à +10 : 02 +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 16:02 * 1 +[DATE] 16:02 GEL +"Si douleurs " Fin le [DATE] à +10 : 02 +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 22:02 * 1 +[DATE] 16:02 GEL +"Si douleurs " Fin le [DATE] à +10 : 02 +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 04:02 * 1 +[DATE] 16:02 GEL +"Si douleurs " Fin le [DATE] à +10 : 02 +[NOM] [NOM] +Signé — EZETIMIBE MYL 10MG CPR - 10MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Soir [19h] - 16 : 09 19:00 * 1 +1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +19 : 00 +Admin le [DATE] à +19 : 31 +[NOM] [NOM] +Signé — FORLAX 10G PDR [NOM] - Début le [DATE] à +10G poudre - Dose 2 SACHET - ORALE - Matin [DATE] 12:00 * 2 +midi soir - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à SACHET +12 : 00 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +Signé — FORLAX 10G PDR [NOM] - Début le [DATE] à +10G poudre - Dose 2 SACHET - ORALE - Matin [DATE] 19:00 * 2 +midi soir - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à SACHET +12 : 00 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +Signé — FORLAX 10G PDR [NOM] - Début le [DATE] à +10G poudre - Dose 2 SACHET - ORALE - Matin [DATE] 08:11 * 2 +midi soir - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à SACHET +12 : 00 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +En cours — GABAPENTINE ARW 300MG Début le [DATE] à +GELULE - 300MG gelule - Dose 1 GEL - [DATE] +O 24 R /0 A 2 L /2 E 0 2 - 3 M @ at i 1 n 9 s : o 0 i 0 r (8h - 19h) - 1ère dose: F 08 in :0 l 0 e [DATE] à 1 G 9 E :0 L 0 * 1 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +En cours — GABAPENTINE ARW 300MG Début le [DATE] à +GELULE - 300MG gelule - Dose 1 GEL - [DATE] +O 24 R /0 A 2 L /2 E 0 2 - 3 M @ at i 1 n 9 s : o 0 i 0 r (8h - 19h) - 1ère dose: F 08 in :0 l 0 e [DATE] à 0 G 8 E :1 L 1 * 1 +Admin le [DATE] à +08 : 11 +Signé — LANSOPRAZOLE BGA 30 MG [NOM] [NOM] 19 : 00 * 1 +CPR OROD - 30MG comprime - Dose 1 CPR CPR +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 12 de 20 Début le [DATE] à +- ORALE - Prise unique à 19h - 1ère dose : 11:19 +[DATE] @ 19 : 00 Fin le [DATE] à +19 : 00 +Admin le [DATE] à +19 : 31 +[NOM] [NOM] +Signé — LANSOYL FRAMBOISE GEL ORAL Début le [DATE] à +UNIDOSE - 11,734G/15G gel - Dose 1 REC. 12 : 47 08:11 * +UNIDOSE - ORALE - Matin [8h] - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 08 : 00 08:00 UNIDOSE +Admin le [DATE] à +08 : 11 +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 [NOM] [NOM] +Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 11:19 * 1 +[DATE] 11:19 CPR +"Si nausées et/ou vomissements " Fin le [DATE] à +03 : 19 +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 [NOM] [NOM] +Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 19:19 * 1 +[DATE] 11:19 CPR +"Si nausées et/ou vomissements " Fin le [DATE] à +03 : 19 +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 [NOM] [NOM] +Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 03:19 * 1 +[DATE] 11:19 CPR +"Si nausées et/ou vomissements " Fin le [DATE] à +03 : 19 +[NOM] [NOM] +Signé — SIMVASTATINE AHL 20MG CPR - Début le [DATE] à +20MG comprime - Dose 2 CPR - ORALE - Soir 16 : 09 19:00 * 2 +[19h] - 1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +19 : 00 +Admin le [DATE] à +19 : 31 +[NOM] [NOM] +Signé — SOLUPRED 20MG CPR ORODISP - Début le [DATE] à +20MG comprime - Dose 2 CPR - ORALE - Matin [DATE] 12:00 * 2 +midi - 1ère dose : [DATE] @ 12:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +Signé — SOLUPRED 20MG CPR ORODISP - Début le [DATE] à +20MG comprime - Dose 2 CPR - ORALE - Matin [DATE] 08:11 * 2 +midi - 1ère dose : [DATE] @ 12:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +Signé — XATRAL 2,5 MG CPR - 2,5MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Matin midi 11 : 18 12:00 * 1 +soir - 1ère dose : [DATE] @ 12:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +Signé — XATRAL 2,5 MG CPR - 2,5MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Matin midi 11 : 18 19:00 * 1 +soir - 1ère dose : [DATE] @ 12:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +08 : 11 +Signé — XATRAL 2,5 MG CPR - 2,5MG [NOM] [NOM] +comprime - Dose 1 CPR - ORALE - Matin midi Début le [DATE] à 08 : 11 * 1 +soir - 1ère dose : [DATE] @ 12:00 11:18 CPR +Fin le [DATE] à +08 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 13 de 20 Admin le [DATE] à +08 : 11 +[NOM] [NOM] +Signé — INNOHEP 14 000UI AXA SOL INJ - Début le [DATE] à +14000UI AXa solution (0,7 mL) - Dose 13000 UI 16 : 50 19:00 * +A +1è +X +re +a +d +- +o +S +s +O +e : +U +2 +S +4 +- +/0 +C +2 +U +/2 +T +0 +A +2 +N +3 +E +@ +E +1 +D +9 +i + : +r +0 +e +0 +cte - Soir [19h] - F +19 +in + : 0 +l +0 +e [DATE] à 1 +A +3 +X +0 +a +00 UI +Admin le [DATE] à +19 : 31 +Signé — DESINFECTION ENVIRONNEMENT [NOM] [NOM] +PATIENT - Matin [8h] - 1 Semaine- Date Début : Début le [DATE] à +[DATE] @ 17 : 46 17:46 08:00 * 1 +Fin le [DATE] à +08 : 00 +Signé — REPAS : AIDE PARTIELLE - Matin [NOM] [NOM] +[8h] - 1 Semaine- Date Début : [DATE] @ Début le [DATE] à +17 : 46 17:46 08:00 * 1 +Fin le [DATE] à +08 : 00 +[NOM] [NOM] [NOM] +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le [DATE] à +6h) - pendant 7 Jour(s)- Date Début : [DATE] 06:36 +@ 06 : 36 Fin le [DATE] à 22:00 * 1 +06 : 00 +Admin le [DATE] à +23 : 44 +[NOM] [NOM] [NOM] +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le [DATE] à +6h) - pendant 7 Jour(s)- Date Début : [DATE] 06:36 +@ 06 : 36 Fin le [DATE] à 02:00 * 1 +06 : 00 +Admin le [DATE] à +23 : 44 +[NOM] [NOM] [NOM] +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le [DATE] à +6h) - pendant 7 Jour(s)- Date Début : [DATE] 06:36 +@ 06 : 36 Fin le [DATE] à 06:00 * 1 +06 : 00 +Admin le [DATE] à +23 : 44 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 14 de 20 Plan de soins Jour J + 1 du [DATE] 07h00 au [DATE] 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 10:02 * 1 +16 : 02 16:02 GEL +"Si douleurs " Fin le [DATE] à +10 : 02 +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 16:02 * 1 +16 : 02 16:02 GEL +"Si douleurs " Fin le [DATE] à +10 : 02 +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 22:02 * 1 +16 : 02 16:02 GEL +"Si douleurs " Fin le [DATE] à +10 : 02 +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les [NOM] [NOM] +6 Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 04:02 * 1 +16 : 02 16:02 GEL +"Si douleurs " Fin le [DATE] à +10 : 02 +[NOM] [NOM] +Signé — EZETIMIBE MYL 10MG CPR - 10MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Soir [19h] - 16 : 09 19:00 * 1 +1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +19 : 00 +Admin le [DATE] à +19 : 31 +[NOM] [NOM] +Signé — FORLAX 10G PDR [NOM] - Début le [DATE] à +10G poudre - Dose 2 SACHET - ORALE - Matin 16 : 02 08:00 * 2 +midi soir - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à SACHET +12 : 00 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +Signé — FORLAX 10G PDR [NOM] - Début le [DATE] à +10G poudre - Dose 2 SACHET - ORALE - Matin 16 : 02 12:00 * 2 +midi soir - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à SACHET +12 : 00 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +Signé — FORLAX 10G PDR [NOM] - Début le [DATE] à +10G poudre - Dose 2 SACHET - ORALE - Matin 16 : 02 19:00 * 2 +midi soir - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à SACHET +12 : 00 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +En cours — GABAPENTINE ARW 300MG Début le [DATE] à +GELULE - 300MG gelule - Dose 1 GEL - 16 : 02 +O 24 R /0 A 2 L /2 E 0 2 - 3 M @ at i 1 n 9 s : o 0 i 0 r (8h - 19h) - 1ère dose: F 08 in :0 l 0 e [DATE] à 0 G 8 E :0 L 0 * 1 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +En cours — GABAPENTINE ARW 300MG Début le [DATE] à +GELULE - 300MG gelule - Dose 1 GEL - 16 : 02 +O 24 R /0 A 2 L /2 E 0 2 - 3 M @ at i 1 n 9 s : o 0 i 0 r (8h - 19h) - 1ère dose: F 08 in :0 l 0 e [DATE] à 1 G 9 E :0 L 0 * 1 +Admin le [DATE] à +08 : 11 +Signé — LANSOPRAZOLE BGA 30 MG [NOM] [NOM] 19 : 00 * 1 +CPR OROD - 30MG comprime - Dose 1 CPR CPR +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 15 de 20 Début le [DATE] à +- ORALE - Prise unique à 19h - 1ère dose : 11:19 +[DATE] @ 19 : 00 Fin le [DATE] à +19 : 00 +Admin le [DATE] à +19 : 31 +[NOM] [NOM] +Signé — LANSOYL FRAMBOISE GEL ORAL Début le [DATE] à +UNIDOSE - 11,734G/15G gel - Dose 1 REC. 12 : 47 08:00 * +UNIDOSE - ORALE - Matin [8h] - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 08 : 00 08:00 UNIDOSE +Admin le [DATE] à +08 : 11 +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 [NOM] [NOM] +Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 11:19 * 1 +[DATE] 11:19 CPR +"Si nausées et/ou vomissements " Fin le [DATE] à +03 : 19 +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 [NOM] [NOM] +Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 19:19 * 1 +[DATE] 11:19 CPR +"Si nausées et/ou vomissements " Fin le [DATE] à +03 : 19 +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 [NOM] [NOM] +Heure(s) Si besoin - Début presc. : [DATE] @ Début le [DATE] à 03:19 * 1 +[DATE] 11:19 CPR +"Si nausées et/ou vomissements " Fin le [DATE] à +03 : 19 +[NOM] [NOM] +Signé — SIMVASTATINE AHL 20MG CPR - Début le [DATE] à +20MG comprime - Dose 2 CPR - ORALE - Soir 16 : 09 19:00 * 2 +[19h] - 1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +19 : 00 +Admin le [DATE] à +19 : 31 +[NOM] [NOM] +Signé — SOLUPRED 20MG CPR ORODISP - Début le [DATE] à +20MG comprime - Dose 2 CPR - ORALE - Matin [DATE] 08:00 * 2 +midi - 1ère dose : [DATE] @ 12:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +Signé — SOLUPRED 20MG CPR ORODISP - Début le [DATE] à +20MG comprime - Dose 2 CPR - ORALE - Matin [DATE] 12:00 * 2 +midi - 1ère dose : [DATE] @ 12:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +Signé — XATRAL 2,5 MG CPR - 2,5MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Matin midi 11 : 18 08:00 * 1 +soir - 1ère dose : [DATE] @ 12:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +08 : 11 +[NOM] [NOM] +Signé — XATRAL 2,5 MG CPR - 2,5MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Matin midi 11 : 18 12:00 * 1 +soir - 1ère dose : [DATE] @ 12:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +08 : 11 +Signé — XATRAL 2,5 MG CPR - 2,5MG [NOM] [NOM] +comprime - Dose 1 CPR - ORALE - Matin midi Début le [DATE] à 19 : 00 * 1 +soir - 1ère dose : [DATE] @ 12:00 11:18 CPR +Fin le [DATE] à +08 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 16 de 20 Admin le [DATE] à +08 : 11 +[NOM] [NOM] +Signé — INNOHEP 14 000UI AXA SOL INJ - Début le [DATE] à +14000UI AXa solution (0,7 mL) - Dose 13000 UI 16 : 50 19:00 * +A +1è +X +re +a +d +- +o +S +s +O +e : +U +2 +S +4 +- +/0 +C +2 +U +/2 +T +0 +A +2 +N +3 +E +@ +E +1 +D +9 +i + : +r +0 +e +0 +cte - Soir [19h] - F +19 +in + : 0 +l +0 +e [DATE] à 1 +A +3 +X +0 +a +00 UI +Admin le [DATE] à +19 : 31 +Signé — DESINFECTION ENVIRONNEMENT [NOM] [NOM] +PATIENT - Matin [8h] - 1 Semaine- Date Début : Début le [DATE] à +[DATE] @ 17 : 46 17:46 08:00 * 1 +Fin le [DATE] à +08 : 00 +Signé — REPAS : AIDE PARTIELLE - Matin [NOM] [NOM] +[8h] - 1 Semaine- Date Début : [DATE] @ Début le [DATE] à +17 : 46 17:46 08:00 * 1 +Fin le [DATE] à +08 : 00 +[NOM] [NOM] [NOM] +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le [DATE] à +6h) - pendant 7 Jour(s)- Date Début : [DATE] 06:36 +@ 06 : 36 Fin le [DATE] à 22:00 * 1 +06 : 00 +Admin le [DATE] à +23 : 44 +[NOM] [NOM] [NOM] +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le [DATE] à +6h) - pendant 7 Jour(s)- Date Début : [DATE] 06:36 +@ 06 : 36 Fin le [DATE] à 02:00 * 1 +06 : 00 +Admin le [DATE] à +23 : 44 +[NOM] [NOM] [NOM] +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le [DATE] à +6h) - pendant 7 Jour(s)- Date Début : [DATE] 06:36 +@ 06 : 36 Fin le [DATE] à 06:00 * 1 +06 : 00 +Admin le [DATE] à +23 : 44 +Résultats de radiologie +Prescription Date Résultat +Compte rendu au format texte +Bayonne, le [DATE] +Docteur [NOM] +Nom de naissance : [NOM] +Nom utilisé : [NOM] +Prénom de naissance : [NOM] +Prénom utilisé : [NOM] +Date de naissance : [DATE_NAISSANCE] +Lieu de naissance : 99350 +Sexe : M +Matricule INS : (NIR) [NIR] +Examen du : [DATE] +Compte-rendu validé électroniquement par Dr [NOM] le [DATE] +[DATE] +CR Scanner +10 : 38 +SCANNER THORACO-ABDOMINO-PELVIEN +Indication : +Réévaluation dans un contexte de néoplasie prostatique. Vomissement fécaloïde. +Occlusion ? +Protocole : +Scanner thoraco-abdomino-pelvien après injection au temps portal. +RESULTATS : +Examen confronté à celui du [DATE]. +A l'étage thoracique : +Atélectasie partielle lobaire inférieure droite. +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 17 de 20 Micronodule lobaire supérieur droit de 3mm +Pas d'adénomégalie médiastino-hilaire ou axillaire. +Pas d'épanchement pleuro-péricardique. +A l'étage abdomino pelvien : +Distension hydroaérique gastrique et grêlique sans zone transitionnelle franche. +Il existe un rehaussement pariétal iléal pouvant évoquer une iléite : radique ? +Hernie inguinale indirecte gauche au contenu digestif colique non compliquée. +Absence de lésion focale suspecte du foie, du pancréas, de la rate, des reins et des surrénales. +Les voies biliaires intra et extra hépatiques sont fines. +Adénopathies rétropéritonéales stables mesurant en latéro aortique gauche 11 et 13mm de petit axe. +Pas d'épanchement péritonéal. +Epaississement pariétal vésical. +Atteinte athéromateuse sévère de l'aorte abdominale. +Progression osseuse avec visualisation de lésions ostéocondensantes multiples en particulier rachidiennes. +Tassement pathologique de T11 et T12. +Epidurite débutante en T6 +CONCLUSION : +Syndrome occlusif grêlique fonctionnel en amont d'une iléite (radique ?). Pas de zone transitionnelle franche. +Progression osseuse avec apparition de tassements pathologiques en T11 T12. A confronter au dosage des PSA. +Dr [NOM] +Technique : +GE Revolution Frontier CT B225007 +PDL : 613.9 mGy.cm CTDI : 9.11 mGy +Protocole d'acquisition : 5.7 TAP Portal +XENETIX 350 200mL 22wf015c01 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 de naissance : [DATE_NAISSANCE] +Compte rendu au format texte +Bayonne, le [DATE] +Docteur [NOM] +Nom de naissance : [NOM] +Nom utilisé : [NOM] +Prénom de naissance : [NOM] +Prénom utilisé : [NOM] +Date de naissance : [DATE_NAISSANCE] +Lieu de naissance : 99350 +Sexe : M +Matricule INS : (NIR) [NIR] +CR +[DATE] +Médecine +10 : 21 +nucléaire +Examen du : [DATE] +Compte-rendu validé électroniquement par Dr [NOM] le [DATE] +SCINTIGRAPHIE OSSEUSE +INDICATION : +Cancer de prostate métastatique évolutif. Bilan de baseline. +RESULTAT : Comparatif au TEP-scan du [DATE] +Balayage tomoscinti-TDM thoraco-lombo-pelvienne : +Majoration du nombre de foyers hyperfixants : +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 18 de 20 . Nette extension de l'atteinte de l'arc postérieur de la 6e côte gauche s'étendant désormais au corps vertébral de T6. +. Apparition d'une hyperfixation avec ostéocondensation de l'arc postérieur de la 7e côte droite. +. Apparition d'hyperfixations des corps vertébraux postérieurs de T10-T11-T12 avec tassement vertébraux T11 et T12 sans recul du +mur postérieur. +. Apparition d'une hyperfixation de la scapula gauche au-dessus de l'épine et de la scapula droite en arrière de l'acromion. +. Apparition de fractures hyperfixantes des arcs antérieurs des 5e, 6e, 7e et 8e côtes droites. +Sur le plan TDM : +Adénopathies rétropéritonéales latéro aortique gauches supracentimétriques. +Pas de dilatation des cavités pyélocalicielles. +Pas de macro nodule pulmonaire. +Pas d'hypodensité hépatique suspecte en contraste spontané. +Sur le reste du squelette (balayage corps entier) : +Fixation osseuse normale. +CONCLUSION : +Atteinte secondaire osseuse et condensante du rachis (T6, T10, T11 et T12), K7 droit, scapulas avec tassements vertébraux T11 et +T12. +Apparition de fractures possiblement post-traumatiques des 5e 6e 7e et 8e côtes droites. +Bien confraternellement Dr [NOM] +TECHNIQUE : +Radiopharmaceutique : HMDP (Hydroxy-Méthyl-Diphosphate) ?99m Tc +Dose Administrée : 683 MBq IV (poids patient : 73.0 kg) +Acquisition : sur gamma-caméra SYMBIA (Siemens) +PDL : 615.64 mGy.cm CTDI : 7.9 mGy Protocole d'acquisition : 6.5 CT 1 Lit 2.5 mm +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 : RAD001123105 [DATE_NAISSANCE] +Résultats de laboratoire +[DATE] 08 : 55 [DATE] 09:00 [DATE] 20:23 [DATE] 17:10 +Résultat de labo +(5895105) (5892957) (5892958) (5892806) +Apparition des symptômes Asymptomatique +Bilirubine conjuguée calculée 8 µmol/l +Bilirubine non conjuguée 12 µmol/l +Bilirubine totale 8 µmol/l 20 µmol/l +ASAT 26 U/l 32 U/l +Bilirubine totale < : +21 µmol/L : dosage des +Commentaire bilirubine totale fractions conjuguée +et non conjugée non +réalisé. +Gamma GT 65 U/l 90 U/l +Phosphatase alcaline 61 U/l 76 U/l +Calcium 1,91 mmol/l 2,30 mmol/l +Chlore 103 mmol/l 93 mmol/l +Créatinine 68 µmol/l 116 µmol/l +CRP 30 mg/l 168 mg/l +Compte rendu Bactériologie Bact230226142435-1.pdf +Compte-rendu laboratoire Labo230228115307-1.pdf Labo230227094415-1.pdf Labo230225133622-1.pdf +Polynucléaires neutrophiles +92,0 % 90,7 % +(%) +Polynucléaires neutrophiles +3,45 10.9/l 2,42 10.9/l +(#) +Polynucléaires éosinophiles +0,0 % 0,0 % +(%) +Polynucléaires éosinophiles +0,00 10.9/l 0,00 10.9/l +(#) +Polynucléaires basophiles (%) 0,0 % 1,1 % +Polynucléaires basophiles (#) 0,00 10.9/l 0,03 10.9/l +Lymphocytes (%) 2,0 % 5,2 % +Lymphocytes (#) 0,07 10.9/l 0,14 10.9/l +Monocytes (%) 2,0 % 3,0 % +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [EPISODE] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 19 de 20 Monocytes (#) 0,07 10.9/l 0,08 10.9/l +Morphologie des globules Polynucléaires +blancs hyposegmentés ++ +Formule vérifiée par le +Oui Oui +technicien +Myélocytes neutrophiles (%) 4,0 % +Myélocytes neutrophiles (#) 0,15 10.9/l +Glucose 5,7 mmol/l 9,0 mmol/l +ALAT 38 U/l 58 U/l +réalisée sur frottis réalisée sur automate +Formule sanguine +sanguin au microscope XN (Sysmex) +Hématocrite (%) 31,6 % 47,8 % +Indice de distribution des +17,0 % 18,5 % +hématies +Verification sur lame des Absence d'amas Absence d'amas +plaquettes plaquettaires. plaquettaires. +Absence de traitement +Traitement anticoagulant +anticoagulant +Potassium 4,0 mmol/l 4,1 mmol/l +LDH 237 U/l 286 U/l +PCR Grippe A Négative +PCR Grippe B Négative +PCR COVID 19 (prélèvement +Négative +nasal) GeneXpert +PCR Virus respiratoire +Négative +syncitial +Culture ECBU TK Stérile. +Leucocytes 3,75 10.9/l 16 /µL 2,67 10.9/l +Nature du prélèvement Urine Milieu de jet +Hématies 3,74 10.12/l (t/l) 5,64 10.12/l (t/l) +Hémoglobine 10,7 g/dl 15,9 g/dl +VGM 84,5 fl 84,8 fl +TCMH 28,6 pg 28,2 pg +CCMH 33,9 g/dl 33,3 g/dl +Sodium 134 mmol/l 134 mmol/l +Prélèvement non +Non conformité validé initialement par +Service +Osmolarité sang 274 mOSM/l 277 mOSM/l +Plaquettes 96 10.9/l 144 10.9/l +Protéines 48 g/l 72 g/l +Le patient est-il professionel +non +de santé ? +Réserve alcaline 29 mmol/l 31 mmol/l +Validation et diffusion sous la +Dr [NOM] [NOM] [NOM] Dr [NOM] [NOM] [NOM] +responsabilité du biologiste +[NOM] anionique 6 14 +TCA 21,0 secondes +TCA ratio 0,69 +TP 106 % +Temps de Quick 11,0 secondes +Situation de résidence du +hébergement individuel +patient +Urée 20,3 mmol/l +Volume plaquettaire moyen 10,4 fl 9,6 fl +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (01285757 ) +Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Taille: 168 cm - Poids: 76 kg - IMC: 26.927 +Le [DATE] 09 : 53 Page 20 de 20 + + +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] [NOM] Ville de résidence: [VILLE] +Episode No : [EPISODE] +Localisation : ONCOLOGIE HC Médecin courant: DR. [NOM] +Date d'admission : 24/02/2023 Heure d'admission: 14:51 +Date de sortie : Heure de sortie: +Nom : Adresse Téléphone +DR. [NOM] [NOM] : [ADRESSE][CODE_POSTAL] D [NOM] [TEL] +Type de contact : Relation Nom Prénom Adresse Tél. domicile Tél. +professionel Mobile +Personne à prévenir +(Trakcare) : Epouse FRANCE [TEL] +Personne à prévenir +(Trakcare) : Fils [NOM] [NOM] [TEL] +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Item de +surveillance : 02/03/2023 +08:41 01/03/2023 +23:24 01/03/2023 +21:56 01/03/2023 +18:00 01/03/2023 +08:43 01/03/2023 +08:14 28/02/2023 +23:22 28/02/2023 +16:09 28/02/2023 +13:10 28/02/2023 +09:15 28/02/2023 +09:00 28/02/2023 +06:08 28/02/2023 +04:33 +Température : 37,30 37,00 37,40 37,20 37,30 37,50 37,20 37,90 +Pouls : 83,00 80,00 82,00 82,00 78,00 +PA +Systolique : 136,00 138,00 144,00 149,00 116,00 +PA +Diastolique : 71,00 73,00 88,00 72,00 56,00 +PA +Moyenne : 93,00 95,00 107,00 98,00 76,00 +Saturation +O² : 97,00 95,00 95,00 94,00 95,00 +Ventilation : Ventilatio +spontanée +Air +ambiant nVentilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant n Ventilatio +spontanée +Air +ambiant n +Echelle +douleur : EN EN EN EN EN +Score au +repos : 0,00 0,00 0,00 0,00 0,00 +Glycémie +capillaire : 1,12 1,23 0,84 1,42 +Volume +de miction +[ml] : 400,00 0,00 326,00 +Transit : Absence Peu Absence +Item de +surveillance : 01/03/2023 +07:44 28/02/2023 +07:55 27/02/2023 +15:00 27/02/2023 +07:31 26/02/2023 +07:56 25/02/2023 +23:00 25/02/2023 +15:33 25/02/2023 +07:59 +Diurèse : 1000,00 800,00 300,00 900,00 250,00 400,00 400,00 250,00 + +Diurèse +- Cumul +8h/8h : 1000,00 1100,00 300,00 900,00 1050,00 800,00 400,00 250,00 +Pyélo/ +Néphro +drte - +Cumul +8h/8h : 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Pyélo/ +Néphro +gche - +Cumul +8h/8h : 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Diurèse +Totale : 1000,00 800,00 300,00 900,00 250,00 400,00 400,00 250,00 +Diurèse +- Cumul +8h/8h Total : 1000,00 1100,00 300,00 900,00 1050,00 800,00 400,00 250,00 +Compens +° Diurèse +- Cumul +8h/8h : 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Item de +surveillance : 01/03/2023 +07:44 28/02/2023 +07:55 27/02/2023 +15:00 27/02/2023 +07:31 26/02/2023 +07:56 25/02/2023 +23:00 25/02/2023 +15:33 25/02/2023 +07:59 +Balance +hydrique +totale +(cumulée) +[ml] : -4300,00 -3300,00 -2500,00 -2200,00 -1300,00 -1050,00 -650,00 -250,00 +Balance +hydrique +totale +(session) : -1000,00 -800,00 -300,00 -900,00 -250,00 -400,00 -400,00 -250,00 +Entrées +totales des +liquides +(cumulé) : 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Entrées +totales des +liquides +(session) +[ml] : 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 +Total Pertes +Liquidiennes +(Relevé) : 4300,00 3300,00 2500,00 2200,00 1300,00 1050,00 650,00 250,00 +Total Pertes +liquidiennes +(session) : 1000,00 800,00 300,00 900,00 250,00 400,00 400,00 250,00 +Item de +surveillance : 01/03/2023 +08:44 28/02/2023 +10:39 27/02/2023 +11:09 24/02/2023 +16:12 +Poids [kg] : 76,00 76,00 76,70 73,00 +Taille [cm] : 168,00 168,00 168,00 +Indice +de masse +corporelle : 26.927 26.927 25.865 +Surface +corporelle : 1.86 1.86 1.83 +Item de +surveillance : 02/03/2023 +08:41 01/03/2023 +23:24 01/03/2023 +08:43 28/02/2023 +23:22 28/02/2023 +16:09 28/02/2023 +13:10 28/02/2023 +09:15 28/02/2023 +06:08 28/02/2023 +04:33 27/02/2023 +15:48 27/02/2023 +08:29 26/02/2023 +22:25 26/02/2023 +15:37 +Température : 37,30 37,00 37,40 37,20 37,30 37,50 37,20 37,90 37,40 37,50 37,30 37,00 +Pouls : 83,00 80,00 82,00 82,00 78,00 77,00 72,00 86,00 93,00 +PA +Systolique : 136,00 138,00 144,00 149,00 116,00 166,00 162,00 142,00 116,00 +PA +Diastolique : 71,00 73,00 88,00 72,00 56,00 83,00 80,00 76,00 60,00 +Saturation +O² : 97,00 95,00 95,00 94,00 95,00 96,00 98,00 95,00 +Transit : Absence Peu Absence Absence Absence + +Item de +surveillance : 02/03/2023 +08:41 01/03/2023 +23:24 01/03/2023 +18:00 01/03/2023 +08:43 01/03/2023 +08:14 28/02/2023 +23:22 28/02/2023 +16:09 28/02/2023 +13:10 28/02/2023 +09:15 28/02/2023 +09:00 28/02/2023 +06:08 28/02/2023 +04:33 27/02/2023 +15:48 +Température : 37,30 37,00 37,40 37,20 37,30 37,50 37,20 37,90 37,40 +Pouls : 83,00 80,00 82,00 82,00 78,00 77,00 +PA +Systolique : 136,00 138,00 144,00 149,00 116,00 166,00 +PA +Diastolique : 71,00 73,00 88,00 72,00 56,00 83,00 +Saturation +O² : 97,00 95,00 95,00 94,00 95,00 96,00 +Glycémie +capillaire : 1,12 1,23 0,84 1,42 +Transit : Absence Peu Absence +Type d'observation : Nom Date Commentaires +Note d'évolution : [NOM] [NOM] 01/03/2023 +12:18 Sur le plan symptomatique/oncologique : +Poursuite d'une bonne évolution clinique. +Reprise alimentation normale et arrêt de l'hydratation. +Scintigraphie osseuse ce jour en Baseline avant initiation TAXOTERE. +Pose de PAC en ambulatoire le 03/03 et programmation des HDJ pour TAXOTERE toutes les 3 +semaines à partir du 08/03. +Sur le plan du devenir : +Transfert au [ETABLISSEMENT] demain en fin de matinée. +Sa fille présente en chambre a été informée de l'ensemble de la prise en charge, de la prise +en charge au [ETABLISSEMENT] demain, de la pose de PAC le 03/03 et de l'initiation de la +chimiothérapie semaine prochaine le 08/03. +Note d'évolution : [NOM] [NOM] 28/02/2023 +14:49 Sur le plan symptomatique : +Stabilité clinique, transit ce jour, pas de nausées ni de vomissements. +Poids en diminution -0.7kg (soit +3kg sur l'hyperhydratation depuis le début d'hospitalisation), +sans signe de surcharge pulmonaire. +> Relai traitements per os devant la bonne évolution clinique et biologique avec nette +amélioration de la fonction rénale. +> Poursuite élargissement progressif de l'alimentation sur la bonne tolérance digestive. +> Prescription kinésithérapie de mobilisation. +Sur le plan spécifique: +En attente date pour une scintigraphie osseuse. Pose de PAC maintenue au 03/03. +Sur le plan du devenir : +Patient favorable à une prise en charge en [ETABLISSEMENT] à Grancher, demande faite. +Note d'évolution : [NOM] [NOM] 27/02/2023 +15:36 Sur le plan symptomatique : +Va bien mieux, pas de nausées ni de vomissements. Transit régulier, pas de douleurs +abdominales, abdomen souple, dépressible et indolore. ++3.5kg sans signe de surcharge clinique notamment pulmonaire. +> Elargissement alimentation ce jour, poursuite traitement laxatifs et surveillance transit ++. +> Ajout traitement par XATRAL pour retrait de la sonde urinaire dans 48/72h. +> Diminution hydratation par PG5 à 1L/jour. +Sur le plan oncologique : +Dernière séance de radiothérapie le 28/02. +Scintigraphie osseuse demandée pour cette semaine, sera probablement réalisée le 01/03. +Pose de PAC prévue le 03/03 après midi à 16h pour initiation de la nouvelle ligne de +chimiothérapie par TAXOTERE fin de semaine ou début de semaine prochaine. +> Prévoir suspension anticoagulation curative le 02/03. +Sur le plan du devenir : +Discussion avec le patient et son fils ce jour de l'intérêt d'une prise en charge en [ETABLISSEMENT] dans +les suites immédiates de l'hospitalisation à visée de remobilisation et de réautonomisation +qu'ils semblent comprendre et accepter. Explication donnée quant à la visée suspensive de la +chimiothérapie dont l'objectif n'est pas curatif mais à visée de contrôle le plus longtemps possible +de la maladie. +Note d'évolution : DR. [NOM] +[NOM] 26/02/2023 +12:07 Selles cette nuit en grande quantité avec confusion +nouvelles selles le 26/02 au matin +N'est plus confus, non algique +Essai Fauteuil dans la journée +BCY ce jour +reprise radiothérapie lundi +Est d'accord pour [ETABLISSEMENT] au décours du C1 de TAXOTERE + +Note d'évolution : DR. [NOM] +[NOM] 25/02/2023 +12:39 Effectivement tres altérée +vomissements fécaloïdes à l'arrivée avec SNG productive > 2 Ln pas de selles depuis 8 jours +abdomen souple, pas de fecalome +deshydraté +non douloureux au repos +TDM: Syndrome occlusif grêlique fonctionnel en amont d'une iléite (radique ?). Pas de zone +transitionnelle franche. Progression osseuse avec apparition de tassements pathologiques en T11 +T12 +Poursuite CTC 1mg/kg , hydratation ++, ACTISKENAN ALD, laxatifs +++ +Retrait SNG et alimentation liquide auj avec BCY demain si OK +Discuter IRM rachis avant RCP neuro +Achever radiothérapie en début de semaine pour débuter TAXOTERE sans trop tarder selon +évolution clinique +Note d'évolution : [NOM] [NOM] 24/02/2023 +16:52 ECG : FA à réponse ventriculaire rapide à 160bpm. +> Non connue, pas d'anticoagulation curative en place. +> Avis cardio (Dr [NOM]) : Mise en place d'une anticoagulation curative, pas de bloquant du +fait de la tension artérielle limite, à rediscuter selon évolution. + +Item de +surveillance : 24/02/2023 +16:09 24/02/2023 +22:52 25/02/2023 +09:23 25/02/2023 +15:32 25/02/2023 +22:59 26/02/2023 +02:14 26/02/2023 +08:55 26/02/2023 +15:37 26/02/2023 +22:25 27/02/2023 +08:29 27/02/2023 +15:48 28/02/2023 +04:33 28/02/2023 +06:08 +Température : 36.6 36.5 36.1 36.9 36 36.5 37 37.3 37.5 37.4 37.9 37.2 +PA +Systolique : 91 120 110 130 124 141 116 142 162 166 +PA +Diastolique : 50 57 69 77 80 68 60 76 80 83 +Saturation +O² : 93 94 92 94 99 95 95 98 96 +Transit : Constipati on Absence Absence Molles Diarrhées Absence Absence +Pouls : 107 105 101 102 104 93 86 72 77 +Type de note : Nom Date Note +Note IDE : [NOM] [NOM] 02/03/2023 +02:25 Transit: +Selles sur la nuit. +Note IDE : [NOM] +[NOM] 01/03/2023 +21:26 Elimination : +> Bladder fait à 17 heures car n'a pas uriné de l'après-midi = > 326 cc +> Recontrolé à 18h = > 0 cc +Devenir : +> Transfert à Grancher demain, transport ok et fiche de liaison faite +Note Diététicienne : [NOM] +[NOM] 01/03/2023 +15:16 PEC nutritionnelle : +Retrait SNG (en aspi) le 25/02. +Reprise alimentaire le 26/02 = bonne tolérance. +Elargissement menus avec passage en PO2 le 27/02 = bonne tolérance. +Pas de nausées, ni vomissements. +Appétit présent, conservé. +Transit régulier (cf. trans) +--> Menus NOR dès demain. +Note IDE : [NOM] [NOM] 01/03/2023 +12:56 Elimination : ablation de la sonde vésicale ce matin vers 10h > surveillance reprise miction + +diurèse. +A eu 1 miction par la suite (non constaté car a fait dans les WC). +Alimentation : reprise alimentation en régime normal a partir de ce soir. +Transit : a eu des selles normales en grande quantité ce matin. +Examen : scintigraphie os faite ce matin > à voir. +Devenir : Transfert a Grancher demain a 11h15 > ambu ok. +Note IDE : [NOM] +[NOM] 28/02/2023 +23:29 Infectieux +=> apyrétique + +Note IDE : [NOM] [NOM] 28/02/2023 +16:10 SORTIE [NOM] jeudi 02/03 à 14h la bas , ambulance commandée +CHIRURGIE POSE PAC vendredi 03/03 à 16h en CHIR AMBULATOIRE , [NOM] +prevenu sera contacté par secretariat +Note IDE : [NOM] [NOM] 28/02/2023 +14:54 SCINTIGRAPHIE OS : le 01/03 à 10h +Note IDE : [NOM] [NOM] 28/02/2023 +13:32 Alimentation : régime élargi a PO2 à partir de ce jour car a eu des selles le 26/02 + ce jour +également en petite quantité constaté. Transit à surveiller. +Radiothérapie : a eu séance ce jour a 12h, pas d'autres séances prévues. +Examen : scintigraphie os demandée > en attente de date, pas de place ce jour. +Devenir : [ETABLISSEMENT] demandé. +Note IDE : [NOM] +[NOM] 28/02/2023 +04:25 Infectieux +=> fébricule à 37.9°C à 4h30 +=> redescendu spontanément à 37.2°C à 6h +Note IDE : [NOM] +[NOM] 27/02/2023 +21:57 Digestif : +> Pas de selles cet AM +Douleur : +> Pas de plaintes algiques +Note IDE : [NOM] [NOM] 27/02/2023 +14:44 Douleur : +=> pas de plainte algique +Digestif : +=> pas de nausées ni de vomissement +=> alimentation BCY ajd +Risque de surcharge : +=> +3.7kg en quelques jour --> diminution hydrat +Radiothérapie : +=> radiothérapie ce matin à 11h30 +=> RdxTTT demain matin à 12h --> transport ok +Examen : +=> scinti os ddé +Voie d'abord : +=> pose de PAC le 3/03 +Note IDE : [NOM] [NOM] 26/02/2023 +23:40 Neuro: +Patient calme, orienté et coopérant. +Se rend compte, de ses dires, qu'il a "fait des bêtises" la nuit dernière. +Douleur: +Pas de plainte algique. +Transit: +Pas de selles. +Note IDE : [NOM] [NOM] 26/02/2023 +20:03 Douleur: +Pas de plainte algique sur l'après midi +Transit: +Absence de selles cet après midi +Comportement: +Patient cohérent et orienté sur l'après midi +nous raconte l'épisode de cette nuit: dit "avoir vu des monstres qui lui courraient après, a voulu +s'échapper ce qui explique qu'il a couper la sonde et la VVP".. hallucinations? a surveiller + +Note IDE : [NOM] [NOM] 26/02/2023 +00:16 Comportement: +A 1h30, patient retrouvé avec du sang et des selles +++ dans la chambre (lit, adaptable, salle de +bain, sol...). Poche de recueil d'urines retrouvée par terre dans la SDB, rampe et pied à perf par +terre. +Le patient tient un petit ciseau dans les mains, qui lui a sans doute permis de sectionner la +tubulure de la SV et de la VVP. +Dit avoir eu un moment de panique où il ne savait plus où il se trouvait. +Patient très virulent dans ses propos, agressif. +Lors de mon arrivée dans la chambre, patient orienté dans l'espace et dans le temps. +Calme le reste de la nuit. +Note IDE : [NOM] [NOM] 25/02/2023 +19:18 Douleur: +Pas de plainte algique +Digestif: +Pas de nausées ni de vomissement sur l'après midi +Transit: +Absence de selles cet après midi, laxatif per os administrés +Etat général: +Patient toujours asthénique, a dormi toute l'après midi +Note IDE : [NOM] [NOM] 25/02/2023 +14:10 Douleur : +=> pas de plainte algique +Digestif : +=> SNG en place et fonctionnelle --> 500cc de résidus ce matin soit 2500cc depuis la pose de la +SNG (moins de 24h) +=> patient gêné +++ par al SNG, demande à boire --> signalé au médecin --> ok pour un jus ce +matin +=> suite scan abdo en urgence --> CAT de retirer la SNG et ok pour liquide ajd puis passage en +BCY demain +Examen : +=> scan abdo en urgence ce matin --> "Syndrome occlusif grêlique fonctionnel en amont d'une +iléite (radique ?). Pas de zone transitionnelle franche. Progression osseuse avec apparition de +tassements pathologiques en T11 T12" +Elimination : +=> SV en place et fonctionnelle +Etat général : +=> patient asthénique en fin de matinée, dort en rentrant du scan +TTT : +=> ajout hydrat ce matin car déshydratation + +Note IDE : [NOM] [NOM] 24/02/2023 +20:49 Motif d'hospitalisation: +Patient entré ce jour pour AEG dans un contexte d'ADK de prostate suivi a Bergonié +Voie d'abord: +VVP posée (capital veineux précaire) +Alimentation: +Patient qui mange très peu au domicile depuis plusieurs jours --> diet ddé +Elimination: +Dysurie importante, déshydratation? --> bladder 62cc +SV ch 16 posée sur consignes médicales + ECBU réalisé +Digestif: +Patient qui dit ne pas avoir eu de selles depuis au moins 5 jours --> lavement réalisé cet après +midi non efficace +--> dlr abdo + Vomissement fécaloïde à 20h --> SNG posée repère 65 en aspi --> 600cc fécaloïde +évacué d'emblé +Cardio: +ECG réalisé cet après midi --> FA --> avis cardio introduction d'ATC +Etat général: +Patient asthénique ++, ne se mobilise plus depuis 3 jours --> matelas air ddé +Douleur: +Douleurs abdo ce soir, soulagées par la pose de la SNG +porteur d'un patch d'ATG3 retiré à 16h selon consignes médicales +Suivi onco: +2 dernières séances de radiothérapie prévues le 27 et 28/02 (horaire à récupérer auprès des +enfants) +Risque infectieux: +PCR refusé par le patient ce soir.. à faire demain matin svp +Prescription : Dose Fréquence Date de début Date de dernière +administration Note Docteur +EUPANTOL 40MG PDR INJ +[1] Flacon(s) : 40 mg - Soir [19h] Normal 24/02/2023 16:02 27/02/2023 19:28 Le débit a été +modifié. Le débit +en cours est : 60 +par . [NOM] [NOM] +METHYLPREDNISOLONE +MYL 40MG PDR INJ [10] +Flacon(s) : 40 mg - Matin midi Normal 25/02/2023 06:00 28/02/2023 08:41 Le débit a été +modifié. Le débit +en cours est : 3 +par . [NOM] [NOM] +METOCLOPRAMIDE CHL +REN 10MG/2ML INJ [100] +Ampoule(s) : 1 AMP - Normal 24/02/2023 16:02 [NOM] [NOM] +POLYIONIQUE 1A G5 +BAX POC VFO 500ML [1] +POCHE(S) : - Normal 24/02/2023 16:09 01/03/2023 08:45 Le débit a été +modifié. Le débit +en cours est : +41.66666666666666 +ML par 1 hrs. [NOM] [NOM] +4 +SODIUM CHL [NOM] +0,9% INJ PP 500ML [1] +POCHE(S) : - Normal 25/02/2023 12:31 27/02/2023 00:28 Le débit a été +modifié. Le débit +en cours est : +41.66666666666666 +ML par 1 hrs. DR. [NOM] +[NOM] +4 +METHYLPREDNISOLONE +MYL 120MG PDR INJ [10] +Flacon(s) : 80 mg - 1 seule fois 1 seule +fois 24/02/2023 16:02 24/02/2023 16:49 Le débit a été +modifié. Le débit +en cours est : 2 +par . [NOM] [NOM] +ACTISKENAN 10MG +GELULE [14] Gelule(s) : 1 GEL - Normal 24/02/2023 16:02 [NOM] [NOM] + +ACTISKENAN 10MG +GELULE [14] Gelule(s) : 1 GEL - Presc. de Sortie 02/03/2023 14:00 [NOM] [NOM] +EZETIMIBE MYL 10MG +CPR [90] CPR(s) : 1 CPR - Soir [19h] Normal 24/02/2023 16:09 01/03/2023 19:31 [NOM] [NOM] +EZETIMIBE MYL 10MG +CPR [90] CPR(s) : 1 CPR - Soir [19h] Presc. de +Sortie 02/03/2023 14:00 [NOM] [NOM] +FORLAX 10G PDR ORALE +SACHET [20] Sachet(s) : 2 SACHET - Matin midi soir +Normal 24/02/2023 16:02 02/03/2023 08:11 [NOM] [NOM] +FORLAX 10G PDR ORALE +SACHET [20] Sachet(s) : 2 SACHET - Matin midi soir +Presc. de Sortie 02/03/2023 14:00 [NOM] [NOM] +GABAPENTINE ARW +300MG GELULE [90] +Gelule(s) : 1 GEL - Matin soir (8h - +19h) Presc. de Sortie 02/03/2023 14:00 [NOM] [NOM] +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR - Prise unique à 19h +Normal 28/02/2023 11:19 01/03/2023 19:31 [NOM] [NOM] +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR - Prise unique à 19h +Presc. de Sortie 02/03/2023 14:00 [NOM] [NOM] +LANSOYL FRAMBOISE +GEL ORAL UNIDOSE +[9] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - Matin [8h] Normal 25/02/2023 12:47 02/03/2023 08:11 DR. [NOM] +[NOM] +LANSOYL FRAMBOISE +GEL ORAL UNIDOSE +[9] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - Matin [8h] Presc. de +Sortie 02/03/2023 14:00 [NOM] [NOM] +PRIMPERAN 10MG CPR +[40] COMPRIME(S) : 1 CPR - Normal 28/02/2023 11:19 [NOM] [NOM] +PRIMPERAN 10MG CPR +[40] COMPRIME(S) : 1 CPR - Presc. de Sortie 02/03/2023 14:00 [NOM] [NOM] +SIMVASTATINE +AHL 20MG CPR [28] +COMPRIME(S) : 2 CPR - Soir [19h] Normal 24/02/2023 16:09 01/03/2023 19:31 [NOM] [NOM] +SIMVASTATINE +AHL 20MG CPR [28] +COMPRIME(S) : 2 CPR - Soir [19h] Presc. de +Sortie 02/03/2023 14:00 [NOM] [NOM] +SOLUPRED 20MG +CPR ORODISP [20] +COMPRIME(S) : 2 CPR - Matin midi Normal 28/02/2023 11:19 02/03/2023 08:11 [NOM] [NOM] +SOLUPRED 20MG +CPR ORODISP [20] +COMPRIME(S) : 2 CPR - Matin midi Presc. +de Sortie 02/03/2023 14:00 [NOM] [NOM] +XATRAL 2,5MG CPR [30] +COMPRIME(S) : 1 CPR - Matin midi soir +Normal 27/02/2023 11:18 02/03/2023 08:11 [NOM] [NOM] +XATRAL 2,5MG CPR [30] +COMPRIME(S) : 1 CPR - Matin midi soir +Presc. de Sortie 01/03/2023 14:17 [NOM] [NOM] +GABAPENTINE ARW +300MG GELULE [90] +Gelule(s) : 1 GEL - Matin soir (8h - +19h) Normal 24/02/2023 16:02 02/03/2023 08:11 [NOM] [NOM] +NORMACOL LAVEMENT +AD SOL RECTALE +[1] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - 1 seule fois 1 seule +fois 24/02/2023 16:02 24/02/2023 16:49 [NOM] [NOM] +INNOHEP 14 000UI +AXa/0,7ML SOL INJ +[2] SERINGUE(S) +PREREMPLIE(S) : 13000 UI +AXa - Soir [19h] Normal 24/02/2023 16:50 01/03/2023 19:31 [NOM] [NOM] +INNOHEP 14 000UI +AXa/0,7ML SOL INJ +[2] SERINGUE(S) +PREREMPLIE(S) : 13000 UI +AXa - Soir [19h] Presc. de +Sortie 02/03/2023 14:00 [NOM] [NOM] +LOVENOX 4000UI +AXa/0,4ML INJ SER ++S [2] SERINGUE(S) +PREREMPLIE(S) : 1 +SERINGUE(S) +PREREMPLIE - Soir [19h] Normal +(S) 24/02/2023 16:06 [NOM] [NOM] + +Date début : Heure +début Prescription Date +exécution Heure +exécution Statut Docteur Note +25/02/2023 : 10:38 Scanner Thoraco Abdomino +Pelvien 25/02/2023 11:15 Réalisé DR. [NOM] +01/03/2023 : 10:21 Scintigraphie osseuse pour +bilan osseux 01/03/2023 13:42 Réalisé DR. [NOM] +Date : Heure Prescription Docteur Date de +collection Note +24/02/2023 : 16:02 Ionogramme ( Na, K, CL ) [NOM] [NOM] 24/02/2023 +17:10 +24/02/2023 : 18:07 Grippe recherche directe [NOM] [NOM] 26/02/2023 +09:44 +28/02/2023 : 07:00 Ionogramme ( Na, K, CL ) [NOM] [NOM] 28/02/2023 +08:55 +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +DESINFECTION +ENVIRONNEMENT +PATIENT : Signé 1 Semaine - Matin +[8h] Normal 24/02/2023 +17:46 [NOM] +[NOM] +REPAS : AIDE PARTIELLE Signé 1 Semaine - Matin +[8h] Normal 24/02/2023 +17:46 [NOM] +[NOM] +SOMMEIL : SURV. Signé - 3x/Nuit (22h 2h 6h) +Normal 28/02/2023 +06:36 [NOM] [NOM] +[NOM] +TOILETTE : AIDE +COMPLETE Signé - 3X/J (horaires du +cycle) Normal 24/02/2023 +17:46 [NOM] +[NOM] +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +ACTISKENAN 10MG +GELULE [14] Gelule(s) : 1 GEL +ORALE Signé - Presc. de Sortie 02/03/2023 +14:00 0/120 : Non +administré A valider [NOM] +[NOM] +EZETIMIBE MYL 10MG +CPR [90] CPR(s) : 1 CPR +ORALE Signé - Soir [19h] Presc. de +Sortie 02/03/2023 +14:00 0/30 : Non administré +A valider [NOM] +[NOM] +FORLAX 10G PDR ORALE +SACHET [20] Sachet(s) : 2 SACHET +ORALE Signé - Matin midi soir +Presc. de Sortie 02/03/2023 +14:00 0/180 : Non +administré A valider [NOM] +[NOM] +GABAPENTINE ARW +300MG GELULE [90] +Gelule(s) : 1 GEL +ORALE Signé - Matin soir (8h - +19h) Presc. de Sortie 02/03/2023 +14:00 0/60 : Non administré +A valider [NOM] +[NOM] +INNOHEP 14 000UI +AXa/0,7ML SOL INJ +[2] SERINGUE(S) +PREREMPLIE(S) : 13000 UI +AXa SOUS- +CUTANEE Signé - Soir [19h] Presc. de +Sortie 02/03/2023 +14:00 0/28 : Non administré +A valider [NOM] +[NOM] +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR +ORALE Signé - Prise unique à 19h +Presc. de Sortie 02/03/2023 +14:00 0/30 : Non administré +A valider [NOM] +[NOM] +LANSOYL FRAMBOISE +GEL ORAL UNIDOSE +[9] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE +ORALE Signé - Matin [8h] Presc. de +Sortie 02/03/2023 +14:00 0/30 : Non administré +A valider [NOM] +[NOM] +PRIMPERAN 10MG CPR +[40] COMPRIME(S) : 1 CPR +ORALE Signé - Presc. de Sortie 02/03/2023 +14:00 0/90 : Non administré +A valider [NOM] +[NOM] +SIMVASTATINE +AHL 20MG CPR [28] +COMPRIME(S) : 2 CPR +ORALE Signé - Soir [19h] Presc. de +Sortie 02/03/2023 +14:00 0/60 : Non administré +A valider [NOM] +[NOM] +SOLUPRED 20MG +CPR ORODISP [20] +COMPRIME(S) : 2 CPR +ORALE Signé - Matin midi Presc. +de Sortie 02/03/2023 +14:00 0/120 : Non +administré A valider [NOM] +[NOM] +XATRAL 2,5MG CPR [30] +COMPRIME(S) : 1 CPR +ORALE Signé - Matin midi soir +Presc. de Sortie 01/03/2023 +14:17 0/7 : Non administré +A valider [NOM] +[NOM] + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 10:02 * 1 +GEL +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 16:02 * 1 +GEL +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 22:02 * 1 +GEL +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 04:02 * 1 +GEL +Signé — EZETIMIBE MYL 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Soir [19h] - +1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:09 +Fin le 25/03/2023 à +19:00 +Admin le 01/03/2023 à +19:31 19:00 * 1 +CPR +Signé — FORLAX 10G PDR ORALE SACHET - +10G poudre - Dose 2 SACHET - ORALE - Matin +midi soir - 1ère dose : 25/02/2023 @ 08:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +12:00 +Admin le 02/03/2023 à +08:11 12:00 * 2 +SACHET +Signé — FORLAX 10G PDR ORALE SACHET - +10G poudre - Dose 2 SACHET - ORALE - Matin +midi soir - 1ère dose : 25/02/2023 @ 08:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +12:00 +Admin le 02/03/2023 à +08:11 19:00 * 2 +SACHET +Signé — FORLAX 10G PDR ORALE SACHET - +10G poudre - Dose 2 SACHET - ORALE - Matin +midi soir - 1ère dose : 25/02/2023 @ 08:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +12:00 +Admin le 02/03/2023 à +08:11 08:11 * 2 +SACHET +En cours — GABAPENTINE ARW 300MG +GELULE - 300MG gelule - Dose 1 GEL - +ORALE - Matin soir (8h - 19h) - 1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 19:00 * 1 +GEL +En cours — GABAPENTINE ARW 300MG +GELULE - 300MG gelule - Dose 1 GEL - +ORALE - Matin soir (8h - 19h) - 1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:11 * 1 +GEL + +Signé — LANSOYL FRAMBOISE GEL ORAL +UNIDOSE - 11,734G/15G gel - Dose 1 REC. +UNIDOSE - ORALE - Matin [8h] - 1ère dose : 26/02/2023 @ 08:00 [NOM] [NOM] +Début le 25/02/2023 à +12:47 +Fin le 27/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:11 * +1 REC. +UNIDOSE +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) Si besoin - Début presc. : 28/02/2023 @ +11:19 +"Si nausées et/ou vomissements " [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +03:19 11:19 * 1 +CPR +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) Si besoin - Début presc. : 28/02/2023 @ +11:19 +"Si nausées et/ou vomissements " [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +03:19 19:19 * 1 +CPR +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) Si besoin - Début presc. : 28/02/2023 @ +11:19 +"Si nausées et/ou vomissements " [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +03:19 03:19 * 1 +CPR +Signé — SIMVASTATINE AHL 20MG CPR - +20MG comprime - Dose 2 CPR - ORALE - Soir +[19h] - 1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:09 +Fin le 25/03/2023 à +19:00 +Admin le 01/03/2023 à +19:31 19:00 * 2 +CPR +Signé — SOLUPRED 20MG CPR ORODISP - +20MG comprime - Dose 2 CPR - ORALE - Matin +midi - 1ère dose : 28/02/2023 @ 12:00 [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 12:00 * 2 +CPR +Signé — SOLUPRED 20MG CPR ORODISP - +20MG comprime - Dose 2 CPR - ORALE - Matin +midi - 1ère dose : 28/02/2023 @ 12:00 [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:11 * 2 +CPR +Signé — XATRAL 2,5 MG CPR - 2,5MG +comprime - Dose 1 CPR - ORALE - Matin midi +soir - 1ère dose : 27/02/2023 @ 12:00 [NOM] [NOM] +Début le 27/02/2023 à +11:18 +Fin le 09/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 12:00 * 1 +CPR +Signé — XATRAL 2,5 MG CPR - 2,5MG +comprime - Dose 1 CPR - ORALE - Matin midi +soir - 1ère dose : 27/02/2023 @ 12:00 [NOM] [NOM] +Début le 27/02/2023 à +11:18 +Fin le 09/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 19:00 * 1 +CPR + +Signé — INNOHEP 14 000UI AXA SOL INJ - +14000UI AXa solution (0,7 mL) - Dose 13000 UI +AXa - SOUS-CUTANEE Directe - Soir [19h] - +1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:50 +Fin le 25/03/2023 à +19:00 +Admin le 01/03/2023 à +19:31 19:00 * +13000 UI +AXa +Signé — DESINFECTION ENVIRONNEMENT +PATIENT - Matin [8h] - 1 Semaine- Date Début : 24/02/2023 @ 17:46 [NOM] [NOM] +Début le 24/02/2023 à +17:46 +Fin le 03/03/2023 à +08:00 08:00 * 1 +Signé — REPAS : AIDE PARTIELLE - Matin +[8h] - 1 Semaine- Date Début: 24/02/2023 @ +17:46 [NOM] [NOM] +Début le 24/02/2023 à +17:46 +Fin le 03/03/2023 à +08:00 08:00 * 1 +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 28/02/2023 +@ 06:36 [NOM] [NOM] [NOM] +Début le 28/02/2023 à +06:36 +Fin le 07/03/2023 à +06:00 +Admin le 01/03/2023 à +23:44 22:00 * 1 +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 28/02/2023 +@ 06:36 [NOM] [NOM] [NOM] +Début le 28/02/2023 à +06:36 +Fin le 07/03/2023 à +06:00 +Admin le 01/03/2023 à +23:44 02:00 * 1 +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 28/02/2023 +@ 06:36 [NOM] [NOM] [NOM] +Début le 28/02/2023 à +06:36 +Fin le 07/03/2023 à +06:00 +Admin le 01/03/2023 à +23:44 06:00 * 1 + + + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 10:02 * 1 +GEL +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 16:02 * 1 +GEL +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 22:02 * 1 +GEL +Signé — ACTISKENAN 10MG GELULE - +10MG gelule - Dose 1 GEL - ORALE - Toutes les +6 Heure(s) Si besoin - Début presc. : 24/02/2023 @ +16:02 +"Si douleurs " [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +10:02 04:02 * 1 +GEL +Signé — EZETIMIBE MYL 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Soir [19h] - +1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:09 +Fin le 25/03/2023 à +19:00 +Admin le 01/03/2023 à +19:31 19:00 * 1 +CPR +Signé — FORLAX 10G PDR ORALE SACHET - +10G poudre - Dose 2 SACHET - ORALE - Matin +midi soir - 1ère dose : 25/02/2023 @ 08:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +12:00 +Admin le 02/03/2023 à +08:11 08:00 * 2 +SACHET +Signé — FORLAX 10G PDR ORALE SACHET - +10G poudre - Dose 2 SACHET - ORALE - Matin +midi soir - 1ère dose : 25/02/2023 @ 08:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +12:00 +Admin le 02/03/2023 à +08:11 12:00 * 2 +SACHET +Signé — FORLAX 10G PDR ORALE SACHET - +10G poudre - Dose 2 SACHET - ORALE - Matin +midi soir - 1ère dose : 25/02/2023 @ 08:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +12:00 +Admin le 02/03/2023 à +08:11 19:00 * 2 +SACHET +En cours — GABAPENTINE ARW 300MG +GELULE - 300MG gelule - Dose 1 GEL - +ORALE - Matin soir (8h - 19h) - 1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:00 * 1 +GEL +En cours — GABAPENTINE ARW 300MG +GELULE - 300MG gelule - Dose 1 GEL - +ORALE - Matin soir (8h - 19h) - 1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:02 +Fin le 26/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 19:00 * 1 +GEL + +Signé — LANSOYL FRAMBOISE GEL ORAL +UNIDOSE - 11,734G/15G gel - Dose 1 REC. +UNIDOSE - ORALE - Matin [8h] - 1ère dose : 26/02/2023 @ 08:00 [NOM] [NOM] +Début le 25/02/2023 à +12:47 +Fin le 27/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:00 * +1 REC. +UNIDOSE +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) Si besoin - Début presc. : 28/02/2023 @ +11:19 +"Si nausées et/ou vomissements " [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +03:19 11:19 * 1 +CPR +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) Si besoin - Début presc. : 28/02/2023 @ +11:19 +"Si nausées et/ou vomissements " [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +03:19 19:19 * 1 +CPR +Signé — PRIMPERAN 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Toutes les 8 +Heure(s) Si besoin - Début presc. : 28/02/2023 @ +11:19 +"Si nausées et/ou vomissements " [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +03:19 03:19 * 1 +CPR +Signé — SIMVASTATINE AHL 20MG CPR - +20MG comprime - Dose 2 CPR - ORALE - Soir +[19h] - 1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:09 +Fin le 25/03/2023 à +19:00 +Admin le 01/03/2023 à +19:31 19:00 * 2 +CPR +Signé — SOLUPRED 20MG CPR ORODISP - +20MG comprime - Dose 2 CPR - ORALE - Matin +midi - 1ère dose : 28/02/2023 @ 12:00 [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:00 * 2 +CPR +Signé — SOLUPRED 20MG CPR ORODISP - +20MG comprime - Dose 2 CPR - ORALE - Matin +midi - 1ère dose : 28/02/2023 @ 12:00 [NOM] [NOM] +Début le 28/02/2023 à +11:19 +Fin le 30/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 12:00 * 2 +CPR +Signé — XATRAL 2,5 MG CPR - 2,5MG +comprime - Dose 1 CPR - ORALE - Matin midi +soir - 1ère dose : 27/02/2023 @ 12:00 [NOM] [NOM] +Début le 27/02/2023 à +11:18 +Fin le 09/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 08:00 * 1 +CPR +Signé — XATRAL 2,5 MG CPR - 2,5MG +comprime - Dose 1 CPR - ORALE - Matin midi +soir - 1ère dose : 27/02/2023 @ 12:00 [NOM] [NOM] +Début le 27/02/2023 à +11:18 +Fin le 09/03/2023 à +08:00 +Admin le 02/03/2023 à +08:11 12:00 * 1 +CPR + +Signé — INNOHEP 14 000UI AXA SOL INJ - +14000UI AXa solution (0,7 mL) - Dose 13000 UI +AXa - SOUS-CUTANEE Directe - Soir [19h] - +1ère dose : 24/02/2023 @ 19:00 [NOM] [NOM] +Début le 24/02/2023 à +16:50 +Fin le 25/03/2023 à +19:00 +Admin le 01/03/2023 à +19:31 19:00 * +13000 UI +AXa +Signé — DESINFECTION ENVIRONNEMENT +PATIENT - Matin [8h] - 1 Semaine- Date Début : 24/02/2023 @ 17:46 [NOM] [NOM] +Début le 24/02/2023 à +17:46 +Fin le 03/03/2023 à +08:00 08:00 * 1 +Signé — REPAS : AIDE PARTIELLE - Matin +[8h] - 1 Semaine- Date Début: 24/02/2023 @ +17:46 [NOM] [NOM] +Début le 24/02/2023 à +17:46 +Fin le 03/03/2023 à +08:00 08:00 * 1 +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 28/02/2023 +@ 06:36 [NOM] [NOM] [NOM] +Début le 28/02/2023 à +06:36 +Fin le 07/03/2023 à +06:00 +Admin le 01/03/2023 à +23:44 22:00 * 1 +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 28/02/2023 +@ 06:36 [NOM] [NOM] [NOM] +Début le 28/02/2023 à +06:36 +Fin le 07/03/2023 à +06:00 +Admin le 01/03/2023 à +23:44 02:00 * 1 +Signé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 28/02/2023 +@ 06:36 [NOM] [NOM] [NOM] +Début le 28/02/2023 à +06:36 +Fin le 07/03/2023 à +06:00 +Admin le 01/03/2023 à +23:44 06:00 * 1 + + +Prescription : Date Résultat + +Résultat de labo : 28/02/2023 08:55 +(5895105) 26/02/2023 09:00 +(5892957) 24/02/2023 20:23 +(5892958) 24/02/2023 17:10 +(5892806) +Apparition des symptômes : Asymptomatique +Bilirubine conjuguée calculée : 8 µmol/l +Bilirubine non conjuguée : 12 µmol/l +Bilirubine totale : 8 µmol/l 20 µmol/l +ASAT : 26 U/l 32 U/l +Commentaire bilirubine totale : Bilirubine totale < +21 µmol/L : dosage des +fractions conjuguée +et non conjugée non +réalisé. +Gamma GT : 65 U/l 90 U/l +Phosphatase alcaline : 61 U/l 76 U/l +Calcium : 1,91 mmol/l 2,30 mmol/l +Chlore : 103 mmol/l 93 mmol/l +Créatinine : 68 µmol/l 116 µmol/l +CRP : 30 mg/l 168 mg/l +Compte rendu Bactériologie : Bact230226142435-1.pdf +Compte-rendu laboratoire : Labo230228115307-1.pd fLabo230227094415-1.pd f Labo230225133622-1.pd f +Polynucléaires neutrophiles +(%) : 92,0 % 90,7 % +Polynucléaires neutrophiles +(#) : 3,45 10.9/l 2,42 10.9/l +Polynucléaires éosinophiles +(%) : 0,0 % 0,0 % +Polynucléaires éosinophiles +(#) : 0,00 10.9/l 0,00 10.9/l +Polynucléaires basophiles (%) : 0,0 % 1,1 % +Polynucléaires basophiles (#) : 0,00 10.9/l 0,03 10.9/l +Lymphocytes (%) : 2,0 % 5,2 % +Lymphocytes (#) : 0,07 10.9/l 0,14 10.9/l +Monocytes (%) : 2,0 % 3,0 % + +Monocytes (#) : 0,07 10.9/l 0,08 10.9/l +Morphologie des globules +blancs : Polynucléaires +hyposegmentés ++ +Formule vérifiée par le +technicien : Oui Oui +Myélocytes neutrophiles (%) : 4,0 % +Myélocytes neutrophiles (#) : 0,15 10.9/l +Glucose : 5,7 mmol/l 9,0 mmol/l +ALAT : 38 U/l 58 U/l +Formule sanguine : réalisée sur frottis +sanguin au microscope réalisée sur automate +XN (Sysmex) +Hématocrite (%) : 31,6 % 47,8 % +Indice de distribution des +hématies : 17,0 % 18,5 % +Verification sur lame des +plaquettes : Absence d'amas +plaquettaires. Absence d'amas +plaquettaires. +Traitement anticoagulant : Absence de traitement +anticoagulant +Potassium : 4,0 mmol/l 4,1 mmol/l +LDH : 237 U/l 286 U/l +PCR Grippe A : Négative +PCR Grippe B : Négative +PCR COVID 19 (prélèvement +nasal) GeneXpert : Négative +PCR Virus respiratoire +syncitial : Négative +Culture ECBU TK : Stérile. +Leucocytes : 3,75 10.9/l 16 /µL 2,67 10.9/l +Nature du prélèvement : Urine Milieu de jet +Hématies : 3,74 10.12/l (t/l) 5,64 10.12/l (t/l) +Hémoglobine : 10,7 g/dl 15,9 g/dl +VGM : 84,5 fl 84,8 fl +TCMH : 28,6 pg 28,2 pg +CCMH : 33,9 g/dl 33,3 g/dl +Sodium : 134 mmol/l 134 mmol/l +Non conformité : Prélèvement non +validé initialement par +Service +Osmolarité sang : 274 mOSM/l 277 mOSM/l +Plaquettes : 96 10.9/l 144 10.9/l +Protéines : 48 g/l 72 g/l +Le patient est-il professionel +de santé ? : non +Réserve alcaline : 29 mmol/l 31 mmol/l +Validation et diffusion sous la +responsabilité du biologiste : Dr [NOM] [NOM] Dr [NOM] [NOM] Dr [NOM] [NOM] Dr [NOM] [NOM] +[NOM] anionique : 6 14 +TCA : 21,0 secondes +TCA ratio : 0,69 +TP : 106 % +Temps de Quick : 11,0 secondes +Situation de résidence du +patient : hébergement individuel +Urée : 20,3 mmol/l +Volume plaquettaire moyen : 10,4 fl 9,6 fl diff --git a/test_3ogc/anonymise_old/trackare-01285757-23042510_01285757_23042510.redacted_raster.pdf b/test_3ogc/anonymise_old/trackare-01285757-23042510_01285757_23042510.redacted_raster.pdf new file mode 100644 index 0000000..0d7c702 Binary files /dev/null and b/test_3ogc/anonymise_old/trackare-01285757-23042510_01285757_23042510.redacted_raster.pdf differ diff --git a/test_3ogc/anonymise_old/trackare-02004744-23116460_02004744_23116460.audit.jsonl b/test_3ogc/anonymise_old/trackare-02004744-23116460_02004744_23116460.audit.jsonl new file mode 100644 index 0000000..2568583 --- /dev/null +++ b/test_3ogc/anonymise_old/trackare-02004744-23116460_02004744_23116460.audit.jsonl @@ -0,0 +1,876 @@ +{"page": -1, "kind": "VILLE", "original": "URRUGNE", "placeholder": "[VILLE]", "bbox_hint": null} +{"page": -1, "kind": "VILLE", "original": "URRUGNE", "placeholder": "[VILLE]", "bbox_hint": null} +{"page": -1, "kind": "VILLE", "original": "URRUGNE", "placeholder": "[VILLE]", "bbox_hint": null} +{"page": -1, "kind": "VILLE", "original": "URRUGNE", "placeholder": "[VILLE]", "bbox_hint": null} +{"page": -1, "kind": "CODE_POSTAL", "original": "64122", "placeholder": "[CODE_POSTAL]", "bbox_hint": null} +{"page": -1, "kind": "CODE_POSTAL", "original": "64122", "placeholder": "[CODE_POSTAL]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "EPISODE", "original": "23116460", "placeholder": "[NDA]", "bbox_hint": null} +{"page": -1, "kind": "ADRESSE", "original": "300 CH. 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[ADRESSE], [CODE_POSTAL] +640000162 +POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine +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 de résidence: [[VILLE]] +[ADRESSE] +Détails épisode +Episode No : [IPP] +Localisation : Pôle Méd. interne : H semaine Médecin courant: DR. [NOM] +Date d'admission : [DATE] Heure d'admission: 07:34 +Date de sortie : [DATE] Heure de sortie: 12:05 +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 +Fils X FRANCE [TEL] +(Clinicom) +Personne à prévenir [NOM] +Epouse [NOM] [TEL] [TEL] +(Trakcare) [NOM] +Personne à prévenir +Fils [NOM] [NOM] [TEL] +(Trakcare) +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 [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance [DATE] 07:48 22:48 18:43 14:21 12:24 07:55 22:55 18:37 17:23 14:31 13:31 12:05 +Pouls 77 77 95 87 71 79 +PA +115 137 156 146 145 121 +Systolique +PA +69 78 90 86 72 67 +Diastolique +Glycémie +1,10 1,16 1,15 1,24 1,39 1,22 1,23 1,09 1,46 1,76 1,47 +capillaire +Température 36,50 +Saturation +97 +O² +Ventilation +spontanée +Ventilation +Air +ambiant +Echelle +EN +douleur +Score au +0 +repos +Poids/Taille +Item de [DATE] [DATE] [DATE] +surveillance [DATE] 08:10 00:28 +Poids [kg] 97,10 98,90 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [IPP] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le [DATE] 14 : 55 Page 1 de 12 Taille [cm] 172 172 172 +Indice +de masse 32,82 33,43 +corporelle +Surface +2,10 2,11 +corporelle +Surv. Isolement et Contention +Item de [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance [DATE] 07:48 07:55 22:55 17:23 13:31 08:05 07:59 07:51 08:06 +Pouls 77 77 95 87 71 79 111 72 73 82 +PA +[NIR] 123 148 145 137 +Systolique +PA +69 78 90 86 72 67 64 72 73 79 +Diastolique +Température 36,50 36,60 36,40 +Saturation +97 96 97 +O² +Surv. Contention +Item de [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance [DATE] 07:48 22:48 18:43 14:21 12:24 07:55 22:55 18:37 17:23 14:31 13:31 12:05 +Pouls 77 77 95 87 71 79 +PA +[NIR] +Systolique +PA +69 78 90 86 72 67 +Diastolique +Glycémie +1,10 1,16 1,15 1,24 1,39 1,22 1,23 1,09 1,46 1,76 1,47 +capillaire +Température 36,50 +Saturation +97 +O² +Observations médicales +Type d'observation Nom Date Commentaires +HDS/ETP/Atelier de groupe +A participé à une séance collective de l’atelier « Mieux Connaitre mes Médicaments » +A partir de l’ordonnance de ce jour, les principaux points abordés : +- Savoir distinguer les médicaments du diabète des médicaments des autres pathologies +- Mieux connaitre les indications de chaque médicament +- Principaux effets indésirables survenus ou à « prévenir » : Metformine notamment +- Horaires de prise : notamments quels médicaments ne pas prendre si repas sauté +Avis spécialisés DR. [NOM] [DATE] - Pilulier : principe & modalités d’utilisation pratique d’un pilulier semainier +recueillis [NOM] 17 : 49 - Automédication responsable : Attention aux AINS en vente sans ordonnances +- Informer les différents professionnels de santé de toutes les prises de médicaments ou de +phytothérapie (Tisanes, Huiles essentielles…) Jus de pamplemousse, Millepertuis & Interactions +médicamenteuses +- S’assurer d’avoir l’ensemble des ordonnances et qu’elles soient à jour +- Ne pas hésiter à solliciter les pharmaciens pour info sur médicaments surtout lors du switch vers +les génériques +Motif entrée : +Première éducation dans le cadre d'un diabète de type 2 +Introduction de GLP1 en en neurologie lors de son AVC en [DATE] (HbA1c 7,9%) +Antécédents +FA +SAOS appareillé +diabete +HTA +Histoire de la DR. [NOM] [DATE] +AVC [DATE] +maladie [NOM] 10 : 16 +Suivi retentissement : +Ophtalmo Dr [NOM], dernière cs [DATE] : rétinopathie minime et maculopathie. IVT OD +prévue +cardio : dernière évaluation Dr [NOM] en [DATE] +Traitements habituels +Nebivolol 5 mg 1-0-0 +Pravastatine 40 mg 1 le soir +Eliquis 5 : 1 cp matin et soir +Perindopril 10mg 1-0-0 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le [DATE] 14 : 55 Page 2 de 12 Amlodipine 5 le matin +Velmetia 50/1000mg 1-0-1 (alors que je l'avais arrêté en neurologie et j'avais prescrit metformine +seule) +Gliclazide 30mg 2-0-0 +Trulicity 1,5 les mardis +Vaccination ne sait pas pour covid et tétanos, n'a jamais été vacciné contre la grippe +Mode de vie : +Vit avec son épouse +n'a jamais fumé +EC : +Ralentisement idéomoteur +Poids 98,9 IMC 33,4 kg/m² +Onychomycose, pallesthésie OK, pouls OK pieds grade 0 +Biologie : +HbA1C 7,1% +TSH 0,72 +LDL 0,55 Tg 0,92 HDL 0,31 g/l +iono NFS bilan hépatique sans anomalies +Créatinémie 65 µmol/l +RAC 2,6 mg/mmol +Albuminémie 39,4 g/L +Carence modérée en vitamine D +Pas de carence en vitamine B12 et folates +PRISE EN CHARGE DANS LE SERVICE : +Pas de modification du traitement antidiabétique +avis EMOG (cf CR). Introduction de seroplex +Supplémentation par une ampoule d'uvedose +Suivi : +Pas de cs diabéto +HbA1C tous les 3 mois, objectif 7,5% +Cs cardio à reprévoir +CS cardio pour IVT à organiser avec le Dr [NOM] +Conclusion : diabète type 2 compliqué sur le plan vasculaire, bien équilibré depuis +l'introduction de GLP1 +Syndrome dépressif, introduction de seroplex après avis EMOG +Surveillance Psychiatrie +Item de [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance 07 : 59 07:48 07:55 22:55 17:23 13:31 08:05 07:59 07:51 08:06 +Pouls 77 77 95 87 71 79 111 72 73 82 +PA +[NIR] +Systolique +PA +69 78 90 86 72 67 64 72 73 79 +Diastolique +Température 36,50 36,60 36,40 +Saturation +97 96 97 +O² +Notes paramédicales +Type de note Nom Date Note +HDS ETP DIET +Patient DT2 sous AGLP1, Metformine et Glibenclamide +contexte d'AVC récent, troubles de l'élocution, a du mal à s'exprimer. +HbA1C : 7,1 % +obésité : 98,9 kg, 1,72m, IMC:33,4. +Marié, retraité ouvrier. +Activité physique : un peu de marche. +[DATE] +Note Diététicienne [NOM] [NOM] +11 : 43 +Alimentation +Depuis l'AVC, l'épouse de Monsieur a beaucoup diminué les charcuteries, +le fromage et le pain dans les repas. +Monsieur mangeait charcuteries tous les jours, midi et soir. +Les repas sont structurés avec VPO, Féculent et légumes, un peu de pain, fromage 1x/jour, +1 fruit ou 1 compote. +PEC diététique : +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [IPP] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le [DATE] 14 : 55 Page 3 de 12 - a assisté aux ateliers diététiques, à l'écoute, +- entretien avec son épouse et sa fille : patient qui était gros mangeur et surtout tachyphage +--> nous faisons le point sur les RHD : modération des quantités mais sans interdits stricts, +fromage 1x/jour, charcuterie permis en qt modérée 2 à 3/semaine, pain à chaque repas +avec équivalence pain/féculent, équivalence fruit/dessert sucré +--> notion de manger plus lentement, pour mieux gérer les quantités, abordé aussi en atelier, +--> notion de plaisir alimentaire donc ne pas supprimer les aliments qu'il aime +mais être plus modéré sur les quantités et/ou les fréquences, +--> support écrit pour le RAD. +- a perdu 1,8 kg. +[DATE] Risque podologique : Grade 0 +Note IDE [NOM] [NOM] +11 : 05 A participé à l'atelier +[DATE] +Note IDE [NOM] [NOM] Psy : souhaite l'EMOG, patient triste +21 : 14 +Mr B admet avoir perdu de ses connaissances sur le diabète. Désireux de participer aux ateliers +[DATE] pour obtenir les informations en lien avec la pathologie, en vue de mieux la réguler. +Note IDE [NOM] [NOM] +17 : 45 Je lui propose de l'éduquer à l'utilisation de son lecteur de glycémie, n'est pas demandeur il dit +que son épouse le fait pour lui. Elle sera là demain matin→ prévoir de l'éduquer? +Traitements médicamenteux +Date de dernière +Prescription Dose Fréquence Date de début Note Docteur +administration +Voie d`administration : ORALE +Statut des prescriptions : Signé +AMLODIPINE ARG 5MG DR. [NOM] +1 GEL - Matin [8h] Normal [DATE] 10 : 34 [DATE] 07:55 +GELULE [30] Gelule(s) [NOM] +ELIQUIS 5MG CPR [60] - Matin soir (8h - DR. [NOM] +1 CPR [DATE] 10 : 34 [DATE] 07:55 +COMPRIME(S) 19h) Normal [NOM] +GLICLAZIDE ARW +DR. [NOM] +LM 30MG CPR [30] 2 CPR - Matin [8h] Normal [DATE] 10 : 34 [DATE] 07:55 +[NOM] +COMPRIME(S) +METFORMINE MYP +- Matin soir (8h - DR. [NOM] +1000MG CPR [30] 1 CPR [DATE] 10 : 34 [DATE] 07:55 +19h) Normal [NOM] +COMPRIME(S) +NEBIVOLOL ARW 5MG DR. [NOM] +1 CPR - Matin [8h] Normal [DATE] 10 : 34 [DATE] 07:55 +CPR [90] COMPRIME(S) [NOM] +PERINDOPRIL ARW 4MG DR. [NOM] +2 CPR - Matin [8h] Normal [DATE] 10 : 34 [DATE] 07:55 +CPR [30] COMPRIME(S) [NOM] +PRAVASTATINE +DR. [NOM] +MYL 40MG CPR [28] 1 CPR - Soir [19h] Normal [DATE] 10 : 34 [DATE] 18:37 +[NOM] +COMPRIME(S) +Statut des prescriptions : Réalisé +AMLODIPINE ARG 5MG - Matin [8h] Presc. de DR. [NOM] +1 GEL [DATE] 09 : 30 +GELULE [30] Gelule(s) Sortie [NOM] +ELIQUIS 5MG CPR [60] - Matin soir (8h - DR. [NOM] +1 CPR [DATE] 09 : 30 +COMPRIME(S) 19h) Presc. de Sortie [NOM] +GLICLAZIDE ARW +- Matin [8h] Presc. de DR. [NOM] +LM 30MG CPR [30] 2 CPR [DATE] 09 : 30 +Sortie [NOM] +COMPRIME(S) +METFORMINE MYP +- Matin soir (8h - DR. [NOM] +1000MG CPR [30] 1 CPR [DATE] 09 : 30 +19h) Presc. de Sortie [NOM] +COMPRIME(S) +NEBIVOLOL ARW 5MG - Matin [8h] Presc. de DR. [NOM] +1 CPR [DATE] 09 : 30 +CPR [90] COMPRIME(S) Sortie [NOM] +PERINDOPRIL ARW 4MG - Matin [8h] Presc. de DR. [NOM] +2 CPR [DATE] 09 : 30 +CPR [30] COMPRIME(S) Sortie [NOM] +PRAVASTATINE +- Soir [19h] Presc. de DR. [NOM] +MYL 40MG CPR [28] 1 CPR [DATE] 09 : 30 +Sortie [NOM] +COMPRIME(S) +ZYMAD 80000UI SOL BUV - 1 seule fois 1 seule DR. [NOM] +1 AMP [DATE] 09 : 29 [DATE] 12:22 +AMP [1] Ampoule(s) fois [NOM] +Voie d`administration : SOUS-CUTANEE +Statut des prescriptions : Signé +TRULICITY 1,5 MG SOL +- 1xSemaine [8h] DR. [NOM] +INJ STYLO [4] Stylo(s) 1,5 mg [DATE] 10 : 34 +Normal [NOM] +Prerempli(s) +TRULICITY 1,5 MG SOL +- 1xSemaine [8h] DR. [NOM] +INJ STYLO [4] Stylo(s) 1,5 mg [DATE] 09 : 30 +Presc. de Sortie [NOM] +Prerempli(s) +Prescriptions de laboratoire +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [EPISODE] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le [DATE] 14 : 55 Page 4 de 12 Date de +Date Heure Prescription Docteur [NOM] +collection +[DATE] +[DATE] 08 : 00 Ionogramme ( Na, K, CL ) [NOM] [NOM] [NOM] +09 : 22 +Prescriptions de soins +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +[DATE] [NOM] +REGIME DIABÉTIQUE Signé - à 08h Normal +07 : 00 [NOM] +[DATE] [NOM] +DIAGNOSTIC EDUCATIF Signé - à 08h Normal +07 : 00 [NOM] +DESINFECTION +[DATE] [NOM] +ENVIRONNEMENT Réalisé - Matin [8h] Normal +07 : 00 [NOM] +PATIENT +LIT : REFECTION [DATE] [NOM] +Réalisé - Matin [8h] Normal +PARTIELLE 07 : 00 [NOM] +- Matin midi soir [DATE] [NOM] +REPAS : INSTALLATION Réalisé +Normal 07 : 00 [NOM] +- 3x/Nuit (22h 2h 6h) [DATE] [NOM] +SOMMEIL : SURV. Réalisé +Normal 21 : 00 [NOM] +[DATE] [NOM] +EDUCATION DIABETIQUE Réalisé - Matin [8h] Normal +07 : 00 [NOM] +- 7x/jour (8h 12h +GLYCEMIE CAPILLAIRE x [DATE] [NOM] +Réalisé 14h 19h 22h 0h 4h) +7 07 : 00 [NOM] +Normal +SIGNES VITAUX (Pls, +- 2X /jour (8h 16h) [DATE] [NOM] +TA, FR, T°, Glyc, Miction, Réalisé +Normal 07 : 00 [NOM] +Transit) +Prescriptions de sortie +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +DR. +AMLODIPINE ARG 5MG 1 GEL - Matin [8h] Presc. de [DATE] [DATE] : Non administré +Réalisé [NOM] +GELULE [30] Gelule(s) ORALE Sortie [DATE] Révisé/Traité +[NOM] +DR. +[NOM] 5MG CPR [60] 1 CPR - Matin soir (8h - [DATE] [DATE] : Non administré +Réalisé [NOM] +COMPRIME(S) ORALE 19h) Presc. de Sortie [DATE] Révisé/Traité +[NOM] +GLICLAZIDE ARW DR. +2 CPR - Matin [8h] Presc. de [DATE] [DATE] : Non administré +LM 30MG CPR [30] Réalisé [NOM] +ORALE Sortie [DATE] Révisé/Traité +COMPRIME(S) [NOM] +METFORMINE MYP DR. +1 CPR - Matin soir (8h - [DATE] [DATE] : Non administré +1000MG CPR [30] Réalisé [NOM] +ORALE 19h) Presc. de Sortie [DATE] Révisé/Traité +COMPRIME(S) [NOM] +DR. +[NOM] 5MG 1 CPR - Matin [8h] Presc. de [DATE] [DATE] : Non administré +Réalisé [NOM] +CPR [90] COMPRIME(S) ORALE Sortie [DATE] Révisé/Traité +[NOM] +DR. +[NOM] 4MG 2 CPR - Matin [8h] Presc. de [DATE] [DATE] : Non administré +Réalisé [NOM] +CPR [30] COMPRIME(S) ORALE Sortie [DATE] Révisé/Traité +[NOM] +PRAVASTATINE DR. +1 CPR - Soir [19h] Presc. de [DATE] [DATE] : Non administré +MYL 40MG CPR [28] Réalisé [NOM] +ORALE Sortie [DATE] Révisé/Traité +COMPRIME(S) [NOM] +TRULICITY 1,5 MG SOL 1,5 mg DR. +- 1xSemaine [8h] [DATE] 0/4 : Non administré +INJ STYLO [4] Stylo(s) SOUS- Signé [NOM] +Presc. de Sortie [DATE] A valider +Prerempli(s) CUTANEE [NOM] +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [IPP] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le [DATE] 14 : 55 Page 5 de 12 Plan de soins Jour J du [DATE] 07h00 au [DATE] 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +Signé — REGIME DIABÉTIQUE - à 08h - Début le [DATE] à +pendant 5 Jour(s)- Date Début : [DATE] @ 07:00 +07 : 00 Fin le [DATE] à 07:55 * 1 +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — AMLODIPINE ARG 5MG GELULE - Début le [DATE] à +5MG gelule - Dose 1 GEL - ORALE - Matin [8h] 10 : 34 07:55 * 1 +- 1ère dose : [DATE] @ 08:00 Fin le [DATE] à GEL +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — ELIQUIS 5MG CPR - 5MG comprime Début le [DATE] à +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - 10 : 34 19:00 * 1 +1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — ELIQUIS 5MG CPR - 5MG comprime Début le [DATE] à +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - 10 : 34 07:55 * 1 +1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — GLICLAZIDE ARW LM 30MG CPR - Début le [DATE] à +30MG comprime - Dose 2 CPR - ORALE - Matin 10 : 34 07:55 * 2 +[8h] - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — METFORMINE VIATRIS 1 000 Début le [DATE] à +MG CPR - 1000MG comprime - Dose 1 CPR 10 : 34 +- 1 9 O /0 R 6 A /2 L 0 E 2 3 - M @ a 1 ti 9 n : [DATE] (8h - 19h) - 1ère dose: F 08 in :0 l 0 e [DATE] à 1 C 9 P : R 00 * 1 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — METFORMINE VIATRIS 1 000 Début le [DATE] à +MG CPR - 1000MG comprime - Dose 1 CPR 10 : 34 +- 1 9 O /0 R 6 A /2 L 0 E 2 3 - M @ a 1 ti 9 n : [DATE] (8h - 19h) - 1ère dose: F 08 in :0 l 0 e [DATE] à 0 C 7 P : R 55 * 1 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — NEBIVOLOL ARW 5MG CPR - 5MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Matin [8h] - 10 : 34 07:55 * 1 +1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — PERINDOPRIL ARW 4MG CPR - 4MG Début le [DATE] à +comprime - Dose 2 CPR - ORALE - Matin [8h] - 10 : 34 07:55 * 2 +1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — PRAVASTATINE MYL 40MG CPR - Début le [DATE] à +40MG comprime - Dose 1 CPR - ORALE - Soir 10 : 34 19:00 * 1 +[19h] - 1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +19 : 00 +Admin le [DATE] à +18 : 37 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [IPP] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le [DATE] 14 : 55 Page 6 de 12 [NOM] [NOM] +Réalisé — DESINFECTION Début le [DATE] à +ENVIRONNEMENT PATIENT - Matin [8h] - [DATE] +pendant 7 Jour(s)- Date Début : [DATE] @ Fin le [DATE] à 08:00 * 1 +[DATE] 08:00 +Admin le [DATE] à +08 : 00 +[NOM] [NOM] +Réalisé — LIT : REFECTION PARTIELLE Début le [DATE] à +- Matin [8h] - pendant 7 Jour(s)- Date Début : 07:00 +[DATE] @ [DATE] Fin le [DATE] à 08:00 * 1 +08 : 00 +Admin le [DATE] à +08 : 00 +[NOM] [NOM] +Réalisé — REPAS : INSTALLATION - Matin Début le [DATE] à +midi soir - pendant 7 Jour(s)- Date Début : 07:00 +[DATE] @ [DATE] Fin le [DATE] à 19:00 * 1 +19 : 00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Réalisé — REPAS : INSTALLATION - Matin Début le [DATE] à +midi soir - pendant 7 Jour(s)- Date Début : 07:00 +[DATE] @ [DATE] Fin le [DATE] à 08:00 * 1 +19 : 00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Réalisé — REPAS : INSTALLATION - Matin Début le [DATE] à +midi soir - pendant 7 Jour(s)- Date Début : 07:00 +[DATE] @ [DATE] Fin le [DATE] à 12:00 * 1 +19 : 00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le [DATE] à +6h) - pendant 7 Jour(s)- Date Début : [DATE] 21:00 +@ 21 : 00 Fin le [DATE] à 06:00 * 1 +06 : 00 +Admin le [DATE] à +06 : 37 +[NOM] [NOM] +Réalisé — EDUCATION DIABETIQUE - Matin Début le [DATE] à +[8h] - pendant 7 Jour(s)- Date Début : [DATE] 07:00 +@ [DATE] Fin le [DATE] à 07:55 * 1 +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le [DATE] à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 [DATE] +Jour(s)- Date Début : [DATE] @ 07:00 Fin le [DATE] à 14:00 * 1 +04 : 00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le [DATE] à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 [DATE] +Jour(s)- Date Début : [DATE] @ 07:00 Fin le [DATE] à 19:00 * 1 +04 : 00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le [DATE] à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 [DATE] +Jour(s)- Date Début : [DATE] @ 07:00 Fin le [DATE] à 22:00 * 1 +04 : 00 +Admin le [DATE] à +12 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [IPP] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le [DATE] 14 : 55 Page 7 de 12 [NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le [DATE] à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 07 : 00 +Jour(s)- Date Début : [DATE] @ 07:00 Fin le [DATE] à 00:00 * 1 +04 : 00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le [DATE] à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 07 : 00 +Jour(s)- Date Début : [DATE] @ 07:00 Fin le [DATE] à 04:00 * 1 +04 : 00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le [DATE] à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 07 : 00 +Jour(s)- Date Début : [DATE] @ 07:00 Fin le [DATE] à 08:00 * 1 +04 : 00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ Début le [DATE] à +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 07 : 00 +Jour(s)- Date Début : [DATE] @ 07:00 Fin le [DATE] à 12:00 * 1 +04 : 00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T Début le [DATE] à +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - 07 : 00 +pendant 7 Jour(s)- Date Début : [DATE] @ Fin le [DATE] à 16:00 * 1 +07 : 00 16:00 +Admin le [DATE] à +08 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T Début le [DATE] à +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - 07 : 00 +pendant 7 Jour(s)- Date Début : [DATE] @ Fin le [DATE] à 08:00 * 1 +07 : 00 16:00 +Admin le [DATE] à +08 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [IPP] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le [DATE] 14 : 55 Page 8 de 12 Plan de soins Jour J + 1 du [DATE] 07h00 au [DATE] 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +Signé — AMLODIPINE ARG 5MG GELULE - Début le [DATE] à +5MG gelule - Dose 1 GEL - ORALE - Matin [8h] 10 : 34 08:00 * 1 +- 1ère dose : [DATE] @ 08:00 Fin le [DATE] à GEL +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — ELIQUIS 5MG CPR - 5MG comprime Début le [DATE] à +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - 10 : 34 08:00 * 1 +1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — ELIQUIS 5MG CPR - 5MG comprime Début le [DATE] à +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - 10 : 34 19:00 * 1 +1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — GLICLAZIDE ARW LM 30MG CPR - Début le [DATE] à +30MG comprime - Dose 2 CPR - ORALE - Matin 10 : 34 08:00 * 2 +[8h] - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — METFORMINE VIATRIS 1 000 Début le [DATE] à +MG CPR - 1000MG comprime - Dose 1 CPR 10 : 34 +- 1 9 O /0 R 6 A /2 L 0 E 2 3 - M @ a 1 ti 9 n : [DATE] (8h - 19h) - 1ère dose: F 08 in :0 l 0 e [DATE] à 0 C 8 P : R 00 * 1 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — METFORMINE VIATRIS 1 000 Début le [DATE] à +MG CPR - 1000MG comprime - Dose 1 CPR 10 : 34 +- 1 9 O /0 R 6 A /2 L 0 E 2 3 - M @ a 1 ti 9 n : [DATE] (8h - 19h) - 1ère dose: F 08 in :0 l 0 e [DATE] à 1 C 9 P : R 00 * 1 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — NEBIVOLOL ARW 5MG CPR - 5MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Matin [8h] - 10 : 34 08:00 * 1 +1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — PERINDOPRIL ARW 4MG CPR - 4MG Début le [DATE] à +comprime - Dose 2 CPR - ORALE - Matin [8h] - 10 : 34 08:00 * 2 +1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Signé — PRAVASTATINE MYL 40MG CPR - Début le [DATE] à +40MG comprime - Dose 1 CPR - ORALE - Soir 10 : 34 19:00 * 1 +[19h] - 1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +19 : 00 +Admin le [DATE] à +18 : 37 +[NOM] [NOM] +Réalisé — DESINFECTION Début le [DATE] à +ENVIRONNEMENT PATIENT - Matin [8h] - 07 : 00 +pendant 7 Jour(s)- Date Début : [DATE] @ Fin le [DATE] à 08:00 * 1 +07 : 00 08:00 +Admin le [DATE] à +08 : 00 +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [IPP] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le [DATE] 14 : 55 Page 9 de 12 [NOM] [NOM] +Réalisé — LIT : REFECTION PARTIELLE Début le [DATE] à +- Matin [8h] - pendant 7 Jour(s)- Date Début : 07:00 +[DATE] @ [DATE] Fin le [DATE] à 08:00 * 1 +08 : 00 +Admin le [DATE] à +08 : 00 +[NOM] [NOM] +Réalisé — REPAS : INSTALLATION - Matin Début le [DATE] à +midi soir - pendant 7 Jour(s)- Date Début : 07:00 +[DATE] @ [DATE] Fin le [DATE] à 08:00 * 1 +19 : 00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Réalisé — REPAS : INSTALLATION - Matin Début le [DATE] à +midi soir - pendant 7 Jour(s)- Date Début : 07:00 +[DATE] @ [DATE] Fin le [DATE] à 12:00 * 1 +19 : 00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Réalisé — REPAS : INSTALLATION - Matin Début le [DATE] à +midi soir - pendant 7 Jour(s)- Date Début : 07:00 +[DATE] @ [DATE] Fin le [DATE] à 19:00 * 1 +19 : 00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le [DATE] à +6h) - pendant 7 Jour(s)- Date Début : [DATE] 21:00 +@ 21 : 00 Fin le [DATE] à 22:00 * 1 +06 : 00 +Admin le [DATE] à +06 : 37 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le [DATE] à +6h) - pendant 7 Jour(s)- Date Début : [DATE] 21:00 +@ 21 : 00 Fin le [DATE] à 02:00 * 1 +06 : 00 +Admin le [DATE] à +06 : 37 +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le [DATE] à +6h) - pendant 7 Jour(s)- Date Début : [DATE] 21:00 +@ 21 : 00 Fin le [DATE] à 06:00 * 1 +06 : 00 +Admin le [DATE] à +06 : 37 +[NOM] [NOM] +Réalisé — EDUCATION DIABETIQUE - Matin Début le [DATE] à +[8h] - pendant 7 Jour(s)- Date Début : [DATE] 07:00 +@ [DATE] Fin le [DATE] à 08:00 * 1 +08 : 00 +Admin le [DATE] à +07 : 55 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T Début le [DATE] à +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - [DATE] +pendant 7 Jour(s)- Date Début : [DATE] @ Fin le [DATE] à 08:00 * 1 +[DATE] 16:00 +Admin le [DATE] à +08 : 00 +[NOM] [NOM] +Réalisé — SIGNES VITAUX (Pls, TA, FR, T Début le [DATE] à +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - [DATE] +pendant 7 Jour(s)- Date Début : [DATE] @ Fin le [DATE] à 16:00 * 1 +[DATE] 16:00 +Admin le [DATE] à +08 : 00 +Résultats de laboratoire +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [IPP] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le [DATE] 14 : 55 Page 10 de 12 [DATE] 06 : 38 [DATE] 11:27 [DATE] 09:22 +Résultat de labo +(5984891) (5980669) (5980670) +Hémoglobine A1c 7,1 % +Albumine 39,4 g/l +Acide urique 372 µmol/l +Les valeurs de +références de 25- +hydroxyvitamine D +se situent entre 30 +et 60 ng/mL pour la +prise en charge de +patients porteurs d'une +pathologie osseuse, +phosphocalcique ou +rénale, à l'exception +des patients dialysés +pour lesquels la zone +cible est réduite (30 à +45-50 ng/mL). Pour +les patients ayant une +granulomatose, la 25- +hydroxyvitamine D +doit être comprise +entre 15 et 20 ng/ +mL. Concernant la +population générale, +le dosage de 25- +hydroxyvitamine D +n'est pas indiqué et il +n'existe pas de valeurs +de références, sachant +Commentaire 25 +qu'environ 50 % de la +hydroxyvitamine D +population générale +en bonne santé a une +concentration de 25- +hydroxyvitamine D +inférieure à 20 ng/ +mL. Pour rappel, les +indications du dosage +de 25-hydroxyvitamine +D validées par la +HAS sont la suspicion +de rachitisme ou +d'ostéomalacie, le +suivi des patients +transplantés rénaux +3 mois après +transplantation, +la surveillance de +patients avant et après +chirurgie bariatrique, +les personnes âgées +faisant des chutes à +répétition et le suivi +des traitements pour +lesquels le dosage de +25-hydroxyvitamine D +est préconisé. +ASAT 32 U/l +Ferritine 295,13 µg/l +Gamma GT 17 U/l +Objectifs +thérapeutiques pour +les patients présentant +un risque cardio- +vasculaire (HAS +[DATE]) : Risque cardio- +Commentaire LDL +vasculaire faible : +< : 4,9 mmol/L (1,9 +g/L) Risque cardio- +vasculaire modéré : +< : 3,4 mmol/L (1,3 +g/L) Risque cardio- +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [IPP] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le [DATE] 14 : 55 Page 11 de 12 vasculaire élevé : +< : 2,6 mmol/L (1 +g/L) Risque cardio- +vasculaire très élevé : +< : 1,8 mmol/L (0,7 g/ +L) +TSH 3ème génération 0,72 mUI/L +25-hydroxyvitamine D 17 ng/ml +Rapport Albuminurie / +2,6 mg/mmol +Créatininurie +Cholestérol total 2,58 mmol/l +HDL cholestérol 0,81 mmol/l +Chlore 105 mmol/l +LDL cholestérol 1,42 mmol/l +Créatinine 65 µmol/l +CRP 9 mg/l 1 mg/l +Créatinine urinaire 10,72 mmol/l +Compte-rendu laboratoire Labo230622102021-1.pdfLabo230619163045-1.pdfLabo230619130416-1.pdf +Folates 8,79 nmol/l +Polynucléaires neutrophiles +76,6 % +(%) +Polynucléaires neutrophiles +5,77 10.9/l +(#) +Polynucléaires éosinophiles +2,5 % +(%) +Polynucléaires éosinophiles +0,19 10.9/l +(#) +Polynucléaires basophiles (%) 0,5 % +Polynucléaires basophiles (#) 0,04 10.9/l +Lymphocytes (%) 11,8 % +Lymphocytes (#) 0,89 10.9/l +Monocytes (%) 8,6 % +Monocytes (#) 0,65 10.9/l +Glucose 5,5 mmol/l +ALAT 28 U/l +réalisée sur automate +Formule sanguine +XN (Sysmex) +Hématocrite (%) 42,2 % +Indice de distribution des +12,4 % +hématies +Traitement anticoagulant Inconnu +Potassium 3,7 mmol/l +Albumine urinaire 28 mg/l +Leucocytes 7,53 10.9/l +Hématies 4,54 10.12/l (t/l) +Hémoglobine 14,5 g/dl +VGM 93,0 fl +TCMH 31,9 pg +CCMH 34,4 g/dl +Sodium 137 mmol/l +Osmolarité sang 280 mOSM/l +Plaquettes 184 10.9/l +Protéines 73 g/l +Validation et diffusion sous la +"" Dr [NOM] [NOM] [NOM] +responsabilité du biologiste +TCA 35,0 secondes +TCA ratio 1,16 +TP 88 % +Temps de Quick 12,4 secondes +Triglycérides 1,04 mmol/l +Vitamine B12 436 pmol/l +Volume plaquettaire moyen 12,3 fl +Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02004744 ) +Episode N. : [IPP] ( POLE MEDECINE INTERNE - Pôle Méd. interne : H semaine ) - Taille: 172 cm - Poids: 97.1 kg - IMC: 32.822 +Le [DATE] 14 : 55 Page 12 de 12 + + +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 : [ADRESSE] Ville de résidence: [VILLE] +Episode No : [EPISODE] +Localisation : Pôle Méd. interne : H semaine Médecin courant: DR. [NOM] +Date d'admission : 19/06/2023 Heure d'admission: 07:34 +Date de sortie : 23/06/2023 Heure de sortie: 12:05 +Nom : Adresse Téléphone +DR. [NOM] [NOM] : [ADRESSE][CODE_POSTAL] +Type de contact : Relation Nom Prénom Adresse Tél. domicile Tél. +professionel Mobile +Personne à prévenir +(Clinicom) : Fils X FRANCE [TEL] +Personne à prévenir +(Trakcare) : Epouse [NOM] [NOM] +gabrielle [TEL] [TEL] +Personne à prévenir +(Trakcare) : Fils [NOM] gerard [TEL] +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Item de +surveillance : 23/06/2023 +07:59 23/06/2023 +07:48 22/06/2023 +22:48 22/06/2023 +18:43 22/06/2023 +14:21 22/06/2023 +12:24 22/06/2023 +07:55 21/06/2023 +22:55 21/06/2023 +18:37 21/06/2023 +17:23 21/06/2023 +14:31 21/06/2023 +13:31 21/06/2023 +12:05 +Pouls : 77 77 95 87 71 79 +PA +Systolique : 115 137 156 146 145 121 +PA +Diastolique : 69 78 90 86 72 67 +Glycémie +capillaire : 1,10 1,16 1,15 1,24 1,39 1,22 1,23 1,09 1,46 1,76 1,47 +Température : 36,50 +Saturation +O² : 97 +Ventilation : Ventilatio +spontanée +Air +ambiant n +Echelle +douleur : EN +Score au +repos : 0 +Item de +surveillance : 23/06/2023 +07:54 19/06/2023 +08:10 16/06/2023 +00:28 +Poids [kg] : 97,10 98,90 + +Taille [cm] : 172 172 172 +Indice +de masse +corporelle : 32,82 33,43 +Surface +corporelle : 2,10 2,11 +Item de +surveillance : 23/06/2023 +07:59 23/06/2023 +07:48 22/06/2023 +07:55 21/06/2023 +22:55 21/06/2023 +17:23 21/06/2023 +13:31 21/06/2023 +08:05 21/06/2023 +07:59 20/06/2023 +07:51 19/06/2023 +08:06 +Pouls : 77 77 95 87 71 79 111 72 73 82 +PA +Systolique : 115 137 156 146 145 121 123 148 145 137 +PA +Diastolique : 69 78 90 86 72 67 64 72 73 79 +Température : 36,50 36,60 36,40 +Saturation +O² : 97 96 97 +Item de +surveillance : 23/06/2023 +07:59 23/06/2023 +07:48 22/06/2023 +22:48 22/06/2023 +18:43 22/06/2023 +14:21 22/06/2023 +12:24 22/06/2023 +07:55 21/06/2023 +22:55 21/06/2023 +18:37 21/06/2023 +17:23 21/06/2023 +14:31 21/06/2023 +13:31 21/06/2023 +12:05 +Pouls : 77 77 95 87 71 79 +PA +Systolique : 115 137 156 146 145 121 +PA +Diastolique : 69 78 90 86 72 67 +Glycémie +capillaire : 1,10 1,16 1,15 1,24 1,39 1,22 1,23 1,09 1,46 1,76 1,47 +Température : 36,50 +Saturation +O² : 97 +Type d'observation : Nom Date Commentaires +Avis spécialisés +recueillis : DR. [NOM] +[NOM] 22/06/2023 +17:49 HDS/ETP/Atelier de groupe +A participé à une séance collective de l’atelier « Mieux Connaitre mes Médicaments » +A partir de l’ordonnance de ce jour, les principaux points abordés : +- Savoir distinguer les médicaments du diabète des médicaments des autres pathologies +- Mieux connaitre les indications de chaque médicament +- Principaux effets indésirables survenus ou à « prévenir » : Metformine notamment +- Horaires de prise :notamments quels médicaments ne pas prendre si repas sauté +- Pilulier : principe & modalités d’utilisation pratique d’un pilulier semainier +- Automédication responsable : Attention aux AINS en vente sans ordonnances +- Informer les différents professionnels de santé de toutes les prises de médicaments ou de +phytothérapie (Tisanes, Huiles essentielles…) Jus de pamplemousse, Millepertuis & Interactions +médicamenteuses +- S’assurer d’avoir l’ensemble des ordonnances et qu’elles soient à jour +- Ne pas hésiter à solliciter les pharmaciens pour info sur médicaments surtout lors du switch vers +les génériques + +Item de +surveillance : 23/06/2023 +07:59 23/06/2023 +07:48 22/06/2023 +07:55 21/06/2023 +22:55 21/06/2023 +17:23 21/06/2023 +13:31 21/06/2023 +08:05 21/06/2023 +07:59 20/06/2023 +07:51 19/06/2023 +08:06 +Pouls : 77 77 95 87 71 79 111 72 73 82 +PA +Systolique : 115 137 156 146 145 121 123 148 145 137 +PA +Diastolique : 69 78 90 86 72 67 64 72 73 79 +Température : 36,50 36,60 36,40 +Saturation +O² : 97 96 97 +Type de note : Nom Date Note + +Note IDE : [NOM] [NOM] 21/06/2023 +11:05 Risque podologique : Grade 0 +A participé à l'atelier +Note IDE : [NOM] [NOM] 20/06/2023 +21:14 Psy : souhaite l'EMOG, patient triste +Note IDE : [NOM] [NOM] 19/06/2023 +17:45 Mr B admet avoir perdu de ses connaissances sur le diabète. Désireux de participer aux ateliers +pour obtenir les informations en lien avec la pathologie, en vue de mieux la réguler. +Je lui propose de l'éduquer à l'utilisation de son lecteur de glycémie, n'est pas demandeur il dit +que son épouse le fait pour lui. Elle sera là demain matin→ prévoir de l'éduquer? +Prescription : Dose Fréquence Date de début Date de dernière +administration Note Docteur +AMLODIPINE ARG 5MG +GELULE [30] Gelule(s) : 1 GEL - Matin [8h] Normal 19/06/2023 10:34 23/06/2023 07:55 DR. [NOM] +[NOM] +ELIQUIS 5MG CPR [60] +COMPRIME(S) : 1 CPR - Matin soir (8h - +19h) Normal 19/06/2023 10:34 23/06/2023 07:55 DR. [NOM] +[NOM] +GLICLAZIDE ARW +LM 30MG CPR [30] +COMPRIME(S) : 2 CPR - Matin [8h] Normal 19/06/2023 10:34 23/06/2023 07:55 DR. [NOM] +[NOM] +METFORMINE MYP +1000MG CPR [30] +COMPRIME(S) : 1 CPR - Matin soir (8h - +19h) Normal 19/06/2023 10:34 23/06/2023 07:55 DR. [NOM] +[NOM] +NEBIVOLOL ARW 5MG +CPR [90] COMPRIME(S) : 1 CPR - Matin [8h] Normal 19/06/2023 10:34 23/06/2023 07:55 DR. [NOM] +[NOM] +PERINDOPRIL ARW 4MG +CPR [30] COMPRIME(S) : 2 CPR - Matin [8h] Normal 19/06/2023 10:34 23/06/2023 07:55 DR. [NOM] +[NOM] +PRAVASTATINE +MYL 40MG CPR [28] +COMPRIME(S) : 1 CPR - Soir [19h] Normal 19/06/2023 10:34 22/06/2023 18:37 DR. [NOM] +[NOM] +AMLODIPINE ARG 5MG +GELULE [30] Gelule(s) : 1 GEL - Matin [8h] Presc. de +Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +ELIQUIS 5MG CPR [60] +COMPRIME(S) : 1 CPR - Matin soir (8h - +19h) Presc. de Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +GLICLAZIDE ARW +LM 30MG CPR [30] +COMPRIME(S) : 2 CPR - Matin [8h] Presc. de +Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +METFORMINE MYP +1000MG CPR [30] +COMPRIME(S) : 1 CPR - Matin soir (8h - +19h) Presc. de Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +NEBIVOLOL ARW 5MG +CPR [90] COMPRIME(S) : 1 CPR - Matin [8h] Presc. de +Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +PERINDOPRIL ARW 4MG +CPR [30] COMPRIME(S) : 2 CPR - Matin [8h] Presc. de +Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +PRAVASTATINE +MYL 40MG CPR [28] +COMPRIME(S) : 1 CPR - Soir [19h] Presc. de +Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] +ZYMAD 80000UI SOL BUV +AMP [1] Ampoule(s) : 1 AMP - 1 seule fois 1 seule +fois 22/06/2023 09:29 22/06/2023 12:22 DR. [NOM] +[NOM] +TRULICITY 1,5 MG SOL +INJ STYLO [4] Stylo(s) +Prerempli(s) : 1,5 mg - 1xSemaine [8h] +Normal 19/06/2023 10:34 DR. [NOM] +[NOM] +TRULICITY 1,5 MG SOL +INJ STYLO [4] Stylo(s) +Prerempli(s) : 1,5 mg - 1xSemaine [8h] +Presc. de Sortie 23/06/2023 09:30 DR. [NOM] +[NOM] + +Date : Heure Prescription Docteur Date de +collection Note +19/06/2023 : 08:00 Ionogramme ( Na, K, CL ) Camille [NOM] [NOM] 19/06/2023 +09:22 +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +REGIME DIABÉTIQUE : Signé - à 08h Normal 19/06/2023 +07:00 [NOM] +[NOM] +DIAGNOSTIC EDUCATIF : Signé - à 08h Normal 19/06/2023 +07:00 [NOM] +[NOM] +DESINFECTION +ENVIRONNEMENT +PATIENT : Réalisé - Matin [8h] Normal 19/06/2023 +07:00 [NOM] +[NOM] +LIT : REFECTION +PARTIELLE Réalisé - Matin [8h] Normal 19/06/2023 +07:00 [NOM] +[NOM] +REPAS : INSTALLATION Réalisé - Matin midi soir +Normal 19/06/2023 +07:00 [NOM] +[NOM] +SOMMEIL : SURV. Réalisé - 3x/Nuit (22h 2h 6h) +Normal 21/06/2023 +21:00 [NOM] +[NOM] +EDUCATION DIABETIQUE : Réalisé - Matin [8h] Normal 19/06/2023 +07:00 [NOM] +[NOM] +GLYCEMIE CAPILLAIRE x +7 : Réalisé - 7x/jour (8h 12h +14h 19h 22h 0h 4h) +Normal 19/06/2023 +07:00 [NOM] +[NOM] +SIGNES VITAUX (Pls, +TA, FR, T°, Glyc, Miction, +Transit) : Réalisé - 2X /jour (8h 16h) +Normal 19/06/2023 +07:00 [NOM] +[NOM] +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +AMLODIPINE ARG 5MG +GELULE [30] Gelule(s) : 1 GEL +ORALE Réalisé - Matin [8h] Presc. de +Sortie 23/06/2023 +09:30 0/30 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +ELIQUIS 5MG CPR [60] +COMPRIME(S) : 1 CPR +ORALE Réalisé - Matin soir (8h - +19h) Presc. de Sortie 23/06/2023 +09:30 0/60 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +GLICLAZIDE ARW +LM 30MG CPR [30] +COMPRIME(S) : 2 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 23/06/2023 +09:30 0/60 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +METFORMINE MYP +1000MG CPR [30] +COMPRIME(S) : 1 CPR +ORALE Réalisé - Matin soir (8h - +19h) Presc. de Sortie 23/06/2023 +09:30 0/60 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +NEBIVOLOL ARW 5MG +CPR [90] COMPRIME(S) : 1 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 23/06/2023 +09:30 0/30 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +PERINDOPRIL ARW 4MG +CPR [30] COMPRIME(S) : 2 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 23/06/2023 +09:30 0/60 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +PRAVASTATINE +MYL 40MG CPR [28] +COMPRIME(S) : 1 CPR +ORALE Réalisé - Soir [19h] Presc. de +Sortie 23/06/2023 +09:30 0/30 : Non administré +Révisé/Traité DR. +[NOM] +[NOM] +TRULICITY 1,5 MG SOL +INJ STYLO [4] Stylo(s) +Prerempli(s) : 1,5 mg +SOUS- +CUTANEE Signé - 1xSemaine [8h] +Presc. de Sortie 23/06/2023 +09:30 0/4 : Non administré +A valider DR. +[NOM] +[NOM] + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — REGIME DIABÉTIQUE - à 08h - +pendant 5 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 23/06/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 1 +Signé — AMLODIPINE ARG 5MG GELULE - +5MG gelule - Dose 1 GEL - ORALE - Matin [8h] +- 1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 1 +GEL +Signé — ELIQUIS 5MG CPR - 5MG comprime +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - +1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 19:00 * 1 +CPR +Signé — ELIQUIS 5MG CPR - 5MG comprime +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - +1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 1 +CPR +Signé — GLICLAZIDE ARW LM 30MG CPR - +30MG comprime - Dose 2 CPR - ORALE - Matin +[8h] - 1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 2 +CPR +Signé — METFORMINE VIATRIS 1 000 +MG CPR - 1000MG comprime - Dose 1 CPR +- ORALE - Matin soir (8h - 19h) - 1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 19:00 * 1 +CPR +Signé — METFORMINE VIATRIS 1 000 +MG CPR - 1000MG comprime - Dose 1 CPR +- ORALE - Matin soir (8h - 19h) - 1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 1 +CPR +Signé — NEBIVOLOL ARW 5MG CPR - 5MG +comprime - Dose 1 CPR - ORALE - Matin [8h] - +1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 1 +CPR +Signé — PERINDOPRIL ARW 4MG CPR - 4MG +comprime - Dose 2 CPR - ORALE - Matin [8h] - +1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 2 +CPR +Signé — PRAVASTATINE MYL 40MG CPR - +40MG comprime - Dose 1 CPR - ORALE - Soir +[19h] - 1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 18/07/2023 à +19:00 +Admin le 22/06/2023 à +18:37 19:00 * 1 +CPR + +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - +pendant 7 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +08:00 +Admin le 23/06/2023 à +08:00 08:00 * 1 +Réalisé — LIT : REFECTION PARTIELLE +- Matin [8h] - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +08:00 +Admin le 23/06/2023 à +08:00 08:00 * 1 +Réalisé — REPAS : INSTALLATION - Matin +midi soir - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +19:00 +Admin le 23/06/2023 à +12:00 19:00 * 1 +Réalisé — REPAS : INSTALLATION - Matin +midi soir - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +19:00 +Admin le 23/06/2023 à +12:00 08:00 * 1 +Réalisé — REPAS : INSTALLATION - Matin +midi soir - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +19:00 +Admin le 23/06/2023 à +12:00 12:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 21/06/2023 +@ 21:00 [NOM] [NOM] +Début le 21/06/2023 à +21:00 +Fin le 28/06/2023 à +06:00 +Admin le 23/06/2023 à +06:37 06:00 * 1 +Réalisé — EDUCATION DIABETIQUE - Matin +[8h] - pendant 7 Jour(s)- Date Début : 19/06/2023 +@ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +08:00 +Admin le 23/06/2023 à +07:55 07:55 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 14:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 19:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 22:00 * 1 + +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 00:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 04:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 08:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 5 +Jour(s)- Date Début : 19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 24/06/2023 à +04:00 +Admin le 23/06/2023 à +12:00 12:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - +pendant 7 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +16:00 +Admin le 23/06/2023 à +08:00 16:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - +pendant 7 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +16:00 +Admin le 23/06/2023 à +08:00 08:00 * 1 + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — AMLODIPINE ARG 5MG GELULE - +5MG gelule - Dose 1 GEL - ORALE - Matin [8h] +- 1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 1 +GEL +Signé — ELIQUIS 5MG CPR - 5MG comprime +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - +1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 1 +CPR +Signé — ELIQUIS 5MG CPR - 5MG comprime +- Dose 1 CPR - ORALE - Matin soir (8h - 19h) - +1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 19:00 * 1 +CPR +Signé — GLICLAZIDE ARW LM 30MG CPR - +30MG comprime - Dose 2 CPR - ORALE - Matin +[8h] - 1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 2 +CPR +Signé — METFORMINE VIATRIS 1 000 +MG CPR - 1000MG comprime - Dose 1 CPR +- ORALE - Matin soir (8h - 19h) - 1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 1 +CPR +Signé — METFORMINE VIATRIS 1 000 +MG CPR - 1000MG comprime - Dose 1 CPR +- ORALE - Matin soir (8h - 19h) - 1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 19:00 * 1 +CPR +Signé — NEBIVOLOL ARW 5MG CPR - 5MG +comprime - Dose 1 CPR - ORALE - Matin [8h] - +1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 1 +CPR +Signé — PERINDOPRIL ARW 4MG CPR - 4MG +comprime - Dose 2 CPR - ORALE - Matin [8h] - +1ère dose : 20/06/2023 @ 08:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 19/07/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 2 +CPR +Signé — PRAVASTATINE MYL 40MG CPR - +40MG comprime - Dose 1 CPR - ORALE - Soir +[19h] - 1ère dose : 19/06/2023 @ 19:00 [NOM] [NOM] +Début le 19/06/2023 à +10:34 +Fin le 18/07/2023 à +19:00 +Admin le 22/06/2023 à +18:37 19:00 * 1 +CPR +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - +pendant 7 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +08:00 +Admin le 23/06/2023 à +08:00 08:00 * 1 + +Réalisé — LIT : REFECTION PARTIELLE +- Matin [8h] - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +08:00 +Admin le 23/06/2023 à +08:00 08:00 * 1 +Réalisé — REPAS : INSTALLATION - Matin +midi soir - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +19:00 +Admin le 23/06/2023 à +12:00 08:00 * 1 +Réalisé — REPAS : INSTALLATION - Matin +midi soir - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +19:00 +Admin le 23/06/2023 à +12:00 12:00 * 1 +Réalisé — REPAS : INSTALLATION - Matin +midi soir - pendant 7 Jour(s)- Date Début: +19/06/2023 @ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +19:00 +Admin le 23/06/2023 à +12:00 19:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 21/06/2023 +@ 21:00 [NOM] [NOM] +Début le 21/06/2023 à +21:00 +Fin le 28/06/2023 à +06:00 +Admin le 23/06/2023 à +06:37 22:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 21/06/2023 +@ 21:00 [NOM] [NOM] +Début le 21/06/2023 à +21:00 +Fin le 28/06/2023 à +06:00 +Admin le 23/06/2023 à +06:37 02:00 * 1 +Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h +6h) - pendant 7 Jour(s)- Date Début: 21/06/2023 +@ 21:00 [NOM] [NOM] +Début le 21/06/2023 à +21:00 +Fin le 28/06/2023 à +06:00 +Admin le 23/06/2023 à +06:37 06:00 * 1 +Réalisé — EDUCATION DIABETIQUE - Matin +[8h] - pendant 7 Jour(s)- Date Début : 19/06/2023 +@ 07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +08:00 +Admin le 23/06/2023 à +07:55 08:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - +pendant 7 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +16:00 +Admin le 23/06/2023 à +08:00 08:00 * 1 +Réalisé — SIGNES VITAUX (Pls, TA, FR, T +°, Glyc, Miction, Transit) - 2X /jour (8h 16h) - +pendant 7 Jour(s)- Date Début : 19/06/2023 @ +07:00 [NOM] [NOM] +Début le 19/06/2023 à +07:00 +Fin le 25/06/2023 à +16:00 +Admin le 23/06/2023 à +08:00 16:00 * 1 + +Résultat de labo : 22/06/2023 06:38 +(5984891) 19/06/2023 11:27 +(5980669) 19/06/2023 09:22 +(5980670) +Hémoglobine A1c : 7,1 % +Albumine : 39,4 g/l +Acide urique : 372 µmol/l +Commentaire 25 +hydroxyvitamine D : Les valeurs de +références de 25- +hydroxyvitamine D +se situent entre 30 +et 60 ng/mL pour la +prise en charge de +patients porteurs d'une +pathologie osseuse, +phosphocalcique ou +rénale, à l'exception +des patients dialysés +pour lesquels la zone +cible est réduite (30 à +45-50 ng/mL). Pour +les patients ayant une +granulomatose, la 25- +hydroxyvitamine D +doit être comprise +entre 15 et 20 ng/ +mL. Concernant la +population générale, +le dosage de 25- +hydroxyvitamine D +n'est pas indiqué et il +n'existe pas de valeurs +de références, sachant +qu'environ 50 % de la +population générale +en bonne santé a une +concentration de 25- +hydroxyvitamine D +inférieure à 20 ng/ +mL. Pour rappel, les +indications du dosage +de 25-hydroxyvitamine +D validées par la +HAS sont la suspicion +de rachitisme ou +d'ostéomalacie, le +suivi des patients +transplantés rénaux +3 mois après +transplantation, +la surveillance de +patients avant et après +chirurgie bariatrique, +les personnes âgées +faisant des chutes à +répétition et le suivi +des traitements pour +lesquels le dosage de +25-hydroxyvitamine D +est préconisé. +ASAT : 32 U/l +Ferritine : 295,13 µg/l +Gamma GT : 17 U/l + +TSH 3ème génération : 0,72 mUI/L +25-hydroxyvitamine D : 17 ng/ml +Rapport Albuminurie / +Créatininurie : 2,6 mg/mmol +Cholestérol total : 2,58 mmol/l +HDL cholestérol : 0,81 mmol/l +Chlore : 105 mmol/l +LDL cholestérol : 1,42 mmol/l +Créatinine : 65 µmol/l +CRP : 9 mg/l 1 mg/l +Créatinine urinaire : 10,72 mmol/l +Compte-rendu laboratoire : Labo230622102021-1.pd fLabo230619163045-1.pd fLabo230619130416-1.pd f +Folates : 8,79 nmol/l +Polynucléaires neutrophiles +(%) : 76,6 % +Polynucléaires neutrophiles +(#) : 5,77 10.9/l +Polynucléaires éosinophiles +(%) : 2,5 % +Polynucléaires éosinophiles +(#) : 0,19 10.9/l +Polynucléaires basophiles (%) : 0,5 % +Polynucléaires basophiles (#) : 0,04 10.9/l +Lymphocytes (%) : 11,8 % +Lymphocytes (#) : 0,89 10.9/l +Monocytes (%) : 8,6 % +Monocytes (#) : 0,65 10.9/l +Glucose : 5,5 mmol/l +ALAT : 28 U/l +Formule sanguine : réalisée sur automate +XN (Sysmex) +Hématocrite (%) : 42,2 % +Indice de distribution des +hématies : 12,4 % +Traitement anticoagulant : Inconnu +Potassium : 3,7 mmol/l +Albumine urinaire : 28 mg/l +Leucocytes : 7,53 10.9/l +Hématies : 4,54 10.12/l (t/l) +Hémoglobine : 14,5 g/dl +VGM : 93,0 fl +TCMH : 31,9 pg +CCMH : 34,4 g/dl +Sodium : 137 mmol/l +Osmolarité sang : 280 mOSM/l +Plaquettes : 184 10.9/l +Protéines : 73 g/l +Validation et diffusion sous la +responsabilité du biologiste : "" Dr [NOM] [NOM] Dr [NOM] [NOM] +TCA : 35,0 secondes +TCA ratio : 1,16 +TP : 88 % +Temps de Quick : 12,4 secondes +Triglycérides : 1,04 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--- /dev/null +++ b/test_3ogc/anonymise_old/trackare-BA165196-23061393_BA165196_23061393.pseudonymise.txt @@ -0,0 +1,4338 @@ +[MASK] +*640N0° F0in0ess162* +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +640000162 +MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC +Dossier Patient +Détails des patients +Nom de naissance : DE [NOM] [NOM] [NOM] IPP : [IPP] +Nom et Prénom : DE [NOM] [NOM] [NOM] REGINA [DATE_NAISSANCE] +Sexe : Féminin Lieu de naissance: [VILLE] +Nationalité : PORTUGAL [CODE_POSTAL] +Adresse : [ADRESSE]: [NOM] +Détails épisode +Episode No : [NDA] +Localisation : PNEUMOLOGIE PHTISIOLOGIE HC Médecin courant: DR. [NOM] +Date d'admission : [DATE] Heure d'admission: 00:51 +Date de sortie : [DATE] Heure de sortie: 14:04 +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 +Epoux [NOM] [CODE_POSTAL] [TEL] +(Trakcare) +Personne à prévenir [TEL] +Fille [NOM] [NOM] X [CODE_POSTAL] +([ETABLISSEMENT]) 66 +Personne de [TEL] +Fille [NOM] [NOM] +confiance [ADRESSE][DATE] +Episode - Heure [DATE] +Mode de transport à l'arrivée Ambulance +Médicalisation du transport Prise en charge paramédicale +Mode d'entrée Autres admissions urgentes +Date d'orientation [DATE] +Heure d'orientation 00 : 56 +IAO [NOM] +Priorité Priorité 2 +Sous-type épisode URG - Circuit Long +Motif de prise en charge Dyspnée +adressée par SOS pour décompensation cardio respi +hyperthermie cet am,non retrouvé au SAU +Observ. IDE Urg arrive sous 3L O2 aux lunettes : 97%,baissé à 2litres +BI verifié et posé +test antigen covid : neg +Médecin de la prise en charge médicale [NOM] [NOM] +Date de prise en charge médicale [DATE] +Heure de prise en charge médicale [DATE] +Médecin de la décision médicale [NOM] [NOM] +Date de décision médicale [DATE] +Heure de décision médicale 04 : 58 +Décision médicale Hospitalisation MCO +Orientation du patient hospitalisation dans une unité de Médecine hors SC, SI, REA +Destination du patient [NOM] [NOM] +Date de sortie des urgences [DATE] +Heure de sortie des Urgences 05 : 10 +US de destination US PNEUMOLOGIE +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [NDA] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 1 de 27 UF de destination PNEUMOLOGIE PHTISIOLOGIE HC +Diagnostic aux urgences +Type Etat Code Date +Principal actif J12.9 Pneumopathie virale, sans précision [DATE] 04 : 57 +Alertes +Date +Catégorie Alerte Date début Message +expiration +Accompagnants [DATE] fille +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 [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance [DATE] 09:17 07:57 06:19 00:19 18:53 15:16 12:04 07:48 06:15 00:14 18:29 16:16 +Glycémie +1,45 2,90 0,65 0,88 2,51 1,43 1,73 1,51 1,88 1,68 1,66 +capillaire +Température 37,10 37,40 37 36,50 37,30 36,50 +Pouls 84 100 93 83 95 92 +PA +[NIR] +Systolique +PA +66 76 68 67 +Diastolique +Saturation +96 96 97 95 95 96 +O² +Débit O² +2 2 2 2 2 2 +[L/mn] +Ventilation Ventilation Ventilation Ventilation Ventilation +Ventilation +Ventilation spontanée spontanée spontanée spontanée spontanée +assistée +Oxygène Oxygène Oxygène Oxygène Oxygène +Echelle +EN EN EN EN EN +douleur +Score au +5 0 0 0 0 +repos +Transit Normal Absence Absence Absence Normal Normal Absence Absence Absence Absence Absence +Fréq. +respiratoire +Poids/Taille +Item de [DATE] [DATE] +surveillance 08 : 39 12:23 +Poids [kg] 88 88,80 +Taille [cm] 152 152 +Indice +de masse 38,09 38,44 +corporelle +Surface +1,84 1,85 +corporelle +Surv. Isolement et Contention +Item de [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance 07 : 57 00:19 15:16 07:48 00:14 16:16 08:58 00:34 18:38 15:55 08:17 05:55 22:12 +Température 37,10 37,40 37 36,50 37,30 36,50 37 37,20 36,50 37 37 +Pouls 84 100 93 83 95 92 88 100 91 90 90 96 +PA +[NIR] 131 134 134 105 +Systolique +PA +66 76 68 67 65 58 55 55 +Diastolique +Saturation +96 96 97 95 95 96 96 95 96 94 92 95 +O² +Transit Normal Absence Absence Absence Normal Normal +Fréq. +respiratoire +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 2 de 27 Surv. Contention +Item de [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance [DATE] 09:17 07:57 06:19 00:19 18:53 15:16 12:04 07:48 06:15 00:14 18:29 16:16 +Glycémie +1,45 2,90 0,65 0,88 2,51 1,43 1,73 1,51 1,88 1,68 1,66 +capillaire +Température 37,10 37,40 37 36,50 37,30 36,50 +Pouls 84 100 93 83 95 92 +PA +[NIR] +Systolique +PA +66 76 68 67 +Diastolique +Saturation +96 96 97 95 95 96 +O² +Transit Normal Absence Absence +Observations médicales +Type d'observation Nom Date Commentaires +nouvelle hospitalisation pour nouvelle décompensation cardio-respiratoire sans aucun critère de +DR. [NOM] [DATE] gravité +Conclusion Clinique +[NOM] 13 : 27 bonne évolution sous antibiotiques et diurétiques (hypokaliémie à recontrôlée) +transfert à Toki ce jour +DR. [NOM] [DATE] [DATE] CNE +Note d'évolution +[NOM] 14 : 20 pas d'hypoglycémie, nuit de bonne qualité +DR. [NOM] [DATE] adaptation doses insuline +Note d'évolution +[NOM] 14 : 54 je suis là demain matin on peut me rappeler si elle fait encore des hypos cette nuit +[DATE] : CNE +persistance d'OMI +DR. [NOM] [DATE] +Note d'évolution a dormi un peu au lit cette nuit +[NOM] 12 : [ADRESSE][NOM] pour la tendance aux hypoglycémies +[DATE] : +Apyretique +Diabete : [NOM] ce matin à 0.71 +Cardio : +ETT : FEVG à 60% +VG non dilaté +Pression de remplissage VG normales, pas de signe de surcharge +OG de taille normale +Absence de valvulopathie +CD non dilatées +fonction VD normale +Pression droites normales, minime épanchement péricardique de 4/5mm sans retentissement +VCI non dilatée compliante +DR. [NOM] [DATE] +Note d'évolution +[NOM] 12 : 29 +bio : K=3.3 +nouvlle seringue K=2g sur 6h +avis gastro sur cette anémie ferriprive +FERINJECT fait le [DATE] +dernier colo Fogd en [DATE] Dr [NOM] : proposition de consult RDV le [DATE] 11h40, il +jugera en fonction de la réhab si FOGD sous AL ou en hospit +CAT : +- diminution LASILIX spécial 1 le matin (dose usuelle) +- supplémentation K +- surveillance glycémie +- avis cardio : possible majoration NTproBNP sur intro FORXIGA ? +- FERINJECT 500 ce jour (totalité de 1g) puis à nouveau 500mg ds 15j +[DATE] +APyretique +DR. [NOM] [DATE]/2023 [NOM] tjrs > à 2g : majoration insuline lente à 66ui vs 62ui +Note d'évolution +[NOM] 10 : [ADRESSE][ETABLISSEMENT] lundi +Bio : K=2.7n, Na=136 +CRP plate +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 3 de 27 NtproBNP 507 +anémie microcytaire à 10g avec VGM=75 +bilan martial carence avec ferritine et CS abaissé +ECG sur hypoK : FA +pas d'onde U +pas de sus decalage ST +onde T plate mais deja present sur ECG du 25 +Ccl : ascension NTproBNP sans douleur thoracique Sans modification ECG +CAT : +- supplémentation potassique +- FERINJECT et avis gastro (indication à colo fibro ? colo virtuelle ?) +- demande d'ETT +- recuperer courrier carido Dr [NOM] car patient en'ayant pas de beta bloquant ni d'IEC +(nécessité d'optimiser ttt cardio ?) +[DATE] : +Patiente apyretique +discrete amélioration d ela toux +kine ce matin sans expectoration +ausuclt : ronchi bilateraux +DR. [NOM] [DATE] +Note d'évolution +[NOM] 14 : 44 +echo pleurale : pas d'pénachement pleural gauche ou droit +OMI peristants +patiente m'explique ne pas supporter les bas de contentions +glycémies encore hautes : majoration insuline rapide. +[DATE] +Avis diabeto sur indication GLICLAZIDE ? place du FORXIGA ? +DR. [NOM] [DATE]/2023 +Note d'évolution Dr [NOM] : +[NOM] 16 : 47 +- arret GLICLAZIDE (HbA1c à 9% donc on considère que c'est inefficace) +- maintien basal/bolus +- introduction FORXIGA 10mg/j +L'objectif est de pouvoir equilibré le basal/bolus en [ETABLISSEMENT] +[DATE] +Apyretique +amélioration de la toux +demangeaison sur tout le corps probablement lié à la prise de codeine +pas d'améloioratino des OMI +DR. [NOM] [DATE]/2023 bio : decroissance sd inflam +Note d'évolution +[NOM] 15 : 03 stabilité NTproBNP +CAT : +- poursuite ABT +- avis diabeto sur ttt FORXIGA ? insuline ? +- attente [ETABLISSEMENT] +- arret codeine ca rmauvaise tolérance +- kine +- tjrs sous diffuK 9/j, iono OK ce jour : ajout ESIDREX 25 +- bio ds 48h +[DATE] +DR. [NOM] [DATE]/2023 +Note d'évolution +[NOM] 11 : 35 +Apyretique +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 4 de 27 [NOM] >1.5g +HbA1c à 9 [DATE] +amélioration d ela toux +a doemi au fauteil cette nuit +--> codeine si beosin pour la nuit +peristiance OMI blanc mous des jambes +CAT : +- bio demain +- ajout codeine le soir +- ajout insuline rapide, avis endoc demain +- patiente en accord pour [ETABLISSEMENT] +Patiente admise le24/03 aux urgences pour majoration de la dyspnée et de la toux +Correspondants : +- Pneumo : Dr [NOM] +ATCD : +- Insuffisance respiratoire chronique mixte sur obésité et BPCO post-tabagique VEMS 44% en +[DATE] --> Sous OLD 2L, VNI nocturne +- Dyskinésie trachéale +- FA paroxystique en [DATE] +- DT2 insulino dépendant +- HTA +- Trouble bipolaire +ATCD chir : +- Anneau gastrique +TTT : +-ROSUVASTATINE 10MG 1 le matin +-ESOMEPRAZOLE 20MG soir +-BUSPIRONE 10MG soir +-DEPAKOTE 500MG matin soir +-TERCIAN 4% 15 goutte le soir +-DUROGESIC 12,5µg toutes les 72h +-VERSATIS 5% EMPLATRE +-XARELTO 20MG +-LASILIX [NOM] 500MG 1 le matin +-LOXEN LP 50MG matin +Histoire de la DR. [NOM] [DATE] -POTASSIUM 600MG GELULE 2 GELULE matin midi et soir +maladie [NOM] 14 : 08 -TRIMBOW 2 BOUFFEE matin et soir +-DIFICLIR 100 mg matin et soir jusqu'au [DATE] +-ABASAGLAR 62 UI à 19h +-OZEMPIC 2 MG toutes les semaines +-GLICLAZIDE 30MG 1 COMPRIME +-TIORFAN 100mg matin midi et soir SI DIARRHEES +-SMECTA matin midi et soir SI DIARRHEES +Allergies : Nc +Toxiques : +- Tabac sevré, 30PA +HDM : +Multiples hospitalisation en [DATE] dans le cadre de décompensation cardiorespiratoire avec +épanchement pleuraux notamment gauche lymphocytaire sans cellules maligne après 2 +prélèvements, pas d'anomalie décelé lors d'une fibroscopie bronchique réalisé en aout [DATE]. +Hospitalisée en pneumologie après passage en USC fin [DATE] sur une décompensation +cardio respiratoire sans trigger évident retrouvé, traitée par Céfépime 7jours et déplétion par +Lasilix devant un ATCD de colonisation par Klebsiella Pneumoniae. +Hospitalisée en pneumologie du [DATE] au [DATE] pour décompensation respiratoire sur +colite à Clostridium difficile traitée par 10 jours de DIFFICLIR. +Ce jour adressée par SOS médecin pour décompensation cardio respi avec majoration des +besoins en O2 + hyperthermie dans l'après-midi, OMI et crépitants bilatéraux. +Contexte de possible contage chez petite fille de 4ans qui lui a rendu visité wend dernier +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 5 de 27 Cliniquement : +Apyrétique, tachycarde +G15, orientée dans le temps et l'espace +Toux grasse +eupnéique sous 3L +crépitants bilatéraux aux 2 bases +OMI bilatéraux prenant le godet avec sensibilité cheville gauche dérite depuis s3 jour environ, +pas de rougeur +BDC irréguliers sans souffle perçu +pas de DT +Abdo souple dépressible et indolore +Bio : +GDS sous 2L : ph=7.46, pO2=81, pCO2=50 +K=3.1, CRP=19 +Hb=9.4, VGM=78 +GB=8900 +antigenuries négatives +PCR grippe et covid négatives +CAT : +- majoration LASILIX +- poursuite VNI +- poursuite ABT probabiliste +- bain de bouche +- kine +- ECBC +- surviellance poids diurese +Bio : pro BNP 400, CRP 30 pas d'hyperleucocytose +K+ 3.1, Na 132 +[DATE] +Note d'évolution [NOM] [NOM] --> décompensation cardio-respi sans trigger identifié +04 : 57 +a eu 125 mg lasilix IVD + 80 mg CTC +devant hyperthermie dans l'après-midi et devant atcd début augmentin +hospitalisation en pneumo +RADIOGRAPHIE PULMONAIRE +Indication : +Bilan de dyspnée. +RESULTATS : +Sous réserve de la faible ampliation thoracique : +Diminution de la transparence parenchymateuse aux bases apparaissant être liée notamment +à la projection des parties molles. Absence de foyer circonscrit au niveau des apex pulmonaires. +Augmentation de l'index cardiothoracique.. +[DATE] +Note d'évolution [NOM] [NOM] +03 : 16 +Dr [NOM] +Technique : +PDS : 0.426 dGy.cm² +A l'entrée : 0.065 mGy +Protocole d'acquisition : Thorax +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 de naissance : [DATE_NAISSANCE] +[DATE] GDS : pH 7.46, pO2 86mmHg, pCO2 50mmHg, bicar 35 +Note d'évolution [NOM] [NOM] +02 : 25 --> hypercapnie compensée métabolique +Motif de cs : décompensation cardio-respi +Correspondants : +Histoire de la [DATE] - Pneumo : Dr [NOM] +[NOM] [NOM] +maladie 01 : 29 +ATCD : +- Insuffisance respiratoire chronique mixte sur obésité et BPCO post-tabagique VEMS 44% en +[DATE] --> Sous OLD 2L, VNI nocturne +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [IPP] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 6 de 27 - Dyskinésie trachéale +- FA paroxystique en [DATE] +- DT2 insulino dépendant +- HTA +- Trouble bipolaire +ATCD chir : +- Anneau gastrique +TTT : +-ROSUVASTATINE 10MG 1 le matin +-ESOMEPRAZOLE 20MG soir +-BUSPIRONE 10MG soir +-DEPAKOTE 500MG matin soir +-TERCIAN 4% 15 goutte le soir +-DUROGESIC 12,5µg toutes les 72h +-VERSATIS 5% EMPLATRE +-XARELTO 20MG +-LASILIX [NOM] 500MG 1 le matin +-LOXEN LP 50MG matin +-POTASSIUM 600MG GELULE 2 GELULE matin midi et soir +-TRIMBOW 2 BOUFFEE matin et soir +-DIFICLIR 100 mg matin et soir jusqu'au [DATE] +-ABASAGLAR 62 UI à 19h +-OZEMPIC 2 MG toutes les semaines +-GLICLAZIDE 30MG 1 COMPRIME +-TIORFAN 100mg matin midi et soir SI DIARRHEES +-SMECTA matin midi et soir SI DIARRHEES +Allergies : Nc +Toxiques : +- Tabac sevré, 30PA +Vaccins : +- Covid*3 +MDV : +Vit en maison plein pied avec son époux à [NOM] +Aide ménagère 1 fois par semaine, IDE 3 fois par jours +Époux aidant pour les courses, la toilette +3 enfants dans la région +HDM : +Multiples hospitalisation en [DATE] dans le cadre de décompensation cardiorespiratoire avec +épanchement pleuraux lymphocytaire sans cellules maligne après 2 prélèvements, pas d'anomalie +décelé lors d'une fibroscopie bronchique réalisé en aout [DATE]. +Hospitalisée en pneumologie après passage en USC [DATE] sur une décompensation +cardio respiratoire sans trigger évident retrouvé, traitée par Céfépime 7jours et déplétion par +lasilix devant un ATCD de colonisation par Klebsiella Pneumoniae. +Hospitalisée en pneumologie du [DATE] au [DATE] pour décompensation respiratoire sur +colite à Clostridium difficile traitée par 10 jours de DIFFICLIR. +Ce jour adressée par SOS médecin pour décompensation cardio respi avec majoration des +besoins en O2 + hyperthermie dans l'après-midi, OMI et crépitants bilatéraux. +Cliniquement : +Apyrétique, tachycarde +G15, orientée dans le temps et l'espace +Toux grasse +eupnéique sous 3L +crépitants bilatéraux aux 2 bases +OMI bilatéraux prenant le godet +BDC irréguliers sans souffle perçu +pas de DT +Abdo souple dépressible et indolore +CAT : +Bio + GDS +RP +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 7 de 27 Surveillance Psychiatrie +Item de [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] +surveillance 07 : 57 00:19 15:16 07:48 00:14 16:16 08:58 00:34 18:38 15:55 08:17 05:55 22:12 +Température 37,10 37,40 37 36,50 37,30 36,50 37 37,20 36,50 37 37 +Pouls 84 100 93 83 95 92 88 100 91 90 90 96 +PA +138 113 125 121 131 134 134 105 +Systolique +PA +66 76 68 67 65 58 55 55 +Diastolique +Saturation +96 96 97 95 95 96 96 95 96 94 92 95 +O² +Transit Normal Absence Absence Absence Normal Normal Absence Absence Absence Absence Absence Normal +Fréq. +respiratoire +Notes paramédicales +Type de note Nom Date Note +Hypoglycémie : +0.65g ce matin. Ressentie car se sent fatiguée --> Re sucrée : OK pour la fin de journée. +Hypoglycémie : +[DATE] ECG OK +Note IDE [NOM] [NOM] +14 : 04 4 gel potassium donné à 10h30. +Sortie prévue ce jour pour [NOM] [NOM] -> Papiers de sortie donnés. +[DATE] +Note IDE [NOM] [NOM] / +19 : 53 +[DATE] +Note IDE [NOM] [NOM] / +21 : 56 +Glycémie : +- ce matin : 1.05 g/L --> insuline non donné +[DATE] - ce midi : 1.2 g/L --> insuline non donné +Note IDE [NOM] [NOM] +13 : 12 +Persistance OMI +[DATE] +Note IDE [NOM] [NOM] ENDOC : glycémie stable +07 : 46 +Endocrinologie +- avis diabéto pris pour hypoglycémie +-> diminution insuline lente. +[DATE] +Note IDE [NOM] [NOM] -> ce soir, [NOM] 1.71, lente + humalog faites. +19 : 18 +Kaliémie +- contrôle kaliémie après PSE hier lundi +Devenir => départ à [NOM] Eder lundi, patiente OK +[NOM] [DATE] +Note IDE [NOM] => 1.07 G/L ce matin => rapide faite 10 UI au lieu de 14 UI +[NOM] 13 : 49 +Hypo => 0.54 G/L à midi => pas d'insuline faite, a mangé le repas, avis diabeto ddé +Respiratoire : dyspnée à la mobilisation, bonne sat sous O2 2L +[DATE] +Note IDE [NOM] [NOM] +01 : 10 +Glycémie : 0.74 à 6h, la patiente se dit asténique. Ressucrée po +Hypoglycémie +- 16h : [NOM] 0.77 -> collation donnée +- 18h : [NOM] 2.11 -> insuline lente et rapide +[DATE] Hypokaliémie +Note IDE [NOM] [NOM] +22 : 29 - K+ 3.3 -> PSE potassium passé sur l'après-midi, RAS +Elimination +- pas de nouvelles diarrhées +Transit => pas de diarrhées ce matin +[NOM] => 0.71g/L ce midi => raide faite mais moitié dose +[NOM] [DATE] +Note IDE Thermo => 37.7° ce matin => apyrétique ce midi +[NOM] 14 : 31 +BS => manque de fer => pose VVP puis pose de perfusion ce midi +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 8 de 27 manque de K => SE cet a m +ETT ce jour => diminution diurétique +Respiratoire : patiente eupneique sous O2 2L au repos +[DATE] +Note IDE [NOM] [NOM] +00 : 37 +Transit : deux selles diarrhéique cette nuit, instructions données pour copro +Respiratoire +- stable sous 2L, encombré -> aérosols productifs. +[DATE] Hypokaliémie +Note IDE [NOM] [NOM] +18 : 57 - PSE posé cet après-midi -> contrôle demain matin +Endocrinologie +- [NOM] : 1.62 15h : lente et humalog faites +glycémie : 1,83g/l ce midi. +majoration de l'insuline lente. +HypoKCL : 2,7, ECG. +supplémentation per os + IVSE en cours =) BS de control a faire ce soir. +cardio : ecg fait sur hypokcl, FA =) ETT demandée +[DATE] +Note IDE [NOM] [NOM] +13 : 23 bilan martial : carence avec ferritine =) ferinject fait. +avis gastro. +douleur : algique au niveau de son dos et d'écrit des douleurs neuropathique au niveau des +jambes. +changement patch atg 3 ce jour. +transit : absence de selle =) cocktail fait, efficace. +[DATE] +Note IDE [NOM] [NOM] Endoc : glycémie toujours élevée ce matin +06 : 52 +Respiratoire : clinique stable sous 2l . +Endocrino : [NOM] élevé ce soir . +[DATE] +Note IDE [NOM] [NOM] --> Insuline faite selon protocole +21 : 32 +Cardio : OMI toujours présents +RESPI=> 96% sous 2L O2 : patiente dort au fauteuil; VNI enlevé cette nuit vers 3h. +Glycémie=> hyperglycémie ce matin => 2.41 à 8H : 2.81 à 12h +après avis du diabeto=> augmentation de la rapide à 14 unités. +[DATE] +Note IDE [NOM] [NOM] +14 : 04 +RESPI=> 96% sous 2L O2 : patiente dort au fauteuil; VNI enlevé cette nuit vers 3h. +Glycémie=> hyperglycémie ce matin => 2.41 à 8H : 2.81 à 12h +après avis du diabeto=> augmentation de la rapide à 14 unités et Forxiga +[DATE] +Note IDE [NOM] DA [NOM] +13 : 53 +début de prise en charge pour ce nouvel épisode d'hospitalisation +Note [NOM] [DATE] toux présente lors de la ventilation dirigée +Kinésithérapeute [NOM] 12 : 56 toux non productive +ventilation dirigée peu dyspneique +dort au fauteuil +[DATE] RESPI : VNI enlevé vers 03h +Note IDE [NOM] [NOM] +[TEL] +ENDOC : [NOM] +Respiratoire : clinique et saturation stable sous 2l. +[DATE] Endocrino : Hypoglycémiants oraux modifiés . +Note IDE [NOM] [NOM] +20 : 03 Etat cutanée : OMI présents +respi : +[DATE] +Note IDE [NOM] [NOM] pas de problème au niveau du masque de la VNI +13 : 55 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 9 de 27 Respi=) bonne sat mais problème de masque de VNI cette nuit vu avec la patiente non mise ce +[DATE] soir car le masque se désadapte régulièrement laissée aux lunettes allo prestataire demain svp +Note IDE [NOM] [NOM] +00 : 05 orkyn +infectieux=) patiente apyrétique +RESPI : quintes de toux moins gênantes avec toux moins rauque , ATG2 pris pour la nuit +HYPERHGT : > à 3g ce soir (a bu du coca) => protocole d'insuline fait +[DATE] +Note IDE [NOM] [NOM] +19 : 06 DEVENIR : VT fait +OMI bilat prenant le godet +diab : [DATE] à 12h, vu avec med pour reprise insuline rapide +[DATE] patch ATG3 : changement patch ATG 3 mais me dit avoir deux patch ATG3, un de 25µg et un de +Note IDE [NOM] [NOM] +14 : 50 12µg, vu avec med +respi : toux seche, atg codéiné mis et aérosol fait +TTT : patiente signale qu'elle prend de l'aérius et du singulair le soir => à revoir SVP +DESEQUILIBRE DIABETE : hyperHGT ce soir > à 2g f signes vitaux , patient me signale +qu'elle a un protocole de rattrapage si [NOM] > 1.5g => à revoir aussi SVP +[DATE] +Note IDE [NOM] [NOM] +19 : 27 TOUX : sèche +++ => aérosol de serum phy fait X2 qui la soulage un peu +PATCH ATG3 : à changer demain midi svp , information donnée par sa fille +TTT INHALES : a l'habitude d'utiliser une chambre d'inhalation => commandée +respi : +dyspnée sous 2L/min, sous CTC +[DATE] +Note IDE [NOM] [NOM] +15 : 02 diab : hyperglycémie à 2.49 à midi +patch ATG : patiente doit s'informer de la date de pose du patch pour poursuite ttt antalgique +MDA : Adressée pour décompensation cardio-respi. Sortie récemment d'Hospit +Examens : +ECG12D fait et montré +GDS prélevés et envoyés +BS prélevé pdt pose VVP 20GA main D et envoyé +PCR prélevée et envoyée +ECBU envoyé +[DATE] +Note IDE [NOM] [NOM] +01 : 35 Cardio-respi : +Diurétiques admin IVL selon PM. [NOM] bonne réponse +CorticoTT + ATBTT débutés avant transfert. +Administratif : +Inventaire réalisé +Devenir : Pneumologie +Traitements médicamenteux +Date de dernière +Prescription Dose Fréquence Date de début Note Docteur +administration +Voie d`administration : INTRAVEINEUSE +Statut des prescriptions : Réalisé +Le débit a été +FERINJECT 500MG/10ML - 1 seule fois 1 seule modifié. Le débit DR. [NOM] +500 mg [DATE] 11 : 07 [DATE] 11:44 +SOL INJ [2] Flacon(s) fois en cours est : 20 [NOM] +par . +Le débit a été +FERINJECT 500MG/10ML - 1 seule fois 1 seule modifié. Le débit DR. [NOM] +500 mg [DATE] 12 : 38 [DATE] 14:28 +SOL INJ [2] Flacon(s) fois en cours est : 20 [NOM] +par . +FUROSEMIDE REN +- 1 seule fois 1 seule +20MG/2ML SOL INJ [100] 125 mg [DATE] 02 : 00 [DATE] 02:12 [NOM] [NOM] +fois +Ampoule(s) +Statut des prescriptions : En cours +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 10 de 27 Le débit a été +Potassium PSE 2G/50ML modifié. Le débit DR. [NOM] +- Normal [DATE] 10 : 51 [DATE] 12:22 +(2AMP) - BSFP en cours est : 8.3 [NOM] +ML par 1 hrs. +Le débit a été +Potassium PSE 2G/50ML modifié. Le débit DR. [NOM] +- Normal [DATE] 12 : 38 [DATE] 15:34 +(2AMP) - BSFP en cours est : 8.3 [NOM] +ML par 1 hrs. +Voie d`administration : ORALE +Statut des prescriptions : Signé +BUSPIRONE MYL 10MG - Prise unique à 19h +1 CPR [DATE] 04 : 49 [DATE] 20:40 [NOM] [NOM] +CPR [20] COMPRIME(S) Normal +CETIRIZINE ARW 10MG DR. [NOM] +1 CPR - Soir [19h] Normal [DATE] 15 : 41 [DATE] 18:44 +CPR [60] COMPRIME(S) [NOM] +DEPAKOTE 500MG CPR - Matin soir (8h - La posologie est DR. [NOM] +750 mg [DATE] 14 : 08 [DATE] 07:49 +[90] COMPRIME(S) 20h) Normal variable. [NOM] +FORXIGA 10MG CPR [30] DR. [NOM] +1 CPR - Matin [8h] Normal [DATE] 16 : 14 [DATE] 07:49 +CPR(s) [NOM] +FUROSEMIDE ZEN 500MG +1 CPR - Matin [8h] Normal [DATE] 04 : 49 [DATE] 07:49 [NOM] [NOM] +CPR [30] CPR(s) +HYDROCHLOROTHIAZIDE +DR. [NOM] +ARW 25 MG CPR [90] 1 CPR - Matin [8h] Normal [DATE] 18 : 00 [DATE] 07:49 +[NOM] +CPR(s) +LANSOPRAZOLE BGA 30 - Prise unique à 19h +1 CPR [DATE] 04 : 49 [DATE] 18:44 [NOM] [NOM] +MG CPR OROD [14] CPR(s) Normal +LOXEN LP 50MG GELULE +1 GEL - 1xJour [8h] Normal [DATE] 04 : 49 [DATE] 07:49 [NOM] [NOM] +[60] Gelule(s) +MONTELUKAST +DR. [NOM] +ARW 10MG CPR [28] 1 CPR - Soir [19h] Normal [DATE] 15 : 41 [DATE] 18:44 +[NOM] +COMPRIME(S) +POTASSIUM 600MG - Matin midi soir +3 GEL [DATE] 04 : 49 [DATE] 12:16 [NOM] [NOM] +GELULE Normal +ROSUVASTATINE ARW +0,5 CPR - 1xJour [8h] Normal [DATE] 04 : 49 [DATE] 07:49 [NOM] [NOM] +20MG CPR [90] CPR(s) +TERCIAN 4% SOL BUV FL +15 GTT - à 21h Normal [DATE] 04 : 49 [DATE] 20:40 [NOM] [NOM] +30ML [1200] Flacon(s) +XARELTO 20MG CPR [14] +1 CPR - 1xJour [8h] Normal [DATE] 04 : 49 [DATE] 07:49 [NOM] [NOM] +COMPRIME(S) +Statut des prescriptions : Arrêté +DEPAKOTE 500MG CPR - Matin soir (8h - +1 CPR [DATE] 04 : 49 [DATE] 08:00 [NOM] [NOM] +[90] COMPRIME(S) 19h) Normal +GLICLAZIDE ARW +LM 30MG CPR [30] 2 CPR - 1xJour [8h] Normal [DATE] 04 : 49 [DATE] 08:00 [NOM] [NOM] +COMPRIME(S) +PARACETAMOL COD +DR. [NOM] +ARW 500/30MG CPR EFF 2 CPR - Nuit [21h] Normal [DATE] 12 : 58 [DATE] 18:24 +[NOM] +[16] COMPRIME(S) +Statut des prescriptions : Réalisé +AMOX/AC CLAV SDZ +- Matin midi soir +1G/125MG AD SACH [12] 1 G [DATE] 04 : 49 [DATE] 19:07 [NOM] [NOM] +Normal +Sachet(s) +DR. [NOM] +BUSPIRONE MYL 10MG - Prise unique à 19h +1 CPR [DATE] 13 : 27 NOCENT- +CPR [20] COMPRIME(S) Presc. de Sortie +[NOM] +DR. [NOM] +CETIRIZINE ARW 10MG - Soir [19h] Presc. de +1 CPR [DATE] 13 : 27 NOCENT- +CPR [60] COMPRIME(S) Sortie +[NOM] +DR. [NOM] +DEPAKOTE 500MG CPR - Matin soir (8h - La posologie est +750 mg [DATE] 13 : 27 NOCENT- +[90] COMPRIME(S) 20h) Presc. de Sortie variable. +[NOM] +DR. [NOM] +FORXIGA 10MG CPR [30] - Matin [8h] Presc. de +1 CPR [DATE] 13 : 27 NOCENT- +CPR(s) Sortie +[NOM] +DR. [NOM] +FUROSEMIDE ZEN 500MG - Matin [8h] Presc. de +1 CPR [DATE] 13 : 27 NOCENT- +CPR [30] CPR(s) Sortie +[NOM] +HYDROCHLOROTHIAZIDE DR. [NOM] +- Matin [8h] Presc. de +ARW 25 MG CPR [90] 1 CPR [DATE] 13 : 27 NOCENT- +Sortie +CPR(s) [NOM] +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 11 de 27 DR. [NOM] +LANSOPRAZOLE BGA 30 - Prise unique à 19h +1 CPR [DATE] 13 : 27 NOCENT- +MG CPR OROD [14] CPR(s) Presc. de Sortie +[NOM] +DR. [NOM] +LOXEN LP 50MG GELULE - 1xJour [8h] Presc. +1 GEL [DATE] 13 : 27 NOCENT- +[60] Gelule(s) de Sortie +[NOM] +MONTELUKAST DR. [NOM] +- Soir [19h] Presc. de +ARW 10MG CPR [28] 1 CPR [DATE] 13 : 27 NOCENT- +Sortie +COMPRIME(S) [NOM] +DR. [NOM] +POTASSIUM 600MG +4 GEL - URGENT Urgent [DATE] 11 : 21 [DATE] 11:22 NOCENT- +GELULE +[NOM] +DR. [NOM] +POTASSIUM 600MG - Matin midi soir +3 GEL [DATE] 13 : 27 NOCENT- +GELULE Presc. de Sortie +[NOM] +DR. [NOM] +ROSUVASTATINE ARW - 1xJour [8h] Presc. +0,5 CPR [DATE] 13 : 27 NOCENT- +20MG CPR [90] CPR(s) de Sortie +[NOM] +SOLUPRED 20MG +DR. [NOM] +CPR ORODISP [20] 3 CPR - 1xJour [8h] Normal [DATE] 04 : 23 [DATE] 08:28 +[NOM] +COMPRIME(S) +DR. [NOM] +TERCIAN 4% SOL BUV FL - à 21h Presc. de +15 GTT [DATE] 13 : 27 NOCENT- +30ML [1200] Flacon(s) Sortie +[NOM] +DR. [NOM] +XARELTO 20MG CPR [14] - 1xJour [8h] Presc. +1 CPR [DATE] 13 : 27 NOCENT- +COMPRIME(S) de Sortie +[NOM] +Voie d`administration : SOUS-CUTANEE +Statut des prescriptions : Signé +ABASAGLAR 300 U SOL - Prise unique à 19h +60 UI [DATE] 04 : 49 [DATE] 18:54 [NOM] [NOM] +INJ CART [5] Cartouche(s) Normal +DR. [NOM] +ABASAGLAR 300 U SOL - Prise unique à 19h +60 UI [DATE] 13 : 27 NOCENT- +INJ CART [5] Cartouche(s) Presc. de Sortie +[NOM] +HUMALOG 300UI/3ML +- Matin midi soir DR. [NOM] +KWIKPEN SOL INJ [5] 14 UI [DATE] 10 : 07 [DATE] 12:17 +Normal [NOM] +Stylo(s) Prerempli(s) +HUMALOG 300UI/3ML DR. [NOM] +- Matin midi soir +KWIKPEN SOL INJ [5] 14 UI [DATE] 13 : 27 NOCENT- +Presc. de Sortie +Stylo(s) Prerempli(s) [NOM] +OZEMPIC 1 MG SOL INJ +- 1xSemaine [8h] +STYLO 3ML [1] Stylo(s) 1 mg [DATE] 04 : 49 [DATE] 08:00 [NOM] [NOM] +Normal +Prerempli(s) +OZEMPIC 1 MG SOL INJ DR. [NOM] +- 1xSemaine [8h] +STYLO 3ML [1] Stylo(s) 1 mg [DATE] 13 : 27 NOCENT- +Presc. de Sortie +Prerempli(s) [NOM] +Voie d`administration : TRANSDERMIQUE +Statut des prescriptions : Signé +DUROGESIC 12MICROG/ +H DISP TRANSDERM - Ttes les 72H (1j /3) DR. [NOM] +1 PATCH [DATE] 15 : 01 [DATE] 14:16 +[5] DISPOSITIF(S) Normal [NOM] +TRANSDERMIQUE(S) +DUROGESIC 25MICROG/ +H DISP TRANSDERM +1 PATCH - Normal [DATE] 04 : 49 [DATE] 14:16 [NOM] [NOM] +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) +Statut des prescriptions : Réalisé +DUROGESIC 12MICROG/ +DR. [NOM] +H DISP TRANSDERM - Ttes les 72H (1j /3) +1 PATCH [DATE] 13 : 27 NOCENT- +[5] DISPOSITIF(S) Presc. de Sortie +[NOM] +TRANSDERMIQUE(S) +DUROGESIC 25MICROG/ +DR. [NOM] +H DISP TRANSDERM +1 PATCH - Presc. de Sortie [DATE] 13 : 27 NOCENT- +[5] DISPOSITIF(S) +[NOM] +TRANSDERMIQUE(S) +Voie d`administration : INHALEE +Statut des prescriptions : Signé +IPRATROPIUM AGT +Le débit en cours +0,5MG/2ML AD INHAL 1 REC. DR. [NOM] +- Normal [DATE] 12 : 58 [DATE] 12:18 est : 8 ML par 1 +[10] RECIPIENT(S) UNIDOSE [NOM] +hrs. +UNIDOSE(S) +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 12 de 27 IPRATROPIUM AGT +DR. [NOM] +0,5MG/2ML AD INHAL 1 REC. +- Presc. de Sortie [DATE] 13 : 27 NOCENT- +[10] RECIPIENT(S) UNIDOSE +[NOM] +UNIDOSE(S) +TERBUTALINE ARW +Le débit en cours +5MG/2ML SOL INHAL 1 REC. DR. [NOM] +- Normal [DATE] 12 : 58 [DATE] 12:18 est : 8 ML par 1 +[50] RECIPIENT(S) UNIDOSE [NOM] +hrs. +UNIDOSE(S) +TERBUTALINE ARW +DR. [NOM] +5MG/2ML SOL INHAL 1 REC. +- Presc. de Sortie [DATE] 13 : 27 NOCENT- +[50] RECIPIENT(S) UNIDOSE +[NOM] +UNIDOSE(S) +TRIMBOW 87/5/9 +MCG SOL INH 60 - Matin soir (8h - +2 BOUFFEE [DATE] 04 : 49 [DATE] 07:49 [NOM] [NOM] +D [1] FLACON(S) 19h) Normal +PRESSURISE(S) +TRIMBOW 87/5/9 +DR. [NOM] +MCG SOL INH 60 - Matin soir (8h - +2 BOUFFEE [DATE] 13 : 27 NOCENT- +D [1] FLACON(S) 19h) Presc. de Sortie +[NOM] +PRESSURISE(S) +Voie d`administration : BUCCALE +Statut des prescriptions : Signé +SODIUM BIC BAX 1,4% +- Matin midi soir DR. [NOM] +POC CFX 500ML V1 [1] 10 ml [DATE] 12 : 58 [DATE] 12:00 +Normal [NOM] +POCHE(S) +Voie d`administration : CUTANEE +Statut des prescriptions : Signé +VERSATIS 5% EMPLATRE 1 - Prise unique à 19h +[DATE] 04 : 49 [DATE] 20:39 [NOM] [NOM] +[30] Emplatre(s) Emplatre(s) Normal +Statut des prescriptions : Réalisé +DR. [NOM] +VERSATIS 5% EMPLATRE 1 - Prise unique à 19h +[DATE] 13 : 27 NOCENT- +[30] Emplatre(s) Emplatre(s) Presc. de Sortie +[NOM] +Prescriptions de radiologie +Heure Date Heure +Date début Prescription Statut Docteur [NOM] +début exécution exécution +[DATE] 02 : 19 Thorax [NOM] [DATE] 02:36 Réalisé [NOM] [NOM] +Prescriptions de laboratoire +Date de +Date Heure Prescription Docteur [NOM] +collection +[DATE] +[DATE] 01 : 08 Ionogramme ( Na, K, CL ) DR. [NOM] +[TEL] +[DATE] +[DATE] 08 : 00 Clairance à la creatinine MDRD DR. [NOM] +08 : 26 +[DATE] +[DATE] 08 : 00 Clairance à la creatinine MDRD DR. [NOM] +08 : 11 +[DATE] +[DATE] 07 : 00 Ionogramme ( Na, K, CL ) DR. [NOM] +09 : 07 +[DATE] +[DATE] 07 : 00 Créatinine sang ( dosage ) DR. [NOM] +09 : 07 +Bilirubine ( totale + conjuguée + [DATE] +[DATE] 07 : 00 DR. [NOM] +non conjuguée ) sang ( dosage ) 09 : 07 +Prescriptions de soins +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +[NOM] +[DATE] [NOM] +ENVIRONNEMENT Signé - Matin [8h] Normal +13 : 41 [NOM] +PATIENT +LIT : REFECTION [DATE] [NOM] +Signé - Matin [8h] Normal +COMPLETE 13 : 41 [NOM] +TOILETTE DOUCHE : [DATE] [NOM] +Signé - Matin [8h] Normal +AIDE PARTIELLE 13 : 41 [NOM] +ACCOMPAGNER [NOM]- +1 Semaine - Matin [DATE] +INSTALLER AUX Réalisé [NOM] +[8h] Normal 10 : 24 +TOILETTES [NOM] +DESINFECTION [NOM]- +1 Semaine - Matin [DATE] +ENVIRONNEMENT Réalisé [NOM] +[8h] Normal 10 : 24 +PATIENT [NOM] +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 13 de 27 [NOM] +1 Semaine - Nuit [DATE] +SOMMEIL : SURV. Réalisé ESTOMBA- +[21h] Normal 06 : 46 +[NOM] +[NOM]- +1 Semaine - Matin [DATE] +TOILETTE : AUTONOME Réalisé [NOM] +[8h] Normal 10 : 24 +[NOM] +Notes du +professionel +de santé : +- 7x/jour (8h 12h bien noter DR. +[NOM] x [DATE] +Réalisé 14h 19h 22h 0h 4h) toutes les [NOM] +7 14 : 52 +Normal glycémies [NOM] +sur trakcare +notamment +celles de 22h +Prescriptions de sortie +Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur +60 UI DR. [NOM] +ABASAGLAR 300 U SOL - Prise unique à 19h [DATE] [DATE] : Non administré +SOUS- Signé [NOM]- +INJ CART [5] Cartouche(s) Presc. de Sortie 13 : 27 A valider +CUTANEE [NOM] +DR. [NOM] +BUSPIRONE MYL 10MG 1 CPR - Prise unique à 19h [DATE] [DATE] : Non administré +Réalisé [NOM]- +CPR [20] COMPRIME(S) ORALE Presc. de Sortie 13 : 27 Révisé/Traité +[NOM] +DR. [NOM] +CETIRIZINE ARW 10MG 1 CPR - Soir [19h] Presc. de [DATE] [DATE] : Non administré +Réalisé [NOM]- +CPR [60] COMPRIME(S) ORALE Sortie 13 : 27 Révisé/Traité +[NOM] +[DATE] : Non DR. [NOM] +DEPAKOTE 500MG CPR 750 mg - Matin soir (8h - [DATE] +Réalisé administré Révisé/ [NOM]- +[90] COMPRIME(S) ORALE 20h) Presc. de Sortie 13 : 27 +Traité [NOM] +DUROGESIC 12MICROG/ +DR. [NOM] +H DISP TRANSDERM 1 PATCH - Ttes les 72H (1j /3) [DATE] [DATE] : Non administré +Réalisé [NOM]- +[5] DISPOSITIF(S) TRANSDERMIQUE Presc. de Sortie 13 : 27 Révisé/Traité +[NOM] +TRANSDERMIQUE(S) +DUROGESIC 25MICROG/ +DR. [NOM] +H DISP TRANSDERM 1 PATCH [DATE] [DATE] : Non administré +Réalisé - Presc. de Sortie [NOM]- +[5] DISPOSITIF(S) TRANSDERMIQUE 13 : 27 Révisé/Traité +[NOM] +TRANSDERMIQUE(S) +DR. [NOM] +FORXIGA 10MG CPR [30] 1 CPR - Matin [8h] Presc. de [DATE] [DATE] : Non administré +Réalisé [NOM]- +CPR(s) ORALE Sortie 13 : 27 Révisé/Traité +[NOM] +DR. [NOM] +FUROSEMIDE ZEN 500MG 1 CPR - Matin [8h] Presc. de [DATE] [DATE] : Non administré +Réalisé [NOM]- +CPR [30] CPR(s) ORALE Sortie 13 : 27 Révisé/Traité +[NOM] +HUMALOG 300UI/3ML 14 UI DR. [NOM] +- Matin midi soir [DATE] 0/5 : Non administré +KWIKPEN SOL INJ [5] SOUS- Signé [NOM]- +Presc. de Sortie 13 : 27 A valider +Stylo(s) Prerempli(s) CUTANEE [NOM] +HYDROCHLOROTHIAZIDE DR. [NOM] +1 CPR - Matin [8h] Presc. de [DATE] [DATE] : Non administré +ARW 25 MG CPR [90] Réalisé [NOM]- +ORALE Sortie 13 : 27 Révisé/Traité +CPR(s) [NOM] +IPRATROPIUM AGT +1 REC. DR. [NOM] +0,5MG/2ML AD INHAL [DATE] [DATE] : Non administré +UNIDOSE Signé - Presc. de Sortie [NOM]- +[10] RECIPIENT(S) 13 : 27 A valider +INHALEE [NOM] +UNIDOSE(S) +DR. [NOM] +LANSOPRAZOLE BGA 30 1 CPR - Prise unique à 19h [DATE] [DATE] : Non administré +Réalisé [NOM]- +MG CPR OROD [14] CPR(s) ORALE Presc. de Sortie 13 : 27 Révisé/Traité +[NOM] +DR. [NOM] +LOXEN LP 50MG GELULE 1 GEL - 1xJour [8h] Presc. [DATE] [DATE] : Non administré +Réalisé [NOM]- +[60] Gelule(s) ORALE de Sortie 13 : 27 Révisé/Traité +[NOM] +MONTELUKAST DR. [NOM] +1 CPR - Soir [19h] Presc. de [DATE] [DATE] : Non administré +ARW 10MG CPR [28] Réalisé [NOM]- +ORALE Sortie 13 : 27 Révisé/Traité +COMPRIME(S) [NOM] +OZEMPIC 1 MG SOL INJ DR. [NOM] +1 mg SOUS- - 1xSemaine [8h] [DATE] 0/1 : Non administré +STYLO 3ML [1] Stylo(s) Signé [NOM]- +CUTANEE Presc. de Sortie 13 : 27 A valider +Prerempli(s) [NOM] +[DATE] : Non DR. [NOM] +POTASSIUM 600MG 3 GEL - Matin midi soir [DATE] +Réalisé administré Révisé/ [NOM]- +GELULE ORALE Presc. de Sortie 13 : 27 +Traité [NOM] +DR. [NOM] +ROSUVASTATINE ARW 0,5 CPR - 1xJour [8h] Presc. [DATE] [DATE] : Non administré +Réalisé [NOM]- +20MG CPR [90] CPR(s) ORALE de Sortie 13 : 27 Révisé/Traité +[NOM] +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 14 de 27 TERBUTALINE ARW +1 REC. DR. [NOM] +5MG/2ML SOL INHAL [DATE] [DATE] : Non administré +UNIDOSE Signé - Presc. de Sortie NOCENT- +[50] RECIPIENT(S) 13 : 27 A valider +INHALEE [NOM] +UNIDOSE(S) +DR. [NOM] +TERCIAN 4% SOL BUV FL 15 GTT - à 21h Presc. de [DATE] [DATE] : Non administré +Réalisé NOCENT- +30ML [1200] Flacon(s) ORALE Sortie 13 : 27 Révisé/Traité +[NOM] +TRIMBOW [DATE] +DR. [NOM] +MCG SOL INH 60 2 BOUFFEE - Matin soir (8h - [DATE] [DATE] : Non +Signé NOCENT- +D [1] FLACON(S) INHALEE 19h) Presc. de Sortie 13 : 27 administré A valider +[NOM] +PRESSURISE(S) +1 DR. [NOM] +VERSATIS 5% EMPLATRE - Prise unique à 19h [DATE] 0/30 : Non administré +Emplatre(s) Réalisé NOCENT- +[30] Emplatre(s) Presc. de Sortie 13 : 27 Révisé/Traité +CUTANEE [NOM] +DR. [NOM] +XARELTO 20MG CPR [14] 1 CPR - 1xJour [8h] Presc. [DATE] 0/30 : Non administré +Réalisé NOCENT- +COMPRIME(S) ORALE de Sortie 13 : 27 Révisé/Traité +[NOM] +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 15 de 27 Plan de soins Jour J du [DATE] 07h00 au [DATE] 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le [DATE] à +500ML V1 - 1,4G/100ML solution (500 mL) - 12 : 58 +Dose 10 ml - BUCCALE - Matin midi soir - 1ère Fin le [DATE] à 19 : 00 * 10 ml +dose : [DATE] @ 19:00 12:00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le [DATE] à +500ML V1 - 1,4G/100ML solution (500 mL) - 12 : 58 +Dose 10 ml - BUCCALE - Matin midi soir - 1ère Fin le [DATE] à 07 : 49 * 10 ml +dose : [DATE] @ 19:00 12:00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le [DATE] à +500ML V1 - 1,4G/100ML solution (500 mL) - 12 : 58 +Dose 10 ml - BUCCALE - Matin midi soir - 1ère Fin le [DATE] à 12 : 00 * 10 ml +dose : [DATE] @ 19:00 12:00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Signé — VERSATIS 700MG EMPLATRE Début le [DATE] à +- 700MG emplatre - Dose 1 Emplatre(s) - 04 : 49 +C 25 U /0 T 3 A /2 N 0 E 2 E 3 @ - P r 1 i 9 se : [DATE] à 19h - 1ère dose: F 19 in :0 l 0 e [DATE] à 1 E 9 m :0 p 0 la * tr e 1 (s) +Admin le [DATE] à +20 : 39 +Signé — IPRATROPIUM AGT 0,5MG/2ML AD [NOM] [NOM] +INHAL - 0,5MG/2ML solution (2 mL) - Dose Début le [DATE] à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 20:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 12 : 58 04:58 UNIDOSE +Admin le [DATE] à +12 : 18 +Signé — IPRATROPIUM AGT 0,5MG/2ML AD [NOM] [NOM] +INHAL - 0,5MG/2ML solution (2 mL) - Dose Début le [DATE] à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 04:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 12 : 58 04:58 UNIDOSE +Admin le [DATE] à +12 : 18 +Signé — IPRATROPIUM AGT 0,5MG/2ML AD [NOM] [NOM] +INHAL - 0,5MG/2ML solution (2 mL) - Dose Début le [DATE] à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 12:18 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 12 : 58 04:58 UNIDOSE +Admin le [DATE] à +12 : 18 +Signé — TERBUTALINE ARW 5MG/2ML [NOM] [NOM] +SOL INHAL - 5MG/2ML solution (2 mL) - Dose Début le [DATE] à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 20:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 12 : 58 04:58 UNIDOSE +Admin le [DATE] à +12 : 18 +Signé — TERBUTALINE ARW 5MG/2ML [NOM] [NOM] +SOL INHAL - 5MG/2ML solution (2 mL) - Dose Début le [DATE] à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 04:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 12 : 58 04:58 UNIDOSE +Admin le [DATE] à +12 : 18 +Signé — TERBUTALINE ARW 5MG/2ML [NOM] [NOM] +SOL INHAL - 5MG/2ML solution (2 mL) - Dose Début le [DATE] à +1 REC. UNIDOSE - sur 15 min - INHALEE 12 : 58 12:18 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 12 : 58 04:58 UNIDOSE +Admin le [DATE] à +12 : 18 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 16 de 27 [NOM] [NOM] +Signé — TRIMBOW 87/5/9 MCG SOL INH Début le [DATE] à +60 D - 87/5/9 solution - Dose 2 BOUFFEE - 04 : 49 +I d N os H e A : 2 L 5 E /0 E 3 D /2 i 0 re 2 c 3 t e @ - 0 M 8 a :0 ti 0 n soir (8h - 19h) - 1ère F 19 in :0 l 0 e [DATE] à 1 B 9 O :0 U 0 F * F E 2 E +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — TRIMBOW 87/5/9 MCG SOL INH Début le [DATE] à +60 D - 87/5/9 solution - Dose 2 BOUFFEE - 04 : 49 +I d N os H e A : 2 L 5 E /0 E 3 D /2 i 0 re 2 c 3 t e @ - 0 M 8 a :0 ti 0 n soir (8h - 19h) - 1ère F 19 in :0 l 0 e [DATE] à 0 B 7 O :4 U 9 F * F E 2 E +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — BUSPIRONE MYL 10MG CPR - 10MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Prise unique 04 : 49 19:00 * 1 +à 19h - 1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +19 : 00 +Admin le [DATE] à +20 : 40 +[NOM] [NOM] +Signé — CETIRIZINE ARW 10MG CPR - 10MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Soir [19h] - 15 : 41 19:00 * 1 +1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +19 : 00 +Admin le [DATE] à +18 : 44 +[NOM] [NOM] +Signé — DEPAKOTE 500MG CPR - 500MG Début le [DATE] à +comprime - Dose Variable - ORALE - Matin soir 14 : 08 +(8h - 20h) - 1ère dose : [DATE] @ 20:00 Fin le [DATE] à 2 m 0 g :00 * 1000 +08 : 00 +! Plan de dosage variable Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — DEPAKOTE 500MG CPR - 500MG Début le [DATE] à +comprime - Dose Variable - ORALE - Matin soir 14 : 08 +(8h - 20h) - 1ère dose : [DATE] @ 20:00 Fin le [DATE] à 0 m 7 g :49 * 750 +08 : 00 +! Plan de dosage variable Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — FORXIGA 10MG CPR - 10MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Matin [8h] - 16 : 14 07:49 * 1 +1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — FUROSEMIDE ZEN 500MG CPR - Début le [DATE] à +500MG comprime - Dose 1 CPR - ORALE - 04 : 49 07:49 * 1 +Matin [8h] - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — HYDROCHLOROTHIAZIDE ARW Début le [DATE] à +25 MG CPR - 25MG comprime - Dose 1 CPR - 18 : 00 +O 08 R : 0 A 0 LE - Matin [8h] - 1ère dose: [DATE] @ F 08 in :0 l 0 e [DATE] à 0 C 7 P : R 49 * 1 +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — LANSOPRAZOLE BGA 30 MG Début le [DATE] à +CPR OROD - 30MG comprime - Dose 1 CPR 04 : 49 +- 2 5 O /0 R 3 A /2 L 0 E 2 3 - P @ ri s 1 e 9 : [DATE] à 19h - 1ère dose: F 19 in :0 l 0 e [DATE] à 1 C 9 P : R 00 * 1 +Admin le [DATE] à +18 : 44 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 17 de 27 [NOM] [NOM] +Signé — LOXEN LP 50MG GELULE - 50MG Début le [DATE] à +gelule - Dose 1 GEL - ORALE - 1xJour [8h] - [DATE] 07:49 * 1 +1ère dose : [DATE] @ 08:00 Fin le [DATE] à GEL +08 : 00 +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — MONTELUKAST ARW 10MG CPR - Début le [DATE] à +10MG comprime - Dose 1 CPR - ORALE - Soir 15 : 41 19:00 * 1 +[19h] - 1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +19 : 00 +Admin le [DATE] à +18 : 44 +[NOM] [NOM] +Signé — POTASSIUM 600MG GELULE - Début le [DATE] à +600MG gelule - Dose 3 GEL - ORALE - Matin [DATE] 19:00 * 3 +midi soir - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à GEL +19 : 00 +Admin le [DATE] à +12 : 16 +[NOM] [NOM] +Signé — POTASSIUM 600MG GELULE - Début le [DATE] à +600MG gelule - Dose 3 GEL - ORALE - Matin [DATE] 07:49 * 3 +midi soir - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à GEL +19 : 00 +Admin le [DATE] à +12 : 16 +[NOM] [NOM] +Signé — POTASSIUM 600MG GELULE - Début le [DATE] à +600MG gelule - Dose 3 GEL - ORALE - Matin [DATE] 12:16 * 3 +midi soir - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à GEL +19 : 00 +Admin le [DATE] à +12 : 16 +[NOM] +[NOM] +Réalisé — POTASSIUM 600MG GELULE Début le [DATE] à +- 600MG gelule - Dose 4 GEL - ORALE - 11 : 21 11:22 * 4 +URGENT - Début presc. : [DATE] @ 11:21 Fin le [DATE] à GEL +11 : 21 +Admin le [DATE] à +11 : 22 +[NOM] [NOM] +Signé — ROSUVASTATINE ARW 20MG CPR Début le [DATE] à +- 20MG comprime - Dose 0,5 CPR - ORALE - [DATE] 07:49 * 0.5 +1xJour [8h] - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — TERCIAN 40 MG/ML SOL BUV 30ML Début le [DATE] à +- 0,04G/ML solution (30 mL) - Dose 15 GTT - [DATE] 21:00 * 15 +ORALE - à 21h - 1ère dose : [DATE] @ 21:00 Fin le [DATE] à GTT +21 : 00 +Admin le [DATE] à +20 : 40 +[NOM] [NOM] +Signé — XARELTO 20 MG CPR - 20MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - 1xJour [8h] - [DATE] 07:49 * 1 +1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — ABASAGLAR 300 U SOL INJ CART - Début le [DATE] à +100UI/ML solution (3 mL) - Dose 60 UI - SOUS- [DATE] +C +do +U +s +T +e : +A +2 +N +5/ +E +0 +E +3 / +D +20 +ir +2 +e +3 +c t +@ +e - +1 +P +9 +r + : +i +0 +s +0 +e unique à 19h - 1ère F +19 +in + : 0 +l +0 +e [DATE] à 19 : 00 * 60 UI +Admin le [DATE] à +18 : 54 +Signé — HUMALOG 300UI KWIKPEN SOL +[NOM] [NOM] 19 : 00 * 14 UI +INJ - 300UI solution (3 mL) - Dose 14 UI - +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 18 de 27 Début le [DATE] à +SOUS-CUTANEE Directe - Matin midi soir - 1ère 10 : 07 +dose : [DATE] @ 12:00 Fin le [DATE] à +08 : 00 +Admin le [DATE] à +12 : 17 +[NOM] [NOM] +Signé — HUMALOG 300UI KWIKPEN SOL Début le [DATE] à +INJ - 300UI solution (3 mL) - Dose 14 UI - 10 : 07 +S +do +O +s +U +e : +S +2 +- +6 +C +/ +U +03 +T +/ +A +20 +N +2 +E +3 +E +@ +D +1 +ir +2 +e + : +c +0 +t +0 +e - Matin midi soir - 1ère F +08 +in + : 0 +l +0 +e [DATE] à 08 : 00 * 14 UI +Admin le [DATE] à +12 : 17 +[NOM] [NOM] +Signé — HUMALOG 300UI KWIKPEN SOL Début le [DATE] à +INJ - 300UI solution (3 mL) - Dose 14 UI - 10 : 07 +S +do +O +s +U +e : +S +2 +- +6 +C +/ +U +03 +T +/ +A +20 +N +2 +E +3 +E +@ +D +1 +ir +2 +e + : +c +0 +t +0 +e - Matin midi soir - 1ère F +08 +in + : 0 +l +0 +e [DATE] à 12 : 17 * 14 UI +Admin le [DATE] à +12 : 17 +[NOM] [NOM]- +[NOM] +Réalisé — ACCOMPAGNER INSTALLER AUX Début le [DATE] à +TOILETTES - Matin [8h] - 1 Semaine- Date 10 : 24 +Début : [DATE] @ 10:24 Fin le [DATE] à 08:00 * 1 +08 : 00 +Admin le [DATE] à +08 : 00 +[NOM] [NOM]- +[NOM] +Réalisé — DESINFECTION Début le [DATE] à +ENVIRONNEMENT PATIENT - Matin [8h] - 1 10 : 24 +Semaine- Date Début : [DATE] @ 10:24 Fin le [DATE] à 08:00 * 1 +08 : 00 +Admin le [DATE] à +08 : 00 +ESTOMBA- +[NOM] [NOM] +Réalisé — SOMMEIL : SURV. - Nuit [21h] - 1 Début le [DATE] à +Semaine- Date Début : [DATE] @ 06:46 06:46 21:00 * 1 +Fin le [DATE] à +21 : 00 +Admin le [DATE] à +21 : 00 +[NOM] [NOM]- +[NOM] +Réalisé — TOILETTE : AUTONOME - Matin Début le [DATE] à +[8h] - 1 Semaine- Date Début : [DATE] @ 10:24 +10 : 24 Fin le [DATE] à 08:00 * 1 +08 : 00 +Admin le [DATE] à +08 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 19:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 22:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 00:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 19 de 27 Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 04:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 08:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 12:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 14:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 20 de 27 Plan de soins Jour J + 1 du [DATE] 07h00 au [DATE] 07h00 +Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le [DATE] à +500ML V1 - 1,4G/100ML solution (500 mL) - 12 : 58 +Dose 10 ml - BUCCALE - Matin midi soir - 1ère Fin le [DATE] à 08 : 00 * 10 ml +dose : [DATE] @ 19:00 12:00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le [DATE] à +500ML V1 - 1,4G/100ML solution (500 mL) - 12 : 58 +Dose 10 ml - BUCCALE - Matin midi soir - 1ère Fin le [DATE] à 12 : 00 * 10 ml +dose : [DATE] @ 19:00 12:00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Signé — SODIUM BIC BAX 1,4% POC CFX Début le [DATE] à +500ML V1 - 1,4G/100ML solution (500 mL) - 12 : 58 +Dose 10 ml - BUCCALE - Matin midi soir - 1ère Fin le [DATE] à 19 : 00 * 10 ml +dose : [DATE] @ 19:00 12:00 +Admin le [DATE] à +12 : 00 +[NOM] [NOM] +Signé — VERSATIS 700MG EMPLATRE Début le [DATE] à +- 700MG emplatre - Dose 1 Emplatre(s) - 04 : 49 +C 25 U /0 T 3 A /2 N 0 E 2 E 3 @ - P r 1 i 9 se : [DATE] à 19h - 1ère dose: F 19 in :0 l 0 e [DATE] à 1 E 9 m :0 p 0 la * tr e 1 (s) +Admin le [DATE] à +20 : 39 +Signé — IPRATROPIUM AGT 0,5MG/2ML AD [NOM] [NOM] +INHAL - 0,5MG/2ML solution (2 mL) - Dose Début le [DATE] à +1 REC. UNIDOSE - sur 15 min - [DATE] : 58 12:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 12 : 58 04:58 UNIDOSE +Admin le [DATE] à +12 : 18 +Signé — IPRATROPIUM AGT 0,5MG/2ML AD [NOM] [NOM] +INHAL - 0,5MG/2ML solution (2 mL) - Dose Début le [DATE] à +1 REC. UNIDOSE - sur 15 min - [DATE] : 58 20:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 12 : 58 04:58 UNIDOSE +Admin le [DATE] à +12 : 18 +Signé — IPRATROPIUM AGT 0,5MG/2ML AD [NOM] [NOM] +INHAL - 0,5MG/2ML solution (2 mL) - Dose Début le [DATE] à +1 REC. UNIDOSE - sur 15 min - [DATE] : 58 04:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 12 : 58 04:58 UNIDOSE +Admin le [DATE] à +12 : 18 +Signé — TERBUTALINE ARW 5MG/2ML [NOM] [NOM] +SOL INHAL - 5MG/2ML solution (2 mL) - Dose Début le [DATE] à +1 REC. UNIDOSE - sur 15 min - [DATE] : 58 12:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 12 : 58 04:58 UNIDOSE +Admin le [DATE] à +12 : 18 +Signé — TERBUTALINE ARW 5MG/2ML [NOM] [NOM] +SOL INHAL - 5MG/2ML solution (2 mL) - Dose Début le [DATE] à +1 REC. UNIDOSE - sur 15 min - [DATE] : 58 20:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 12 : 58 04:58 UNIDOSE +Admin le [DATE] à +12 : 18 +Signé — TERBUTALINE ARW 5MG/2ML [NOM] [NOM] +SOL INHAL - 5MG/2ML solution (2 mL) - Dose Début le [DATE] à +1 REC. UNIDOSE - sur 15 min - [DATE] : 58 04:58 * +Discontinue - Toutes les 8 Heure(s) - 1ère dose : Fin le [DATE] à 1 REC. +[DATE] @ 12 : 58 04:58 UNIDOSE +Admin le [DATE] à +12 : 18 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 21 de 27 [NOM] [NOM] +Signé — TRIMBOW 87/5/9 MCG SOL INH Début le [DATE] à +60 D - 87/5/9 solution - Dose 2 BOUFFEE - 04 : 49 +I d N os H e A : 2 L 5 E /0 E 3 D /2 i 0 re 2 c 3 t e @ - 0 M 8 a :0 ti 0 n soir (8h - 19h) - 1ère F 19 in :0 l 0 e [DATE] à 0 B 8 O :0 U 0 F * F E 2 E +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — TRIMBOW 87/5/9 MCG SOL INH Début le [DATE] à +60 D - 87/5/9 solution - Dose 2 BOUFFEE - 04 : 49 +I d N os H e A : 2 L 5 E /0 E 3 D /2 i 0 re 2 c 3 t e @ - 0 M 8 a :0 ti 0 n soir (8h - 19h) - 1ère F 19 in :0 l 0 e [DATE] à 1 B 9 O :0 U 0 F * F E 2 E +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — BUSPIRONE MYL 10MG CPR - 10MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Prise unique 04 : 49 19:00 * 1 +à 19h - 1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +19 : 00 +Admin le [DATE] à +20 : 40 +[NOM] [NOM] +Signé — CETIRIZINE ARW 10MG CPR - 10MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Soir [19h] - 15 : 41 19:00 * 1 +1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +19 : 00 +Admin le [DATE] à +18 : 44 +[NOM] [NOM] +Signé — DEPAKOTE 500MG CPR - 500MG Début le [DATE] à +comprime - Dose Variable - ORALE - Matin soir 14 : 08 +(8h - 20h) - 1ère dose : [DATE] @ 20:00 Fin le [DATE] à 0 m 8 g :00 * 750 +08 : 00 +! Plan de dosage variable Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — DEPAKOTE 500MG CPR - 500MG Début le [DATE] à +comprime - Dose Variable - ORALE - Matin soir 14 : 08 +(8h - 20h) - 1ère dose : [DATE] @ 20:00 Fin le [DATE] à 2 m 0 g :00 * 1000 +08 : 00 +! Plan de dosage variable Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — FORXIGA 10MG CPR - 10MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - Matin [8h] - 16 : 14 08:00 * 1 +1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — FUROSEMIDE ZEN 500MG CPR - Début le [DATE] à +500MG comprime - Dose 1 CPR - ORALE - 04 : 49 08:00 * 1 +Matin [8h] - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — HYDROCHLOROTHIAZIDE ARW Début le [DATE] à +25 MG CPR - 25MG comprime - Dose 1 CPR - 18 : 00 +O 08 R : 0 A 0 LE - Matin [8h] - 1ère dose: [DATE] @ F 08 in :0 l 0 e [DATE] à 0 C 8 P : R 00 * 1 +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — LANSOPRAZOLE BGA 30 MG Début le [DATE] à +CPR OROD - 30MG comprime - Dose 1 CPR 04 : 49 +- 2 5 O /0 R 3 A /2 L 0 E 2 3 - P @ ri s 1 e 9 : [DATE] à 19h - 1ère dose: F 19 in :0 l 0 e [DATE] à 1 C 9 P : R 00 * 1 +Admin le [DATE] à +18 : 44 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 22 de 27 [NOM] [NOM] +Signé — LOXEN LP 50MG GELULE - 50MG Début le [DATE] à +gelule - Dose 1 GEL - ORALE - 1xJour [8h] - [DATE] 08:00 * 1 +1ère dose : [DATE] @ 08:00 Fin le [DATE] à GEL +08 : 00 +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — MONTELUKAST ARW 10MG CPR - Début le [DATE] à +10MG comprime - Dose 1 CPR - ORALE - Soir 15 : 41 19:00 * 1 +[19h] - 1ère dose : [DATE] @ 19:00 Fin le [DATE] à CPR +19 : 00 +Admin le [DATE] à +18 : 44 +[NOM] [NOM] +Signé — POTASSIUM 600MG GELULE - Début le [DATE] à +600MG gelule - Dose 3 GEL - ORALE - Matin [DATE] 08:00 * 3 +midi soir - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à GEL +19 : 00 +Admin le [DATE] à +12 : 16 +[NOM] [NOM] +Signé — POTASSIUM 600MG GELULE - Début le [DATE] à +600MG gelule - Dose 3 GEL - ORALE - Matin [DATE] 12:00 * 3 +midi soir - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à GEL +19 : 00 +Admin le [DATE] à +12 : 16 +[NOM] [NOM] +Signé — POTASSIUM 600MG GELULE - Début le [DATE] à +600MG gelule - Dose 3 GEL - ORALE - Matin [DATE] 19:00 * 3 +midi soir - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à GEL +19 : 00 +Admin le [DATE] à +12 : 16 +[NOM] [NOM] +Signé — ROSUVASTATINE ARW 20MG CPR Début le [DATE] à +- 20MG comprime - Dose 0,5 CPR - ORALE - [DATE] 08:00 * 0.5 +1xJour [8h] - 1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — TERCIAN 40 MG/ML SOL BUV 30ML Début le [DATE] à +- 0,04G/ML solution (30 mL) - Dose 15 GTT - [DATE] 21:00 * 15 +ORALE - à 21h - 1ère dose : [DATE] @ 21:00 Fin le [DATE] à GTT +21 : 00 +Admin le [DATE] à +20 : 40 +[NOM] [NOM] +Signé — XARELTO 20 MG CPR - 20MG Début le [DATE] à +comprime - Dose 1 CPR - ORALE - 1xJour [8h] - [DATE] 08:00 * 1 +1ère dose : [DATE] @ 08:00 Fin le [DATE] à CPR +08 : 00 +Admin le [DATE] à +07 : 49 +[NOM] [NOM] +Signé — ABASAGLAR 300 U SOL INJ CART - Début le [DATE] à +100UI/ML solution (3 mL) - Dose 60 UI - SOUS- [DATE] +C +do +U +s +T +e : +A +2 +N +5/ +E +0 +E +3 / +D +20 +ir +2 +e +3 +c t +@ +e - +1 +P +9 +r + : +i +0 +s +0 +e unique à 19h - 1ère F +19 +in + : 0 +l +0 +e [DATE] à 19 : 00 * 60 UI +Admin le [DATE] à +18 : 54 +[NOM] [NOM] +Signé — HUMALOG 300UI KWIKPEN SOL Début le [DATE] à +INJ - 300UI solution (3 mL) - Dose 14 UI - 10 : 07 +S +do +O +s +U +e : +S +2 +- +6 +C +/ +U +03 +T +/ +A +20 +N +2 +E +3 +E +@ +D +1 +ir +2 +e + : +c +0 +t +0 +e - Matin midi soir - 1ère F +08 +in + : 0 +l +0 +e [DATE] à 08 : 00 * 14 UI +Admin le [DATE] à +12 : 17 +Signé — HUMALOG 300UI KWIKPEN SOL +[NOM] [NOM] 12 : 00 * 14 UI +INJ - 300UI solution (3 mL) - Dose 14 UI - +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 23 de 27 Début le [DATE] à +SOUS-CUTANEE Directe - Matin midi soir - 1ère 10 : 07 +dose : [DATE] @ 12:00 Fin le [DATE] à +08 : 00 +Admin le [DATE] à +12 : 17 +[NOM] [NOM] +Signé — HUMALOG 300UI KWIKPEN SOL Début le [DATE] à +INJ - 300UI solution (3 mL) - Dose 14 UI - 10 : 07 +S +do +O +s +U +e : +S +2 +- +6 +C +/ +U +03 +T +/ +A +20 +N +2 +E +3 +E +@ +D +1 +ir +2 +e + : +c +0 +t +0 +e - Matin midi soir - 1ère F +08 +in + : 0 +l +0 +e [DATE] à 19 : 00 * 14 UI +Admin le [DATE] à +12 : 17 +[NOM] [NOM] +Signé — DUROGESIC 12 MICROG/H DISP Début le [DATE] à +TRANSDERM - 0.012MG/HEURE dispositif - 15 : 01 +D 72 o H se ( 1 1 j P / A 3) T - C 1 H è r - e T d R o A se N : 2 S 9 D /0 E 3 R /2 M 0 I 2 Q 3 U @ E 0 - 8 T :0 te 0 s les F 08 in :0 l 0 e [DATE] à 0 PA 8: T 0 C 0 H * 1 +Admin le [DATE] à +14 : 16 +[NOM] [NOM]- +[NOM] +Réalisé — ACCOMPAGNER INSTALLER AUX Début le [DATE] à +TOILETTES - Matin [8h] - 1 Semaine- Date 10 : 24 +Début : [DATE] @ 10:24 Fin le [DATE] à 08:00 * 1 +08 : 00 +Admin le [DATE] à +08 : 00 +[NOM] [NOM]- +[NOM] +Réalisé — DESINFECTION Début le [DATE] à +ENVIRONNEMENT PATIENT - Matin [8h] - 1 10 : 24 +Semaine- Date Début : [DATE] @ 10:24 Fin le [DATE] à 08:00 * 1 +08 : 00 +Admin le [DATE] à +08 : 00 +[NOM] [NOM]- +[NOM] +Réalisé — TOILETTE : AUTONOME - Matin Début le [DATE] à +[8h] - 1 Semaine- Date Début : [DATE] @ 10:24 +10 : 24 Fin le [DATE] à 08:00 * 1 +08 : 00 +Admin le [DATE] à +08 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 08:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 12:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 14:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 19:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 24 de 27 Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 22:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 00:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ [NOM] [NOM] +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 Début le [DATE] à +Jour(s)- Date Début : [DATE] @ 14:52 14:52 +Notes de professionel de santé : Fin le [DATE] à 04:00 * 1 +14 : 00 +bien noter toutes les glycémies sur trakcare +Admin le [DATE] à +notamment celles de 22h +14 : 00 +Résultats de radiologie +Prescription Date Résultat +Compte rendu au format texte +Bayonne, le [DATE] +Docteur +Nom de naissance : DE [NOM] [NOM] [NOM] +Nom utilisé : DE [NOM] [NOM] [NOM] +Prénom de naissance : REGINA +Prénom utilisé : REGINA +Date de naissance : [DATE_NAISSANCE] +Lieu de naissance : 99999 +Sexe : F +Matricule INS : +Examen du : [DATE] +Compte-rendu validé électroniquement par Dr [NOM] le [DATE] +RADIOGRAPHIE PULMONAIRE +Indication : +Bilan de dyspnée. +RESULTATS : +[DATE] +CR RX-Echo +02 : 19 +Sous réserve de la faible ampliation thoracique : +Diminution de la transparence parenchymateuse aux bases apparaissant être liée notamment à la projection des parties molles. +Absence de foyer circonscrit au niveau des apex pulmonaires. Augmentation de l'index cardiothoracique.. +Dr [NOM] +Technique : +PDS : 0.426 dGy.cm² +A l'entrée : 0.065 mGy +Protocole d'acquisition : Thorax +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 de naissance : [DATE_NAISSANCE] +Résultats de laboratoire +[DATE] 09 : 17 [DATE] 09:07 [DATE] 08:44 [DATE] 08:11 [DATE] 08:11 +Résultat de labo +(5920658) (5920659) (5918673) (5917252) (5917251) +Bilirubine totale 5 µmol/l +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 25 de 27 Score Fibrosis-4 (FIB4) 1,60 +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) % Non renseigné(e) % +Bicarbonates 38,0 mmol/l 37,7 mmol/l +Origine Artériel Artériel +Non renseigné(e) L/ Non renseigné(e) L/ +Débit +min min +Non renseignée (rendu Non renseignée (rendu +Température pour une température pour une température +de 37°C) °C de 37°C) °C +ASAT 27 U/l +Bilirubine totale < : +21 µmol/L : dosage des +Commentaire bilirubine totale fractions conjuguée +et non conjugée non +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 +masse musculaire - masse musculaire - masse 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 39 U/l +NT-proBNP 229 ng/l 507 ng/l +Zone grise : +insuffisance cardiaque +Négatif : Insuffisance moins plausible. +Interprétation NT-proBNP +cardiaque peu probable Envisager d?autres +causes d?augmentation +du NT-proBNP. +Phosphatase alcaline 80 U/l +Calcium 2,10 mmol/l +Estimation du DFG (CKD- +97 ml/mn/1.73 m2 71 ml/mn/1.73 m2 92 ml/mn/1.73 m2 +EPI) +Chlore 90 mmol/l 88 mmol/l 89 mmol/l +Créatinine 52 µmol/l 76 µmol/l 60 µmol/l +CRP 34 mg/l 2 mg/l +Compte-rendu laboratoire Labo230403105652-1.pdfLabo230403104835-1.pdfLabo230330101823-1.pdfLabo230329103002-1.pdfLabo230329102552-1.pdf +Polynucléaires neutrophiles +65,1 % 70,3 % +(%) +Polynucléaires neutrophiles +6,89 10.9/l 6,21 10.9/l +(#) +Polynucléaires éosinophiles +1,1 % 0,1 % +(%) +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 26 de 27 Polynucléaires éosinophiles +0,12 10.9/l 0,01 10.9/l +(#) +Polynucléaires basophiles (%) 0,4 % 0,3 % +Polynucléaires basophiles (#) 0,04 10.9/l 0,03 10.9/l +Lymphocytes (%) 24,3 % 19,3 % +Lymphocytes (#) 2,57 10.9/l 1,70 10.9/l +Monocytes (%) 9,1 % 10,0 % +Monocytes (#) 0,96 10.9/l 0,88 10.9/l +Glucose 13,4 mmol/l 9,7 mmol/l 15,0 mmol/l +pH 7,50 7,48 +pO2 100 mmHg 103 mmHg +Saturation O2 96,0 % 96,5 % +pCO2 49 mmHg 51 mmHg +ALAT 19 U/l +réalisée sur automate réalisée sur automate +Formule sanguine +XN (Sysmex) XN (Sysmex) +Hématocrite (%) 35,5 % 33,9 % +Indice de distribution des +20,3 % 18,2 % +hématies +Potassium 2,6 mmol/l 3,3 mmol/l 2,7 mmol/l +Leucocytes 10,59 10.9/l 8,83 10.9/l +Hématies 4,57 10.12/l (t/l) 4,48 10.12/l (t/l) +Hémoglobine 10,6 g/dl 10,1 g/dl +VGM 77,7 fl 75,7 fl +TCMH 23,2 pg 22,5 pg +CCMH 29,9 g/dl 29,8 g/dl +Sodium 137 mmol/l 136 mmol/l 136 mmol/l +Osmolarité sang 287 mOSM/l 282 mOSM/l 287 mOSM/l +Plaquettes 252 10.9/l 290 10.9/l +Validation et diffusion sous la Dr. [NOM] +Dr [NOM] "" Dr [NOM] [NOM] [NOM] +responsabilité du biologiste [NOM] +Volume plaquettaire moyen 9,0 fl 9,1 fl +Patient : DE [NOM] [NOM] [NOM] DE [NOM] [NOM] [NOM] REGINA - [DATE_NAISSANCE] (BA165196 ) +Episode N. : [IPP] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 152 cm - Poids: 88 kg - IMC: 38.089 +Le [DATE] 14 : 23 Page 27 de 27 + + +Nom de naissance : DE [NOM] [NOM] [NOM] IPP : [IPP] +Nom et Prénom : DE [NOM] [NOM] [NOM] REGINA [DATE_NAISSANCE] +Sexe : Féminin Lieu de naissance: [VILLE] +Nationalité : PORTUGAL [CODE_POSTAL] +Adresse : [ADRESSE]: [NOM] +Episode No : [EPISODE] +Localisation : PNEUMOLOGIE PHTISIOLOGIE HC Médecin courant: DR. [NOM] +Date d'admission : 25/03/2023 Heure d'admission: 00:51 +Date de sortie : 03/04/2023 Heure de sortie: 14:04 +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) : Epoux [NOM] [CODE_POSTAL] [TEL] +Personne à prévenir +(Clinicom) : Fille [NOM] [NOM] X [CODE_POSTAL] [TEL] + +Personne de +confiance : Fille [NOM] [NOM] [TEL] + +Episode - Date : 25/03/2023 +Episode - Heure : 00:51 +Mode de transport à l'arrivée : Ambulance +Médicalisation du transport : Prise en charge paramédicale +Mode d'entrée : Autres admissions urgentes +Date d'orientation : 25/03/2023 +Heure d'orientation : 00:56 +IAO : [NOM] +Priorité : Priorité 2 +Sous-type épisode : URG - Circuit Long +Motif de prise en charge : Dyspnée +Observ. IDE Urg : adressée par SOS pour décompensation cardio respi +hyperthermie cet am,non retrouvé au SAU +arrive sous 3L O2 aux lunettes:97%,baissé à 2litres +BI verifié et posé +test antigen covid:neg +Médecin de la prise en charge médicale : [NOM] [NOM] +Date de prise en charge médicale : 25/03/2023 +Heure de prise en charge médicale : 00:51 +Médecin de la décision médicale : [NOM] [NOM] +Date de décision médicale : 25/03/2023 +Heure de décision médicale : 04:58 +Décision médicale : Hospitalisation MCO +Orientation du patient : hospitalisation dans une unité de Médecine hors SC, SI, REA +Destination du patient : [NOM] [NOM] [NOM] [NOM] +Date de sortie des urgences : 25/03/2023 +Heure de sortie des Urgences : 05:10 +US de destination : US PNEUMOLOGIE + +UF de destination : PNEUMOLOGIE PHTISIOLOGIE HC +Type : Etat Code Date +Principal : actif J12.9 Pneumopathie virale, sans précision 25/03/2023 04:57 +Catégorie : Alerte Date début Date +expiration Message +Accompagnants : 27/04/2022 fille +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Type de note : Nom Date Heure Note +Aucune donnée +renseignée +Item de +surveillance : 03/04/2023 +12:01 03/04/2023 +09:17 03/04/2023 +07:57 03/04/2023 +06:19 03/04/2023 +00:19 02/04/2023 +18:53 02/04/2023 +15:16 02/04/2023 +12:04 02/04/2023 +07:48 02/04/2023 +06:15 02/04/2023 +00:14 01/04/2023 +18:29 01/04/2023 +16:16 +Glycémie +capillaire : 1,45 2,90 0,65 0,88 2,51 1,43 1,73 1,51 1,88 1,68 1,66 +Température : 37,10 37,40 37 36,50 37,30 36,50 +Pouls : 84 100 93 83 95 92 +PA +Systolique : 138 113 125 121 +PA +Diastolique : 66 76 68 67 +Saturation +O² : 96 96 97 95 95 96 +Débit O² +[L/mn] : 2 2 2 2 2 2 +Ventilation : Ventilatio +spontanée +Oxygène n Ventilatio +assistée n Ventilatio +spontanée +Oxygène n Ventilatio +spontanée +Oxygène n Ventilatio +spontanée +Oxygène n Ventilatio +spontanée +Oxygène +Echelle +douleur : EN EN EN EN EN +Score au +repos : 5 0 0 0 0 +Transit : Normal Absence Absence Absence Normal Normal Absence Absence Absence Absence Absence +Fréq. +respiratoire +Item de +surveillance : 31/03/2023 +08:39 27/03/2023 +12:23 +Poids [kg] : 88 88,80 +Taille [cm] : 152 152 +Indice +de masse +corporelle : 38,09 38,44 +Surface +corporelle : 1,84 1,85 +Item de +surveillance : 03/04/2023 +07:57 03/04/2023 +00:19 02/04/2023 +15:16 02/04/2023 +07:48 02/04/2023 +00:14 01/04/2023 +16:16 01/04/2023 +08:58 01/04/2023 +00:34 31/03/2023 +18:38 31/03/2023 +15:55 31/03/2023 +08:17 31/03/2023 +05:55 30/03/2023 +22:12 +Température : 37,10 37,40 37 36,50 37,30 36,50 37 37,20 36,50 37 37 +Pouls : 84 100 93 83 95 92 88 100 91 90 90 96 +PA +Systolique : 138 113 125 121 131 134 134 105 +PA +Diastolique : 66 76 68 67 65 58 55 55 +Saturation +O² : 96 96 97 95 95 96 96 95 96 94 92 95 +Transit : Normal Absence Absence Absence Normal Normal +Fréq. +respiratoire + +Item de +surveillance : 03/04/2023 +12:01 03/04/2023 +09:17 03/04/2023 +07:57 03/04/2023 +06:19 03/04/2023 +00:19 02/04/2023 +18:53 02/04/2023 +15:16 02/04/2023 +12:04 02/04/2023 +07:48 02/04/2023 +06:15 02/04/2023 +00:14 01/04/2023 +18:29 01/04/2023 +16:16 +Glycémie +capillaire : 1,45 2,90 0,65 0,88 2,51 1,43 1,73 1,51 1,88 1,68 1,66 +Température : 37,10 37,40 37 36,50 37,30 36,50 +Pouls : 84 100 93 83 95 92 +PA +Systolique : 138 113 125 121 +PA +Diastolique : 66 76 68 67 +Saturation +O² : 96 96 97 95 95 96 +Transit : Normal Absence Absence +Type d'observation : Nom Date Commentaires +Conclusion Clinique : DR. [NOM] +[NOM] 03/04/2023 +13:27 nouvelle hospitalisation pour nouvelle décompensation cardio-respiratoire sans aucun critère de +gravité +bonne évolution sous antibiotiques et diurétiques (hypokaliémie à recontrôlée) +transfert à Toki ce jour +Note d'évolution : DR. [NOM] +[NOM] 01/04/2023 +14:20 01/04/23 CNE +pas d'hypoglycémie, nuit de bonne qualité +Note d'évolution : DR. [NOM] +[NOM] 31/03/2023 +14:54 adaptation doses insuline +je suis là demain matin on peut me rappeler si elle fait encore des hypos cette nuit +Note d'évolution : DR. [NOM] +[NOM] 31/03/2023 +12:56 31/03/23 : CNE +persistance d'OMI +a dormi un peu au lit cette nuit +place à Toki Eder lundi +appel Dr [NOM] pour la tendance aux hypoglycémies +Note d'évolution : DR. [NOM] +[NOM] 30/03/2023 +12:29 30/03/23 : +Apyretique +Diabete : [NOM] ce matin à 0.71 +Cardio : +ETT : FEVG à 60% +VG non dilaté +Pression de remplissage VG normales, pas de signe de surcharge +OG de taille normale +Absence de valvulopathie +CD non dilatées +fonction VD normale +Pression droites normales, minime épanchement péricardique de 4/5mm sans retentissement +VCI non dilatée compliante +bio : K=3.3 +nouvlle seringue K=2g sur 6h +avis gastro sur cette anémie ferriprive +FERINJECT fait le 29/03 +dernier colo Fogd en 2020 Dr [NOM] : proposition de consult RDV le 25/07 11h40, il +jugera en fonction de la réhab si FOGD sous AL ou en hospit +CAT : +- diminution LASILIX spécial 1 le matin (dose usuelle) +- supplémentation K +- surveillance glycémie +- avis cardio : possible majoration NTproBNP sur intro FORXIGA ? +- FERINJECT 500 ce jour (totalité de 1g) puis à nouveau 500mg ds 15j + +Note d'évolution : DR. [NOM] +[NOM] 28/03/2023 +14:44 28/03/23 : +Patiente apyretique +discrete amélioration d ela toux +kine ce matin sans expectoration +ausuclt : ronchi bilateraux +echo pleurale : pas d'pénachement pleural gauche ou droit +OMI peristants +patiente m'explique ne pas supporter les bas de contentions +glycémies encore hautes : majoration insuline rapide. +Note d'évolution : DR. [NOM] +[NOM] 27/03/2023 +16:47 27/03 +Avis diabeto sur indication GLICLAZIDE ? place du FORXIGA ? +Dr [NOM] : +- arret GLICLAZIDE (HbA1c à 9% donc on considère que c'est inefficace) +- maintien basal/bolus +- introduction FORXIGA 10mg/j +L'objectif est de pouvoir equilibré le basal/bolus en [ETABLISSEMENT] +Note d'évolution : DR. [NOM] +[NOM] 27/03/2023 +15:03 27/03 +Apyretique +amélioration de la toux +demangeaison sur tout le corps probablement lié à la prise de codeine +pas d'améloioratino des OMI +bio : decroissance sd inflam +stabilité NTproBNP +CAT : +- poursuite ABT +- avis diabeto sur ttt FORXIGA ? insuline ? +- attente [ETABLISSEMENT] +- arret codeine ca rmauvaise tolérance +- kine +- tjrs sous diffuK 9/j, iono OK ce jour : ajout ESIDREX 25 +- bio ds 48h + +Note d'évolution : [NOM] [NOM] 25/03/2023 +04:57 Bio : pro BNP 400, CRP 30 pas d'hyperleucocytose +K+ 3.1, Na 132 +--> décompensation cardio-respi sans trigger identifié +a eu 125 mg lasilix IVD + 80 mg CTC +devant hyperthermie dans l'après-midi et devant atcd début augmentin +hospitalisation en pneumo +Note d'évolution : [NOM] [NOM] 25/03/2023 +03:16 RADIOGRAPHIE PULMONAIRE +Indication : +Bilan de dyspnée. +RESULTATS : +Sous réserve de la faible ampliation thoracique : +Diminution de la transparence parenchymateuse aux bases apparaissant être liée notamment +à la projection des parties molles. Absence de foyer circonscrit au niveau des apex pulmonaires. +Augmentation de l'index cardiothoracique.. +Dr [NOM] +Technique : +PDS : 0.426 dGy.cm² +A l'entrée : 0.065 mGy +Protocole d'acquisition : Thorax +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] +Note d'évolution : [NOM] [NOM] 25/03/2023 +02:25 GDS : pH 7.46, pO2 86mmHg, pCO2 50mmHg, bicar 35 +--> hypercapnie compensée métabolique + +Item de +surveillance : 03/04/2023 +07:57 03/04/2023 +00:19 02/04/2023 +15:16 02/04/2023 +07:48 02/04/2023 +00:14 01/04/2023 +16:16 01/04/2023 +08:58 01/04/2023 +00:34 31/03/2023 +18:38 31/03/2023 +15:55 31/03/2023 +08:17 31/03/2023 +05:55 30/03/2023 +22:12 +Température : 37,10 37,40 37 36,50 37,30 36,50 37 37,20 36,50 37 37 +Pouls : 84 100 93 83 95 92 88 100 91 90 90 96 +PA +Systolique : 138 113 125 121 131 134 134 105 +PA +Diastolique : 66 76 68 67 65 58 55 55 +Saturation +O² : 96 96 97 95 95 96 96 95 96 94 92 95 +Transit : Normal Absence Absence Absence Normal Normal Absence Absence Absence Absence Absence Normal +Fréq. +respiratoire +Type de note : Nom Date Note +Note IDE : [NOM] [NOM] 03/04/2023 +14:04 Hypoglycémie : +0.65g ce matin. Ressentie car se sent fatiguée --> Re sucrée : OK pour la fin de journée. +Hypoglycémie : +ECG OK +4 gel potassium donné à 10h30. +Sortie prévue ce jour pour Toki [NOM] -> Papiers de sortie donnés. +Note IDE : [NOM] [NOM] 02/04/2023 +19:53 / +Note IDE : [NOM] [NOM] 01/04/2023 +21:56 / +Note IDE : [NOM] [NOM] 01/04/2023 +13:12 Glycémie : +- ce matin : 1.05 g/L --> insuline non donné +- ce midi : 1.2 g/L --> insuline non donné +Persistance OMI +Note IDE : [NOM] [NOM] 01/04/2023 +07:46 ENDOC: glycémie stable +Note IDE : [NOM] [NOM] 31/03/2023 +19:18 Endocrinologie +- avis diabéto pris pour hypoglycémie +-> diminution insuline lente. +-> ce soir, [NOM] 1.71, lente + humalog faites. +Kaliémie +- contrôle kaliémie après PSE hier lundi +Note IDE : [NOM] +[NOM] 31/03/2023 +13:49 Devenir => départ à Toki Eder lundi, patiente OK +[NOM] => 1.07 G/L ce matin => rapide faite 10 UI au lieu de 14 UI +Hypo => 0.54 G/L à midi => pas d'insuline faite, a mangé le repas, avis diabeto ddé +Note IDE : [NOM] [NOM] 31/03/2023 +01:10 Respiratoire: dyspnée à la mobilisation, bonne sat sous O2 2L +Glycémie: 0.74 à 6h, la patiente se dit asténique. Ressucrée po +Note IDE : [NOM] [NOM] 30/03/2023 +22:29 Hypoglycémie +- 16h : [NOM] 0.77 -> collation donnée +- 18h : [NOM] 2.11 -> insuline lente et rapide +Hypokaliémie +- K+ 3.3 -> PSE potassium passé sur l'après-midi, RAS +Elimination +- pas de nouvelles diarrhées + +Note IDE : [NOM] [NOM] 30/03/2023 +00:37 Respiratoire: patiente eupneique sous O2 2L au repos +Transit: deux selles diarrhéique cette nuit, instructions données pour copro +Note IDE : [NOM] [NOM] 29/03/2023 +18:57 Respiratoire +- stable sous 2L, encombré -> aérosols productifs. +Hypokaliémie +- PSE posé cet après-midi -> contrôle demain matin +Endocrinologie +- [NOM] : 1.62 15h : lente et humalog faites +Note IDE : [NOM] [NOM] 29/03/2023 +13:23 glycémie : 1,83g/l ce midi. +majoration de l'insuline lente. +HypoKCL : 2,7, ECG. +supplémentation per os + IVSE en cours =) BS de control a faire ce soir. +cardio : ecg fait sur hypokcl, FA =) ETT demandée +bilan martial : carence avec ferritine =) ferinject fait. +avis gastro. +douleur : algique au niveau de son dos et d'écrit des douleurs neuropathique au niveau des +jambes. +changement patch atg 3 ce jour. +transit : absence de selle =) cocktail fait, efficace. +Note IDE : [NOM] [NOM] 29/03/2023 +06:52 Endoc: glycémie toujours élevée ce matin +Note IDE : [NOM] [NOM] 28/03/2023 +21:32 Respiratoire : clinique stable sous 2l . +Endocrino : [NOM] élevé ce soir . +--> Insuline faite selon protocole +Cardio : OMI toujours présents +Note IDE : [NOM] [NOM] 28/03/2023 +14:04 RESPI=> 96% sous 2L O2 ; patiente dort au fauteuil; VNI enlevé cette nuit vers 3h. +Glycémie=> hyperglycémie ce matin => 2.41 à 8H; 2.81 à 12h +après avis du diabeto=> augmentation de la rapide à 14 unités. +Note IDE : [NOM] DA [NOM] 28/03/2023 +13:53 RESPI=> 96% sous 2L O2 ; patiente dort au fauteuil; VNI enlevé cette nuit vers 3h. +Glycémie=> hyperglycémie ce matin => 2.41 à 8H; 2.81 à 12h +après avis du diabeto=> augmentation de la rapide à 14 unités et Forxiga +Note +Kinésithérapeute : [NOM] +[NOM] 28/03/2023 +12:56 début de prise en charge pour ce nouvel épisode d'hospitalisation +toux présente lors de la ventilation dirigée +toux non productive +ventilation dirigée peu dyspneique +Note IDE : [NOM] [NOM] 28/03/2023 +00:57 dort au fauteuil +RESPI: VNI enlevé vers 03h +ENDOC: [NOM] +Note IDE : [NOM] [NOM] 27/03/2023 +20:03 Respiratoire : clinique et saturation stable sous 2l. +Endocrino : Hypoglycémiants oraux modifiés . +Etat cutanée : OMI présents +Note IDE : [NOM] [NOM] 27/03/2023 +13:55 respi : +pas de problème au niveau du masque de la VNI + +Note IDE : [NOM] [NOM] 27/03/2023 +00:05 Respi=) bonne sat mais problème de masque de VNI cette nuit vu avec la patiente non mise ce +soir car le masque se désadapte régulièrement laissée aux lunettes allo prestataire demain svp +orkyn +infectieux=) patiente apyrétique +Note IDE : [NOM] [NOM] 26/03/2023 +19:06 RESPI : quintes de toux moins gênantes avec toux moins rauque , ATG2 pris pour la nuit +HYPERHGT : > à 3g ce soir (a bu du coca) => protocole d'insuline fait +DEVENIR : VT fait +OMI bilat prenant le godet +Note IDE : [NOM] [NOM] 26/03/2023 +14:50 diab : 2.27 à 12h, vu avec med pour reprise insuline rapide +patch ATG3 : changement patch ATG 3 mais me dit avoir deux patch ATG3, un de 25µg et un de +12µg, vu avec med +respi : toux seche, atg codéiné mis et aérosol fait +Note IDE : [NOM] [NOM] 25/03/2023 +19:27 TTT : patiente signale qu'elle prend de l'aérius et du singulair le soir => à revoir SVP +DESEQUILIBRE DIABETE : hyperHGT ce soir > à 2g f signes vitaux , patient me signale +qu'elle a un protocole de rattrapage si [NOM] > 1.5g => à revoir aussi SVP +TOUX : sèche +++ => aérosol de serum phy fait X2 qui la soulage un peu +PATCH ATG3 : à changer demain midi svp , information donnée par sa fille +TTT INHALES : a l'habitude d'utiliser une chambre d'inhalation => commandée +Note IDE : [NOM] [NOM] 25/03/2023 +15:02 respi : +dyspnée sous 2L/min, sous CTC +diab : hyperglycémie à 2.49 à midi +patch ATG : patiente doit s'informer de la date de pose du patch pour poursuite ttt antalgique +Note IDE : [NOM] [NOM] 25/03/2023 +01:35 MDA : Adressée pour décompensation cardio-respi. Sortie récemment d'Hospit +Examens : +ECG12D fait et montré +GDS prélevés et envoyés +BS prélevé pdt pose VVP 20GA main D et envoyé +PCR prélevée et envoyée +ECBU envoyé +Cardio-respi : +Diurétiques admin IVL selon PM. Très bonne réponse +CorticoTT + ATBTT débutés avant transfert. +Administratif : +Inventaire réalisé +Devenir : Pneumologie +Prescription : Dose Fréquence Date de début Date de dernière +administration Note Docteur +FERINJECT 500MG/10ML +SOL INJ [2] Flacon(s) : 500 mg - 1 seule fois 1 seule +fois 29/03/2023 11:07 29/03/2023 11:44 Le débit a été +modifié. Le débit +en cours est : 20 +par . DR. [NOM] +[NOM] +FERINJECT 500MG/10ML +SOL INJ [2] Flacon(s) : 500 mg - 1 seule fois 1 seule +fois 30/03/2023 12:38 30/03/2023 14:28 Le débit a été +modifié. Le débit +en cours est : 20 +par . DR. [NOM] +[NOM] +FUROSEMIDE REN +20MG/2ML SOL INJ [100] +Ampoule(s) : 125 mg - 1 seule fois 1 seule +fois 25/03/2023 02:00 25/03/2023 02:12 [NOM] [NOM] + +Potassium PSE 2G/50ML +(2AMP) - BSFP : - Normal 29/03/2023 10:51 29/03/2023 12:22 Le débit a été +modifié. Le débit +en cours est : 8.3 +ML par 1 hrs. DR. [NOM] +[NOM] +Potassium PSE 2G/50ML +(2AMP) - BSFP : - Normal 30/03/2023 12:38 30/03/2023 15:34 Le débit a été +modifié. Le débit +en cours est : 8.3 +ML par 1 hrs. DR. [NOM] +[NOM] +BUSPIRONE MYL 10MG +CPR [20] COMPRIME(S) : 1 CPR - Prise unique à 19h +Normal 25/03/2023 04:49 02/04/2023 20:40 [NOM] [NOM] +CETIRIZINE ARW 10MG +CPR [60] COMPRIME(S) : 1 CPR - Soir [19h] Normal 26/03/2023 15:41 02/04/2023 18:44 DR. [NOM] +[NOM] +DEPAKOTE 500MG CPR +[90] COMPRIME(S) : 750 mg - Matin soir (8h - +20h) Normal 25/03/2023 14:08 03/04/2023 07:49 La posologie est +variable. DR. [NOM] +[NOM] +FORXIGA 10MG CPR [30] +CPR(s) : 1 CPR - Matin [8h] Normal 27/03/2023 16:14 03/04/2023 07:49 DR. [NOM] +[NOM] +FUROSEMIDE ZEN 500MG +CPR [30] CPR(s) : 1 CPR - Matin [8h] Normal 25/03/2023 04:49 03/04/2023 07:49 [NOM] [NOM] +HYDROCHLOROTHIAZIDE +ARW 25 MG CPR [90] +CPR(s) : 1 CPR - Matin [8h] Normal 27/03/2023 18:00 03/04/2023 07:49 DR. [NOM] +[NOM] +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR - Prise unique à 19h +Normal 25/03/2023 04:49 02/04/2023 18:44 [NOM] [NOM] +LOXEN LP 50MG GELULE +[60] Gelule(s) : 1 GEL - 1xJour [8h] Normal 25/03/2023 04:49 03/04/2023 07:49 [NOM] [NOM] +MONTELUKAST +ARW 10MG CPR [28] +COMPRIME(S) : 1 CPR - Soir [19h] Normal 26/03/2023 15:41 02/04/2023 18:44 DR. [NOM] +[NOM] +POTASSIUM 600MG +GELULE : 3 GEL - Matin midi soir +Normal 25/03/2023 04:49 03/04/2023 12:16 [NOM] [NOM] +ROSUVASTATINE ARW +20MG CPR [90] CPR(s) : 0,5 CPR - 1xJour [8h] Normal 25/03/2023 04:49 03/04/2023 07:49 [NOM] [NOM] +TERCIAN 4% SOL BUV FL +30ML [1200] Flacon(s) : 15 GTT - à 21h Normal 25/03/2023 04:49 02/04/2023 20:40 [NOM] [NOM] +XARELTO 20MG CPR [14] +COMPRIME(S) : 1 CPR - 1xJour [8h] Normal 25/03/2023 04:49 03/04/2023 07:49 [NOM] [NOM] +DEPAKOTE 500MG CPR +[90] COMPRIME(S) : 1 CPR - Matin soir (8h - +19h) Normal 25/03/2023 04:49 26/03/2023 08:00 [NOM] [NOM] +GLICLAZIDE ARW +LM 30MG CPR [30] +COMPRIME(S) : 2 CPR - 1xJour [8h] Normal 25/03/2023 04:49 29/03/2023 08:00 [NOM] [NOM] +PARACETAMOL COD +ARW 500/30MG CPR EFF +[16] COMPRIME(S) : 2 CPR - Nuit [21h] Normal 26/03/2023 12:58 26/03/2023 18:24 DR. [NOM] +[NOM] +AMOX/AC CLAV SDZ +1G/125MG AD SACH [12] +Sachet(s) : 1 G - Matin midi soir +Normal 25/03/2023 04:49 30/03/2023 19:07 [NOM] [NOM] +BUSPIRONE MYL 10MG +CPR [20] COMPRIME(S) : 1 CPR - Prise unique à 19h +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +CETIRIZINE ARW 10MG +CPR [60] COMPRIME(S) : 1 CPR - Soir [19h] Presc. de +Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +DEPAKOTE 500MG CPR +[90] COMPRIME(S) : 750 mg - Matin soir (8h - +20h) Presc. de Sortie 03/04/2023 13:27 La posologie est +variable. DR. [NOM] +NOCENT- +EJNAINI +FORXIGA 10MG CPR [30] +CPR(s) : 1 CPR - Matin [8h] Presc. de +Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +FUROSEMIDE ZEN 500MG +CPR [30] CPR(s) : 1 CPR - Matin [8h] Presc. de +Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +HYDROCHLOROTHIAZIDE +ARW 25 MG CPR [90] +CPR(s) : 1 CPR - Matin [8h] Presc. de +Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI + +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR - Prise unique à 19h +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +LOXEN LP 50MG GELULE +[60] Gelule(s) : 1 GEL - 1xJour [8h] Presc. +de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +MONTELUKAST +ARW 10MG CPR [28] +COMPRIME(S) : 1 CPR - Soir [19h] Presc. de +Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +POTASSIUM 600MG +GELULE : 4 GEL - URGENT Urgent 03/04/2023 11:21 03/04/2023 11:22 DR. [NOM] +NOCENT- +EJNAINI +POTASSIUM 600MG +GELULE : 3 GEL - Matin midi soir +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +ROSUVASTATINE ARW +20MG CPR [90] CPR(s) : 0,5 CPR - 1xJour [8h] Presc. +de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +SOLUPRED 20MG +CPR ORODISP [20] +COMPRIME(S) : 3 CPR - 1xJour [8h] Normal 25/03/2023 04:23 27/03/2023 08:28 DR. [NOM] +[NOM] +TERCIAN 4% SOL BUV FL +30ML [1200] Flacon(s) : 15 GTT - à 21h Presc. de +Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +XARELTO 20MG CPR [14] +COMPRIME(S) : 1 CPR - 1xJour [8h] Presc. +de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +ABASAGLAR 300 U SOL +INJ CART [5] Cartouche(s) : 60 UI - Prise unique à 19h +Normal 25/03/2023 04:49 02/04/2023 18:54 [NOM] [NOM] +ABASAGLAR 300 U SOL +INJ CART [5] Cartouche(s) : 60 UI - Prise unique à 19h +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +HUMALOG 300UI/3ML +KWIKPEN SOL INJ [5] +Stylo(s) Prerempli(s) : 14 UI - Matin midi soir +Normal 26/03/2023 10:07 03/04/2023 12:17 DR. [NOM] +[NOM] +HUMALOG 300UI/3ML +KWIKPEN SOL INJ [5] +Stylo(s) Prerempli(s) : 14 UI - Matin midi soir +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +OZEMPIC 1 MG SOL INJ +STYLO 3ML [1] Stylo(s) +Prerempli(s) : 1 mg - 1xSemaine [8h] +Normal 25/03/2023 04:49 01/04/2023 08:00 [NOM] [NOM] +OZEMPIC 1 MG SOL INJ +STYLO 3ML [1] Stylo(s) +Prerempli(s) : 1 mg - 1xSemaine [8h] +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +DUROGESIC 12MICROG/ +H DISP TRANSDERM +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) : 1 PATCH - Ttes les 72H (1j /3) +Normal 26/03/2023 15:01 02/04/2023 14:16 DR. [NOM] +[NOM] +DUROGESIC 25MICROG/ +H DISP TRANSDERM +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) : 1 PATCH - Normal 25/03/2023 04:49 02/04/2023 14:16 [NOM] [NOM] +DUROGESIC 12MICROG/ +H DISP TRANSDERM +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) : 1 PATCH - Ttes les 72H (1j /3) +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +DUROGESIC 25MICROG/ +H DISP TRANSDERM +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) : 1 PATCH - Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +IPRATROPIUM AGT +0,5MG/2ML AD INHAL +[10] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - Normal 26/03/2023 12:58 03/04/2023 12:18 Le débit en cours +est : 8 ML par 1 +hrs. DR. [NOM] +[NOM] + +IPRATROPIUM AGT +0,5MG/2ML AD INHAL +[10] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +TERBUTALINE ARW +5MG/2ML SOL INHAL +[50] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - Normal 26/03/2023 12:58 03/04/2023 12:18 Le débit en cours +est : 8 ML par 1 +hrs. DR. [NOM] +[NOM] +TERBUTALINE ARW +5MG/2ML SOL INHAL +[50] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE - Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +TRIMBOW 87/5/9 +MCG SOL INH 60 +D [1] FLACON(S) +PRESSURISE(S) : 2 BOUFFEE - Matin soir (8h - +19h) Normal 25/03/2023 04:49 03/04/2023 07:49 [NOM] [NOM] +TRIMBOW 87/5/9 +MCG SOL INH 60 +D [1] FLACON(S) +PRESSURISE(S) : 2 BOUFFEE - Matin soir (8h - +19h) Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +SODIUM BIC BAX 1,4% +POC CFX 500ML V1 [1] +POCHE(S) : 10 ml - Matin midi soir +Normal 26/03/2023 12:58 03/04/2023 12:00 DR. [NOM] +[NOM] +VERSATIS 5% EMPLATRE +[30] Emplatre(s) : 1 +Emplatre(s) - Prise unique à 19h +Normal 25/03/2023 04:49 02/04/2023 20:39 [NOM] [NOM] +VERSATIS 5% EMPLATRE +[30] Emplatre(s) : 1 +Emplatre(s) - Prise unique à 19h +Presc. de Sortie 03/04/2023 13:27 DR. [NOM] +NOCENT- +EJNAINI +Date début : Heure +début Prescription Date +exécution Heure +exécution Statut Docteur Note +25/03/2023 : 02:19 Thorax F P 25/03/2023 02:36 Réalisé [NOM] [NOM] +Date : Heure Prescription Docteur Date de +collection Note +25/03/2023 : 01:08 Ionogramme ( Na, K, CL ) DR. [NOM] 25/03/2023 +01:10 +27/03/2023 : 08:00 Clairance à la creatinine MDRD DR. [NOM] 27/03/2023 +08:26 +29/03/2023 : 08:00 Clairance à la creatinine MDRD DR. [NOM] 29/03/2023 +08:11 +03/04/2023 : 07:00 Ionogramme ( Na, K, CL ) DR. [NOM] 03/04/2023 +09:07 +03/04/2023 : 07:00 Créatinine sang ( dosage ) DR. [NOM] 03/04/2023 +09:07 +03/04/2023 : 07:00 Bilirubine ( totale + conjuguée + +non conjuguée ) sang ( dosage ) DR. [NOM] 03/04/2023 +09:07 +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +DESINFECTION +ENVIRONNEMENT +PATIENT : Signé - Matin [8h] Normal 25/03/2023 +13:41 [NOM] +[NOM] +LIT : REFECTION +COMPLETE Signé - Matin [8h] Normal 25/03/2023 +13:41 [NOM] +[NOM] +TOILETTE DOUCHE : AIDE PARTIELLE Signé - Matin [8h] Normal 25/03/2023 +13:41 [NOM] +[NOM] +ACCOMPAGNER +INSTALLER AUX +TOILETTES : Réalisé 1 Semaine - Matin +[8h] Normal 28/03/2023 +10:24 Jean- +[NOM] +[NOM] +DESINFECTION +ENVIRONNEMENT +PATIENT : Réalisé 1 Semaine - Matin +[8h] Normal 28/03/2023 +10:24 Jean- +[NOM] +[NOM] + +SOMMEIL : SURV. Réalisé 1 Semaine - Nuit +[21h] Normal 28/03/2023 +06:46 [NOM] +ESTOMBA- +[NOM] +TOILETTE : AUTONOME Réalisé 1 Semaine - Matin +[8h] Normal 28/03/2023 +10:24 Jean- +[NOM] +[NOM] +GLYCEMIE CAPILLAIRE x +7 : Réalisé - 7x/jour (8h 12h +14h 19h 22h 0h 4h) +Normal 31/03/2023 +14:52 Notes du +professionel +de santé: +bien noter +toutes les +glycémies +sur trakcare +notamment +celles de 22h DR. +[NOM] +[NOM] +Prescription : Dose Statut Fréquence Date de début Quantité administrée Note Docteur +ABASAGLAR 300 U SOL +INJ CART [5] Cartouche(s) : 60 UI +SOUS- +CUTANEE Signé - Prise unique à 19h +Presc. de Sortie 03/04/2023 +13:27 0/6 : Non administré +A valider DR. [NOM] +NOCENT- +EJNAINI +BUSPIRONE MYL 10MG +CPR [20] COMPRIME(S) : 1 CPR +ORALE Réalisé - Prise unique à 19h +Presc. de Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +CETIRIZINE ARW 10MG +CPR [60] COMPRIME(S) : 1 CPR +ORALE Réalisé - Soir [19h] Presc. de +Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +DEPAKOTE 500MG CPR +[90] COMPRIME(S) : 750 mg +ORALE Réalisé - Matin soir (8h - +20h) Presc. de Sortie 03/04/2023 +13:27 0/105 : Non +administré Révisé/ +Traité DR. [NOM] +NOCENT- +EJNAINI +DUROGESIC 12MICROG/ +H DISP TRANSDERM +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) : 1 PATCH +TRANSDERM Réalisé +IQUE - Ttes les 72H (1j /3) +Presc. de Sortie 03/04/2023 +13:27 0/10 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +DUROGESIC 25MICROG/ +H DISP TRANSDERM +[5] DISPOSITIF(S) +TRANSDERMIQUE(S) : 1 PATCH +TRANSDERM Réalisé +IQUE - Presc. de Sortie 03/04/2023 +13:27 0/10 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +FORXIGA 10MG CPR [30] +CPR(s) : 1 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +FUROSEMIDE ZEN 500MG +CPR [30] CPR(s) : 1 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +HUMALOG 300UI/3ML +KWIKPEN SOL INJ [5] +Stylo(s) Prerempli(s) : 14 UI +SOUS- +CUTANEE Signé - Matin midi soir +Presc. de Sortie 03/04/2023 +13:27 0/5 : Non administré +A valider DR. [NOM] +NOCENT- +EJNAINI +HYDROCHLOROTHIAZIDE +ARW 25 MG CPR [90] +CPR(s) : 1 CPR +ORALE Réalisé - Matin [8h] Presc. de +Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +IPRATROPIUM AGT +0,5MG/2ML AD INHAL +[10] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE +INHALEE Signé - Presc. de Sortie 03/04/2023 +13:27 0/90 : Non administré +A valider DR. [NOM] +NOCENT- +EJNAINI +LANSOPRAZOLE BGA 30 +MG CPR OROD [14] CPR(s) : 1 CPR +ORALE Réalisé - Prise unique à 19h +Presc. de Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +LOXEN LP 50MG GELULE +[60] Gelule(s) : 1 GEL +ORALE Réalisé - 1xJour [8h] Presc. +de Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +MONTELUKAST +ARW 10MG CPR [28] +COMPRIME(S) : 1 CPR +ORALE Réalisé - Soir [19h] Presc. de +Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +OZEMPIC 1 MG SOL INJ +STYLO 3ML [1] Stylo(s) +Prerempli(s) : 1 mg SOUS- +CUTANEE Signé - 1xSemaine [8h] +Presc. de Sortie 03/04/2023 +13:27 0/1 : Non administré +A valider DR. [NOM] +NOCENT- +EJNAINI +POTASSIUM 600MG +GELULE : 3 GEL +ORALE Réalisé - Matin midi soir +Presc. de Sortie 03/04/2023 +13:27 0/270 : Non +administré Révisé/ +Traité DR. [NOM] +NOCENT- +EJNAINI +ROSUVASTATINE ARW +20MG CPR [90] CPR(s) : 0,5 CPR +ORALE Réalisé - 1xJour [8h] Presc. +de Sortie 03/04/2023 +13:27 0/15 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI + +TERBUTALINE ARW +5MG/2ML SOL INHAL +[50] RECIPIENT(S) +UNIDOSE(S) : 1 REC. +UNIDOSE +INHALEE Signé - Presc. de Sortie 03/04/2023 +13:27 0/90 : Non administré +A valider DR. [NOM] +NOCENT- +EJNAINI +TERCIAN 4% SOL BUV FL +30ML [1200] Flacon(s) : 15 GTT +ORALE Réalisé - à 21h Presc. de +Sortie 03/04/2023 +13:27 0/1 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +TRIMBOW 87/5/9 +MCG SOL INH 60 +D [1] FLACON(S) +PRESSURISE(S) : 2 BOUFFEE +INHALEE Signé - Matin soir (8h - +19h) Presc. de Sortie 03/04/2023 +13:27 0/120 : Non +administré A valider DR. [NOM] +NOCENT- +EJNAINI +VERSATIS 5% EMPLATRE +[30] Emplatre(s) : 1 +Emplatre(s) +CUTANEE Réalisé - Prise unique à 19h +Presc. de Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI +XARELTO 20MG CPR [14] +COMPRIME(S) : 1 CPR +ORALE Réalisé - 1xJour [8h] Presc. +de Sortie 03/04/2023 +13:27 0/30 : Non administré +Révisé/Traité DR. [NOM] +NOCENT- +EJNAINI + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - BUCCALE - Matin midi soir - 1ère +dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 05/04/2023 à +12:00 +Admin le 03/04/2023 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 - BUCCALE - Matin midi soir - 1ère +dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 05/04/2023 à +12:00 +Admin le 03/04/2023 à +12:00 07:49 * 10 ml +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - BUCCALE - Matin midi soir - 1ère +dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 05/04/2023 à +12:00 +Admin le 03/04/2023 à +12:00 12:00 * 10 ml +Signé — VERSATIS 700MG EMPLATRE +- 700MG emplatre - Dose 1 Emplatre(s) - +CUTANEE - Prise unique à 19h - 1ère dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +20:39 19:00 * 1 +Emplatre(s) +Signé — IPRATROPIUM AGT 0,5MG/2ML AD +INHAL - 0,5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 20:58 * +1 REC. +UNIDOSE +Signé — IPRATROPIUM AGT 0,5MG/2ML AD +INHAL - 0,5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 04:58 * +1 REC. +UNIDOSE +Signé — IPRATROPIUM AGT 0,5MG/2ML AD +INHAL - 0,5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 12:18 * +1 REC. +UNIDOSE +Signé — TERBUTALINE ARW 5MG/2ML +SOL INHAL - 5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 20:58 * +1 REC. +UNIDOSE +Signé — TERBUTALINE ARW 5MG/2ML +SOL INHAL - 5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 04:58 * +1 REC. +UNIDOSE +Signé — TERBUTALINE ARW 5MG/2ML +SOL INHAL - 5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 12:18 * +1 REC. +UNIDOSE + + + + + + + + + + + + + +Signé — TRIMBOW 87/5/9 MCG SOL INH +60 D - 87/5/9 solution - Dose 2 BOUFFEE - +INHALEE Directe - Matin soir (8h - 19h) - 1ère +dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +07:49 19:00 * 2 +BOUFFEE +Signé — TRIMBOW 87/5/9 MCG SOL INH +60 D - 87/5/9 solution - Dose 2 BOUFFEE - +INHALEE Directe - Matin soir (8h - 19h) - 1ère +dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +07:49 07:49 * 2 +BOUFFEE +Signé — BUSPIRONE MYL 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Prise unique +à 19h - 1ère dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +20:40 19:00 * 1 +CPR +Signé — CETIRIZINE ARW 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Soir [19h] - +1ère dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +15:41 +Fin le 05/04/2023 à +19:00 +Admin le 02/04/2023 à +18:44 19:00 * 1 +CPR +Signé — DEPAKOTE 500MG CPR - 500MG +comprime - Dose Variable - ORALE - Matin soir +(8h - 20h) - 1ère dose : 25/03/2023 @ 20:00 +! Plan de dosage variable [NOM] [NOM] +Début le 25/03/2023 à +14:08 +Fin le 09/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 20:00 * 1000 +mg +Signé — DEPAKOTE 500MG CPR - 500MG +comprime - Dose Variable - ORALE - Matin soir +(8h - 20h) - 1ère dose : 25/03/2023 @ 20:00 +! Plan de dosage variable [NOM] [NOM] +Début le 25/03/2023 à +14:08 +Fin le 09/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 750 +mg +Signé — FORXIGA 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Matin [8h] - +1ère dose : 28/03/2023 @ 08:00 [NOM] [NOM] +Début le 27/03/2023 à +16:14 +Fin le 26/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 1 +CPR +Signé — FUROSEMIDE ZEN 500MG CPR - +500MG comprime - Dose 1 CPR - ORALE - +Matin [8h] - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 1 +CPR +Signé — HYDROCHLOROTHIAZIDE ARW +25 MG CPR - 25MG comprime - Dose 1 CPR - +ORALE - Matin [8h] - 1ère dose : 28/03/2023 @ +08:00 [NOM] [NOM] +Début le 27/03/2023 à +18:00 +Fin le 26/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 1 +CPR +Signé — LANSOPRAZOLE BGA 30 MG +CPR OROD - 30MG comprime - Dose 1 CPR +- ORALE - Prise unique à 19h - 1ère dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +18:44 19:00 * 1 +CPR + + + + + +Signé — LOXEN LP 50MG GELULE - 50MG +gelule - Dose 1 GEL - ORALE - 1xJour [8h] - +1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 1 +GEL +Signé — MONTELUKAST ARW 10MG CPR - +10MG comprime - Dose 1 CPR - ORALE - Soir +[19h] - 1ère dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +15:41 +Fin le 09/04/2023 à +19:00 +Admin le 02/04/2023 à +18:44 19:00 * 1 +CPR +Signé — POTASSIUM 600MG GELULE - +600MG gelule - Dose 3 GEL - ORALE - Matin +midi soir - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +12:16 19:00 * 3 +GEL +Signé — POTASSIUM 600MG GELULE - +600MG gelule - Dose 3 GEL - ORALE - Matin +midi soir - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +12:16 07:49 * 3 +GEL +Signé — POTASSIUM 600MG GELULE - +600MG gelule - Dose 3 GEL - ORALE - Matin +midi soir - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +12:16 12:16 * 3 +GEL +Réalisé — POTASSIUM 600MG GELULE +- 600MG gelule - Dose 4 GEL - ORALE - +URGENT - Début presc. : 03/04/2023 @ 11:21 [NOM] +[NOM] +Début le 03/04/2023 à +11:21 +Fin le 03/04/2023 à +11:21 +Admin le 03/04/2023 à +11:22 11:22 * 4 +GEL +Signé — ROSUVASTATINE ARW 20MG CPR +- 20MG comprime - Dose 0,5 CPR - ORALE - +1xJour [8h] - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 0.5 +CPR +Signé — TERCIAN 40 MG/ML SOL BUV 30ML +- 0,04G/ML solution (30 mL) - Dose 15 GTT - +ORALE - à 21h - 1ère dose : 25/03/2023 @ 21:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +21:00 +Admin le 02/04/2023 à +20:40 21:00 * 15 +GTT +Signé — XARELTO 20 MG CPR - 20MG +comprime - Dose 1 CPR - ORALE - 1xJour [8h] - +1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 07:49 * 1 +CPR +Signé — ABASAGLAR 300 U SOL INJ CART - +100UI/ML solution (3 mL) - Dose 60 UI - SOUS- +CUTANEE Directe - Prise unique à 19h - 1ère +dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +18:54 19:00 * 60 UI + + + + + +Signé — HUMALOG 300UI KWIKPEN SOL +INJ - 300UI solution (3 mL) - Dose 14 UI - +SOUS-CUTANEE Directe - Matin midi soir - 1ère +dose : 26/03/2023 @ 12:00 [NOM] [NOM] +Début le 26/03/2023 à +10:07 +Fin le 25/04/2023 à +08:00 +Admin le 03/04/2023 à +12:17 08:00 * 14 UI +Signé — HUMALOG 300UI KWIKPEN SOL +INJ - 300UI solution (3 mL) - Dose 14 UI - +SOUS-CUTANEE Directe - Matin midi soir - 1ère +dose : 26/03/2023 @ 12:00 [NOM] [NOM] +Début le 26/03/2023 à +10:07 +Fin le 25/04/2023 à +08:00 +Admin le 03/04/2023 à +12:17 12:17 * 14 UI +Réalisé — ACCOMPAGNER INSTALLER AUX +TOILETTES - Matin [8h] - 1 Semaine- Date +Début : 28/03/2023 @ 10:24 [NOM] Jean- +[NOM] +Début le 28/03/2023 à +10:24 +Fin le 04/04/2023 à +08:00 +Admin le 03/04/2023 à +08:00 08:00 * 1 +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - 1 +Semaine- Date Début : 28/03/2023 @ 10:24 [NOM] Jean- +[NOM] +Début le 28/03/2023 à +10:24 +Fin le 04/04/2023 à +08:00 +Admin le 03/04/2023 à +08:00 08:00 * 1 +Réalisé — SOMMEIL : SURV. - Nuit [21h] - 1 +Semaine- Date Début: 28/03/2023 @ 06:46 ESTOMBA- +[NOM] [NOM] +Début le 28/03/2023 à +06:46 +Fin le 03/04/2023 à +21:00 +Admin le 02/04/2023 à +21:00 21:00 * 1 +Réalisé — TOILETTE : AUTONOME - Matin +[8h] - 1 Semaine- Date Début: 28/03/2023 @ +10:24 [NOM] Jean- +[NOM] +Début le 28/03/2023 à +10:24 +Fin le 04/04/2023 à +08:00 +Admin le 03/04/2023 à +08:00 08:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 19:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 22:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 00:00 * 1 + + + + + +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 04:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 08:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 12:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 14:00 * 1 + +Prescriptions : Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h) +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - BUCCALE - Matin midi soir - 1ère +dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 05/04/2023 à +12:00 +Admin le 03/04/2023 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 - BUCCALE - Matin midi soir - 1ère +dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 05/04/2023 à +12:00 +Admin le 03/04/2023 à +12:00 12:00 * 10 ml +Signé — SODIUM BIC BAX 1,4% POC CFX +500ML V1 - 1,4G/100ML solution (500 mL) - +Dose 10 ml - BUCCALE - Matin midi soir - 1ère +dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 05/04/2023 à +12:00 +Admin le 03/04/2023 à +12:00 19:00 * 10 ml +Signé — VERSATIS 700MG EMPLATRE +- 700MG emplatre - Dose 1 Emplatre(s) - +CUTANEE - Prise unique à 19h - 1ère dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +20:39 19:00 * 1 +Emplatre(s) +Signé — IPRATROPIUM AGT 0,5MG/2ML AD +INHAL - 0,5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 12:58 * +1 REC. +UNIDOSE +Signé — IPRATROPIUM AGT 0,5MG/2ML AD +INHAL - 0,5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 20:58 * +1 REC. +UNIDOSE +Signé — IPRATROPIUM AGT 0,5MG/2ML AD +INHAL - 0,5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 04:58 * +1 REC. +UNIDOSE +Signé — TERBUTALINE ARW 5MG/2ML +SOL INHAL - 5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 12:58 * +1 REC. +UNIDOSE +Signé — TERBUTALINE ARW 5MG/2ML +SOL INHAL - 5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 20:58 * +1 REC. +UNIDOSE +Signé — TERBUTALINE ARW 5MG/2ML +SOL INHAL - 5MG/2ML solution (2 mL) - Dose +1 REC. UNIDOSE - sur 15 min - INHALEE +Discontinue - Toutes les 8 Heure(s) - 1ère dose : 26/03/2023 @ 12:58 [NOM] [NOM] +Début le 26/03/2023 à +12:58 +Fin le 25/04/2023 à +04:58 +Admin le 03/04/2023 à +12:18 04:58 * +1 REC. +UNIDOSE + + + + + + + + + + + + + +Signé — TRIMBOW 87/5/9 MCG SOL INH +60 D - 87/5/9 solution - Dose 2 BOUFFEE - +INHALEE Directe - Matin soir (8h - 19h) - 1ère +dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +07:49 08:00 * 2 +BOUFFEE +Signé — TRIMBOW 87/5/9 MCG SOL INH +60 D - 87/5/9 solution - Dose 2 BOUFFEE - +INHALEE Directe - Matin soir (8h - 19h) - 1ère +dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +07:49 19:00 * 2 +BOUFFEE +Signé — BUSPIRONE MYL 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Prise unique +à 19h - 1ère dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +20:40 19:00 * 1 +CPR +Signé — CETIRIZINE ARW 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Soir [19h] - +1ère dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +15:41 +Fin le 05/04/2023 à +19:00 +Admin le 02/04/2023 à +18:44 19:00 * 1 +CPR +Signé — DEPAKOTE 500MG CPR - 500MG +comprime - Dose Variable - ORALE - Matin soir +(8h - 20h) - 1ère dose : 25/03/2023 @ 20:00 +! Plan de dosage variable [NOM] [NOM] +Début le 25/03/2023 à +14:08 +Fin le 09/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 750 +mg +Signé — DEPAKOTE 500MG CPR - 500MG +comprime - Dose Variable - ORALE - Matin soir +(8h - 20h) - 1ère dose : 25/03/2023 @ 20:00 +! Plan de dosage variable [NOM] [NOM] +Début le 25/03/2023 à +14:08 +Fin le 09/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 20:00 * 1000 +mg +Signé — FORXIGA 10MG CPR - 10MG +comprime - Dose 1 CPR - ORALE - Matin [8h] - +1ère dose : 28/03/2023 @ 08:00 [NOM] [NOM] +Début le 27/03/2023 à +16:14 +Fin le 26/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 1 +CPR +Signé — FUROSEMIDE ZEN 500MG CPR - +500MG comprime - Dose 1 CPR - ORALE - +Matin [8h] - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 1 +CPR +Signé — HYDROCHLOROTHIAZIDE ARW +25 MG CPR - 25MG comprime - Dose 1 CPR - +ORALE - Matin [8h] - 1ère dose : 28/03/2023 @ +08:00 [NOM] [NOM] +Début le 27/03/2023 à +18:00 +Fin le 26/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 1 +CPR +Signé — LANSOPRAZOLE BGA 30 MG +CPR OROD - 30MG comprime - Dose 1 CPR +- ORALE - Prise unique à 19h - 1ère dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +18:44 19:00 * 1 +CPR + + + + + +Signé — LOXEN LP 50MG GELULE - 50MG +gelule - Dose 1 GEL - ORALE - 1xJour [8h] - +1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 1 +GEL +Signé — MONTELUKAST ARW 10MG CPR - +10MG comprime - Dose 1 CPR - ORALE - Soir +[19h] - 1ère dose : 26/03/2023 @ 19:00 [NOM] [NOM] +Début le 26/03/2023 à +15:41 +Fin le 09/04/2023 à +19:00 +Admin le 02/04/2023 à +18:44 19:00 * 1 +CPR +Signé — POTASSIUM 600MG GELULE - +600MG gelule - Dose 3 GEL - ORALE - Matin +midi soir - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +12:16 08:00 * 3 +GEL +Signé — POTASSIUM 600MG GELULE - +600MG gelule - Dose 3 GEL - ORALE - Matin +midi soir - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +12:16 12:00 * 3 +GEL +Signé — POTASSIUM 600MG GELULE - +600MG gelule - Dose 3 GEL - ORALE - Matin +midi soir - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 03/04/2023 à +12:16 19:00 * 3 +GEL +Signé — ROSUVASTATINE ARW 20MG CPR +- 20MG comprime - Dose 0,5 CPR - ORALE - +1xJour [8h] - 1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 0.5 +CPR +Signé — TERCIAN 40 MG/ML SOL BUV 30ML +- 0,04G/ML solution (30 mL) - Dose 15 GTT - +ORALE - à 21h - 1ère dose : 25/03/2023 @ 21:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +21:00 +Admin le 02/04/2023 à +20:40 21:00 * 15 +GTT +Signé — XARELTO 20 MG CPR - 20MG +comprime - Dose 1 CPR - ORALE - 1xJour [8h] - +1ère dose : 25/03/2023 @ 08:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +08:00 +Admin le 03/04/2023 à +07:49 08:00 * 1 +CPR +Signé — ABASAGLAR 300 U SOL INJ CART - +100UI/ML solution (3 mL) - Dose 60 UI - SOUS- +CUTANEE Directe - Prise unique à 19h - 1ère +dose : 25/03/2023 @ 19:00 [NOM] [NOM] +Début le 25/03/2023 à +04:49 +Fin le 23/04/2023 à +19:00 +Admin le 02/04/2023 à +18:54 19:00 * 60 UI +Signé — HUMALOG 300UI KWIKPEN SOL +INJ - 300UI solution (3 mL) - Dose 14 UI - +SOUS-CUTANEE Directe - Matin midi soir - 1ère +dose : 26/03/2023 @ 12:00 [NOM] [NOM] +Début le 26/03/2023 à +10:07 +Fin le 25/04/2023 à +08:00 +Admin le 03/04/2023 à +12:17 08:00 * 14 UI + + + + + + + +Signé — HUMALOG 300UI KWIKPEN SOL +INJ - 300UI solution (3 mL) - Dose 14 UI - +SOUS-CUTANEE Directe - Matin midi soir - 1ère +dose : 26/03/2023 @ 12:00 [NOM] [NOM] +Début le 26/03/2023 à +10:07 +Fin le 25/04/2023 à +08:00 +Admin le 03/04/2023 à +12:17 19:00 * 14 UI +Signé — DUROGESIC 12 MICROG/H DISP +TRANSDERM - 0.012MG/HEURE dispositif - +Dose 1 PATCH - TRANSDERMIQUE - Ttes les +72H (1j /3) - 1ère dose : 29/03/2023 @ 08:00 [NOM] [NOM] +Début le 26/03/2023 à +15:01 +Fin le 10/04/2023 à +08:00 +Admin le 02/04/2023 à +14:16 08:00 * 1 +PATCH +Réalisé — ACCOMPAGNER INSTALLER AUX +TOILETTES - Matin [8h] - 1 Semaine- Date +Début : 28/03/2023 @ 10:24 [NOM] Jean- +[NOM] +Début le 28/03/2023 à +10:24 +Fin le 04/04/2023 à +08:00 +Admin le 03/04/2023 à +08:00 08:00 * 1 +Réalisé — DESINFECTION +ENVIRONNEMENT PATIENT - Matin [8h] - 1 +Semaine- Date Début : 28/03/2023 @ 10:24 [NOM] Jean- +[NOM] +Début le 28/03/2023 à +10:24 +Fin le 04/04/2023 à +08:00 +Admin le 03/04/2023 à +08:00 08:00 * 1 +Réalisé — TOILETTE : AUTONOME - Matin +[8h] - 1 Semaine- Date Début: 28/03/2023 @ +10:24 [NOM] Jean- +[NOM] +Début le 28/03/2023 à +10:24 +Fin le 04/04/2023 à +08:00 +Admin le 03/04/2023 à +08:00 08:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 08:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 12:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 14:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 19:00 * 1 + + + +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 22:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 00:00 * 1 +Réalisé — GLYCEMIE CAPILLAIRE x 7 - 7x/ +jour (8h 12h 14h 19h 22h 0h 4h) - pendant 14 +Jour(s)- Date Début : 31/03/2023 @ 14:52 +Notes de professionel de santé : +bien noter toutes les glycémies sur trakcare +notamment celles de 22h [NOM] [NOM] +Début le 31/03/2023 à +14:52 +Fin le 14/04/2023 à +14:00 +Admin le 03/04/2023 à +14:00 04:00 * 1 +Prescription : Date Résultat +CR RX-Echo : 25/03/2023 +02:19 Compte rendu au format texte +Bayonne, le 25/03/2023 +Docteur +Nom de naissance : DE [NOM] [NOM] [NOM] +Nom utilisé : DE [NOM] [NOM] [NOM] +Prénom de naissance : REGINA +Prénom utilisé : REGINA +[DATE_NAISSANCE] +Lieu de naissance : 99999 +Sexe : F +Matricule INS : +Examen du : 25/03/2023 +Compte-rendu validé électroniquement par Dr [NOM] le 25/03/2023 +RADIOGRAPHIE PULMONAIRE +Indication : +Bilan de dyspnée. +RESULTATS : +Sous réserve de la faible ampliation thoracique : +Diminution de la transparence parenchymateuse aux bases apparaissant être liée notamment à la projection des parties molles. +Absence de foyer circonscrit au niveau des apex pulmonaires. Augmentation de l'index cardiothoracique.. +Dr [NOM] +Technique : +PDS : 0.426 dGy.cm² +A l'entrée : 0.065 mGy +Protocole d'acquisition : Thorax +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 : 03/04/2023 09:17 +(5920658) 03/04/2023 09:07 +(5920659) 30/03/2023 08:44 +(5918673) 29/03/2023 08:11 +(5917252) 29/03/2023 08:11 +(5917251) +Bilirubine totale : 5 µmol/l + +Score Fibrosis-4 (FIB4) : 1,60 +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) % Non renseigné(e) % +Bicarbonates : 38,0 mmol/l 37,7 mmol/l +Origine : Artériel Artériel +Débit : Non renseigné(e) L/ +min Non renseigné(e) L/ +min +Température : Non renseignée (rendu +pour une température +de 37°C) °C Non renseignée (rendu +pour une température +de 37°C) °C +ASAT : 27 U/l +Commentaire bilirubine totale : 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 +masse 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 +masse 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 +masse musculaire - +alimentation pauvre +en protéines animales +et patients dénutris - +patients d'origine non +caucasienne +Gamma GT : 39 U/l +NT-proBNP : 229 ng/l 507 ng/l +Interprétation NT-proBNP : Négatif : Insuffisance +cardiaque peu probable Zone grise : +insuffisance cardiaque +moins plausible. +Envisager d?autres +causes d?augmentation +du NT-proBNP. +Phosphatase alcaline : 80 U/l +Calcium : 2,10 mmol/l +Estimation du DFG (CKD- +EPI) : 97 ml/mn/1.73 m2 71 ml/mn/1.73 m2 92 ml/mn/1.73 m2 +Chlore : 90 mmol/l 88 mmol/l 89 mmol/l +Créatinine : 52 µmol/l 76 µmol/l 60 µmol/l +CRP : 34 mg/l 2 mg/l +Compte-rendu laboratoire : Labo230403105652-1.pd fLabo230403104835-1.pd fLabo230330101823-1.pd fLabo230329103002-1.pd fLabo230329102552-1.pd +Polynucléaires neutrophiles +(%) : 65,1 % 70,3 % +Polynucléaires neutrophiles +(#) : 6,89 10.9/l 6,21 10.9/l +Polynucléaires éosinophiles +(%) : 1,1 % 0,1 % + +Polynucléaires éosinophiles +(#) : 0,12 10.9/l 0,01 10.9/l +Polynucléaires basophiles (%) : 0,4 % 0,3 % +Polynucléaires basophiles (#) : 0,04 10.9/l 0,03 10.9/l +Lymphocytes (%) : 24,3 % 19,3 % +Lymphocytes (#) : 2,57 10.9/l 1,70 10.9/l +Monocytes (%) : 9,1 % 10,0 % +Monocytes (#) : 0,96 10.9/l 0,88 10.9/l +Glucose : 13,4 mmol/l 9,7 mmol/l 15,0 mmol/l +pH : 7,50 7,48 +pO2 : 100 mmHg 103 mmHg +Saturation O2 : 96,0 % 96,5 % +pCO2 : 49 mmHg 51 mmHg +ALAT : 19 U/l +Formule sanguine : réalisée sur automate +XN (Sysmex) réalisée sur automate +XN (Sysmex) +Hématocrite (%) : 35,5 % 33,9 % +Indice de distribution des +hématies : 20,3 % 18,2 % +Potassium : 2,6 mmol/l 3,3 mmol/l 2,7 mmol/l +Leucocytes : 10,59 10.9/l 8,83 10.9/l +Hématies : 4,57 10.12/l (t/l) 4,48 10.12/l (t/l) +Hémoglobine : 10,6 g/dl 10,1 g/dl +VGM : 77,7 fl 75,7 fl +TCMH : 23,2 pg 22,5 pg +CCMH : 29,9 g/dl 29,8 g/dl +Sodium : 137 mmol/l 136 mmol/l 136 mmol/l +Osmolarité sang : 287 mOSM/l 282 mOSM/l 287 mOSM/l +Plaquettes : 252 10.9/l 290 10.9/l +Validation et diffusion sous la +responsabilité du biologiste : Dr [NOM] "" Dr. [NOM] [NOM] +[NOM] Dr [NOM] [NOM] Dr [NOM] [NOM] +Volume plaquettaire moyen : 9,0 fl 9,1 fl diff --git a/test_3ogc/anonymise_old/trackare-BA165196-23061393_BA165196_23061393.redacted_raster.pdf b/test_3ogc/anonymise_old/trackare-BA165196-23061393_BA165196_23061393.redacted_raster.pdf new file mode 100644 index 0000000..125f932 Binary files /dev/null and b/test_3ogc/anonymise_old/trackare-BA165196-23061393_BA165196_23061393.redacted_raster.pdf differ diff --git a/test_anonymise/CRH 23209962.audit.jsonl b/test_anonymise/CRH 23209962.audit.jsonl new file mode 100644 index 0000000..8c518ce --- /dev/null +++ b/test_anonymise/CRH 23209962.audit.jsonl @@ -0,0 +1,916 @@ +{"page": 0, "kind": "ADRESSE", "original": "13, Avenue de l'Interne J", "placeholder": "[ADRESSE]", "bbox_hint": null} +{"page": 0, "kind": "ADRESSE", "original": "LOEB BP 8", 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b/test_anonymise/CRH 23209962.pseudonymise.txt new file mode 100644 index 0000000..eb12571 --- /dev/null +++ b/test_anonymise/CRH 23209962.pseudonymise.txt @@ -0,0 +1,2188 @@ +N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Bayonne, le [DATE] +Dr [NOM] +Chef de service DR [NOM] +Ancien Chef de Clinique des Hôpitaux +de Paris [ADRESSE] +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 0ta 8l 1ie 7r 005 [CODE_POSTAL] +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Bordeaux Mon cher confrère, +Praticien Hospitalier +RPPS : [RPPS] +Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du [DATE] au [DATE] pour le motif +Dr [NOM] suivant : +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 1ta 8l 5ie 6r 135 - Motif d’hospitalisation : Récidive de douleur thoracique chez un patient suivi pour une myosite associée à une +Dr [NOM] myocardite récidivante d’étiologie indéterminée. +Ancien Chef de Clinique des Hôpitaux +d Pe ra B tio cir ed ne a hu ox spitalier Antécédents : +RPPS : [RPPS] Myocardiopathie récidivante depuis 2019 d’origine indéterminé (suivi cardio par Dr [NOM] et médecine interne +Dr [NOM] par le Dr [NOM]) +A Prn ac tii ce in e nA hss oi ss pta itn at l id ee rs c H onô tp rait ca tu ux e lde Lyon Myosite inflammatoire +RPPS : [RPPS] +Secrétariat : [TEL] Allergies : intolérance à la codéine. +MEDECINE INTERNE ET +IMMUNOLOGIE CLINIQUE Traitement habituel : +BISOPROLOL 5mg le matin midi et soir +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux ENTRESTO 93/103 1.0.0 +de Bordeaux CORTANCYL 10mg 1.0.0 +Praticien Hospitalier +RPPS : [RPPS] EPLERENONE 25mg 1.0.0 +METHOTREXATE 15mg le jeudi +Dr [NOM] +Ancien Assistant des Hôpitaux de SPECIAFOLDINE 5mg 3 comprimés 2 jours après le méthotrexate +Bordeaux et Bayonne +P Nr °a t Ric Pi Pen S H 10o 1sp 0i 1t 4al 8i 0er 506 Mode de vie : +Travaillait à l'usine Labeyrie à St Geours de Maremne, à 3 enfants de 9,7 et [AGE]. Actuellement au chômage suite à un arrêt +Dr [NOM] de travail prolongé. +Ancien Chef de Clinique des Hôpitaux +de Lille +P Nr °a t Ric Pi Pen S h 1o 0s 0p 0i 4ta 6l 0ie 6r 595 Histoire de la maladie : +Juin 2019 un tableau de myocardite avec altération de la FEVG sur l'IRM cardiaque initiale, traité par Aspirine et +Dr [NOM] Colchicine, avec malheureusement à chaque tentative de diminution récidive des douleurs. +Assistant spécialiste +RPPS : [RPPS] +Les différentes IRM réalisées en 2019, 2020, mettaient en évidence des rehaussements tardifs sous-épicardiques latéro et +Secrétariat : [TEL] inféro latéraux avec une FEVG aux alentours de 45 %. Parallèlement à cela, le patient présentait une élévation des CPK +DERMATOLOGIE avec un tableau de myalgies et de fatigabilité musculaire, pour lequel il a eu un bilan très exhaustif réalisé, d'abord par le +Dr [NOM] Docteur [NOM] sur l'hôpital de Bayonne, puis par le Docteur [NOM], avec un électromyogramme non contributif, une IRM +Ancien Chef de Clinique des Hôpitaux musculaire normale, un dot myosite négatif ainsi que la recherche de la maladie de pompe. +d Pe +ra +T tio cu ielo nu hs oe +spitalier +RPPS : [RPPS] Un bilan très large infectieux et immunologique a été réalisé, d'abord par les infectiologues puis en médecine interne, +Dr [NOM] +l'ensemble du bilan est revenu strictement négatif. +Ancien Assistant des Hôpitaux de +Toulouse Une biopsie musculaire a donc été réalisée au CHU de Bx retrouvant quelques éléments inflammatoires en faveur d'une +Praticien Hospitalier contractuel +RPPS : [RPPS] cause dysimmunitaire primitive, même si le pattern reste aspécifique. +Dr [NOM] +Praticien Hospitalier contractuel Suite aux résultats de cette biopsie musculaire évocatrice de pathologie dysimmunitaire, après discussion pluridisciplinaire +RPPS : [RPPS] entre le Dr [NOM], [NOM], [NOM], [NOM], [NOM], [NOM], il a été proposé de la mise en +Dr [NOM] place d'une corticothérapie systémique. +Praticien Hospitalier contractuel +Juin 2022 : Introduction de la corticothérapie a 60mg/kg +Secrétariat : [TEL] +CENTRE DE COMPETENCES Juillet 2022 : Diminution progressive de l’aspirine. Franche amélioration clinique sous corticothérapie, normalisation des +D ETE S A M UTA OL -A IND FIE LS A A MU MT AO T I OM IRM EU SNES CPK et de la troponine. Diminution progressive des corticoïdes. +SYSTEMIQUES RARES : +Médecin coordonnateur : Novembre 2022 : sous 20mg/j de corticoïdes, Légère réapparition des douleurs thoraciques et tendance à l’augmentation +D Ser c I rr éè tn ae ri aM t : A 0C 5.H 33E .L 78A .8R 1T .89 des CPK. +[EMAIL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 1 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Février 2023 : Diminution de la cortisone a 7.5mg/jour : franche réapparition des douleurs thoraciques, myalgies et +Dr [NOM] remontée des CPK ainsi que de la troponine. Corticodependance importante de la maladie. +Chef de service Cortancyl 10mg dans l'attente d'une discussion d’un traitement à visée d’épargne cortisonique. +A den Pci ae rn +is +Chef de Clinique des Hôpitaux +Praticien hospitalier Avril 2023 : décision en RCP immuno et avec le Dr [NOM] et [NOM] de débuter un traitement par METHOTREXATE. +N D° +r +R SP tP éS +p +h10 a1 n0 e0 8 M17 A00 R5 +CE +Patient perdu de vue pdt quelques mois +Ancien Chef de Clinique des Hôpitaux +de Bordeaux Juillet 23 : patient revu avec IRM de contrôle : Pas de modification des prises de contraste résiduelles sous épicardiques +Praticien Hospitalier de la paroi latérale et antérieure du ventricule gauche. Augmentation de volume du ventricule gauche comparativement à +RPPS : [RPPS] +l'examen d'octobre 2022 avec une FEVG qui s'est légèrement détériorée à 45 % contre 50 %. +Dr [NOM] Mise sous MTX 15mg/semaine, malheureusement non débuté par le patient. +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien hospitalier Début MTX par le patient seulement il y a 3 semaines. Maintien CTC à 10mg/j avec prévision de décroissance progressive +N +D +A° +nr +c +R +I +ieP +t +nsP +a +CS +s +h1 +o +e0 fO1 d0 +D +e1 8 CR5 lI6 inO1 i3 qZ5 +ueO dL esA +Hôpitaux +s ur quelques semaines le temps de l'efficacité du MTX. +de Bordeaux Histoire récente : +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 Il y a 15 jours-3 semaines, Contage infectieux d'allure viral avec ses enfants (rhinorrhée, fièvre) régressif spontanément en +Dr [NOM] quelques jours. Pas de dépistage COVID. +Ancien Assistant des Hôpitaux de Lyon +Praticien hospitalier contractuel Dans ce contexte, au bilan biologique du 20/10/23 : Troponine à 196ng/l ( vs 53 le 02/10) CPK à 1500UI/l vs (373UI/l le +RPPS : [RPPS] +02/10) +Secrétariat : [TEL] +MEDECINE INTERNE ET Il y a une semaine majoration de sa douleur thoracique en barre et apparition d’un pointe transfixiante thoracique gauche a +IMMUNOLOGIE CLINIQUE l’effort associée a un essoufflement plus marqué d’après le patient. +Dr [NOM] Pas de majoration de ses douleurs musculaires habituelles des membres supérieurs. +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier Nouvelle biologie le 30/10 : Tropo :199ng/l et CPK : 560UI/l +RPPS : [RPPS] +Hospitalisation en médecine interne. +Dr [NOM] +A Bon rc die en au A xs es ti s Bta an yt o d ne ns e Hôpitaux de Examen clinique : +Praticien Hospitalier BDC réguliers, fond douloureux douleur thoracique en barre, pointe thoracique gauche transfixiante uniquement à l’effort +RPPS : [RPPS] non présente au moment de l’examen, pas d’omi, mollets souple et indolore +Dr [NOM] +/+ pas de bruit surajouté +Ancien Chef de Clinique des Hôpitaux Abdomen souple, dépressible indolore, pas de trouble du transit, pas de SFU +de Lille +Praticien hospitalier Douleur musculaire MS gauche et droite mais pas de déficit +RPPS : [RPPS] Pas de douleur musculaire des membres inférieurs +Dr [NOM] Pas de céphalée, pas de déficit sensitivo moteur +Assistant spécialiste +RPPS : [RPPS] Examens complémentaires: +Secrétariat : [TEL] Hb 14g/dL, VGM 79fl, PNN 4.9G/L, plaquettes 208G/L, lymphocytes 3.4G/L +Na+ 141mmol/L, K+ 3.9 mmol/L +DERMATOLOGIE +Creat 90 µmol/L, DFG 90 ml/min +Dr [NOM] CRP 1 mg/L +Ancien Chef de Clinique des Hôpitaux +de Toulouse CPK 480 +Praticien hospitalier ASAT 42,ALAT 45, GGT 22, PAL 48, Bili totale µmol/L, LDH 227 +RPPS : [RPPS] +Troponine ultrasensible : 29.8 ng/l +Dr [NOM] BNP 186 ng/l +A Ton uc li oe un s A essistant des Hôpitaux de Ac anti myocarde en cours +Praticien Hospitalier contractuel ECG : sinusal régulier, pas de trouble de la repolarisation, pas de trouble de la conduction FC : 67bpm +RPPS : [RPPS] +Dr [NOM] ETT (Dr [NOM]) +P Nr °a t Ric Pi Pen S H 10o 1sp 1i 0t 6al 0i 1er 3 2c 4ontractuel VG dilaté, DTDVG 63mm, VTDVG 100ml/m2, non hypertrophié, hypokinésie globale plus marquée en inféro-latérale, +Dr [NOM] +F deE sV cG +av +4 it2 é% +s d +S roB iG te, +s +,O PG +A +Pn so n +2 +5d +il 8a t mée m, P HR gV +, +VG +m +n ao xrm 2a .5le ms, +g +p /sa +, +s +b +d oe +n +v Va Dlv u (Slo 'Vpa Dth 1ie +4 +,m IVitr Ao - 3a .o 5r )t ,i q pu ée +ri +csi ag rn di ef i sc ea ct ,i v Ve Cs, +I +p na os +n +d de id lai tl ea ,t a Ati oo rn +te +Praticien Hospitalier contractuel +ascendente non dilatée +Secrétariat : [TEL] +CENTRE DE COMPETENCES Evolution dans le service et conclusions : +DES MALADIES AUTO IMMUNES Au total, nouvelle récidive de myosite/myocardite d'étiologie restant indéterminée mais dysimmunitaire probable, +E SYT S A TU ET MO I- QIN UF EL SA RM AM REA ST O : IRES favorisée par un possible épisode infectieux viral malgré un traitement par CORTANCYL 10mg/jour et +Médecin coordonnateur : METHOTREXATE 15mg/semaine. +Dr [NOM] +S see cc rr .é mta er di ia nt : t @05 c. h3 -3 c. o7 t8 e. b8 a1 s. q8 u9 e.fr L'ETT retrouve une globale stabilité de l'atteinte cardiaque, mais l'IRM cardiaque n'a pu être réslisée en urgence. +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 2 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE L'introduction du METHOTREXATE il y a à peine 3 semaines ne permet pas de conclure à son inefficacité. +Dr [NOM] +Chef de service Initiation de bolus de SOLUMEDROL 500mg IV sur 3 jours, puis relai à 20mg/j avec décroissance sur quelques +A den Pci ae rn is Chef de Clinique des Hôpitaux semaines le temps de l'efficacité du MTX qui est monté à 20mg/semaine +Praticien hospitalier +N D° +r +R SP tP éS +p +h10 a1 n0 e0 8 M17 A00 R5 +CE +A +à +p +3 +r mès +o +d isi s dc eu ts rs aio itn +e +mav ee nc +t +l pe aD rr +M +B TA XR ,R pI oT uA +r +U juL fT +er +e dt ele +l +'D efr +f +iL caA cB itO +é. +R DD 'iE ciR làIE o : +n +i l +d +e imst id né uc ei d laé cd oe +r +r tié cé ov ta hl éu re ar +p +l ie +e +p jua sti qe un 't +à +d 5a mns +g +.2 mois, +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier Si, à 3 mois de traitement par MTX, persiste une activité de la maladie, il sera discuté collégialement ou non de +RPPS : [RPPS] +l'intérêt d'une biopsie myocardique. +Dr [NOM] +A den Bci oe rn d C eah ue xf de Clinique des Hôpitaux Traitement de sortie : +Praticien hospitalier BISOPROLOL 5mg le matin midi et soir +N +D +A° +nr c +R +I +ieP +t +nsP +a +CS +s +h1 +o +e0 fO1 d0 +D +e1 8 CR5 lI6 inO1 i3 qZ5 +ueO dL esA Hôpitaux +E CN OT RR TAES NT CO +Y +9 L3 2/1 00 m3 +g +1 /j. 0 1. 0 +semaine puis 15mg 1 semaine puis 12,5mg 1 semaine puis 10mg 1 semaine puis 7,5mg 1 semaine +de Bordeaux puis 5 mg/j +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 EPLERENONE 25mg 1.0.0 +Dr [NOM] METHOTREXATE 20mg le jeudi +Ancien Assistant des Hôpitaux de Lyon SPECIAFOLDINE 5mg 3 comprimés le lendemain du MTX +Praticien hospitalier contractuel +RPPS : [RPPS] +Suivi : +Secrétariat : [TEL] +Biologies hébdomadaires +MEDECINE INTERNE ET IRM cardiaque début Janvier en externe +IMMUNOLOGIE CLINIQUE HDJ début Janvier en cardiologie avec le Dr [NOM] pour réévaluation complète +Dr [NOM] HDJ de synthèse medecine interne fin Janvier +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier +RPPS : [RPPS] +Dr [NOM] Les consignes d'usage ont été remises. +Ancien Assistant des Hôpitaux de +Bordeaux et Bayonne +Praticien Hospitalier +RPPS : [RPPS] +Dr [NOM] Bien confraternellement, +Ancien Chef de Clinique des Hôpitaux +de Lille +Praticien hospitalier +RPPS : [RPPS] +Dr [NOM] Docteur [NOM] [NOM] +Assistant spécialiste +RPPS : [RPPS] *10100858090* +Secrétariat : [TEL] +DERMATOLOGIE 10100858090 +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Toulouse +Praticien hospitalier +RPPS : [RPPS] Liste des destinataires: +Dr [NOM]. [NOM] [NOM] +Ancien Assistant des Hôpitaux de +Toulouse DR. [NOM] +Praticien Hospitalier contractuel DR. [NOM] +RPPS : [RPPS] +DR. [NOM] +Dr [NOM]. [NOM] [NOM] +P Nr °a t Ric Pi Pen S H 10o 1sp 1i 0t 6al 0i 1er 3 2c 4ontractuel DR. [NOM] +Dr [NOM] +Praticien Hospitalier contractuel +Secrétariat : [TEL] +CENTRE DE COMPETENCES +DES MALADIES AUTO IMMUNES +ET AUTO-INFLAMMATOIRES +SYSTEMIQUES RARES : +Médecin coordonnateur : +Dr [NOM] +Secrétariat : [TEL] +[EMAIL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 3 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Bayonne, le [DATE] +Dr [NOM] +Chef de service DR [NOM] +Ancien Chef de Clinique des Hôpitaux +de Paris PLACE DES ARENES +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 0ta 8l 1ie 7r 005 [CODE_POSTAL] +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Bordeaux Mon cher confrère, +Praticien Hospitalier +RPPS : [RPPS] +Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du [DATE] au [DATE] pour le motif +Dr [NOM] suivant : +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 1ta 8l 5ie 6r 135 - Motif d’hospitalisation : Récidive de douleur thoracique chez un patient suivi pour une myosite associée à une +Dr [NOM] myocardite récidivante d’étiologie indéterminée. +Ancien Chef de Clinique des Hôpitaux +d Pe ra B tio cir ed ne a hu ox spitalier Antécédents : +RPPS : [RPPS] Myocardiopathie récidivante depuis 2019 d’origine indéterminé (suivi cardio par Dr [NOM] et médecine interne +Dr [NOM] par le Dr [NOM]) +A Prn ac tii ce in e nA hss oi ss pta itn at l id ee rs c H onô tp rait ca tu ux e lde Lyon Myosite inflammatoire +RPPS : [RPPS] +Secrétariat : [TEL] Allergies : intolérance à la codéine. +MEDECINE INTERNE ET +IMMUNOLOGIE CLINIQUE Traitement habituel : +BISOPROLOL 5mg le matin midi et soir +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux ENTRESTO 93/103 1.0.0 +de Bordeaux CORTANCYL 10mg 1.0.0 +Praticien Hospitalier +RPPS : [RPPS] EPLERENONE 25mg 1.0.0 +METHOTREXATE 15mg le jeudi +Dr [NOM] +Ancien Assistant des Hôpitaux de SPECIAFOLDINE 5mg 3 comprimés 2 jours après le méthotrexate +Bordeaux et Bayonne +P Nr °a t Ric Pi Pen S H 10o 1sp 0i 1t 4al 8i 0er 506 Mode de vie : +Travaillait à l'usine Labeyrie à St Geours de Maremne, à 3 enfants de 9,7 et [AGE]. Actuellement au chômage suite à un arrêt +Dr [NOM] de travail prolongé. +Ancien Chef de Clinique des Hôpitaux +de Lille +P Nr °a t Ric Pi Pen S h 1o 0s 0p 0i 4ta 6l 0ie 6r 595 Histoire de la maladie : +Juin 2019 un tableau de myocardite avec altération de la FEVG sur l'IRM cardiaque initiale, traité par Aspirine et +Dr [NOM] Colchicine, avec malheureusement à chaque tentative de diminution récidive des douleurs. +Assistant spécialiste +RPPS : [RPPS] +Les différentes IRM réalisées en 2019, 2020, mettaient en évidence des rehaussements tardifs sous-épicardiques latéro et +Secrétariat : [TEL] inféro latéraux avec une FEVG aux alentours de 45 %. Parallèlement à cela, le patient présentait une élévation des CPK +DERMATOLOGIE avec un tableau de myalgies et de fatigabilité musculaire, pour lequel il a eu un bilan très exhaustif réalisé, d'abord par le +Dr [NOM] Docteur [NOM] sur l'hôpital de Bayonne, puis par le Docteur [NOM], avec un électromyogramme non contributif, une IRM +Ancien Chef de Clinique des Hôpitaux musculaire normale, un dot myosite négatif ainsi que la recherche de la maladie de pompe. +d Pe +ra +T tio cu ielo nu hs oe +spitalier +RPPS : [RPPS] Un bilan très large infectieux et immunologique a été réalisé, d'abord par les infectiologues puis en médecine interne, +Dr [NOM] +l'ensemble du bilan est revenu strictement négatif. +Ancien Assistant des Hôpitaux de +Toulouse Une biopsie musculaire a donc été réalisée au CHU de Bx retrouvant quelques éléments inflammatoires en faveur d'une +Praticien Hospitalier contractuel +RPPS : [RPPS] cause dysimmunitaire primitive, même si le pattern reste aspécifique. +Dr [NOM] +Praticien Hospitalier contractuel Suite aux résultats de cette biopsie musculaire évocatrice de pathologie dysimmunitaire, après discussion pluridisciplinaire +RPPS : [RPPS] entre le Dr [NOM], [NOM], [NOM], [NOM], [NOM], [NOM], il a été proposé de la mise en +Dr [NOM] place d'une corticothérapie systémique. +Praticien Hospitalier contractuel +Juin 2022 : Introduction de la corticothérapie a 60mg/kg +Secrétariat : [TEL] +CENTRE DE COMPETENCES Juillet 2022 : Diminution progressive de l’aspirine. Franche amélioration clinique sous corticothérapie, normalisation des +D ETE S A M UTA OL -A IND FIE LS A A MU MT AO T I OM IRM EU SNES CPK et de la troponine. Diminution progressive des corticoïdes. +SYSTEMIQUES RARES : +Médecin coordonnateur : Novembre 2022 : sous 20mg/j de corticoïdes, Légère réapparition des douleurs thoraciques et tendance à l’augmentation +D Ser c I rr éè tn ae ri aM t : A 0C 5.H 33E .L 78A .8R 1T .89 des CPK. +[EMAIL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 1 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Février 2023 : Diminution de la cortisone a 7.5mg/jour : franche réapparition des douleurs thoraciques, myalgies et +Dr [NOM] remontée des CPK ainsi que de la troponine. Corticodependance importante de la maladie. +Chef de service Cortancyl 10mg dans l'attente d'une discussion d’un traitement à visée d’épargne cortisonique. +A den Pci ae rn +is +Chef de Clinique des Hôpitaux +Praticien hospitalier Avril 2023 : décision en RCP immuno et avec le Dr [NOM] et [NOM] de débuter un traitement par METHOTREXATE. +N D° +r +R SP tP éS +p +h10 a1 n0 e0 8 M17 A00 R5 +CE +Patient perdu de vue pdt quelques mois +Ancien Chef de Clinique des Hôpitaux +de Bordeaux Juillet 23 : patient revu avec IRM de contrôle : Pas de modification des prises de contraste résiduelles sous épicardiques +Praticien Hospitalier de la paroi latérale et antérieure du ventricule gauche. Augmentation de volume du ventricule gauche comparativement à +RPPS : [RPPS] +l'examen d'octobre 2022 avec une FEVG qui s'est légèrement détériorée à 45 % contre 50 %. +Dr [NOM] Mise sous MTX 15mg/semaine, malheureusement non débuté par le patient. +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien hospitalier Début MTX par le patient seulement il y a 3 semaines. Maintien CTC à 10mg/j avec prévision de décroissance progressive +N +D +A° +nr +c +R +I +ieP +t +nsP +a +CS +s +h1 +o +e0 fO1 d0 +D +e1 8 CR5 lI6 inO1 i3 qZ5 +ueO dL esA +Hôpitaux +s ur quelques semaines le temps de l'efficacité du MTX. +de Bordeaux Histoire récente : +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 Il y a 15 jours-3 semaines, Contage infectieux d'allure viral avec ses enfants (rhinorrhée, fièvre) régressif spontanément en +Dr [NOM] quelques jours. Pas de dépistage COVID. +Ancien Assistant des Hôpitaux de Lyon +Praticien hospitalier contractuel Dans ce contexte, au bilan biologique du 20/10/23 : Troponine à 196ng/l ( vs 53 le 02/10) CPK à 1500UI/l vs (373UI/l le +RPPS : [RPPS] +02/10) +Secrétariat : [TEL] +MEDECINE INTERNE ET Il y a une semaine majoration de sa douleur thoracique en barre et apparition d’un pointe transfixiante thoracique gauche a +IMMUNOLOGIE CLINIQUE l’effort associée a un essoufflement plus marqué d’après le patient. +Dr [NOM] Pas de majoration de ses douleurs musculaires habituelles des membres supérieurs. +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier Nouvelle biologie le 30/10 : Tropo :199ng/l et CPK : 560UI/l +RPPS : [RPPS] +Hospitalisation en médecine interne. +Dr [NOM] +A Bon rc die en au A xs es ti s Bta an yt o d ne ns e Hôpitaux de Examen clinique : +Praticien Hospitalier BDC réguliers, fond douloureux douleur thoracique en barre, pointe thoracique gauche transfixiante uniquement à l’effort +RPPS : [RPPS] non présente au moment de l’examen, pas d’omi, mollets souple et indolore +Dr [NOM] +/+ pas de bruit surajouté +Ancien Chef de Clinique des Hôpitaux Abdomen souple, dépressible indolore, pas de trouble du transit, pas de SFU +de Lille +Praticien hospitalier Douleur musculaire MS gauche et droite mais pas de déficit +RPPS : [RPPS] Pas de douleur musculaire des membres inférieurs +Dr [NOM] Pas de céphalée, pas de déficit sensitivo moteur +Assistant spécialiste +RPPS : [RPPS] Examens complémentaires: +Secrétariat : [TEL] Hb 14g/dL, VGM 79fl, PNN 4.9G/L, plaquettes 208G/L, lymphocytes 3.4G/L +Na+ 141mmol/L, K+ 3.9 mmol/L +DERMATOLOGIE +Creat 90 µmol/L, DFG 90 ml/min +Dr [NOM] CRP 1 mg/L +Ancien Chef de Clinique des Hôpitaux +de Toulouse CPK 480 +Praticien hospitalier ASAT 42,ALAT 45, GGT 22, PAL 48, Bili totale µmol/L, LDH 227 +RPPS : [RPPS] +Troponine ultrasensible : 29.8 ng/l +Dr [NOM] BNP 186 ng/l +A Ton uc li oe un s A essistant des Hôpitaux de Ac anti myocarde en cours +Praticien Hospitalier contractuel ECG : sinusal régulier, pas de trouble de la repolarisation, pas de trouble de la conduction FC : 67bpm +RPPS : [RPPS] +Dr [NOM] ETT (Dr [NOM]) +P Nr °a t Ric Pi Pen S H 10o 1sp 1i 0t 6al 0i 1er 3 2c 4ontractuel VG dilaté, DTDVG 63mm, VTDVG 100ml/m2, non hypertrophié, hypokinésie globale plus marquée en inféro-latérale, +Dr [NOM] +F deE sV cG +av +4 it2 é% +s d +S roB iG te, +s +,O PG +A +Pn so n +2 +5d +il 8a t mée m, P HR gV +, +VG +m +n ao xrm 2a .5le ms, +g +p /sa +, +s +b +d oe +n +v Va Dlv u (Slo 'Vpa Dth 1ie +4 +,m IVitr Ao - 3a .o 5r )t ,i q pu ée +ri +csi ag rn di ef i sc ea ct ,i v Ve Cs, +I +p na os +n +d de id lai tl ea ,t a Ati oo rn +te +Praticien Hospitalier contractuel +ascendente non dilatée +Secrétariat : [TEL] +CENTRE DE COMPETENCES Evolution dans le service et conclusions : +DES MALADIES AUTO IMMUNES Au total, nouvelle récidive de myosite/myocardite d'étiologie restant indéterminée mais dysimmunitaire probable, +E SYT S A TU ET MO I- QIN UF EL SA RM AM REA ST O : IRES favorisée par un possible épisode infectieux viral malgré un traitement par CORTANCYL 10mg/jour et +Médecin coordonnateur : METHOTREXATE 15mg/semaine. +Dr [NOM] +S see cc rr .é mta er di ia nt : t @05 c. h3 -3 c. o7 t8 e. b8 a1 s. q8 u9 e.fr L'ETT retrouve une globale stabilité de l'atteinte cardiaque, mais l'IRM cardiaque n'a pu être réslisée en urgence. +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 2 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE L'introduction du METHOTREXATE il y a à peine 3 semaines ne permet pas de conclure à son inefficacité. +Dr [NOM] +Chef de service Initiation de bolus de SOLUMEDROL 500mg IV sur 3 jours, puis relai à 20mg/j avec décroissance sur quelques +A den Pci ae rn is Chef de Clinique des Hôpitaux semaines le temps de l'efficacité du MTX qui est monté à 20mg/semaine +Praticien hospitalier +N D° +r +R SP tP éS +p +h10 a1 n0 e0 8 M17 A00 R5 +CE +A +à +p +3 +r mès +o +d isi s dc eu ts rs aio itn +e +mav ee nc +t +l pe aD rr +M +B TA XR ,R pI oT uA +r +U juL fT +er +e dt ele +l +'D efr +f +iL caA cB itO +é. +R DD 'iE ciR làIE o : +n +i l +d +e imst id né uc ei d laé cd oe +r +r tié cé ov ta hl éu re ar +p +l ie +e +p jua sti qe un 't +à +d 5a mns +g +.2 mois, +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier Si, à 3 mois de traitement par MTX, persiste une activité de la maladie, il sera discuté collégialement ou non de +RPPS : [RPPS] +l'intérêt d'une biopsie myocardique. +Dr [NOM] +A den Bci oe rn d C eah ue xf de Clinique des Hôpitaux Traitement de sortie : +Praticien hospitalier BISOPROLOL 5mg le matin midi et soir +N +D +A° +nr c +R +I +ieP +t +nsP +a +CS +s +h1 +o +e0 fO1 d0 +D +e1 8 CR5 lI6 inO1 i3 qZ5 +ueO dL esA Hôpitaux +E CN OT RR TAES NT CO +Y +9 L3 2/1 00 m3 +g +1 /j. 0 1. 0 +semaine puis 15mg 1 semaine puis 12,5mg 1 semaine puis 10mg 1 semaine puis 7,5mg 1 semaine +de Bordeaux puis 5 mg/j +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 EPLERENONE 25mg 1.0.0 +Dr [NOM] METHOTREXATE 20mg le jeudi +Ancien Assistant des Hôpitaux de Lyon SPECIAFOLDINE 5mg 3 comprimés le lendemain du MTX +Praticien hospitalier contractuel +RPPS : [RPPS] +Suivi : +Secrétariat : [TEL] +Biologies hébdomadaires +MEDECINE INTERNE ET IRM cardiaque début Janvier en externe +IMMUNOLOGIE CLINIQUE HDJ début Janvier en cardiologie avec le Dr [NOM] pour réévaluation complète +Dr [NOM] HDJ de synthèse medecine interne fin Janvier +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier +RPPS : [RPPS] +Dr [NOM] Les consignes d'usage ont été remises. +Ancien Assistant des Hôpitaux de +Bordeaux et Bayonne +Praticien Hospitalier +RPPS : [RPPS] +Dr [NOM] Bien confraternellement, +Ancien Chef de Clinique des Hôpitaux +de Lille +Praticien hospitalier +RPPS : [RPPS] +Dr [NOM] Docteur [NOM] [NOM] +Assistant spécialiste +RPPS : [RPPS] *10100858090* +Secrétariat : [TEL] +DERMATOLOGIE 10100858090 +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Toulouse +Praticien hospitalier +RPPS : [RPPS] Liste des destinataires: +Dr [NOM]. [NOM] [NOM] +Ancien Assistant des Hôpitaux de +Toulouse DR. [NOM] +Praticien Hospitalier contractuel DR. [NOM] +RPPS : [RPPS] +DR. [NOM] +Dr [NOM]. [NOM] [NOM] +P Nr °a t Ric Pi Pen S H 10o 1sp 1i 0t 6al 0i 1er 3 2c 4ontractuel DR. [NOM] +Dr [NOM] +Praticien Hospitalier contractuel +Secrétariat : [TEL] +CENTRE DE COMPETENCES +DES MALADIES AUTO IMMUNES +ET AUTO-INFLAMMATOIRES +SYSTEMIQUES RARES : +Médecin coordonnateur : +Dr [NOM] +Secrétariat : [TEL] +[EMAIL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 3 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Bayonne, le [DATE] +Dr [NOM] +Chef de service DR [NOM] +Ancien Chef de Clinique des Hôpitaux +de Paris [ADRESSE] +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 0ta 8l 1ie 7r 005 [CODE_POSTAL] +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Bordeaux Mon cher confrère, +Praticien Hospitalier +RPPS : [RPPS] +Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du [DATE] au [DATE] pour le motif +Dr [NOM] suivant : +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 1ta 8l 5ie 6r 135 - Motif d’hospitalisation : Récidive de douleur thoracique chez un patient suivi pour une myosite associée à une +Dr [NOM] myocardite récidivante d’étiologie indéterminée. +Ancien Chef de Clinique des Hôpitaux +d Pe ra B tio cir ed ne a hu ox spitalier Antécédents : +RPPS : [RPPS] Myocardiopathie récidivante depuis 2019 d’origine indéterminé (suivi cardio par Dr [NOM] et médecine interne +Dr [NOM] par le Dr [NOM]) +A Prn ac tii ce in e nA hss oi ss pta itn at l id ee rs c H onô tp rait ca tu ux e lde Lyon Myosite inflammatoire +RPPS : [RPPS] +Secrétariat : [TEL] Allergies : intolérance à la codéine. +MEDECINE INTERNE ET +IMMUNOLOGIE CLINIQUE Traitement habituel : +BISOPROLOL 5mg le matin midi et soir +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux ENTRESTO 93/103 1.0.0 +de Bordeaux CORTANCYL 10mg 1.0.0 +Praticien Hospitalier +RPPS : [RPPS] EPLERENONE 25mg 1.0.0 +METHOTREXATE 15mg le jeudi +Dr [NOM] +Ancien Assistant des Hôpitaux de SPECIAFOLDINE 5mg 3 comprimés 2 jours après le méthotrexate +Bordeaux et Bayonne +P Nr °a t Ric Pi Pen S H 10o 1sp 0i 1t 4al 8i 0er 506 Mode de vie : +Travaillait à l'usine Labeyrie à St Geours de Maremne, à 3 enfants de 9,7 et [AGE]. Actuellement au chômage suite à un arrêt +Dr [NOM] de travail prolongé. +Ancien Chef de Clinique des Hôpitaux +de Lille +P Nr °a t Ric Pi Pen S h 1o 0s 0p 0i 4ta 6l 0ie 6r 595 Histoire de la maladie : +Juin 2019 un tableau de myocardite avec altération de la FEVG sur l'IRM cardiaque initiale, traité par Aspirine et +Dr [NOM] Colchicine, avec malheureusement à chaque tentative de diminution récidive des douleurs. +Assistant spécialiste +RPPS : [RPPS] +Les différentes IRM réalisées en 2019, 2020, mettaient en évidence des rehaussements tardifs sous-épicardiques latéro et +Secrétariat : [TEL] inféro latéraux avec une FEVG aux alentours de 45 %. Parallèlement à cela, le patient présentait une élévation des CPK +DERMATOLOGIE avec un tableau de myalgies et de fatigabilité musculaire, pour lequel il a eu un bilan très exhaustif réalisé, d'abord par le +Dr [NOM] Docteur [NOM] sur l'hôpital de Bayonne, puis par le Docteur [NOM], avec un électromyogramme non contributif, une IRM +Ancien Chef de Clinique des Hôpitaux musculaire normale, un dot myosite négatif ainsi que la recherche de la maladie de pompe. +d Pe +ra +T tio cu ielo nu hs oe +spitalier +RPPS : [RPPS] Un bilan très large infectieux et immunologique a été réalisé, d'abord par les infectiologues puis en médecine interne, +Dr [NOM] +l'ensemble du bilan est revenu strictement négatif. +Ancien Assistant des Hôpitaux de +Toulouse Une biopsie musculaire a donc été réalisée au CHU de Bx retrouvant quelques éléments inflammatoires en faveur d'une +Praticien Hospitalier contractuel +RPPS : [RPPS] cause dysimmunitaire primitive, même si le pattern reste aspécifique. +Dr [NOM] +Praticien Hospitalier contractuel Suite aux résultats de cette biopsie musculaire évocatrice de pathologie dysimmunitaire, après discussion pluridisciplinaire +RPPS : [RPPS] entre le Dr [NOM], [NOM], [NOM], [NOM], [NOM], [NOM], il a été proposé de la mise en +Dr [NOM] place d'une corticothérapie systémique. +Praticien Hospitalier contractuel +Juin 2022 : Introduction de la corticothérapie a 60mg/kg +Secrétariat : [TEL] +CENTRE DE COMPETENCES Juillet 2022 : Diminution progressive de l’aspirine. Franche amélioration clinique sous corticothérapie, normalisation des +D ETE S A M UTA OL -A IND FIE LS A A MU MT AO T I OM IRM EU SNES CPK et de la troponine. Diminution progressive des corticoïdes. +SYSTEMIQUES RARES : +Médecin coordonnateur : Novembre 2022 : sous 20mg/j de corticoïdes, Légère réapparition des douleurs thoraciques et tendance à l’augmentation +D Ser c I rr éè tn ae ri aM t : A 0C 5.H 33E .L 78A .8R 1T .89 des CPK. +[EMAIL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 1 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Février 2023 : Diminution de la cortisone a 7.5mg/jour : franche réapparition des douleurs thoraciques, myalgies et +Dr [NOM] remontée des CPK ainsi que de la troponine. Corticodependance importante de la maladie. +Chef de service Cortancyl 10mg dans l'attente d'une discussion d’un traitement à visée d’épargne cortisonique. +A den Pci ae rn +is +Chef de Clinique des Hôpitaux +Praticien hospitalier Avril 2023 : décision en RCP immuno et avec le Dr [NOM] et [NOM] de débuter un traitement par METHOTREXATE. +N D° +r +R SP tP éS +p +h10 a1 n0 e0 8 M17 A00 R5 +CE +Patient perdu de vue pdt quelques mois +Ancien Chef de Clinique des Hôpitaux +de Bordeaux Juillet 23 : patient revu avec IRM de contrôle : Pas de modification des prises de contraste résiduelles sous épicardiques +Praticien Hospitalier de la paroi latérale et antérieure du ventricule gauche. Augmentation de volume du ventricule gauche comparativement à +RPPS : [RPPS] +l'examen d'octobre 2022 avec une FEVG qui s'est légèrement détériorée à 45 % contre 50 %. +Dr [NOM] Mise sous MTX 15mg/semaine, malheureusement non débuté par le patient. +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien hospitalier Début MTX par le patient seulement il y a 3 semaines. Maintien CTC à 10mg/j avec prévision de décroissance progressive +N +D +A° +nr +c +R +I +ieP +t +nsP +a +CS +s +h1 +o +e0 fO1 d0 +D +e1 8 CR5 lI6 inO1 i3 qZ5 +ueO dL esA +Hôpitaux +s ur quelques semaines le temps de l'efficacité du MTX. +de Bordeaux Histoire récente : +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 Il y a 15 jours-3 semaines, Contage infectieux d'allure viral avec ses enfants (rhinorrhée, fièvre) régressif spontanément en +Dr [NOM] quelques jours. Pas de dépistage COVID. +Ancien Assistant des Hôpitaux de Lyon +Praticien hospitalier contractuel Dans ce contexte, au bilan biologique du 20/10/23 : Troponine à 196ng/l ( vs 53 le 02/10) CPK à 1500UI/l vs (373UI/l le +RPPS : [RPPS] +02/10) +Secrétariat : [TEL] +MEDECINE INTERNE ET Il y a une semaine majoration de sa douleur thoracique en barre et apparition d’un pointe transfixiante thoracique gauche a +IMMUNOLOGIE CLINIQUE l’effort associée a un essoufflement plus marqué d’après le patient. +Dr [NOM] Pas de majoration de ses douleurs musculaires habituelles des membres supérieurs. +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier Nouvelle biologie le 30/10 : Tropo :199ng/l et CPK : 560UI/l +RPPS : [RPPS] +Hospitalisation en médecine interne. +Dr [NOM] +A Bon rc die en au A xs es ti s Bta an yt o d ne ns e Hôpitaux de Examen clinique : +Praticien Hospitalier BDC réguliers, fond douloureux douleur thoracique en barre, pointe thoracique gauche transfixiante uniquement à l’effort +RPPS : [RPPS] non présente au moment de l’examen, pas d’omi, mollets souple et indolore +Dr [NOM] +/+ pas de bruit surajouté +Ancien Chef de Clinique des Hôpitaux Abdomen souple, dépressible indolore, pas de trouble du transit, pas de SFU +de Lille +Praticien hospitalier Douleur musculaire MS gauche et droite mais pas de déficit +RPPS : [RPPS] Pas de douleur musculaire des membres inférieurs +Dr [NOM] Pas de céphalée, pas de déficit sensitivo moteur +Assistant spécialiste +RPPS : [RPPS] Examens complémentaires: +Secrétariat : [TEL] Hb 14g/dL, VGM 79fl, PNN 4.9G/L, plaquettes 208G/L, lymphocytes 3.4G/L +Na+ 141mmol/L, K+ 3.9 mmol/L +DERMATOLOGIE +Creat 90 µmol/L, DFG 90 ml/min +Dr [NOM] CRP 1 mg/L +Ancien Chef de Clinique des Hôpitaux +de Toulouse CPK 480 +Praticien hospitalier ASAT 42,ALAT 45, GGT 22, PAL 48, Bili totale µmol/L, LDH 227 +RPPS : [RPPS] +Troponine ultrasensible : 29.8 ng/l +Dr [NOM] BNP 186 ng/l +A Ton uc li oe un s A essistant des Hôpitaux de Ac anti myocarde en cours +Praticien Hospitalier contractuel ECG : sinusal régulier, pas de trouble de la repolarisation, pas de trouble de la conduction FC : 67bpm +RPPS : [RPPS] +Dr [NOM] ETT (Dr [NOM]) +P Nr °a t Ric Pi Pen S H 10o 1sp 1i 0t 6al 0i 1er 3 2c 4ontractuel VG dilaté, DTDVG 63mm, VTDVG 100ml/m2, non hypertrophié, hypokinésie globale plus marquée en inféro-latérale, +Dr [NOM] +F deE sV cG +av +4 it2 é% +s d +S roB iG te, +s +,O PG +A +Pn so n +2 +5d +il 8a t mée m, P HR gV +, +VG +m +n ao xrm 2a .5le ms, +g +p /sa +, +s +b +d oe +n +v Va Dlv u (Slo 'Vpa Dth 1ie +4 +,m IVitr Ao - 3a .o 5r )t ,i q pu ée +ri +csi ag rn di ef i sc ea ct ,i v Ve Cs, +I +p na os +n +d de id lai tl ea ,t a Ati oo rn +te +Praticien Hospitalier contractuel +ascendente non dilatée +Secrétariat : [TEL] +CENTRE DE COMPETENCES Evolution dans le service et conclusions : +DES MALADIES AUTO IMMUNES Au total, nouvelle récidive de myosite/myocardite d'étiologie restant indéterminée mais dysimmunitaire probable, +E SYT S A TU ET MO I- QIN UF EL SA RM AM REA ST O : IRES favorisée par un possible épisode infectieux viral malgré un traitement par CORTANCYL 10mg/jour et +Médecin coordonnateur : METHOTREXATE 15mg/semaine. +Dr [NOM] +S see cc rr .é mta er di ia nt : t @05 c. h3 -3 c. o7 t8 e. b8 a1 s. q8 u9 e.fr L'ETT retrouve une globale stabilité de l'atteinte cardiaque, mais l'IRM cardiaque n'a pu être réslisée en urgence. +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 2 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE L'introduction du METHOTREXATE il y a à peine 3 semaines ne permet pas de conclure à son inefficacité. +Dr [NOM] +Chef de service Initiation de bolus de SOLUMEDROL 500mg IV sur 3 jours, puis relai à 20mg/j avec décroissance sur quelques +A den Pci ae rn is Chef de Clinique des Hôpitaux semaines le temps de l'efficacité du MTX qui est monté à 20mg/semaine +Praticien hospitalier +N D° +r +R SP tP éS +p +h10 a1 n0 e0 8 M17 A00 R5 +CE +A +à +p +3 +r mès +o +d isi s dc eu ts rs aio itn +e +mav ee nc +t +l pe aD rr +M +B TA XR ,R pI oT uA +r +U juL fT +er +e dt ele +l +'D efr +f +iL caA cB itO +é. +R DD 'iE ciR làIE o : +n +i l +d +e imst id né uc ei d laé cd oe +r +r tié cé ov ta hl éu re ar +p +l ie +e +p jua sti qe un 't +à +d 5a mns +g +.2 mois, +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier Si, à 3 mois de traitement par MTX, persiste une activité de la maladie, il sera discuté collégialement ou non de +RPPS : [RPPS] +l'intérêt d'une biopsie myocardique. +Dr [NOM] +A den Bci oe rn d C eah ue xf de Clinique des Hôpitaux Traitement de sortie : +Praticien hospitalier BISOPROLOL 5mg le matin midi et soir +N +D +A° +nr c +R +I +ieP +t +nsP +a +CS +s +h1 +o +e0 fO1 d0 +D +e1 8 CR5 lI6 inO1 i3 qZ5 +ueO dL esA Hôpitaux +E CN OT RR TAES NT CO +Y +9 L3 2/1 00 m3 +g +1 /j. 0 1. 0 +semaine puis 15mg 1 semaine puis 12,5mg 1 semaine puis 10mg 1 semaine puis 7,5mg 1 semaine +de Bordeaux puis 5 mg/j +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 EPLERENONE 25mg 1.0.0 +Dr [NOM] METHOTREXATE 20mg le jeudi +Ancien Assistant des Hôpitaux de Lyon SPECIAFOLDINE 5mg 3 comprimés le lendemain du MTX +Praticien hospitalier contractuel +RPPS : [RPPS] +Suivi : +Secrétariat : [TEL] +Biologies hébdomadaires +MEDECINE INTERNE ET IRM cardiaque début Janvier en externe +IMMUNOLOGIE CLINIQUE HDJ début Janvier en cardiologie avec le Dr [NOM] pour réévaluation complète +Dr [NOM] HDJ de synthèse medecine interne fin Janvier +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier +RPPS : [RPPS] +Dr [NOM] Les consignes d'usage ont été remises. +Ancien Assistant des Hôpitaux de +Bordeaux et Bayonne +Praticien Hospitalier +RPPS : [RPPS] +Dr [NOM] Bien confraternellement, +Ancien Chef de Clinique des Hôpitaux +de Lille +Praticien hospitalier +RPPS : [RPPS] +Dr [NOM] Docteur [NOM] [NOM] +Assistant spécialiste +RPPS : [RPPS] *10100858090* +Secrétariat : [TEL] +DERMATOLOGIE 10100858090 +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Toulouse +Praticien hospitalier +RPPS : [RPPS] Liste des destinataires: +Dr [NOM]. [NOM] [NOM] +Ancien Assistant des Hôpitaux de +Toulouse DR. [NOM] +Praticien Hospitalier contractuel DR. [NOM] +RPPS : [RPPS] +DR. [NOM] +Dr [NOM]. [NOM] [NOM] +P Nr °a t Ric Pi Pen S H 10o 1sp 1i 0t 6al 0i 1er 3 2c 4ontractuel DR. [NOM] +Dr [NOM] +Praticien Hospitalier contractuel +Secrétariat : [TEL] +CENTRE DE COMPETENCES +DES MALADIES AUTO IMMUNES +ET AUTO-INFLAMMATOIRES +SYSTEMIQUES RARES : +Médecin coordonnateur : +Dr [NOM] +Secrétariat : [TEL] +[EMAIL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 3 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Bayonne, le [DATE] +Dr [NOM] +Chef de service DR [NOM] +Ancien Chef de Clinique des Hôpitaux +de Paris CENTRE HOSPITALIER COTE BASQUE +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 0ta 8l 1ie 7r 005 [CODE_POSTAL] +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Bordeaux Mon cher confrère, +Praticien Hospitalier +RPPS : [RPPS] +Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du [DATE] au [DATE] pour le motif +Dr [NOM] suivant : +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 1ta 8l 5ie 6r 135 - Motif d’hospitalisation : Récidive de douleur thoracique chez un patient suivi pour une myosite associée à une +Dr [NOM] myocardite récidivante d’étiologie indéterminée. +Ancien Chef de Clinique des Hôpitaux +d Pe ra B tio cir ed ne a hu ox spitalier Antécédents : +RPPS : [RPPS] Myocardiopathie récidivante depuis 2019 d’origine indéterminé (suivi cardio par Dr [NOM] et médecine interne +Dr [NOM] par le Dr [NOM]) +A Prn ac tii ce in e nA hss oi ss pta itn at l id ee rs c H onô tp rait ca tu ux e lde Lyon Myosite inflammatoire +RPPS : [RPPS] +Secrétariat : [TEL] Allergies : intolérance à la codéine. +MEDECINE INTERNE ET +IMMUNOLOGIE CLINIQUE Traitement habituel : +BISOPROLOL 5mg le matin midi et soir +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux ENTRESTO 93/103 1.0.0 +de Bordeaux CORTANCYL 10mg 1.0.0 +Praticien Hospitalier +RPPS : [RPPS] EPLERENONE 25mg 1.0.0 +METHOTREXATE 15mg le jeudi +Dr [NOM] +Ancien Assistant des Hôpitaux de SPECIAFOLDINE 5mg 3 comprimés 2 jours après le méthotrexate +Bordeaux et Bayonne +P Nr °a t Ric Pi Pen S H 10o 1sp 0i 1t 4al 8i 0er 506 Mode de vie : +Travaillait à l'usine Labeyrie à St Geours de Maremne, à 3 enfants de 9,7 et [AGE]. Actuellement au chômage suite à un arrêt +Dr [NOM] de travail prolongé. +Ancien Chef de Clinique des Hôpitaux +de Lille +P Nr °a t Ric Pi Pen S h 1o 0s 0p 0i 4ta 6l 0ie 6r 595 Histoire de la maladie : +Juin 2019 un tableau de myocardite avec altération de la FEVG sur l'IRM cardiaque initiale, traité par Aspirine et +Dr [NOM] Colchicine, avec malheureusement à chaque tentative de diminution récidive des douleurs. +Assistant spécialiste +RPPS : [RPPS] +Les différentes IRM réalisées en 2019, 2020, mettaient en évidence des rehaussements tardifs sous-épicardiques latéro et +Secrétariat : [TEL] inféro latéraux avec une FEVG aux alentours de 45 %. Parallèlement à cela, le patient présentait une élévation des CPK +DERMATOLOGIE avec un tableau de myalgies et de fatigabilité musculaire, pour lequel il a eu un bilan très exhaustif réalisé, d'abord par le +Dr [NOM] Docteur [NOM] sur l'hôpital de Bayonne, puis par le Docteur [NOM], avec un électromyogramme non contributif, une IRM +Ancien Chef de Clinique des Hôpitaux musculaire normale, un dot myosite négatif ainsi que la recherche de la maladie de pompe. +d Pe +ra +T tio cu ielo nu hs oe +spitalier +RPPS : [RPPS] Un bilan très large infectieux et immunologique a été réalisé, d'abord par les infectiologues puis en médecine interne, +Dr [NOM] +l'ensemble du bilan est revenu strictement négatif. +Ancien Assistant des Hôpitaux de +Toulouse Une biopsie musculaire a donc été réalisée au CHU de Bx retrouvant quelques éléments inflammatoires en faveur d'une +Praticien Hospitalier contractuel +RPPS : [RPPS] cause dysimmunitaire primitive, même si le pattern reste aspécifique. +Dr [NOM] +Praticien Hospitalier contractuel Suite aux résultats de cette biopsie musculaire évocatrice de pathologie dysimmunitaire, après discussion pluridisciplinaire +RPPS : [RPPS] entre le Dr [NOM], [NOM], [NOM], [NOM], [NOM], [NOM], il a été proposé de la mise en +Dr [NOM] place d'une corticothérapie systémique. +Praticien Hospitalier contractuel +Juin 2022 : Introduction de la corticothérapie a 60mg/kg +Secrétariat : [TEL] +CENTRE DE COMPETENCES Juillet 2022 : Diminution progressive de l’aspirine. Franche amélioration clinique sous corticothérapie, normalisation des +D ETE S A M UTA OL -A IND FIE LS A A MU MT AO T I OM IRM EU SNES CPK et de la troponine. Diminution progressive des corticoïdes. +SYSTEMIQUES RARES : +Médecin coordonnateur : Novembre 2022 : sous 20mg/j de corticoïdes, Légère réapparition des douleurs thoraciques et tendance à l’augmentation +D Ser c I rr éè tn ae ri aM t : A 0C 5.H 33E .L 78A .8R 1T .89 des CPK. +[EMAIL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 1 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Février 2023 : Diminution de la cortisone a 7.5mg/jour : franche réapparition des douleurs thoraciques, myalgies et +Dr [NOM] remontée des CPK ainsi que de la troponine. Corticodependance importante de la maladie. +Chef de service Cortancyl 10mg dans l'attente d'une discussion d’un traitement à visée d’épargne cortisonique. +A den Pci ae rn +is +Chef de Clinique des Hôpitaux +Praticien hospitalier Avril 2023 : décision en RCP immuno et avec le Dr [NOM] et [NOM] de débuter un traitement par METHOTREXATE. +N D° +r +R SP tP éS +p +h10 a1 n0 e0 8 M17 A00 R5 +CE +Patient perdu de vue pdt quelques mois +Ancien Chef de Clinique des Hôpitaux +de Bordeaux Juillet 23 : patient revu avec IRM de contrôle : Pas de modification des prises de contraste résiduelles sous épicardiques +Praticien Hospitalier de la paroi latérale et antérieure du ventricule gauche. Augmentation de volume du ventricule gauche comparativement à +RPPS : [RPPS] +l'examen d'octobre 2022 avec une FEVG qui s'est légèrement détériorée à 45 % contre 50 %. +Dr [NOM] Mise sous MTX 15mg/semaine, malheureusement non débuté par le patient. +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien hospitalier Début MTX par le patient seulement il y a 3 semaines. Maintien CTC à 10mg/j avec prévision de décroissance progressive +N +D +A° +nr +c +R +I +ieP +t +nsP +a +CS +s +h1 +o +e0 fO1 d0 +D +e1 8 CR5 lI6 inO1 i3 qZ5 +ueO dL esA +Hôpitaux +s ur quelques semaines le temps de l'efficacité du MTX. +de Bordeaux Histoire récente : +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 Il y a 15 jours-3 semaines, Contage infectieux d'allure viral avec ses enfants (rhinorrhée, fièvre) régressif spontanément en +Dr [NOM] quelques jours. Pas de dépistage COVID. +Ancien Assistant des Hôpitaux de Lyon +Praticien hospitalier contractuel Dans ce contexte, au bilan biologique du 20/10/23 : Troponine à 196ng/l ( vs 53 le 02/10) CPK à 1500UI/l vs (373UI/l le +RPPS : [RPPS] +02/10) +Secrétariat : [TEL] +MEDECINE INTERNE ET Il y a une semaine majoration de sa douleur thoracique en barre et apparition d’un pointe transfixiante thoracique gauche a +IMMUNOLOGIE CLINIQUE l’effort associée a un essoufflement plus marqué d’après le patient. +Dr [NOM] Pas de majoration de ses douleurs musculaires habituelles des membres supérieurs. +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier Nouvelle biologie le 30/10 : Tropo :199ng/l et CPK : 560UI/l +RPPS : [RPPS] +Hospitalisation en médecine interne. +Dr [NOM] +A Bon rc die en au A xs es ti s Bta an yt o d ne ns e Hôpitaux de Examen clinique : +Praticien Hospitalier BDC réguliers, fond douloureux douleur thoracique en barre, pointe thoracique gauche transfixiante uniquement à l’effort +RPPS : [RPPS] non présente au moment de l’examen, pas d’omi, mollets souple et indolore +Dr [NOM] +/+ pas de bruit surajouté +Ancien Chef de Clinique des Hôpitaux Abdomen souple, dépressible indolore, pas de trouble du transit, pas de SFU +de Lille +Praticien hospitalier Douleur musculaire MS gauche et droite mais pas de déficit +RPPS : [RPPS] Pas de douleur musculaire des membres inférieurs +Dr [NOM] Pas de céphalée, pas de déficit sensitivo moteur +Assistant spécialiste +RPPS : [RPPS] Examens complémentaires: +Secrétariat : [TEL] Hb 14g/dL, VGM 79fl, PNN 4.9G/L, plaquettes 208G/L, lymphocytes 3.4G/L +Na+ 141mmol/L, K+ 3.9 mmol/L +DERMATOLOGIE +Creat 90 µmol/L, DFG 90 ml/min +Dr [NOM] CRP 1 mg/L +Ancien Chef de Clinique des Hôpitaux +de Toulouse CPK 480 +Praticien hospitalier ASAT 42,ALAT 45, GGT 22, PAL 48, Bili totale µmol/L, LDH 227 +RPPS : [RPPS] +Troponine ultrasensible : 29.8 ng/l +Dr [NOM] BNP 186 ng/l +A Ton uc li oe un s A essistant des Hôpitaux de Ac anti myocarde en cours +Praticien Hospitalier contractuel ECG : sinusal régulier, pas de trouble de la repolarisation, pas de trouble de la conduction FC : 67bpm +RPPS : [RPPS] +Dr [NOM] ETT (Dr [NOM]) +P Nr °a t Ric Pi Pen S H 10o 1sp 1i 0t 6al 0i 1er 3 2c 4ontractuel VG dilaté, DTDVG 63mm, VTDVG 100ml/m2, non hypertrophié, hypokinésie globale plus marquée en inféro-latérale, +Dr [NOM] +F deE sV cG +av +4 it2 é% +s d +S roB iG te, +s +,O PG +A +Pn so n +2 +5d +il 8a t mée m, P HR gV +, +VG +m +n ao xrm 2a .5le ms, +g +p /sa +, +s +b +d oe +n +v Va Dlv u (Slo 'Vpa Dth 1ie +4 +,m IVitr Ao - 3a .o 5r )t ,i q pu ée +ri +csi ag rn di ef i sc ea ct ,i v Ve Cs, +I +p na os +n +d de id lai tl ea ,t a Ati oo rn +te +Praticien Hospitalier contractuel +ascendente non dilatée +Secrétariat : [TEL] +CENTRE DE COMPETENCES Evolution dans le service et conclusions : +DES MALADIES AUTO IMMUNES Au total, nouvelle récidive de myosite/myocardite d'étiologie restant indéterminée mais dysimmunitaire probable, +E SYT S A TU ET MO I- QIN UF EL SA RM AM REA ST O : IRES favorisée par un possible épisode infectieux viral malgré un traitement par CORTANCYL 10mg/jour et +Médecin coordonnateur : METHOTREXATE 15mg/semaine. +Dr [NOM] +S see cc rr .é mta er di ia nt : t @05 c. h3 -3 c. o7 t8 e. b8 a1 s. q8 u9 e.fr L'ETT retrouve une globale stabilité de l'atteinte cardiaque, mais l'IRM cardiaque n'a pu être réslisée en urgence. +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 2 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE L'introduction du METHOTREXATE il y a à peine 3 semaines ne permet pas de conclure à son inefficacité. +Dr [NOM] +Chef de service Initiation de bolus de SOLUMEDROL 500mg IV sur 3 jours, puis relai à 20mg/j avec décroissance sur quelques +A den Pci ae rn is Chef de Clinique des Hôpitaux semaines le temps de l'efficacité du MTX qui est monté à 20mg/semaine +Praticien hospitalier +N D° +r +R SP tP éS +p +h10 a1 n0 e0 8 M17 A00 R5 +CE +A +à +p +3 +r mès +o +d isi s dc eu ts rs aio itn +e +mav ee nc +t +l pe aD rr +M +B TA XR ,R pI oT uA +r +U juL fT +er +e dt ele +l +'D efr +f +iL caA cB itO +é. +R DD 'iE ciR làIE o : +n +i l +d +e imst id né uc ei d laé cd oe +r +r tié cé ov ta hl éu re ar +p +l ie +e +p jua sti qe un 't +à +d 5a mns +g +.2 mois, +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier Si, à 3 mois de traitement par MTX, persiste une activité de la maladie, il sera discuté collégialement ou non de +RPPS : [RPPS] +l'intérêt d'une biopsie myocardique. +Dr [NOM] +A den Bci oe rn d C eah ue xf de Clinique des Hôpitaux Traitement de sortie : +Praticien hospitalier BISOPROLOL 5mg le matin midi et soir +N +D +A° +nr c +R +I +ieP +t +nsP +a +CS +s +h1 +o +e0 fO1 d0 +D +e1 8 CR5 lI6 inO1 i3 qZ5 +ueO dL esA Hôpitaux +E CN OT RR TAES NT CO +Y +9 L3 2/1 00 m3 +g +1 /j. 0 1. 0 +semaine puis 15mg 1 semaine puis 12,5mg 1 semaine puis 10mg 1 semaine puis 7,5mg 1 semaine +de Bordeaux puis 5 mg/j +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 EPLERENONE 25mg 1.0.0 +Dr [NOM] METHOTREXATE 20mg le jeudi +Ancien Assistant des Hôpitaux de Lyon SPECIAFOLDINE 5mg 3 comprimés le lendemain du MTX +Praticien hospitalier contractuel +RPPS : [RPPS] +Suivi : +Secrétariat : [TEL] +Biologies hébdomadaires +MEDECINE INTERNE ET IRM cardiaque début Janvier en externe +IMMUNOLOGIE CLINIQUE HDJ début Janvier en cardiologie avec le Dr [NOM] pour réévaluation complète +Dr [NOM] HDJ de synthèse medecine interne fin Janvier +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier +RPPS : [RPPS] +Dr [NOM] Les consignes d'usage ont été remises. +Ancien Assistant des Hôpitaux de +Bordeaux et Bayonne +Praticien Hospitalier +RPPS : [RPPS] +Dr [NOM] Bien confraternellement, +Ancien Chef de Clinique des Hôpitaux +de Lille +Praticien hospitalier +RPPS : [RPPS] +Dr [NOM] Docteur [NOM] [NOM] +Assistant spécialiste +RPPS : [RPPS] *10100858090* +Secrétariat : [TEL] +DERMATOLOGIE 10100858090 +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Toulouse +Praticien hospitalier +RPPS : [RPPS] Liste des destinataires: +Dr [NOM]. [NOM] [NOM] +Ancien Assistant des Hôpitaux de +Toulouse DR. [NOM] +Praticien Hospitalier contractuel DR. [NOM] +RPPS : [RPPS] +DR. [NOM] +Dr [NOM]. [NOM] [NOM] +P Nr °a t Ric Pi Pen S H 10o 1sp 1i 0t 6al 0i 1er 3 2c 4ontractuel DR. [NOM] +Dr [NOM] +Praticien Hospitalier contractuel +Secrétariat : [TEL] +CENTRE DE COMPETENCES +DES MALADIES AUTO IMMUNES +ET AUTO-INFLAMMATOIRES +SYSTEMIQUES RARES : +Médecin coordonnateur : +Dr [NOM] +Secrétariat : [TEL] +[EMAIL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 3 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Bayonne, le [DATE] +Dr [NOM] +Chef de service DR [NOM] +Ancien Chef de Clinique des Hôpitaux +de Paris [CODE_POSTAL] +Praticien hospitalier +RPPS : [RPPS] +Dr [NOM] Mon cher confrère, +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +P Nr °a t Ric Pi Pen S H 10o 0sp 0i 2t 8al 1i 5er 024 Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du [DATE] au [DATE] pour le motif +suivant : +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Bordeaux - Motif d’hospitalisation : Récidive de douleur thoracique chez un patient suivi pour une myosite associée à une +Praticien hospitalier +RPPS : [RPPS] myocardite récidivante d’étiologie indéterminée. +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux Antécédents : +d Pe ra B tio cir ed ne a hu ox spitalier Myocardiopathie récidivante depuis 2019 d’origine indéterminé (suivi cardio par Dr [NOM] et médecine interne +RPPS : [RPPS] par le Dr [NOM]) +Dr [NOM] Myosite inflammatoire +A Prn ac tii ce in +e +nA hss oi ss pta itn at +l +id ee rs +c +H onô tp rait ca tu ux +e +lde Lyon +RPPS : [RPPS] Allergies : intolérance à la codéine. +Secrétariat : [TEL] +Traitement habituel : +MEDECINE INTERNE ET +IMMUNOLOGIE CLINIQUE BISOPROLOL 5mg le matin midi et soir +ENTRESTO 93/103 1.0.0 +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux CORTANCYL 10mg 1.0.0 +de Bordeaux EPLERENONE 25mg 1.0.0 +Praticien Hospitalier +RPPS : [RPPS] METHOTREXATE 15mg le jeudi +SPECIAFOLDINE 5mg 3 comprimés 2 jours après le méthotrexate +Dr [NOM] +Ancien Assistant des Hôpitaux de +Bordeaux et Bayonne Mode de vie : +P Nr °a t Ric Pi Pen S H 10o 1sp 0i 1t 4al 8i 0er 506 Travaillait à l'usine Labeyrie à St Geours de Maremne, à 3 enfants de 9,7 et [AGE]. Actuellement au chômage suite à un arrêt +de travail prolongé. +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Lille Histoire de la maladie : +P Nr °a t Ric Pi Pen S h 1o 0s 0p 0i 4ta 6l 0ie 6r 595 Juin 2019 un tableau de myocardite avec altération de la FEVG sur l'IRM cardiaque initiale, traité par Aspirine et +Colchicine, avec malheureusement à chaque tentative de diminution récidive des douleurs. +Dr [NOM] +Assistant spécialiste +RPPS : [RPPS] Les différentes IRM réalisées en 2019, 2020, mettaient en évidence des rehaussements tardifs sous-épicardiques latéro et +inféro latéraux avec une FEVG aux alentours de 45 %. Parallèlement à cela, le patient présentait une élévation des CPK +Secrétariat : [TEL] avec un tableau de myalgies et de fatigabilité musculaire, pour lequel il a eu un bilan très exhaustif réalisé, d'abord par le +DERMATOLOGIE Docteur [NOM] sur l'hôpital de Bayonne, puis par le Docteur [NOM], avec un électromyogramme non contributif, une IRM +Dr [NOM] musculaire normale, un dot myosite négatif ainsi que la recherche de la maladie de pompe. +Ancien Chef de Clinique des Hôpitaux +d Pe ra T tio cu ielo nu hs oe spitalier Un bilan très large infectieux et immunologique a été réalisé, d'abord par les infectiologues puis en médecine interne, +RPPS : [RPPS] l'ensemble du bilan est revenu strictement négatif. +Dr [NOM] +Ancien Assistant des Hôpitaux de Une biopsie musculaire a donc été réalisée au CHU de Bx retrouvant quelques éléments inflammatoires en faveur d'une +Toulouse cause dysimmunitaire primitive, même si le pattern reste aspécifique. +Praticien Hospitalier contractuel +RPPS : [RPPS] +Dr [NOM] +Suite aux résultats de cette biopsie musculaire évocatrice de pathologie dysimmunitaire, après discussion pluridisciplinaire +Praticien Hospitalier contractuel entre le Dr [NOM], [NOM], [NOM], [NOM], [NOM], [NOM], il a été proposé de la mise en +RPPS : [RPPS] place d'une corticothérapie systémique. +Dr [NOM] +Praticien Hospitalier contractuel Juin 2022 : Introduction de la corticothérapie a 60mg/kg +Secrétariat : [TEL] +Juillet 2022 : Diminution progressive de l’aspirine. Franche amélioration clinique sous corticothérapie, normalisation des +CENTRE DE COMPETENCES CPK et de la troponine. Diminution progressive des corticoïdes. +DES MALADIES AUTO IMMUNES +ET AUTO-INFLAMMATOIRES +SYSTEMIQUES RARES : Novembre 2022 : sous 20mg/j de corticoïdes, Légère réapparition des douleurs thoraciques et tendance à l’augmentation +Médecin coordonnateur : des CPK. +D Ser +c +I rr éè tn ae +ri +aM t : A 0C 5.H 33E .L 78A .8R 1T +.89 +[EMAIL] Février 2023 : Diminution de la cortisone a 7.5mg/jour : franche réapparition des douleurs thoraciques, myalgies et +remontée des CPK ainsi que de la troponine. Corticodependance importante de la maladie. +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 1 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Cortancyl 10mg dans l'attente d'une discussion d’un traitement à visée d’épargne cortisonique. +Dr [NOM] +Chef de service Avril 2023 : décision en RCP immuno et avec le Dr [NOM] et [NOM] de débuter un traitement par METHOTREXATE. +A den Pci ae rn is Chef de Clinique des Hôpitaux Patient perdu de vue pdt quelques mois +Praticien hospitalier +N D° +r +R SP tP éS +p +h10 a1 n0 e0 8 M17 A00 R5 +CE +J du ei l ll ae t +p +a2 r3 o : +i +p la at ti ée rn at +l +er e ev +t +u +a +na tv ée rc +ie +I uR reM +d +ud e +v +ec no tn rt ir cô ul le +e +g : aP ua cs +h +d ee +. +m Ao ud gi mfic ea nt ti ao tn +io +d ne ds +e +p vri os le us +m +d ee dc uo n vt era ns trte +ic +r ué ls ei d gu ae ul cl hes +e +s co ou ms pé ap ri ac ta ivrd ei mqu enes +t à +Ancien Chef de Clinique des Hôpitaux +de Bordeaux l'examen d'octobre 2022 avec une FEVG qui s'est légèrement détériorée à 45 % contre 50 %. +Praticien Hospitalier Mise sous MTX 15mg/semaine, malheureusement non débuté par le patient. +RPPS : [RPPS] +Dr [NOM] Début MTX par le patient seulement il y a 3 semaines. Maintien CTC à 10mg/j avec prévision de décroissance progressive +A den Bci oe rn d C eah ue xf de Clinique des Hôpitaux sur quelques semaines le temps de l'efficacité du MTX. +Praticien hospitalier +N +D +A° +nr c +R +I +ieP +t +nsP +a +CS +s +h1 +o +e0 fO1 d0 +D +e1 8 CR5 lI6 inO1 i3 qZ5 +ueO dL esA Hôpitaux +H +Il +i ys t ao i 1r 5e jr oé uc re sn -t 3e s : +emaines, Contage infectieux d'allure viral avec ses enfants (rhinorrhée, fièvre) régressif spontanément en +de Bordeaux quelques jours. Pas de dépistage COVID. +Praticien hospitalier +RPPS : [RPPS] +Dr [NOM] [NOM] Dans ce contexte, au bilan biologique du 20/10/23 : Troponine à 196ng/l ( vs 53 le 02/10) CPK à 1500UI/l vs (373UI/l le +Ancien Assistant des Hôpitaux de Lyon 02/10) +Praticien hospitalier contractuel +RPPS : [RPPS] +Il y a une semaine majoration de sa douleur thoracique en barre et apparition d’un pointe transfixiante thoracique gauche a +Secrétariat : [TEL] +l’effort associée a un essoufflement plus marqué d’après le patient. +MEDECINE INTERNE ET Pas de majoration de ses douleurs musculaires habituelles des membres supérieurs. +IMMUNOLOGIE CLINIQUE +Dr [NOM] [NOM] Nouvelle biologie le 30/10 : Tropo :199ng/l et CPK : 560UI/l +Ancien Chef de Clinique des Hôpitaux +de Bordeaux Hospitalisation en médecine interne. +Praticien Hospitalier +RPPS : [RPPS] +Examen clinique : +Dr [NOM] BDC réguliers, fond douloureux douleur thoracique en barre, pointe thoracique gauche transfixiante uniquement à l’effort +A Bon rc die en au A xs es ti s Bta an yt o d ne ns e Hôpitaux de non présente au moment de l’examen, pas d’omi, mollets souple et indolore +Praticien Hospitalier MV +/+ pas de bruit surajouté +RPPS : [RPPS] Abdomen souple, dépressible indolore, pas de trouble du transit, pas de SFU +Dr [NOM] Douleur musculaire MS gauche et droite mais pas de déficit +Ancien Chef de Clinique des Hôpitaux Pas de douleur musculaire des membres inférieurs +de Lille +Praticien hospitalier Pas de céphalée, pas de déficit sensitivo moteur +RPPS : [RPPS] +Dr [NOM] [NOM] Examens complémentaires : +Assistant spécialiste Hb 14g/dL, VGM 79fl, PNN 4.9G/L, plaquettes 208G/L, lymphocytes 3.4G/L +RPPS : [RPPS] Na+ 141mmol/L, K+ 3.9 mmol/L +Secrétariat : [TEL] Creat 90 µmol/L, DFG 90 ml/min +CRP 1 mg/L +DERMATOLOGIE +CPK 480 +Dr [NOM] ASAT 42,ALAT 45, GGT 22, PAL 48, Bili totale µmol/L, LDH 227 +Ancien Chef de Clinique des Hôpitaux +de Toulouse Troponine ultrasensible : 29.8 ng/l +Praticien hospitalier BNP 186 ng/l +RPPS : [RPPS] +Ac anti myocarde en cours +Dr [NOM] [NOM] ECG : sinusal régulier, pas de trouble de la repolarisation, pas de trouble de la conduction FC : 67bpm +Ancien Assistant des Hôpitaux de +Toulouse +Praticien Hospitalier contractuel ETT (Dr [NOM]) +RPPS : [RPPS] +VG dilaté, DTDVG 63mm, VTDVG 100ml/m2, non hypertrophié, hypokinésie globale plus marquée en inféro-latérale, +Dr [NOM] FEVG 42% SBG, OG non dilatée, PRVG normales, pas de valvulopathie mitro-aortique significatives, pas de dilatation +P Nr °a t Ric Pi Pen S H 10o 1sp 1i 0t 6al 0i 1er 3 2c 4ontractuel des cavités droites, PAPs 25+8 mmHg, Vmax 2.5mg/s, bon VD (S'VD 14, IVA 3.5), péricarde sec, VCI non dilate, Aorte +Dr [NOM] +a scendente non dilatée +Praticien Hospitalier contractuel +Evolution dans le service et conclusions : +Secrétariat : [TEL] Au total, nouvelle récidive de myosite/myocardite d'étiologie restant indéterminée mais dysimmunitaire probable, +CENTRE DE COMPETENCES favorisée par un possible épisode infectieux viral malgré un traitement par CORTANCYL 10mg/jour et +DES MALADIES AUTO IMMUNES METHOTREXATE 15mg/semaine. +ET AUTO-INFLAMMATOIRES +SYSTEMIQUES RARES : +Médecin coordonnateur : L'ETT retrouve une globale stabilité de l'atteinte cardiaque, mais l'IRM cardiaque n'a pu être réslisée en urgence. +Dr [NOM] +S see cc rr .é mta er di ia nt : t @05 c. h3 -3 c. o7 t8 e. b8 a1 s. q8 u9 e.fr L'introduction du METHOTREXATE il y a à peine 3 semaines ne permet pas de conclure à son inefficacité. +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 2 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Initiation de bolus de SOLUMEDROL 500mg IV sur 3 jours, puis relai à 20mg/j avec décroissance sur quelques +Dr [NOM] semaines le temps de l'efficacité du MTX qui est monté à 20mg/semaine +Chef de service +A den Pci ae rn is Chef de Clinique des Hôpitaux Après discussion avec le Dr [NOM] et le Dr [NOM] : il est décidé de réévaluer le patient dans 2 mois, +Praticien hospitalier à 3 mois de traitement par MTX, pour jufer de l'efficacité. D'ici là on diminue la corticothérapie jusqu'à 5mg. +RPPS : [RPPS] +Dr [NOM], à 3 mois de traitement par MTX, persiste une activité de la maladie, il sera discuté collégialement ou non de +Ancien Chef de Clinique des Hôpitaux +de Bordeaux l'intérêt d'une biopsie myocardique. +Praticien Hospitalier +RPPS : [RPPS] +Traitement de sortie : +Dr [NOM] BISOPROLOL 5mg le matin midi et soir +A den Bci oe rn d C eah ue xf de Clinique des Hôpitaux ENTRESTO 93/103 1.0.0 +Praticien hospitalier CORTANCYL 20mg/j 1 semaine puis 15mg 1 semaine puis 12,5mg 1 semaine puis 10mg 1 semaine puis 7,5mg 1 semaine +N +D +A° +nr c +R +I +ieP +t +nsP +a +CS +s +h1 +o +e0 fO1 d0 +D +e1 8 CR5 lI6 inO1 i3 qZ5 +ueO dL esA Hôpitaux +p Eu Pi Ls E5 +R +m Eg N/j +ONE 25mg 1.0.0 +de Bordeaux METHOTREXATE 20mg le jeudi +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 SPECIAFOLDINE 5mg 3 comprimés le lendemain du MTX +Dr [NOM] +Ancien Assistant des Hôpitaux de Lyon Suivi : +Praticien hospitalier contractuel Biologies hébdomadaires +RPPS : [RPPS] +IRM cardiaque début Janvier en externe +Secrétariat : [TEL] +HDJ début Janvier en cardiologie avec le Dr [NOM] pour réévaluation complète +MEDECINE INTERNE ET HDJ de synthèse medecine interne fin Janvier +IMMUNOLOGIE CLINIQUE +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier Les consignes d'usage ont été remises. +RPPS : [RPPS] +Dr [NOM] +Ancien Assistant des Hôpitaux de +Bordeaux et Bayonne +Praticien Hospitalier Bien confraternellement, +RPPS : [RPPS] +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Lille +Praticien hospitalier Docteur [NOM] +RPPS : [RPPS] +*10100858090* +Dr [NOM] +Assistant spécialiste +RPPS : [RPPS] +10100858090 +Secrétariat : [TEL] +DERMATOLOGIE +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux Liste des destinataires : +de Toulouse +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 0ta 1l 6ie 3r 277 DR. [NOM] +Dr [NOM] +D DR R. +. +G BAA RC RH IE TN +A +UC LO TY +F +C loh rr ii as nte nl +e +Ancien Assistant des Hôpitaux de +Toulouse DR. [NOM] +Praticien Hospitalier contractuel DR. [NOM] +RPPS : [RPPS] +DR. [NOM] +Dr [NOM] +Praticien Hospitalier contractuel +RPPS : [RPPS] +Dr [NOM] +Praticien Hospitalier contractuel +Secrétariat : [TEL] +CENTRE DE COMPETENCES +DES MALADIES AUTO IMMUNES +ET AUTO-INFLAMMATOIRES +SYSTEMIQUES RARES : +Médecin coordonnateur : +Dr [NOM] +Secrétariat : [TEL] +[EMAIL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 3 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Bayonne, le [DATE] +Dr [NOM] +Chef de service DR [NOM] +Ancien Chef de Clinique des Hôpitaux +de Paris HOPITAL CARDIOLOGIE HAUT LEVEQUE +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 0ta 8l 1ie 7r 005 [CODE_POSTAL] +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Bordeaux Mon cher confrère, +Praticien Hospitalier +RPPS : [RPPS] +Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du [DATE] au [DATE] pour le motif +Dr [NOM] suivant : +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 1ta 8l 5ie 6r 135 - Motif d’hospitalisation : Récidive de douleur thoracique chez un patient suivi pour une myosite associée à une +Dr [NOM] myocardite récidivante d’étiologie indéterminée. +Ancien Chef de Clinique des Hôpitaux +d Pe ra B tio cir ed ne a hu ox spitalier Antécédents : +RPPS : [RPPS] Myocardiopathie récidivante depuis 2019 d’origine indéterminé (suivi cardio par Dr [NOM] et médecine interne +Dr [NOM] par le Dr [NOM]) +A Prn ac tii ce in e nA hss oi ss pta itn at l id ee rs c H onô tp rait ca tu ux e lde Lyon Myosite inflammatoire +RPPS : [RPPS] +Secrétariat : [TEL] Allergies : intolérance à la codéine. +MEDECINE INTERNE ET +IMMUNOLOGIE CLINIQUE Traitement habituel : +BISOPROLOL 5mg le matin midi et soir +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux ENTRESTO 93/103 1.0.0 +de Bordeaux CORTANCYL 10mg 1.0.0 +Praticien Hospitalier +RPPS : [RPPS] EPLERENONE 25mg 1.0.0 +METHOTREXATE 15mg le jeudi +Dr [NOM] +Ancien Assistant des Hôpitaux de SPECIAFOLDINE 5mg 3 comprimés 2 jours après le méthotrexate +Bordeaux et Bayonne +P Nr °a t Ric Pi Pen S H 10o 1sp 0i 1t 4al 8i 0er 506 Mode de vie : +Travaillait à l'usine Labeyrie à St Geours de Maremne, à 3 enfants de 9,7 et [AGE]. Actuellement au chômage suite à un arrêt +Dr [NOM] de travail prolongé. +Ancien Chef de Clinique des Hôpitaux +de Lille +P Nr °a t Ric Pi Pen S h 1o 0s 0p 0i 4ta 6l 0ie 6r 595 Histoire de la maladie : +Juin 2019 un tableau de myocardite avec altération de la FEVG sur l'IRM cardiaque initiale, traité par Aspirine et +Dr [NOM] Colchicine, avec malheureusement à chaque tentative de diminution récidive des douleurs. +Assistant spécialiste +RPPS : [RPPS] +Les différentes IRM réalisées en 2019, 2020, mettaient en évidence des rehaussements tardifs sous-épicardiques latéro et +Secrétariat : [TEL] inféro latéraux avec une FEVG aux alentours de 45 %. Parallèlement à cela, le patient présentait une élévation des CPK +DERMATOLOGIE avec un tableau de myalgies et de fatigabilité musculaire, pour lequel il a eu un bilan très exhaustif réalisé, d'abord par le +Dr [NOM] Docteur [NOM] sur l'hôpital de Bayonne, puis par le Docteur [NOM], avec un électromyogramme non contributif, une IRM +Ancien Chef de Clinique des Hôpitaux musculaire normale, un dot myosite négatif ainsi que la recherche de la maladie de pompe. +d Pe +ra +T tio cu ielo nu hs oe +spitalier +RPPS : [RPPS] Un bilan très large infectieux et immunologique a été réalisé, d'abord par les infectiologues puis en médecine interne, +Dr [NOM] +l'ensemble du bilan est revenu strictement négatif. +Ancien Assistant des Hôpitaux de +Toulouse Une biopsie musculaire a donc été réalisée au CHU de Bx retrouvant quelques éléments inflammatoires en faveur d'une +Praticien Hospitalier contractuel +RPPS : [RPPS] cause dysimmunitaire primitive, même si le pattern reste aspécifique. +Dr [NOM] +Praticien Hospitalier contractuel Suite aux résultats de cette biopsie musculaire évocatrice de pathologie dysimmunitaire, après discussion pluridisciplinaire +RPPS : [RPPS] entre le Dr [NOM], [NOM], [NOM], [NOM], [NOM], [NOM], il a été proposé de la mise en +Dr [NOM] place d'une corticothérapie systémique. +Praticien Hospitalier contractuel +Juin 2022 : Introduction de la corticothérapie a 60mg/kg +Secrétariat : [TEL] +CENTRE DE COMPETENCES Juillet 2022 : Diminution progressive de l’aspirine. Franche amélioration clinique sous corticothérapie, normalisation des +D ETE S A M UTA OL -A IND FIE LS A A MU MT AO T I OM IRM EU SNES CPK et de la troponine. Diminution progressive des corticoïdes. +SYSTEMIQUES RARES : +Médecin coordonnateur : Novembre 2022 : sous 20mg/j de corticoïdes, Légère réapparition des douleurs thoraciques et tendance à l’augmentation +D Ser c I rr éè tn ae ri aM t : A 0C 5.H 33E .L 78A .8R 1T .89 des CPK. +[EMAIL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 1 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE Février 2023 : Diminution de la cortisone a 7.5mg/jour : franche réapparition des douleurs thoraciques, myalgies et +Dr [NOM] remontée des CPK ainsi que de la troponine. Corticodependance importante de la maladie. +Chef de service Cortancyl 10mg dans l'attente d'une discussion d’un traitement à visée d’épargne cortisonique. +A den Pci ae rn +is +Chef de Clinique des Hôpitaux +Praticien hospitalier Avril 2023 : décision en RCP immuno et avec le Dr [NOM] et [NOM] de débuter un traitement par METHOTREXATE. +N D° +r +R SP tP éS +p +h10 a1 n0 e0 8 M17 A00 R5 +CE +Patient perdu de vue pdt quelques mois +Ancien Chef de Clinique des Hôpitaux +de Bordeaux Juillet 23 : patient revu avec IRM de contrôle : Pas de modification des prises de contraste résiduelles sous épicardiques +Praticien Hospitalier de la paroi latérale et antérieure du ventricule gauche. Augmentation de volume du ventricule gauche comparativement à +RPPS : [RPPS] +l'examen d'octobre 2022 avec une FEVG qui s'est légèrement détériorée à 45 % contre 50 %. +Dr [NOM] Mise sous MTX 15mg/semaine, malheureusement non débuté par le patient. +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien hospitalier Début MTX par le patient seulement il y a 3 semaines. Maintien CTC à 10mg/j avec prévision de décroissance progressive +N +D +A° +nr +c +R +I +ieP +t +nsP +a +CS +s +h1 +o +e0 fO1 d0 +D +e1 8 CR5 lI6 inO1 i3 qZ5 +ueO dL esA +Hôpitaux +s ur quelques semaines le temps de l'efficacité du MTX. +de Bordeaux Histoire récente : +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 Il y a 15 jours-3 semaines, Contage infectieux d'allure viral avec ses enfants (rhinorrhée, fièvre) régressif spontanément en +Dr [NOM] quelques jours. Pas de dépistage COVID. +Ancien Assistant des Hôpitaux de Lyon +Praticien hospitalier contractuel Dans ce contexte, au bilan biologique du 20/10/23 : Troponine à 196ng/l ( vs 53 le 02/10) CPK à 1500UI/l vs (373UI/l le +RPPS : [RPPS] +02/10) +Secrétariat : [TEL] +MEDECINE INTERNE ET Il y a une semaine majoration de sa douleur thoracique en barre et apparition d’un pointe transfixiante thoracique gauche a +IMMUNOLOGIE CLINIQUE l’effort associée a un essoufflement plus marqué d’après le patient. +Dr [NOM] Pas de majoration de ses douleurs musculaires habituelles des membres supérieurs. +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier Nouvelle biologie le 30/10 : Tropo :199ng/l et CPK : 560UI/l +RPPS : [RPPS] +Hospitalisation en médecine interne. +Dr [NOM] +A Bon rc die en au A xs es ti s Bta an yt o d ne ns e Hôpitaux de Examen clinique : +Praticien Hospitalier BDC réguliers, fond douloureux douleur thoracique en barre, pointe thoracique gauche transfixiante uniquement à l’effort +RPPS : [RPPS] non présente au moment de l’examen, pas d’omi, mollets souple et indolore +Dr [NOM] +/+ pas de bruit surajouté +Ancien Chef de Clinique des Hôpitaux Abdomen souple, dépressible indolore, pas de trouble du transit, pas de SFU +de Lille +Praticien hospitalier Douleur musculaire MS gauche et droite mais pas de déficit +RPPS : [RPPS] Pas de douleur musculaire des membres inférieurs +Dr [NOM] Pas de céphalée, pas de déficit sensitivo moteur +Assistant spécialiste +RPPS : [RPPS] Examens complémentaires: +Secrétariat : [TEL] Hb 14g/dL, VGM 79fl, PNN 4.9G/L, plaquettes 208G/L, lymphocytes 3.4G/L +Na+ 141mmol/L, K+ 3.9 mmol/L +DERMATOLOGIE +Creat 90 µmol/L, DFG 90 ml/min +Dr [NOM] CRP 1 mg/L +Ancien Chef de Clinique des Hôpitaux +de Toulouse CPK 480 +Praticien hospitalier ASAT 42,ALAT 45, GGT 22, PAL 48, Bili totale µmol/L, LDH 227 +RPPS : [RPPS] +Troponine ultrasensible : 29.8 ng/l +Dr [NOM] BNP 186 ng/l +A Ton uc li oe un s A essistant des Hôpitaux de Ac anti myocarde en cours +Praticien Hospitalier contractuel ECG : sinusal régulier, pas de trouble de la repolarisation, pas de trouble de la conduction FC : 67bpm +RPPS : [RPPS] +Dr [NOM] ETT (Dr [NOM]) +P Nr °a t Ric Pi Pen S H 10o 1sp 1i 0t 6al 0i 1er 3 2c 4ontractuel VG dilaté, DTDVG 63mm, VTDVG 100ml/m2, non hypertrophié, hypokinésie globale plus marquée en inféro-latérale, +Dr [NOM] +F deE sV cG +av +4 it2 é% +s d +S roB iG te, +s +,O PG +A +Pn so n +2 +5d +il 8a t mée m, P HR gV +, +VG +m +n ao xrm 2a .5le ms, +g +p /sa +, +s +b +d oe +n +v Va Dlv u (Slo 'Vpa Dth 1ie +4 +,m IVitr Ao - 3a .o 5r )t ,i q pu ée +ri +csi ag rn di ef i sc ea ct ,i v Ve Cs, +I +p na os +n +d de id lai tl ea ,t a Ati oo rn +te +Praticien Hospitalier contractuel +ascendente non dilatée +Secrétariat : [TEL] +CENTRE DE COMPETENCES Evolution dans le service et conclusions : +DES MALADIES AUTO IMMUNES Au total, nouvelle récidive de myosite/myocardite d'étiologie restant indéterminée mais dysimmunitaire probable, +E SYT S A TU ET MO I- QIN UF EL SA RM AM REA ST O : IRES favorisée par un possible épisode infectieux viral malgré un traitement par CORTANCYL 10mg/jour et +Médecin coordonnateur : METHOTREXATE 15mg/semaine. +Dr [NOM] +S see cc rr .é mta er di ia nt : t @05 c. h3 -3 c. o7 t8 e. b8 a1 s. q8 u9 e.fr L'ETT retrouve une globale stabilité de l'atteinte cardiaque, mais l'IRM cardiaque n'a pu être réslisée en urgence. +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 2 sur 3 N° Finess CENTRE HOSPITALIER COTE BASQUE +✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL] +☎ [TEL] - Fax : [TEL] +640000162 +PÔLE MÉDECINE INTERNE +SERVICE RHUMATOLOGIE - MEDECINE INTERNE ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE - CENTRE +DE COMPETENCES DES MALADIES AUTO-IMMUNES ET AUTO-INFLAMMATOIRES SYSTEMIQUES RARES +RHUMATOLOGIE L'introduction du METHOTREXATE il y a à peine 3 semaines ne permet pas de conclure à son inefficacité. +Dr [NOM] +Chef de service Initiation de bolus de SOLUMEDROL 500mg IV sur 3 jours, puis relai à 20mg/j avec décroissance sur quelques +A den Pci ae rn is Chef de Clinique des Hôpitaux semaines le temps de l'efficacité du MTX qui est monté à 20mg/semaine +Praticien hospitalier +N D° +r +R SP tP éS +p +h10 a1 n0 e0 8 M17 A00 R5 +CE +A +à +p +3 +r mès +o +d isi s dc eu ts rs aio itn +e +mav ee nc +t +l pe aD rr +M +B TA XR ,R pI oT uA +r +U juL fT +er +e dt ele +l +'D efr +f +iL caA cB itO +é. +R DD 'iE ciR làIE o : +n +i l +d +e imst id né uc ei d laé cd oe +r +r tié cé ov ta hl éu re ar +p +l ie +e +p jua sti qe un 't +à +d 5a mns +g +.2 mois, +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier Si, à 3 mois de traitement par MTX, persiste une activité de la maladie, il sera discuté collégialement ou non de +RPPS : [RPPS] +l'intérêt d'une biopsie myocardique. +Dr [NOM] +A den Bci oe rn d C eah ue xf de Clinique des Hôpitaux Traitement de sortie : +Praticien hospitalier BISOPROLOL 5mg le matin midi et soir +N +D +A° +nr c +R +I +ieP +t +nsP +a +CS +s +h1 +o +e0 fO1 d0 +D +e1 8 CR5 lI6 inO1 i3 qZ5 +ueO dL esA Hôpitaux +E CN OT RR TAES NT CO +Y +9 L3 2/1 00 m3 +g +1 /j. 0 1. 0 +semaine puis 15mg 1 semaine puis 12,5mg 1 semaine puis 10mg 1 semaine puis 7,5mg 1 semaine +de Bordeaux puis 5 mg/j +P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 EPLERENONE 25mg 1.0.0 +Dr [NOM] METHOTREXATE 20mg le jeudi +Ancien Assistant des Hôpitaux de Lyon SPECIAFOLDINE 5mg 3 comprimés le lendemain du MTX +Praticien hospitalier contractuel +RPPS : [RPPS] +Suivi : +Secrétariat : [TEL] +Biologies hébdomadaires +MEDECINE INTERNE ET IRM cardiaque début Janvier en externe +IMMUNOLOGIE CLINIQUE HDJ début Janvier en cardiologie avec le Dr [NOM] pour réévaluation complète +Dr [NOM] HDJ de synthèse medecine interne fin Janvier +Ancien Chef de Clinique des Hôpitaux +de Bordeaux +Praticien Hospitalier +RPPS : [RPPS] +Dr [NOM] Les consignes d'usage ont été remises. +Ancien Assistant des Hôpitaux de +Bordeaux et Bayonne +Praticien Hospitalier +RPPS : [RPPS] +Dr [NOM] Bien confraternellement, +Ancien Chef de Clinique des Hôpitaux +de Lille +Praticien hospitalier +RPPS : [RPPS] +Dr [NOM] Docteur [NOM] [NOM] +Assistant spécialiste +RPPS : [RPPS] *10100858090* +Secrétariat : [TEL] +DERMATOLOGIE 10100858090 +Dr [NOM] +Ancien Chef de Clinique des Hôpitaux +de Toulouse +Praticien hospitalier +RPPS : [RPPS] Liste des destinataires: +Dr [NOM]. [NOM] [NOM] +Ancien Assistant des Hôpitaux de +Toulouse DR. [NOM] +Praticien Hospitalier contractuel DR. [NOM] +RPPS : [RPPS] +DR. [NOM] +Dr [NOM]. [NOM] [NOM] +P Nr °a t Ric Pi Pen S H 10o 1sp 1i 0t 6al 0i 1er 3 2c 4ontractuel DR. [NOM] +Dr [NOM] +Praticien Hospitalier contractuel +Secrétariat : [TEL] +CENTRE DE COMPETENCES +DES MALADIES AUTO IMMUNES +ET AUTO-INFLAMMATOIRES +SYSTEMIQUES RARES : +Médecin coordonnateur : +Dr [NOM] +Secrétariat : [TEL] +[EMAIL] +Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE] +IPP : [IPP] / [EPISODE] (Méd. interne et Immuno cliniq.) +V1 - Imprimé le [DATE] à 16 : 24 par Page(s): 3 sur 3 \ No newline at end of file diff --git a/test_anonymise/FC8_scan_out/FC8_scan.audit.jsonl b/test_anonymise/FC8_scan_out/FC8_scan.audit.jsonl new file mode 100644 index 0000000..0e6b889 --- /dev/null +++ b/test_anonymise/FC8_scan_out/FC8_scan.audit.jsonl @@ -0,0 +1,32 @@ +{"page": -1, "kind": "OCR_USED", "original": "docTR", "placeholder": "", "bbox_hint": null} +{"page": 0, "kind": "OGC", "original": "8", "placeholder": "[OGC]", "bbox_hint": null} +{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null} +{"page": 0, "kind": "FINESS", "original": "640780417", "placeholder": "[FINESS]", "bbox_hint": null} +{"page": 0, "kind": "NOM", "original": "CMA", "placeholder": "[NOM]", "bbox_hint": null} +{"page": 1, "kind": "force_term", "original": "CONCERTATION", "placeholder": "[MASK]", "bbox_hint": null} +{"page": 1, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null} +{"page": 1, "kind": "FINESS", "original": "640780417", "placeholder": "[FINESS]", "bbox_hint": null} +{"page": 1, "kind": "OGC", "original": "8", "placeholder": "[OGC]", "bbox_hint": null} +{"page": 1, "kind": "AGE", "original": "Patient de 70 ans", "placeholder": "[AGE]", "bbox_hint": null} +{"page": 1, "kind": "NOM", "original": "Gilles DE MONREDON", "placeholder": "[NOM]", "bbox_hint": null} +{"page": 1, "kind": "force_term", "original": "CONCERTATION", "placeholder": "[MASK]", "bbox_hint": null} +{"page": 1, "kind": "force_term", "original": "CONCERTATION", "placeholder": "[MASK]", "bbox_hint": null} +{"page": 2, "kind": "force_term", "original": "CONCERTATION", "placeholder": "[MASK]", "bbox_hint": null} +{"page": 2, "kind": "force_term", "original": "CONCERTATION", "placeholder": "[MASK]", "bbox_hint": null} +{"page": 2, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null} +{"page": 2, "kind": "FINESS", "original": "640780417", "placeholder": "[FINESS]", "bbox_hint": null} +{"page": 2, "kind": "OGC", "original": "8", "placeholder": "[OGC]", "bbox_hint": null} +{"page": -1, "kind": "NOM_EXTRACTED", "original": "Atteste", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_EXTRACTED", "original": "FINESS", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_EXTRACTED", "original": "FINESS", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_EXTRACTED", "original": "FINESS", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_EXTRACTED", "original": "DAS", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_EXTRACTED", "original": "DAS", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_EXTRACTED", "original": "IGS", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_EXTRACTED", "original": "CMA", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_EXTRACTED", "original": "FSD", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_GLOBAL", "original": "FINESS", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_GLOBAL", "original": "MONREDON", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_GLOBAL", "original": "Gilles", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_GLOBAL", "original": "Atteste", "placeholder": "[NOM]", "bbox_hint": null} +{"page": -1, "kind": "NOM_GLOBAL", "original": "CMA", "placeholder": "[NOM]", "bbox_hint": null} diff --git a/test_anonymise/FC8_scan_out/FC8_scan.pseudonymise.txt b/test_anonymise/FC8_scan_out/FC8_scan.pseudonymise.txt new file mode 100644 index 0000000..432f5be --- /dev/null +++ b/test_anonymise/FC8_scan_out/FC8_scan.pseudonymise.txt @@ -0,0 +1,136 @@ +No N° OGC : [OGC] +FICHE MEDICALE DE RECUEIL DU PRATICIEN CONSEIL (une fiche par RUM) +Seul le recodage impactant la facturation est renseigné +Etablissement : [MASK] +[NOM] : [[NOM]] Date début contrôle : 12/05/2025 +No champ : 1 +Libellé champ de contrôle : Séjours correspondant à la racine 07C13 +Dossier manquant : 0 +Dates du séjour : 16/04/2023 au 18/04/2023 +Données du +séjour +Etablissement 70 +1 +2 +8 +8 +Recodage +70 +1 +2 +8 +8 +1 +0 +Données du RUM +Nature +Nb +Lits dédiés SP +UM +[NOM] II +Durée RUM +suppl. +suppl. +2 +No RUM Etablissement : 1/1 +0 +53 C +0 +0 +0 +du 16/04/2023 au 18/04/2023 +2 +No RUM Recodage : 1/1 +0 +53 C +U +0 +du 16/04/2023 au 18/04/2023 +Codage de l'Etablissement +Recodage +DP K800 +CALCUL DE LA VESICULE BIL. AVEC CHOLECYSTITE AIG. +K805 +DR +[NOM] +HMFC004 1 CHOLÉCYSTECTOMIE COELIO. +HMFC004 +1 +HMFC004 4 CHOLÉCYSTECTOMIE COELIO. +HMFC004 +4 +Actes +Rappel : : un code CIM de [NOM] suivi d'un astérisque correspond à une [NOM] exclue par le DP +GHM établissement : 07C131 GHS établissement : 2347 GHM après recodage : 07C141 +GHS après recodage : 2351 +Praticien conseil +Médecin DIM +Recodage impactant la facturation : 1 +Accord +GHS injustifié : 0 +SE +FFM [NOM] +Désaccord +En fonction des DP/DR et actes retenus par le PC, seul le recodage d'une des [NOM] les plus élevées ayant une incidence sur la racine GHM +ou sur la facturation des suppléments sera renseigné. Hors RSS injustifié avec actes externes, seuls les actes classants seront recodés FICHE MEDICALE DE [MASK] +Etablissement : [MASK] +[NOM] : [[NOM]] +No N° OGC : [OGC] +No Champ : 1 +Libellé du champ de contrôle : Séjours correspondant à la racine 07C13 +Document couvert par le secret médical +Ne peut pas être produit aux services administratifs de l'établissement et des organismes de sécurité sociale +Nom du praticien-conseil H.PROMAX +Nom du médecin du DIM : +Hospitalisation du 16/04/2023 au +Motif de venue : Douleur abdominale épigastrique avec irradiation +hypochondre droit avec plusieurs vomissements alimentaires +depuis 20h sans trouble du transit. Hyperalgique sans prise +d'antalgique possible +Diagnostic : [AGE] sans ATCD particulier présentant +des crises de colique hépatique répétées depuis environ 1 mois. +Episodes à type de douleurs abdominales postprandiales en +épigastre. Les épisodes ne sont pas accompagnés de fièvre ou de +signes d'ictère. +Cejour, admission aux urgences pour apparition d'une douleur +épigastrique, HCD depuis hier soir après le diner. Pas de fièvre ou +d'ictère associé. Cliniquement, HD stable, apyrexie, diminution des +douleurs depuis hier soir, pas de défense ou contracture, sensibilité +à la palpation de I'HCD sans défense, pas de Murphy. +Biologie : Bilan hépatique normal, pas de SIB +TDM : Vésicule biliaire modérément distendue, contenant +plusieurs calculs dont un de 4 mm situé au sein du canal cystique : +colique hépatique. Pas de signe en faveur d'une cholécystite aiguë. +Pas d'anomalie décelable par ailleurs +CRO du 17/04/2023 : non présenté. +Histologie : Cholécystite chronique diverticulaire. +Désaccord codage DP : Motif de prise en charge = Migration de +calcul vésiculaire. Cholécystectomie pour colique hépatique +récidivante : Cholécystite chronique lithiasique I K80.5 +Accord codage acte +Date de concertation : +NOM et SIGNATURE du MEDECIN RESPONSABLE du CONTRÔLE NOM et SIGNATURE du MEDECIN du DIM +Dr [NOM] +[NOM] avoir pris connaissance des éléments du dossier y compris +ceux couverts par le secret médical et des arguments soutenus par +les médecins contrôleurs et avoir eu l'opportunité d'en débattre +contradictoirement +NOM du ou des autres participants à la [MASK] +NOM du ou des autres membres de l'équipe de contrôle ayant +participé à la [MASK] FICHE ADMINISTRATIVE DE [MASK] 1/2 +(à établir lors de la [MASK] avec le médecin du DIM) +Etablissement : [MASK] +[NOM] : [[NOM]] +No N° OGC : [OGC] +No Champ : 1 +Libellé du champ de contrôle : Séjours correspondant à la racine 07C13 +Document susceptible d'être produit aux services administratifs de l'établissement et des organismes de sécurité sociale, +n'inscrire aucun élément couvert par le secret médical. +ARGUMENTAIRE DU MEDECIN CONTROLEUR +125 : La facturation du GHS parl l'établissement n'est pas conforme à l'article 1 de l'arrêté du 19 février 2015 modifié du fait d'un non- +respect des règles de codage édictées dans l'annexe II de l'arrêté du 23 décembre 2016 modifié. Le non-respect des règles porte sur le +diagnostic principal (DP) codé par l'établissement dans le résumé d'unité médicale (RUM). Le DP n'est pas conforme aux règles de +codage des diagnostics rappelées par l'annexe Il, chapitre V, paragraphe 1 : < Les diagnostics doivent figurer dans le RUM sous forme +codée selon la CIM-10 à usage PMSI publié au Bulletin officiel, et consultable et téléchargeable sur le site Internet de I'ATIH (..). Le +meilleur code est le plus précis par rapport à l'information à coder. >> Au vu des éléments présents dans le dossier du patient, le code +CIM-10 choisi pour le DP par l'établissement n'est pas le plus précis par rapport à l'information à coder. \ No newline at end of file diff --git a/tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.pdf b/tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.pdf new file mode 100644 index 0000000..b01bee5 Binary files /dev/null and b/tests/ground_truth/pdfs/001_simple_unknown_BACTERIO_23018396.pdf differ diff --git a/tests/ground_truth/pdfs/002_simple_unknown_bacterio_476_23159413.pdf b/tests/ground_truth/pdfs/002_simple_unknown_bacterio_476_23159413.pdf new file mode 100644 index 0000000..a0cedb6 Binary files /dev/null and b/tests/ground_truth/pdfs/002_simple_unknown_bacterio_476_23159413.pdf differ diff --git a/tests/ground_truth/pdfs/003_simple_compte_rendu_CRO_23155084.pdf 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0.21, + "pages": 19, + "type": "trackare", + "complexity": "complexe" + }, + { + "path": "/home/dom/Téléchargements/II-1 Ctrl_T2A_2025_CHCB_DocJustificatifs (1)/400_23095226/trackare-02016820-23095226_02016820_23095226.pdf", + "folder": "400_23095226", + "filename": "trackare-02016820-23095226_02016820_23095226.pdf", + "size_mb": 0.29, + "pages": 31, + "type": "trackare", + "complexity": "complexe" + }, + { + "path": "/home/dom/Téléchargements/II-1 Ctrl_T2A_2025_CHCB_DocJustificatifs (1)/343_23074384/trackare-15000536-23074384_15000536_23074384.pdf", + "folder": "343_23074384", + "filename": "trackare-15000536-23074384_15000536_23074384.pdf", + "size_mb": 0.25, + "pages": 25, + "type": "trackare", + "complexity": "complexe" + }, + { + "path": "/home/dom/Téléchargements/II-1 Ctrl_T2A_2025_CHCB_DocJustificatifs (1)/45_23183041/trackare-10027557-23183041_10027557_23183041.pdf", + "folder": "45_23183041", + "filename": "trackare-10027557-23183041_10027557_23183041.pdf", + "size_mb": 0.25, + "pages": 20, + "type": "trackare", + "complexity": "complexe" + } +] \ No newline at end of file diff --git a/tests/unit/test_benchmark.py b/tests/unit/test_benchmark.py new file mode 100644 index 0000000..be6bb3a --- /dev/null +++ b/tests/unit/test_benchmark.py @@ -0,0 +1,79 @@ +#!/usr/bin/env python3 +""" +Tests unitaires pour le benchmark. +""" +import pytest +from pathlib import Path +from evaluation.benchmark import Benchmark, BenchmarkResult + + +class TestBenchmark: + """Tests pour Benchmark.""" + + def test_get_system_info(self): + """Test de récupération des informations système.""" + benchmark = Benchmark(Path("tests/ground_truth")) + + system_info = benchmark.get_system_info() + + assert "os" in system_info + assert "cpu" in system_info + assert "ram_gb" in system_info + assert "python_version" in system_info + assert system_info["ram_gb"] > 0 + + def test_calculate_summary(self): + """Test de calcul du résumé.""" + benchmark = Benchmark(Path("tests/ground_truth")) + + results = [ + BenchmarkResult( + pdf_path="test1.pdf", + processing_time_s=10.0, + cpu_usage_percent=50.0, + ram_usage_mb=100.0, + pii_detected=10 + ), + BenchmarkResult( + pdf_path="test2.pdf", + processing_time_s=20.0, + cpu_usage_percent=60.0, + ram_usage_mb=200.0, + pii_detected=20 + ) + ] + + summary = benchmark.calculate_summary(results) + + assert summary["documents_count"] == 2 + assert summary["avg_time_per_doc"] == 15.0 + assert summary["min_time"] == 10.0 + assert summary["max_time"] == 20.0 + assert summary["avg_cpu_percent"] == 55.0 + assert summary["avg_ram_mb"] == 150.0 + assert summary["total_pii_detected"] == 30 + assert summary["avg_pii_per_doc"] == 15.0 + + def test_benchmark_result_to_dict(self): + """Test de conversion en dictionnaire.""" + result = BenchmarkResult( + pdf_path="test.pdf", + processing_time_s=12.345, + time_per_page_s=4.115, + cpu_usage_percent=67.89, + ram_usage_mb=123.45, + pii_detected=15 + ) + + data = result.to_dict() + + assert data["pdf_path"] == "test.pdf" + assert data["processing_time_s"] == 12.35 # Arrondi à 2 décimales + assert data["time_per_page_s"] == 4.12 + assert data["cpu_usage_percent"] == 67.89 + assert data["ram_usage_mb"] == 123.45 + assert data["pii_detected"] == 15 + + +if __name__ == "__main__": + pytest.main([__file__, "-v"]) diff --git a/tests/unit/test_leak_scanner.py b/tests/unit/test_leak_scanner.py new file mode 100644 index 0000000..fd6c483 --- /dev/null +++ b/tests/unit/test_leak_scanner.py @@ -0,0 +1,110 @@ +#!/usr/bin/env python3 +""" +Tests unitaires pour le scanner de fuite. +""" +import pytest +from pathlib import Path +from evaluation.leak_scanner import LeakScanner, LeakReport + + +class TestLeakScanner: + """Tests pour LeakScanner.""" + + def test_scan_text_no_leak(self): + """Test sans fuite.""" + scanner = LeakScanner() + + text = "Le patient a été examiné par le Dr. [NOM] le [DATE]." + original_pii = [ + {"kind": "NOM", "original": "DUPONT"}, + {"kind": "DATE", "original": "15/01/2024"} + ] + + leaks = scanner.scan_text(text, original_pii) + + assert len(leaks) == 0 + + def test_scan_text_original_pii_present(self): + """Test avec PII original présent.""" + scanner = LeakScanner() + + text = "Le patient DUPONT a été examiné le 15/01/2024." + original_pii = [ + {"kind": "NOM", "original": "DUPONT"}, + {"kind": "DATE", "original": "15/01/2024"} + ] + + leaks = scanner.scan_text(text, original_pii) + + assert len(leaks) == 2 + assert all(leak["severity"] == "CRITIQUE" for leak in leaks) + assert all(leak["type"] == "original_pii_present" for leak in leaks) + + def test_scan_text_new_pii_detected(self): + """Test avec nouveau PII détecté.""" + scanner = LeakScanner() + + text = "Contact: jean.dupont@example.com ou 01 23 45 67 89" + original_pii = [] + + leaks = scanner.scan_text(text, original_pii) + + # Devrait détecter l'email et le téléphone + assert len(leaks) >= 2 + + email_leak = next((l for l in leaks if l["pii_type"] == "EMAIL"), None) + assert email_leak is not None + assert email_leak["severity"] == "HAUTE" + + tel_leak = next((l for l in leaks if l["pii_type"] == "TEL"), None) + assert tel_leak is not None + assert tel_leak["severity"] == "HAUTE" + + def test_leak_report_is_safe(self): + """Test de rapport sûr.""" + report = LeakReport( + is_safe=True, + leak_count=0, + leaks=[], + severity_counts={} + ) + + assert report.is_safe + assert report.leak_count == 0 + + def test_leak_report_not_safe(self): + """Test de rapport non sûr.""" + report = LeakReport( + is_safe=False, + leak_count=2, + leaks=[ + {"severity": "CRITIQUE", "type": "original_pii_present"}, + {"severity": "HAUTE", "type": "new_pii_detected"} + ], + severity_counts={"CRITIQUE": 1, "HAUTE": 1} + ) + + assert not report.is_safe + assert report.leak_count == 2 + assert report.severity_counts["CRITIQUE"] == 1 + assert report.severity_counts["HAUTE"] == 1 + + def test_leak_report_to_dict(self): + """Test de conversion en dictionnaire.""" + report = LeakReport( + is_safe=False, + leak_count=1, + leaks=[{"severity": "CRITIQUE"}], + severity_counts={"CRITIQUE": 1} + ) + + data = report.to_dict() + + assert data["is_safe"] is False + assert data["leak_count"] == 1 + assert len(data["leaks"]) == 1 + assert data["severity_counts"]["CRITIQUE"] == 1 + + +if __name__ == "__main__": + pytest.main([__file__, "-v"]) diff --git a/tests/unit/test_quality_evaluator.py b/tests/unit/test_quality_evaluator.py new file mode 100644 index 0000000..6aedd07 --- /dev/null +++ b/tests/unit/test_quality_evaluator.py @@ -0,0 +1,145 @@ +#!/usr/bin/env python3 +""" +Tests unitaires pour l'évaluateur de qualité. +""" +import pytest +from pathlib import Path +from evaluation.quality_evaluator import QualityEvaluator, EvaluationResult + + +class TestQualityEvaluator: + """Tests pour QualityEvaluator.""" + + def test_normalize_text(self): + """Test de normalisation de texte.""" + evaluator = QualityEvaluator(Path("tests/ground_truth")) + + assert evaluator.normalize_text("DUPONT") == "dupont" + assert evaluator.normalize_text(" DUPONT ") == "dupont" + assert evaluator.normalize_text("DUPONT\n\nMARTIN") == "dupont martin" + assert evaluator.normalize_text("Jean-Pierre") == "jean-pierre" + + def test_types_match(self): + """Test de correspondance des types.""" + evaluator = QualityEvaluator(Path("tests/ground_truth")) + + # Correspondance directe + assert evaluator.types_match("NOM", "NOM") + assert evaluator.types_match("NOM", "NOM_GLOBAL") + assert evaluator.types_match("TEL", "TEL_GLOBAL") + + # Correspondance croisée + assert evaluator.types_match("NOM", "PRENOM") + assert evaluator.types_match("PRENOM", "NOM") + + # Non correspondance + assert not evaluator.types_match("NOM", "TEL") + assert not evaluator.types_match("EMAIL", "ADRESSE") + + def test_calculate_metrics(self): + """Test de calcul des métriques.""" + evaluator = QualityEvaluator(Path("tests/ground_truth")) + + # Cas parfait + precision, recall, f1 = evaluator.calculate_metrics(10, 0, 0) + assert precision == 1.0 + assert recall == 1.0 + assert f1 == 1.0 + + # Cas avec erreurs + precision, recall, f1 = evaluator.calculate_metrics(8, 2, 2) + assert precision == 0.8 # 8 / (8 + 2) + assert recall == 0.8 # 8 / (8 + 2) + assert f1 == 0.8 + + # Cas zéro + precision, recall, f1 = evaluator.calculate_metrics(0, 0, 0) + assert precision == 0.0 + assert recall == 0.0 + assert f1 == 0.0 + + def test_compare_simple(self): + """Test de comparaison simple.""" + evaluator = QualityEvaluator(Path("tests/ground_truth")) + + annotations = [ + {"page": 0, "type": "NOM", "text": "DUPONT", "context": "Dr. DUPONT"}, + {"page": 0, "type": "TEL", "text": "01 23 45 67 89", "context": "Tel: 01 23 45 67 89"} + ] + + detections = [ + {"page": 0, "kind": "NOM", "original": "DUPONT"}, + {"page": 0, "kind": "TEL", "original": "01 23 45 67 89"} + ] + + tp, fn, fp = evaluator.compare(annotations, detections) + + assert len(tp) == 2 + assert len(fn) == 0 + assert len(fp) == 0 + + def test_compare_with_false_negative(self): + """Test avec faux négatif.""" + evaluator = QualityEvaluator(Path("tests/ground_truth")) + + annotations = [ + {"page": 0, "type": "NOM", "text": "DUPONT", "context": "Dr. DUPONT"}, + {"page": 0, "type": "TEL", "text": "01 23 45 67 89", "context": "Tel: 01 23 45 67 89"} + ] + + detections = [ + {"page": 0, "kind": "NOM", "original": "DUPONT"} + # TEL manquant + ] + + tp, fn, fp = evaluator.compare(annotations, detections) + + assert len(tp) == 1 + assert len(fn) == 1 + assert len(fp) == 0 + assert fn[0]["type"] == "TEL" + assert fn[0]["reason"] == "not_detected" + + def test_compare_with_false_positive(self): + """Test avec faux positif.""" + evaluator = QualityEvaluator(Path("tests/ground_truth")) + + annotations = [ + {"page": 0, "type": "NOM", "text": "DUPONT", "context": "Dr. DUPONT"} + ] + + detections = [ + {"page": 0, "kind": "NOM", "original": "DUPONT"}, + {"page": 0, "kind": "NOM", "original": "MARTIN"} # Faux positif + ] + + tp, fn, fp = evaluator.compare(annotations, detections) + + assert len(tp) == 1 + assert len(fn) == 0 + assert len(fp) == 1 + assert fp[0]["text"] == "MARTIN" + + def test_evaluation_result_to_dict(self): + """Test de conversion en dictionnaire.""" + result = EvaluationResult( + pdf_path="test.pdf", + true_positives=10, + false_positives=2, + false_negatives=1, + precision=0.8333, + recall=0.9091, + f1_score=0.8696 + ) + + data = result.to_dict() + + assert data["pdf_path"] == "test.pdf" + assert data["true_positives"] == 10 + assert data["precision"] == 0.8333 + assert data["recall"] == 0.9091 + assert data["f1_score"] == 0.8696 + + +if __name__ == "__main__": + pytest.main([__file__, "-v"]) diff --git a/tools/analyze_corpus.py b/tools/analyze_corpus.py new file mode 100755 index 0000000..4ae13f9 --- /dev/null +++ b/tools/analyze_corpus.py @@ -0,0 +1,194 @@ +#!/usr/bin/env python3 +# -*- coding: utf-8 -*- +""" +Analyse du corpus OGC pour sélection de documents représentatifs. +""" +import sys +from pathlib import Path +import json +import random + +try: + import fitz # PyMuPDF +except ImportError: + print("PyMuPDF non disponible, analyse limitée") + fitz = None + + +def analyze_pdf(pdf_path: Path) -> dict: + """Analyse un PDF : nombre de pages, taille, type.""" + stats = { + "path": str(pdf_path), + "folder": pdf_path.parent.name, + "filename": pdf_path.name, + "size_mb": round(pdf_path.stat().st_size / (1024 * 1024), 2), + "pages": 0, + "type": "unknown", + } + + # Déterminer le type de document + name_lower = pdf_path.name.lower() + if "trackare" in name_lower: + stats["type"] = "trackare" + elif "crh" in name_lower or "cr" in name_lower: + stats["type"] = "compte_rendu" + elif "anapath" in name_lower: + stats["type"] = "anapath" + elif "lettre" in name_lower or "sortie" in name_lower: + stats["type"] = "lettre_sortie" + elif "cro" in name_lower: + stats["type"] = "cro" + + # Compter les pages si PyMuPDF disponible + if fitz: + try: + doc = fitz.open(str(pdf_path)) + stats["pages"] = len(doc) + doc.close() + except Exception: + pass + + return stats + + +def classify_complexity(stats: dict) -> str: + """Classifie la complexité d'un document.""" + pages = stats["pages"] + size_mb = stats["size_mb"] + + if pages <= 2 and size_mb < 0.3: + return "simple" + elif pages >= 6 or size_mb > 1.0: + return "complexe" + else: + return "moyen" + + +def main(): + corpus_dir = Path("/home/dom/Téléchargements/II-1 Ctrl_T2A_2025_CHCB_DocJustificatifs (1)/") + + if not corpus_dir.exists(): + print(f"Erreur : {corpus_dir} n'existe pas") + return 1 + + print("Analyse du corpus OGC...") + print(f"Répertoire : {corpus_dir}") + + # Collecter tous les PDFs + all_pdfs = list(corpus_dir.glob("*/*.pdf")) + print(f"Total PDFs trouvés : {len(all_pdfs)}") + + # Analyser un échantillon pour estimation + sample_size = min(100, len(all_pdfs)) + sample = random.sample(all_pdfs, sample_size) + + print(f"\nAnalyse d'un échantillon de {sample_size} documents...") + + analyzed = [] + for i, pdf_path in enumerate(sample, 1): + if i % 20 == 0: + print(f" Analysé {i}/{sample_size}...") + stats = analyze_pdf(pdf_path) + stats["complexity"] = classify_complexity(stats) + analyzed.append(stats) + + # Statistiques globales + print("\n" + "="*60) + print("STATISTIQUES GLOBALES") + print("="*60) + + # Par type + types_count = {} + for s in analyzed: + types_count[s["type"]] = types_count.get(s["type"], 0) + 1 + + print("\nRépartition par type :") + for doc_type, count in sorted(types_count.items(), key=lambda x: -x[1]): + pct = (count / len(analyzed)) * 100 + print(f" {doc_type:20s} : {count:3d} ({pct:5.1f}%)") + + # Par complexité + complexity_count = {} + for s in analyzed: + complexity_count[s["complexity"]] = complexity_count.get(s["complexity"], 0) + 1 + + print("\nRépartition par complexité :") + for complexity, count in sorted(complexity_count.items()): + pct = (count / len(analyzed)) * 100 + print(f" {complexity:20s} : {count:3d} ({pct:5.1f}%)") + + # Statistiques pages + pages_list = [s["pages"] for s in analyzed if s["pages"] > 0] + if pages_list: + print(f"\nNombre de pages :") + print(f" Min : {min(pages_list)}") + print(f" Max : {max(pages_list)}") + print(f" Moy : {sum(pages_list) / len(pages_list):.1f}") + + # Statistiques taille + sizes_list = [s["size_mb"] for s in analyzed] + print(f"\nTaille (MB) :") + print(f" Min : {min(sizes_list):.2f}") + print(f" Max : {max(sizes_list):.2f}") + print(f" Moy : {sum(sizes_list) / len(sizes_list):.2f}") + + # Sélection de 30 documents représentatifs + print("\n" + "="*60) + print("SÉLECTION DE 30 DOCUMENTS REPRÉSENTATIFS") + print("="*60) + + # Stratégie : 10 simples, 15 moyens, 5 complexes + # Varier les types de documents + + simples = [s for s in analyzed if s["complexity"] == "simple"] + moyens = [s for s in analyzed if s["complexity"] == "moyen"] + complexes = [s for s in analyzed if s["complexity"] == "complexe"] + + print(f"\nDisponibles : {len(simples)} simples, {len(moyens)} moyens, {len(complexes)} complexes") + + selected = [] + + # Sélectionner 10 simples + if len(simples) >= 10: + selected.extend(random.sample(simples, 10)) + else: + selected.extend(simples) + print(f"⚠️ Seulement {len(simples)} documents simples disponibles") + + # Sélectionner 15 moyens + if len(moyens) >= 15: + selected.extend(random.sample(moyens, 15)) + else: + selected.extend(moyens) + print(f"⚠️ Seulement {len(moyens)} documents moyens disponibles") + + # Sélectionner 5 complexes + if len(complexes) >= 5: + selected.extend(random.sample(complexes, 5)) + else: + selected.extend(complexes) + print(f"⚠️ Seulement {len(complexes)} documents complexes disponibles") + + print(f"\nTotal sélectionnés : {len(selected)}") + + # Sauvegarder la sélection + output_file = Path("tests/ground_truth/selected_documents.json") + output_file.parent.mkdir(parents=True, exist_ok=True) + + with open(output_file, "w", encoding="utf-8") as f: + json.dump(selected, f, indent=2, ensure_ascii=False) + + print(f"\nSélection sauvegardée dans : {output_file}") + + # Afficher la liste + print("\nDocuments sélectionnés :") + print("-" * 80) + for i, doc in enumerate(selected, 1): + print(f"{i:2d}. [{doc['complexity']:8s}] {doc['folder']}/{doc['filename']}") + print(f" {doc['pages']} pages, {doc['size_mb']} MB, type: {doc['type']}") + + return 0 + + +if __name__ == "__main__": + sys.exit(main()) diff --git a/tools/annotation_tool.py b/tools/annotation_tool.py new file mode 100755 index 0000000..d54eaaa --- /dev/null +++ b/tools/annotation_tool.py @@ -0,0 +1,400 @@ +#!/usr/bin/env python3 +""" +Outil d'annotation CLI pour créer le dataset de test annoté. + +Usage: + python tools/annotation_tool.py + python tools/annotation_tool.py --list + python tools/annotation_tool.py --resume +""" +import json +import sys +from pathlib import Path +from datetime import datetime +from typing import List, Dict, Optional, Tuple +import re + +try: + import pymupdf as fitz +except ImportError: + import fitz + + +class AnnotationTool: + """Outil d'annotation interactif pour les documents PDF.""" + + PII_TYPES = [ + "NOM", "PRENOM", "DATE_NAISSANCE", "AGE", + "TEL", "EMAIL", "ADRESSE", "CODE_POSTAL", "VILLE", + "NIR", "IPP", "NDA", "RPPS", "FINESS", "OGC", + "NUMERO_PATIENT", "NUMERO_LOT", "NUMERO_ORDONNANCE", "NUMERO_SEJOUR", + "ETABLISSEMENT", "SERVICE", "DATE", "AUTRE" + ] + + def __init__(self, pdf_path: Path): + self.pdf_path = pdf_path + self.annotations_path = pdf_path.parent / f"{pdf_path.stem}.annotations.json" + self.doc = None + self.annotations = [] + self.medical_terms = [] + self.metadata = { + "annotator": "annotator_1", + "annotation_date": datetime.now().isoformat(), + "document_type": "unknown", + "page_count": 0, + "difficulty": "medium" + } + + def load_pdf(self) -> bool: + """Charge le PDF et extrait le texte.""" + try: + self.doc = fitz.open(self.pdf_path) + self.metadata["page_count"] = len(self.doc) + print(f"✓ PDF chargé: {self.pdf_path.name}") + print(f" Pages: {len(self.doc)}") + return True + except Exception as e: + print(f"✗ Erreur lors du chargement du PDF: {e}") + return False + + def extract_text(self, page_num: int) -> str: + """Extrait le texte d'une page.""" + if not self.doc or page_num >= len(self.doc): + return "" + + page = self.doc[page_num] + return page.get_text() + + def display_page(self, page_num: int): + """Affiche le texte d'une page.""" + text = self.extract_text(page_num) + + print(f"\n{'='*80}") + print(f"PAGE {page_num + 1}/{len(self.doc)}") + print(f"{'='*80}") + print(text) + print(f"{'='*80}\n") + + def get_context(self, text: str, pii_text: str, window: int = 50) -> str: + """Extrait le contexte autour d'un PII.""" + pos = text.find(pii_text) + if pos == -1: + return "" + + start = max(0, pos - window) + end = min(len(text), pos + len(pii_text) + window) + context = text[start:end] + + # Nettoyer les retours à la ligne multiples + context = re.sub(r'\n+', ' ', context) + context = re.sub(r'\s+', ' ', context) + + return context.strip() + + def input_with_default(self, prompt: str, default: str = "") -> str: + """Demande une entrée avec valeur par défaut.""" + if default: + user_input = input(f"{prompt} [{default}]: ").strip() + return user_input if user_input else default + else: + return input(f"{prompt}: ").strip() + + def select_from_list(self, prompt: str, options: List[str], default: Optional[str] = None) -> str: + """Sélection dans une liste d'options.""" + print(f"\n{prompt}") + for i, option in enumerate(options, 1): + marker = " (défaut)" if option == default else "" + print(f" {i}. {option}{marker}") + + while True: + choice = input(f"Choix [1-{len(options)}]: ").strip() + + if not choice and default: + return default + + try: + idx = int(choice) - 1 + if 0 <= idx < len(options): + return options[idx] + except ValueError: + pass + + print(f"✗ Choix invalide. Entrez un nombre entre 1 et {len(options)}") + + def annotate_pii(self, page_num: int, text: str) -> List[Dict]: + """Annotation interactive des PII d'une page.""" + page_annotations = [] + + print(f"\n--- Annotation de la page {page_num + 1} ---") + print("Commandes: 'q' pour terminer la page, 's' pour sauter") + + ann_id = len(self.annotations) + 1 + + while True: + print(f"\n[Annotation #{ann_id}]") + + # Texte du PII + pii_text = input("Texte du PII (ou 'q' pour terminer, 's' pour sauter): ").strip() + + if pii_text.lower() == 'q': + break + if pii_text.lower() == 's': + continue + if not pii_text: + print("✗ Le texte ne peut pas être vide") + continue + + # Type de PII + pii_type = self.select_from_list( + "Type de PII:", + self.PII_TYPES, + default="NOM" + ) + + # Contexte + context = self.get_context(text, pii_text) + if context: + print(f"Contexte détecté: {context[:100]}...") + use_context = input("Utiliser ce contexte? [O/n]: ").strip().lower() + if use_context == 'n': + context = input("Contexte manuel: ").strip() + else: + context = input("Contexte: ").strip() + + # Obligatoire? + mandatory_input = input("PII obligatoire (RGPD)? [O/n]: ").strip().lower() + mandatory = mandatory_input != 'n' + + # Difficulté + difficulty = self.select_from_list( + "Difficulté de détection:", + ["easy", "medium", "hard"], + default="medium" + ) + + # Méthodes de détection attendues + print("\nMéthodes de détection attendues (séparées par des virgules):") + print(" Options: regex, vlm, ner, contextual, trackare") + methods_input = input("Méthodes [regex,ner]: ").strip() + if not methods_input: + methods = ["regex", "ner"] + else: + methods = [m.strip() for m in methods_input.split(',')] + + # Créer l'annotation + annotation = { + "id": f"ann_{ann_id:03d}", + "page": page_num, + "type": pii_type, + "text": pii_text, + "bbox": None, # Pas de bbox pour l'instant (annotation manuelle) + "context": context, + "mandatory": mandatory, + "difficulty": difficulty, + "detection_method_expected": methods + } + + page_annotations.append(annotation) + print(f"✓ Annotation ajoutée: {pii_type} = '{pii_text}'") + + ann_id += 1 + + return page_annotations + + def annotate_document(self): + """Annotation complète du document.""" + if not self.load_pdf(): + return False + + # Métadonnées du document + print("\n=== Métadonnées du document ===") + + self.metadata["annotator"] = self.input_with_default( + "Nom de l'annotateur", + default="annotator_1" + ) + + self.metadata["document_type"] = self.select_from_list( + "Type de document:", + ["compte_rendu", "trackare", "anapath", "bacterio", "consultation", "autre"], + default="compte_rendu" + ) + + self.metadata["difficulty"] = self.select_from_list( + "Difficulté globale du document:", + ["simple", "moyen", "complexe"], + default="moyen" + ) + + # Annoter chaque page + for page_num in range(len(self.doc)): + self.display_page(page_num) + + annotate_page = input(f"\nAnnoter cette page? [O/n]: ").strip().lower() + if annotate_page == 'n': + continue + + text = self.extract_text(page_num) + page_annotations = self.annotate_pii(page_num, text) + self.annotations.extend(page_annotations) + + # Termes médicaux à préserver + print("\n=== Termes médicaux à préserver ===") + print("Entrez les termes médicaux qui ne doivent PAS être masqués") + print("(un par ligne, ligne vide pour terminer)") + + while True: + term = input("Terme médical: ").strip() + if not term: + break + self.medical_terms.append(term) + print(f"✓ Ajouté: {term}") + + return True + + def save_annotations(self): + """Sauvegarde les annotations au format JSON.""" + # Calculer les statistiques + stats = { + "total_pii": len(self.annotations), + "by_type": {} + } + + for ann in self.annotations: + pii_type = ann["type"] + stats["by_type"][pii_type] = stats["by_type"].get(pii_type, 0) + 1 + + # Créer la structure finale + output = { + "pdf_path": str(self.pdf_path), + "metadata": self.metadata, + "annotations": self.annotations, + "medical_terms_to_preserve": self.medical_terms, + "statistics": stats + } + + # Sauvegarder + with open(self.annotations_path, 'w', encoding='utf-8') as f: + json.dump(output, f, indent=2, ensure_ascii=False) + + print(f"\n✓ Annotations sauvegardées: {self.annotations_path}") + print(f" Total PII: {stats['total_pii']}") + print(f" Types: {', '.join(f'{k}={v}' for k, v in stats['by_type'].items())}") + print(f" Termes médicaux: {len(self.medical_terms)}") + + def load_existing_annotations(self) -> bool: + """Charge les annotations existantes si disponibles.""" + if not self.annotations_path.exists(): + return False + + try: + with open(self.annotations_path, 'r', encoding='utf-8') as f: + data = json.load(f) + + self.metadata = data.get("metadata", self.metadata) + self.annotations = data.get("annotations", []) + self.medical_terms = data.get("medical_terms_to_preserve", []) + + print(f"✓ Annotations existantes chargées: {len(self.annotations)} PII") + return True + except Exception as e: + print(f"✗ Erreur lors du chargement des annotations: {e}") + return False + + def run(self): + """Exécute l'outil d'annotation.""" + print(f"\n{'='*80}") + print(f"OUTIL D'ANNOTATION - {self.pdf_path.name}") + print(f"{'='*80}") + + # Vérifier si des annotations existent déjà + if self.annotations_path.exists(): + overwrite = input(f"\n⚠ Des annotations existent déjà. Écraser? [o/N]: ").strip().lower() + if overwrite != 'o': + print("Annotation annulée.") + return False + + # Annoter le document + if not self.annotate_document(): + return False + + # Sauvegarder + self.save_annotations() + + return True + + +def list_documents(): + """Liste les documents disponibles pour annotation.""" + pdfs_dir = Path("tests/ground_truth/pdfs") + + if not pdfs_dir.exists(): + print(f"✗ Répertoire introuvable: {pdfs_dir}") + return + + pdfs = sorted(pdfs_dir.glob("*.pdf")) + + if not pdfs: + print(f"✗ Aucun PDF trouvé dans {pdfs_dir}") + return + + print(f"\n{'='*80}") + print(f"DOCUMENTS DISPONIBLES ({len(pdfs)})") + print(f"{'='*80}\n") + + for pdf in pdfs: + annotation_file = pdf.parent / f"{pdf.stem}.annotations.json" + status = "✓ Annoté" if annotation_file.exists() else "○ À annoter" + print(f"{status} {pdf.name}") + + +def find_next_unannotated() -> Optional[Path]: + """Trouve le prochain document non annoté.""" + pdfs_dir = Path("tests/ground_truth/pdfs") + + if not pdfs_dir.exists(): + return None + + for pdf in sorted(pdfs_dir.glob("*.pdf")): + annotation_file = pdf.parent / f"{pdf.stem}.annotations.json" + if not annotation_file.exists(): + return pdf + + return None + + +def main(): + if len(sys.argv) > 1: + if sys.argv[1] == "--list": + list_documents() + return + elif sys.argv[1] == "--resume": + next_pdf = find_next_unannotated() + if next_pdf: + print(f"Prochain document à annoter: {next_pdf.name}") + tool = AnnotationTool(next_pdf) + tool.run() + else: + print("✓ Tous les documents sont annotés!") + return + else: + pdf_path = Path(sys.argv[1]) + else: + print("Usage:") + print(" python tools/annotation_tool.py ") + print(" python tools/annotation_tool.py --list") + print(" python tools/annotation_tool.py --resume") + sys.exit(1) + + if not pdf_path.exists(): + print(f"✗ Fichier introuvable: {pdf_path}") + sys.exit(1) + + tool = AnnotationTool(pdf_path) + success = tool.run() + + sys.exit(0 if success else 1) + + +if __name__ == "__main__": + main() diff --git a/tools/copy_selected_docs.py b/tools/copy_selected_docs.py new file mode 100644 index 0000000..15c2cdc --- /dev/null +++ b/tools/copy_selected_docs.py @@ -0,0 +1,96 @@ +#!/usr/bin/env python3 +""" +Script pour copier les documents sélectionnés dans tests/ground_truth/ +""" +import json +import shutil +from pathlib import Path + +def copy_selected_documents(): + """Copie les documents sélectionnés dans le répertoire de test.""" + + # Charger la liste des documents sélectionnés + selected_file = Path("tests/ground_truth/selected_documents.json") + with open(selected_file, 'r', encoding='utf-8') as f: + documents = json.load(f) + + # Créer le répertoire de destination + dest_dir = Path("tests/ground_truth/pdfs") + dest_dir.mkdir(parents=True, exist_ok=True) + + # Copier chaque document + copied = 0 + errors = [] + + for i, doc in enumerate(documents, 1): + src_path = Path(doc['path']) + + # Créer un nom de fichier unique et descriptif + # Format: {index:03d}_{complexity}_{type}_{original_name} + doc_type = doc.get('type', 'unknown') + complexity = doc.get('complexity', 'unknown') + original_name = doc['filename'] + + # Nettoyer le nom de fichier + safe_name = original_name.replace(' ', '_') + dest_name = f"{i:03d}_{complexity}_{doc_type}_{safe_name}" + dest_path = dest_dir / dest_name + + try: + if src_path.exists(): + shutil.copy2(src_path, dest_path) + print(f"✓ Copié: {dest_name}") + copied += 1 + else: + error_msg = f"✗ Fichier introuvable: {src_path}" + print(error_msg) + errors.append(error_msg) + except Exception as e: + error_msg = f"✗ Erreur lors de la copie de {src_path}: {e}" + print(error_msg) + errors.append(error_msg) + + # Résumé + print(f"\n{'='*60}") + print(f"Résumé:") + print(f" Documents copiés: {copied}/{len(documents)}") + print(f" Erreurs: {len(errors)}") + print(f" Destination: {dest_dir.absolute()}") + + if errors: + print(f"\nErreurs rencontrées:") + for error in errors: + print(f" {error}") + + # Créer un fichier de mapping + mapping = [] + for i, doc in enumerate(documents, 1): + doc_type = doc.get('type', 'unknown') + complexity = doc.get('complexity', 'unknown') + original_name = doc['filename'] + safe_name = original_name.replace(' ', '_') + dest_name = f"{i:03d}_{complexity}_{doc_type}_{safe_name}" + + mapping.append({ + "id": i, + "dest_filename": dest_name, + "original_path": doc['path'], + "folder": doc['folder'], + "original_filename": doc['filename'], + "type": doc_type, + "complexity": complexity, + "pages": doc.get('pages', 0), + "size_mb": doc.get('size_mb', 0) + }) + + mapping_file = dest_dir / "mapping.json" + with open(mapping_file, 'w', encoding='utf-8') as f: + json.dump(mapping, f, indent=2, ensure_ascii=False) + + print(f"\nFichier de mapping créé: {mapping_file}") + + return copied, len(errors) + +if __name__ == "__main__": + copied, errors = copy_selected_documents() + exit(0 if errors == 0 else 1)