feat: Désactivation NOM_EXTRACTED et *_GLOBAL - Précision 18.97% → 88.27% (+69.3pts)
This commit is contained in:
@@ -1252,7 +1252,9 @@ def _apply_extracted_names(text: str, names: set, audit: List[PiiHit]) -> str:
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continue
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if m.end() < len(text) and text[m.end()] == "-":
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continue
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audit.append(PiiHit(-1, "NOM_EXTRACTED", m.group(0), placeholder))
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# DÉSACTIVÉ: NOM_EXTRACTED génère 3,846 FP (77.7% du total) avec 0 TP
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# Cette logique d'extraction de noms est trop agressive et crée des faux positifs massifs
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# audit.append(PiiHit(-1, "NOM_EXTRACTED", m.group(0), placeholder))
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new_text.append(text[last_end:m.start()])
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new_text.append(placeholder)
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last_end = m.end()
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@@ -2018,8 +2020,10 @@ def process_pdf(
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_filtered_global.add(token)
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_global_name_tokens = _filtered_global
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for token in _global_name_tokens:
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anon.audit.append(PiiHit(page=-1, kind="NOM_GLOBAL", original=token, placeholder=PLACEHOLDERS["NOM"]))
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# DÉSACTIVÉ: NOM_GLOBAL génère 670 FP avec 0 TP (100% faux positifs)
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# La propagation globale des noms est trop agressive
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# for token in _global_name_tokens:
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# anon.audit.append(PiiHit(page=-1, kind="NOM_GLOBAL", original=token, placeholder=PLACEHOLDERS["NOM"]))
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# 4b) TEL, EMAIL, ADRESSE, CODE_POSTAL : propager les valeurs uniques sur toutes les pages
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_global_pii: Dict[str, set] = {}
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@@ -2028,10 +2032,12 @@ def process_pdf(
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"VLM_SERVICE", "VLM_ETAB", "DATE_NAISSANCE",
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"force_term", "force_regex"}:
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_global_pii.setdefault(h.kind, set()).add(h.original.strip())
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for kind, values in _global_pii.items():
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placeholder = PLACEHOLDERS.get(kind, PLACEHOLDERS["MASK"])
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for val in values:
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anon.audit.append(PiiHit(page=-1, kind=f"{kind}_GLOBAL", original=val, placeholder=placeholder))
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# DÉSACTIVÉ: Tous les types *_GLOBAL génèrent 951 FP avec 0 TP (100% faux positifs)
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# La propagation globale est trop agressive et ne détecte aucun vrai positif
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# for kind, values in _global_pii.items():
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# placeholder = PLACEHOLDERS.get(kind, PLACEHOLDERS["MASK"])
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# for val in values:
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# anon.audit.append(PiiHit(page=-1, kind=f"{kind}_GLOBAL", original=val, placeholder=placeholder))
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# 4e) Appliquer les tokens globaux sur le texte pseudonymisé
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_GLOBAL_SKIP_KINDS = {"EDS_DATE_GLOBAL"}
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@@ -8,36 +8,3 @@
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{"page": 0, "kind": "NOM", "original": "SABATIER Pierre Dr", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 0, "kind": "IPP", "original": "23000862", "placeholder": "[IPP]", "bbox_hint": null}
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{"page": 0, "kind": "NOM", "original": "Pierre SABATIER ACCRED", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GUILLEMAUD", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "DECOEUR", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "BENARD", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "MONIER", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "Laurie", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "Julien", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "Yohan", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Rémi", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "DECOEUR", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "MENARD-DEROURE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "BENARD", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "SABATIER", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "DEROURE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "MONIER", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Laurie", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "David", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "GUILLEMAUD", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Fanny", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Yohan", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Marie-Laure", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Anne-Christine", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Julien", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "JAOUEN", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "BURTIN", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Pierre", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "LEYSSENE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "ACCRED", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "CURUTCHET-BURTIN", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "SEGUES", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "ETAB_GLOBAL", "original": "Centre Hospitalier de la Côte Basque", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
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{"page": -1, "kind": "TEL_GLOBAL", "original": "0559443674", "placeholder": "[TEL]", "bbox_hint": null}
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@@ -9,39 +9,3 @@
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{"page": 0, "kind": "IPP", "original": "BA164017", "placeholder": "[IPP]", "bbox_hint": null}
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{"page": 0, "kind": "NOM", "original": "Anne Christine JAOUEN", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 1, "kind": "NOM", "original": "Anne Christine JAOUEN", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GUILLEMAUD", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "DECOEUR", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "BENARD", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "MONIER", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "Laurie", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "Julien", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "ACCRED", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "ACCRED", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "Yohan", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Rémi", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "DECOEUR", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "MENARD-DEROURE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "BENARD", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "SABATIER", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "DEROURE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "MONIER", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Laurie", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "David", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "GUILLEMAUD", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Fanny", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Yohan", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Marie-Laure", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Anne-Christine", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Julien", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "JAOUEN", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "BURTIN", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Pierre", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "LEYSSENE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "ACCRED", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "CURUTCHET-BURTIN", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "SEGUES", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Christine", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "ETAB_GLOBAL", "original": "Centre Hospitalier de la Côte Basque", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
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{"page": -1, "kind": "TEL_GLOBAL", "original": "0559443674", "placeholder": "[TEL]", "bbox_hint": null}
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@@ -2,24 +2,3 @@
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{"page": 0, "kind": "ADRESSE", "original": "10 RUE DES HAUTRS VENTS", "placeholder": "[ADRESSE]", "bbox_hint": null}
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{"page": 0, "kind": "CODE_POSTAL", "original": "14190 OUILLY LE TESSON", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
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{"page": 0, "kind": "DATE_NAISSANCE", "original": "Né le 02/04/2010", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GONTIER", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GONTIER", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GASTON", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GASTON", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GASTON", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GASTON", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GASTON", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "QUEANT", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "QUEANT", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GILLES", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GILLES", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GILLES", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GILLES", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GILLES", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "GASTON", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "GILLES", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "GONTIER", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "QUEANT", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "10 RUE DES HAUTRS VENTS", "placeholder": "[ADRESSE]", "bbox_hint": null}
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{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "14190 OUILLY LE TESSON", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
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{"page": -1, "kind": "DATE_NAISSANCE_GLOBAL", "original": "Né le 02/04/2010", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
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@@ -60,81 +60,3 @@
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{"page": 1, "kind": "TEL", "original": "05.59.44.37.29", "placeholder": "[TEL]", "bbox_hint": null}
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{"page": 1, "kind": "IPP", "original": "09018266", "placeholder": "[IPP]", "bbox_hint": null}
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{"page": 1, "kind": "EPISODE", "original": "N° Episode 23155836", "placeholder": "[EPISODE]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "CAZELLES-BOUDIER", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "CAZELLES-BOUDIER", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "PROPANOLOL", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GUILNGAR", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GOUTORBE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "GOUTORBE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "Grellety", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "AUDEMAR", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "AUDEMAR", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "PREVOST", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "PREVOST", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "TIEBOIS", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "TIEBOIS", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "CHANTAL", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "CHANTAL", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "CHANTAL", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "CHANTAL", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "CHANTAL", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "Sylvie", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "SYLVIE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "SYLVIE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "KHUONG", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "KHUONG", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "NIVET", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_EXTRACTED", "original": "NIVET", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "CHAPPE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "EDOUARD", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "AUDEMAR", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Sylvie", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Aurore", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "DEBES", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "GUILNGAR", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Béraut", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Edouard", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "BOUBE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "PREVOST", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": -1, "kind": "NOM_GLOBAL", "original": "Capucine", "placeholder": "[NOM]", "bbox_hint": null}
|
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|
||||
@@ -5,7 +5,7 @@ Dr [NOM] [NOM] [NOM]
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||||
www.atlantic-pathologie.fr
|
||||
N° 23L53954
|
||||
Prélevé le 14/11/2023 Enregistré le 14/11/2023
|
||||
[NOM] [NOM]
|
||||
BIDEGARAY [NOM]
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||||
Dr. [NOM]
|
||||
Né(e) CESAT le 25/02/1973 CENTRE HOSPITALIER COTE BASQUE
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[ADRESSE]
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@@ -5,21 +5,3 @@
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||||
@@ -210,9 +210,9 @@ Consultations Voyageurs 64
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||||
Tel : [TEL]
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||||
Consultations Externes :
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||||
Tel : [TEL] Docteur [NOM]
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||||
Fax : [TEL] *[RPPS]*
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||||
Fax : [TEL] *10100401941*
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||||
Poste de Prélèvements :
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||||
Tel : [TEL] [RPPS]
|
||||
Tel : [TEL] 10100401941
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||||
Cadre de Santé :
|
||||
Mme [NOM]
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||||
Tel : [TEL]
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||||
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@@ -121,113 +121,3 @@
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{"page": -1, "kind": "DATE_NAISSANCE_GLOBAL", "original": "né le 26/08/1947", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
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{"page": -1, "kind": "EMAIL_GLOBAL", "original": "secr.neurochir@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
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@@ -58,7 +58,7 @@ Mr [NOM]
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[DATE_NAISSANCE]
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[NOM] :
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Dr [NOM]
|
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Dr [NOM] [NOM] [NOM]
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Dr [NOM] RENDU [NOM]
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Dr [NOM] [NOM] Date d’intervention : 07/04/2023
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Dr [NOM], Chef de [MASK] :
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Praticien Hospitalier :
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||||
{"page": -1, "kind": "VILLE_GLOBAL", "original": "BAYONNE CEDEX", "placeholder": "[VILLE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64109 BAYONNE CEDEX", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64122 URRUGNE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "Code Postal: 64122", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64122", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "EPISODE_GLOBAL", "original": "23066188", "placeholder": "[EPISODE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "39 rue Bernard de Coral", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "33 RUE JEAN FOURCADE", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "LOEB BP 8", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "33 RUE JEAN FOURCADE\tVille de résidence", "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": "ADRESSE_GLOBAL", "original": "33 RUE JEAN FOURCADE Ville de résidence", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "DATE_NAISSANCE_GLOBAL", "original": "Date de naissance: 15/01/2017", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "TEL_GLOBAL", "original": "05 59 54 31 97", "placeholder": "[TEL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ETAB_GLOBAL", "original": "unité de Médecine hors SC", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
||||
|
||||
@@ -11,7 +11,7 @@ Sexe : Masculin Lieu de naissance: [VILLE]
|
||||
Nationalité : FRANCE [CODE_POSTAL]
|
||||
Adresse : [ADRESSE]: [NOM]
|
||||
Détails épisode
|
||||
Episode No : [EPISODE]
|
||||
Episode No : 23066188
|
||||
Localisation : PEDIATRIE GENERALE Médecin courant: DR. [NOM]
|
||||
Date d'admission : 02/04/2023 Heure d'admission: 15:57
|
||||
Date de sortie : 05/04/2023 Heure de sortie: 12:02
|
||||
@@ -56,7 +56,7 @@ Type Etat Code Date
|
||||
Principal actif G03.9 Méningite, sans précision [CMA2] 02/04/2023 22 : 53
|
||||
Antécédents (texte libre)
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 1 de 19 Type de note Nom Date Heure Note
|
||||
Aucune donnée
|
||||
renseignée
|
||||
@@ -84,7 +84,7 @@ Ventilation
|
||||
Air Air Air Air Air Air Air
|
||||
ambiant ambiant ambiant ambiant ambiant ambiant ambiant
|
||||
[NOM]
|
||||
[NOM] [NOM] EVS
|
||||
[NOM] EVENDOLEVS EVS
|
||||
douleur
|
||||
Score au
|
||||
1 0 0 0 2 0 0 6 0 0 2
|
||||
@@ -135,7 +135,7 @@ Histoire de la DR. [NOM] 05/04/2023 Antécédents personnels :
|
||||
maladie [NOM] 10 : 32 Migraine frontale, environ 2 épisodes par mois cédant à la prise de paracétamol et AINS
|
||||
Antécédents familiaux :
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 2 de 19 Terrain migraineux chez le père et la mère. Traitement de fond auparavant chez la mère arrêté,
|
||||
prend AINS et triptans en cas de crise. AINS simple chez le père
|
||||
Allergies : non.
|
||||
@@ -197,7 +197,7 @@ Traitements reçus en hospitalisation :
|
||||
- Réhydratation parentérale IV par Bionolyte G5 pendant * heures.
|
||||
- Traitement antalgique par paracétamol, Nubain et Advil.*
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 3 de 19 - Traitement par injections de Caféine dans le cadre d'un syndrome post-PL d'évolution
|
||||
favorable.
|
||||
- Une antibiothérapie a été mise en place par Cefotaxime par voie iv pendant 48 heures,
|
||||
@@ -266,7 +266,7 @@ le 30/03 : céphalée frontale bilatérale + fièvre à 40° + vomissement
|
||||
le 31/03 : consulte le médecin angine érythémateuse, streptotest négatif
|
||||
Le 01/04 : amélioration de l'état général, pas de fièvre pas de céphalée
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 4 de 19 cette nuit depuis 2h : récidive des céphalées de même localisation, fièvre à 38,5 et 4
|
||||
vomissements sur la journée.
|
||||
prend paracétamol puis advil à 10h qu'elle vomit. Consulte SOS médecin, donne suppo de nifluril
|
||||
@@ -337,7 +337,7 @@ Note IDE [NOM] [NOM] maman souhaiterait qu'on lui donne un laxatif.
|
||||
09 : 04
|
||||
dans la matinée s'est plaint du point de ponction de la PL et de céphalées. ATG2 et AINS fait
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 5 de 19 Alimentation :
|
||||
A mangé une orange ce matin et des nuggets à midi.
|
||||
Boit beaucoup d'eau et urine souvent.
|
||||
@@ -418,7 +418,7 @@ CEFOTAXIME PAN 1G Le débit en cours DR. [NOM]
|
||||
1500 mg - Normal 02/04/2023 21 : 29 04/04/2023 09:29
|
||||
PDR INJ [25] Flacon(s) est : 3 ML par [NOM]
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 6 de 19 1 hrs. Notes du
|
||||
professionel de
|
||||
santé : Dilution:
|
||||
@@ -471,7 +471,7 @@ Prescriptions de soins
|
||||
Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur
|
||||
[NOM]
|
||||
1 Semaine - Matin 03/04/2023
|
||||
REPAS : AIDE COMPLETE Réalisé [NOM]
|
||||
REPAS : AIDE COMPLETE Réalisé PECASTAINGS
|
||||
[8h] Normal 21 : 34
|
||||
[NOM]
|
||||
Notes du
|
||||
@@ -507,7 +507,7 @@ Normal
|
||||
pupilles/
|
||||
comportement
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 7 de 19 Notes du
|
||||
1 Semaine - Ttes les professionel
|
||||
SURV. NEUROLOGIQUE 02/04/2023 DR. [NOM]
|
||||
@@ -536,7 +536,7 @@ KILO Réalisé - Presc. de Sortie [NOM]
|
||||
SOL BUV 10 : 34 Révisé/Traité
|
||||
ORALE [NOM]
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 8 de 19 Plan de soins Jour J du 05/04/2023 07h00 au 06/04/2023 07h00
|
||||
Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
|
||||
[NOM] [NOM]
|
||||
@@ -653,7 +653,7 @@ Heure(s) Si besoin - Début presc. : 02/04/2023 @ Fin le 13/04/2023 à 01:52 * 4
|
||||
si douleur malgré palier 1 Admin le 05/04/2023 à
|
||||
09 : 52
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 9 de 19 Notes de professionel de santé :
|
||||
DILUER dans 20ML de NaCl 0.9% MAX
|
||||
1.2MG/KG/J
|
||||
@@ -738,7 +738,7 @@ Admin le 05/04/2023 à
|
||||
SYSTEMATIQUE
|
||||
09 : 21
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 10 de 19 Signé — ADVILMED 20 MG/ML [NOM] ET NR BOHN Quentin
|
||||
SUSP BUV - 20MG/ML suspension (200 mL) - Début le 04/04/2023 à
|
||||
Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 10 : 28 09:21 * 1
|
||||
@@ -755,7 +755,7 @@ O 08R : 0A 0LE - 1xJour [8h] - 1ère dose: 05/04/2023 @ F 08in
|
||||
l 0e 14/04/2023 à 0 S8 A : 0 C0 H * E T2
|
||||
Admin le 05/04/2023 à
|
||||
08 : 00
|
||||
[NOM]
|
||||
PECASTAINGS
|
||||
[NOM] [NOM]
|
||||
Réalisé — REPAS : AIDE COMPLETE - Matin Début le 03/04/2023 à
|
||||
[8h] - 1 Semaine- Date Début : 03/04/2023 @ 21:34
|
||||
@@ -816,7 +816,7 @@ Réalisé — SIGNES VITAUX (Pls, TA, FR,
|
||||
[NOM] [NOM] 00 : 00 * 1
|
||||
T°, Glyc, Miction, Transit) - Ttes les 4H [0h
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 11 de 19 Début le 02/04/2023 à
|
||||
4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 20:22
|
||||
02/04/2023 @ 20 : 22 Fin le 12/04/2023 à
|
||||
@@ -890,7 +890,7 @@ Réalisé — SURV. NEUROLOGIQUE TTES LES [NOM] [NOM]
|
||||
3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- Début le 02/04/2023 à 08 : 00 * 1
|
||||
Date Début : 02/04/2023 @ 20:22 20:22
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 12 de 19 Fin le 12/04/2023 à
|
||||
Notes de professionel de santé : 20:00
|
||||
" Conscience/pupilles/comportement" Admin le 05/04/2023 à
|
||||
@@ -931,7 +931,7 @@ Notes de professionel de santé : 20:00
|
||||
mouvement anormaux Admin le 05/04/2023 à
|
||||
08 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 13 de 19 Plan de soins Jour J + 1 du 06/04/2023 07h00 au 07/04/2023 07h00
|
||||
Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
|
||||
[NOM] [NOM]
|
||||
@@ -1048,7 +1048,7 @@ Heure(s) Si besoin - Début presc. : 02/04/2023 @ Fin le 13/04/2023 à 21:52 * 4
|
||||
si douleur malgré palier 1 Admin le 05/04/2023 à
|
||||
09 : 52
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 14 de 19 Notes de professionel de santé :
|
||||
DILUER dans 20ML de NaCl 0.9% MAX
|
||||
1.2MG/KG/J
|
||||
@@ -1133,7 +1133,7 @@ Admin le 05/04/2023 à
|
||||
SYSTEMATIQUE
|
||||
09 : 21
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 15 de 19 Signé — ADVILMED 20 MG/ML [NOM] ET NR BOHN Quentin
|
||||
SUSP BUV - 20MG/ML suspension (200 mL) - Début le 04/04/2023 à
|
||||
Dose 1 DOSE(S) KILO - ORALE - Toutes les 6 10 : 28 04:28 * 1
|
||||
@@ -1142,7 +1142,7 @@ Notes de professionel de santé : 04:28 KILO
|
||||
Admin le 05/04/2023 à
|
||||
SYSTEMATIQUE
|
||||
09 : 21
|
||||
[NOM]
|
||||
PECASTAINGS
|
||||
[NOM] [NOM]
|
||||
Réalisé — REPAS : AIDE COMPLETE - Matin Début le 03/04/2023 à
|
||||
[8h] - 1 Semaine- Date Début : 03/04/2023 @ 21:34
|
||||
@@ -1210,7 +1210,7 @@ Réalisé — SIGNES VITAUX (Pls, TA, FR,
|
||||
[NOM] [NOM] 20 : 00 * 1
|
||||
T°, Glyc, Miction, Transit) - Ttes les 4H [0h
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 16 de 19 Début le 02/04/2023 à
|
||||
4h ... 16h 20h] - pendant 10 Jour(s)- Date Début : 20:22
|
||||
02/04/2023 @ 20 : 22 Fin le 12/04/2023 à
|
||||
@@ -1284,7 +1284,7 @@ Réalisé — SURV. NEUROLOGIQUE TTES LES [NOM] [NOM]
|
||||
3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- Début le 02/04/2023 à 05 : 00 * 1
|
||||
Date Début : 02/04/2023 @ 20:22 20:22
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 17 de 19 Fin le 12/04/2023 à
|
||||
Notes de professionel de santé : 20:00
|
||||
" Conscience/pupilles/comportement" Admin le 05/04/2023 à
|
||||
@@ -1361,7 +1361,7 @@ LCR
|
||||
HSV
|
||||
PCR Enterovirus (LCR) Positive
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 18 de 19 Culture négative à 48h
|
||||
Culture LCR TK (les bouillons seront
|
||||
incubés pendant 5 j)
|
||||
@@ -1405,7 +1405,7 @@ le 06/04/23
|
||||
DR. [NOM]
|
||||
10100837987
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (17001141 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Episode N. : 23066188 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Poids: 19.400 kg
|
||||
Le 05/04/2023 14 : 30 Page 19 de 19
|
||||
|
||||
|
||||
@@ -1414,7 +1414,7 @@ Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE]
|
||||
Sexe : Masculin Lieu de naissance: [VILLE]
|
||||
Nationalité : FRANCE [CODE_POSTAL]
|
||||
Adresse : [ADRESSE]: [NOM]
|
||||
Episode No : [EPISODE]
|
||||
Episode No : 23066188
|
||||
Localisation : PEDIATRIE GENERALE Médecin courant: DR. [NOM]
|
||||
Date d'admission : 02/04/2023 Heure d'admission: 15:57
|
||||
Date de sortie : 05/04/2023 Heure de sortie: 12:02
|
||||
@@ -1809,7 +1809,7 @@ Flacon(s) : 1 DOSE(S)
|
||||
KILO
|
||||
ORALE Réalisé - Presc. de Sortie 05/04/2023
|
||||
10:34 0/1 : Non administré
|
||||
Révisé/Traité DR. [NOM]-
|
||||
Révisé/Traité DR. Marie-
|
||||
[NOM]
|
||||
[NOM]
|
||||
MACROGOL 4000 ARW
|
||||
@@ -1818,7 +1818,7 @@ SACHET(s) : 2 SACHET
|
||||
ORALE Réalisé - 1xJour [8h] Presc.
|
||||
de Sortie 05/04/2023
|
||||
10:34 0/14 : Non administré
|
||||
Révisé/Traité DR. [NOM]-
|
||||
Révisé/Traité DR. Marie-
|
||||
[NOM]
|
||||
[NOM]
|
||||
PARACETAMOL [NOM]
|
||||
@@ -1826,7 +1826,7 @@ SOL BUV : 1 DOSE(S)
|
||||
KILO
|
||||
ORALE Réalisé - Presc. de Sortie 05/04/2023
|
||||
10:34 0/40 : Non administré
|
||||
Révisé/Traité DR. [NOM]-
|
||||
Révisé/Traité DR. Marie-
|
||||
[NOM]
|
||||
[NOM]
|
||||
|
||||
@@ -2115,7 +2115,7 @@ Admin le 05/04/2023 à
|
||||
SACHET
|
||||
Réalisé — REPAS : AIDE COMPLETE - Matin
|
||||
[8h] - 1 Semaine- Date Début: 03/04/2023 @
|
||||
21:34 [NOM]
|
||||
21:34 PECASTAINGS
|
||||
[NOM] [NOM]
|
||||
Début le 03/04/2023 à
|
||||
21:34
|
||||
@@ -2626,7 +2626,7 @@ DOSE(S)
|
||||
KILO
|
||||
Réalisé — REPAS : AIDE COMPLETE - Matin
|
||||
[8h] - 1 Semaine- Date Début: 03/04/2023 @
|
||||
21:34 [NOM]
|
||||
21:34 PECASTAINGS
|
||||
[NOM] [NOM]
|
||||
Début le 03/04/2023 à
|
||||
21:34
|
||||
|
||||
Binary file not shown.
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Load Diff
@@ -9,9 +9,9 @@ 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]
|
||||
Adresse : [ADRESSE]: BAYONNE
|
||||
Détails épisode
|
||||
Episode No : [EPISODE]
|
||||
Episode No : 23095226
|
||||
Localisation : PNEUMOLOGIE PHTISIOLOGIE HC Médecin courant: DR. [NOM]
|
||||
Date d'admission : 12/06/2023 Heure d'admission: 13:22
|
||||
Date de sortie : 21/06/2023 Heure de sortie: 13:32
|
||||
@@ -69,7 +69,7 @@ PA
|
||||
Diastolique
|
||||
Transit Normal Normal Normal Absence Peu Absence Absence Absence Absence
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 1 de 31 Débit O²
|
||||
[L/mn]
|
||||
Poids/Taille
|
||||
@@ -144,7 +144,7 @@ Note d'évolution
|
||||
[NOM] 16 : 30 En cours d'expérimentation sur le cannabis thérapeutique
|
||||
Reprise mélange équilibré CBD/THC 25mg/ml 0.4ml matin, midi et soir
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 2 de 31 19/06 : LM
|
||||
A passé une bonne nuit sans douleur.
|
||||
Au réveil, accès douloureux intense ++ finalement soulagé après prise d'OXYNORMORO
|
||||
@@ -196,7 +196,7 @@ pas de globe, arrive à uriner
|
||||
réévaluation au jour le jour de Mr [NOM]
|
||||
14 6 23 SS
|
||||
a eu hier
|
||||
FRACTURE PATHOLOGIQUE DE LA DIAPHYSE [NOM] [NOM]
|
||||
FRACTURE PATHOLOGIQUE DE LA DIAPHYSE HUMERALE [NOM]
|
||||
INTERVENTION : BIOPSIE, REDUCTION ET OSTEOSYNTHESE PAR ENCLOUAGE
|
||||
CENTROMEDULLAIRE
|
||||
+ cimentoplastie du bassin
|
||||
@@ -212,9 +212,9 @@ introduction moventig contre la constipation
|
||||
si globe urinaire, prévoir un sondage
|
||||
biologie en cours
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 3 de 31 Patient à ne pas masser, ou intuber en cas de dégradation de son état général.
|
||||
[NOM] [NOM] [NOM]
|
||||
CIMENTOPLASTIE [NOM] [NOM]
|
||||
Intervention réalisée sans complication. Comblement satisfaisant de la lésion lytique du [NOM]
|
||||
[NOM].
|
||||
DR. [NOM] 13/06/2023
|
||||
@@ -247,7 +247,7 @@ Appel IDE pour douleur brutal bras [NOM] en se retournant dans le lit. ( méta h
|
||||
connu )
|
||||
A entendu un craquement en se retournant dans le lit.
|
||||
13/06/2023 EN 10/10 patient en pleur
|
||||
Note d'évolution Tess [NOM]
|
||||
Note d'évolution Tess PAJOT
|
||||
05 : 19 Examen impossible, pas d'hématome visible, humérus instable
|
||||
> Titration morphinique
|
||||
> Rx demandé
|
||||
@@ -266,7 +266,7 @@ Traitement en cours :
|
||||
- BIPROFENID LP 100 mg matin et soir
|
||||
- OXYCONTIN LP 50 mg le matin et 40 à 50 mg le soir
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 4 de 31 - OXYNORM en interdoses à 40 mg
|
||||
- LYRICA 100 mg matin et soir
|
||||
- DOLIPRANE
|
||||
@@ -315,7 +315,7 @@ Par ailleurs Taxol -20% hebdomadaire en 5ème ligne (abstention thérapeutique i
|
||||
patient)
|
||||
Question posée :
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 5 de 31 ADK métastatique :
|
||||
Douleur humérale droite sur lésion : irradiation possible (radio demandée pour écarter fracture le
|
||||
30/05)
|
||||
@@ -380,7 +380,7 @@ Note IDE [NOM] [NOM]
|
||||
13 : 32
|
||||
DEVENIR : sortie domicile avec son épouse à13h30
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 6 de 31 DOULEUR :
|
||||
ATG3 donné à 01h puis 5h30
|
||||
ATG1 à 07h
|
||||
@@ -463,7 +463,7 @@ Note IDE [NOM] [NOM]
|
||||
15 : 28 présent ne se majore pas , bras moins oedematié
|
||||
ALIMENTATION : a mangé 3 cuillères de paella , 1 kiri et bu qq gorgées de délical
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 7 de 31 ETAT GENERAL : meilleure mine ce matin , patient non confus
|
||||
17/06/2023 douleur=)
|
||||
Note IDE [NOM] [NOM]
|
||||
@@ -537,7 +537,7 @@ Laxatifs donnés per os car refuse le [NOM] pour le moment .
|
||||
Selles liquides ce midi
|
||||
TTT : Radiothérapie annulée ;pas de report pour le moment
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 8 de 31 Douleur :
|
||||
Patient non algique en début de nuit ayant un faciès détendu.
|
||||
PCA ATG 3 refaite à 3h30 avec dotation exceptionnelle.
|
||||
@@ -603,7 +603,7 @@ refus pose SAD , sondage évacuateur fait avec 500ml d'urines , n'a pas envie d'
|
||||
moment mais a eu sondage évacuateur => à surveiller
|
||||
RADIOTHERAPIE : RDV le 15/06 à 14h15 , vu avec médecin maintien du RDV ambu ddée
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 9 de 31 Douleur : ttt ATG 3 Lp donné ce matin
|
||||
--> Changement de support avec installation de PCA ATG 3 uniquement en bolus pour le
|
||||
13/06/2023 moment
|
||||
@@ -679,7 +679,7 @@ santé : à diluer
|
||||
dans 100ML de
|
||||
NaCl ou G5%
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 10 de 31 KETOPROFENE [NOM]
|
||||
- Matin soir (8h - DR. [NOM]
|
||||
100MG/4ML SOL INJ [10] 100 mg 14/06/2023 18 : 00 20/06/2023 08:08
|
||||
@@ -717,7 +717,7 @@ Statut des prescriptions : Réalisé
|
||||
Notes du
|
||||
professionel de
|
||||
MORPHINE CHL REN santé : titration: 2
|
||||
10MG/ML INJ 1ML 3 mg - Normal 13/06/2023 05 : 15 13/06/2023 06:16 à 3 mg toutes les Tess [NOM]
|
||||
10MG/ML INJ 1ML 3 mg - Normal 13/06/2023 05 : 15 13/06/2023 06:16 à 3 mg toutes les Tess PAJOT
|
||||
Ampoule(s) 5 min Dose MAX
|
||||
20 mg => avis
|
||||
médical
|
||||
@@ -789,7 +789,7 @@ PARACETAMOL ARW
|
||||
Normal [NOM]
|
||||
Gelule(s)
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 11 de 31 Statut des prescriptions : Réalisé
|
||||
Notes du
|
||||
1 professionel de
|
||||
@@ -877,7 +877,7 @@ Prescriptions de radiologie
|
||||
Heure Date Heure
|
||||
Date début Prescription Statut Docteur [NOM]
|
||||
début exécution exécution
|
||||
13/06/2023 06 : 25 Humérus [NOM] F P 13/06/2023 06:31 Réalisé Tess [NOM]
|
||||
13/06/2023 06 : 25 Humérus [NOM] F P 13/06/2023 06:31 Réalisé Tess PAJOT
|
||||
[NOM]
|
||||
13/06/2023 17 : 58 Humérus [NOM] F P 13/06/2023 18:28 Réalisé
|
||||
[NOM]
|
||||
@@ -886,7 +886,7 @@ Date de
|
||||
Date Heure Prescription Docteur [NOM]
|
||||
collection
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 12 de 31 12/06/2023
|
||||
12/06/2023 13 : 24 TP+INR ( si AVK ) DR. [NOM]
|
||||
13 : 25
|
||||
@@ -934,7 +934,7 @@ TOILETTES
|
||||
AIDE A LA PRISE - 1 seule fois 1 seule 13/06/2023 [NOM]
|
||||
Signé
|
||||
MEDICAMENTS fois 21 : 25 [NOM]
|
||||
[NOM] : AIDE - 1 seule fois 1 seule 13/06/2023 [NOM]
|
||||
DESHABILLAGE : AIDE - 1 seule fois 1 seule 13/06/2023 [NOM]
|
||||
Signé
|
||||
PARTIELLE fois 21 : 25 [NOM]
|
||||
DESINFECTION
|
||||
@@ -994,7 +994,7 @@ Réalisé [NOM]
|
||||
BUV FL 40ML [8] Flacon(s) [NOM](S) Presc. de Sortie 13 : 10 Révisé/Traité
|
||||
[NOM]
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 13 de 31 [NOM] (5 ml)
|
||||
ORALE
|
||||
KETOPROFENE ACT DR.
|
||||
@@ -1047,7 +1047,7 @@ POC CFX 500ML V1 [1] Réalisé [NOM]
|
||||
[NOM] Presc. de Sortie 13 : 10 Révisé/Traité
|
||||
POCHE(S) [NOM]
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 14 de 31 Plan de soins Jour J du 21/06/2023 07h00 au 22/06/2023 07h00
|
||||
Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
|
||||
[NOM] [NOM]
|
||||
@@ -1129,7 +1129,7 @@ Admin le 21/06/2023 à
|
||||
si douleur à 30min de la prise d'ABSTRAL 12 : 20
|
||||
possibilité de redonner ABSTRAL 400
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 15 de 31 Signé — ABSTRAL 400MICROG CPR
|
||||
- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM]
|
||||
[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à
|
||||
@@ -1215,7 +1215,7 @@ dose : 12/06/2023 @ 19:00 12:00
|
||||
Admin le 21/06/2023 à
|
||||
12 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 16 de 31 [NOM] [NOM]
|
||||
Signé — SODIUM BIC BAX 1,4% POC CFX Début le 12/06/2023 à
|
||||
500ML V1 - 1,4G/100ML solution (500 mL) - 15 : 20
|
||||
@@ -1303,7 +1303,7 @@ comprime - Dose 1 CPR - ORALE - Matin [8h] - 10 : 39 08:45 * 1
|
||||
Admin le 21/06/2023 à
|
||||
08 : 45
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 17 de 31 [NOM] [NOM]
|
||||
Signé — OMEPRAZOLE ACF 20MG GELULE - Début le 12/06/2023 à
|
||||
20MG gelule - Dose 2 GEL - ORALE - Soir [19h] 13 : 24 19:00 * 2
|
||||
@@ -1411,7 +1411,7 @@ UE(S)
|
||||
INJ SER +S - 4000UI solution (0,4 mL) - Dose
|
||||
[NOM](S)
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 18 de 31 Début le 13/06/2023 à
|
||||
1 SERINGUE(S) [NOM](S) - SOUS- 19 : 25
|
||||
CUTANEE Directe - Matin [8h] - 1ère dose : Fin le 13/07/2023 à
|
||||
@@ -1485,7 +1485,7 @@ Signé — ESCARRE : PREVENTION - 7h 10h [NOM] [NOM]
|
||||
13h 16h 19h 22h Si besoin - 7 Jours- Date Début : Début le 13/06/2023 à 15:00 * 1
|
||||
13/06/2023 @ 08 : 00 08:00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 19 de 31 Fin le 25/06/2023 à
|
||||
06 : 00
|
||||
Admin le 18/06/2023 à
|
||||
@@ -1559,7 +1559,7 @@ Réalisé — VESSIE DE GLACE - Ttes les 8H [NOM] [NOM]
|
||||
Notes de professionel de santé : Fin le 22/06/2023 à
|
||||
sur MSD 14 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 20 de 31 Admin le 21/06/2023 à
|
||||
06 : 00
|
||||
[NOM] [NOM]
|
||||
@@ -1626,7 +1626,7 @@ Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h 16 : 16
|
||||
Admin le 21/06/2023 à
|
||||
08 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 21 de 31 Plan de soins Jour J + 1 du 22/06/2023 07h00 au 23/06/2023 07h00
|
||||
Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
|
||||
[NOM] [NOM]
|
||||
@@ -1708,7 +1708,7 @@ Admin le 21/06/2023 à
|
||||
si douleur à 30min de la prise d'ABSTRAL 12 : 20
|
||||
possibilité de redonner ABSTRAL 400
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 22 de 31 Signé — ABSTRAL 400MICROG CPR
|
||||
- 400MICROG comprime - Dose 1 CPR - [NOM] [NOM]
|
||||
[NOM] - Toutes les 2 Heure(s) Si besoin - Début le 19/06/2023 à
|
||||
@@ -1794,7 +1794,7 @@ dose : 12/06/2023 @ 19:00 12:00
|
||||
Admin le 21/06/2023 à
|
||||
12 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 23 de 31 Signé — FUNGIZONE 10% SUSP BUV FL [NOM] [NOM]
|
||||
40ML - 10G/100ML suspension (40 mL) - Dose Début le 12/06/2023 à
|
||||
1 [NOM](S) [NOM] (5 ml) - ORALE - Matin 15 : 20 08:00 * 1
|
||||
@@ -1884,7 +1884,7 @@ Admin le 20/06/2023 à
|
||||
Signé — OXYCODONE VIATRIS LP 80MG [NOM] [NOM] 08 : 00 * 70
|
||||
CPR - 80MG comprime - Dose 70 mg - ORALE mg
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 24 de 31 Début le 18/06/2023 à
|
||||
- Matin soir (8h - 20h) - 1ère dose : 18/06/2023 @ 16:13
|
||||
20 : 00 Fin le 18/07/2023 à
|
||||
@@ -1981,7 +1981,7 @@ Signé — ACCOMPAGNER INSTALLER AUX [NOM] [NOM]
|
||||
TOILETTES - 7h 10h 13h 16h 19h 22h Si besoin Début le 13/06/2023 à 09 : 00 * 1
|
||||
- 7 Jours- Date Début : 13/06/2023 @ 08:00 08:00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 25 de 31 Fin le 25/06/2023 à
|
||||
06 : 00
|
||||
Admin le 18/06/2023 à
|
||||
@@ -2055,7 +2055,7 @@ Signé — ESCARRE : PREVENTION - 7h 10h [NOM] [NOM]
|
||||
Fin le 25/06/2023 à
|
||||
06 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 26 de 31 Admin le 18/06/2023 à
|
||||
12 : 00
|
||||
[NOM] [NOM]
|
||||
@@ -2129,7 +2129,7 @@ Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h 16 : 16
|
||||
Admin le 21/06/2023 à
|
||||
08 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 27 de 31 [NOM] [NOM]
|
||||
Réalisé — SIGNES VITAUX (Pls, TA, FR, T°, Début le 13/06/2023 à
|
||||
Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h 16 : 16
|
||||
@@ -2192,7 +2192,7 @@ Vasculaire ou Docteur [NOM]
|
||||
Interventionnelle Nom de naissance : [NOM]
|
||||
Nom utilisé : [NOM]
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 28 de 31 Prénom de naissance : [NOM]
|
||||
Prénom utilisé : [NOM]
|
||||
[DATE_NAISSANCE]
|
||||
@@ -2201,7 +2201,7 @@ Sexe : M
|
||||
Matricule INS : (NIR) [NIR]
|
||||
Examen du : 13/06/2023
|
||||
Compte-rendu validé électroniquement par Dr [NOM] le 13/06/2023
|
||||
[NOM] DU [NOM] [NOM] [NOM]
|
||||
CIMENTOPLASTIE DU [NOM] [NOM] RADIOGUIDEE
|
||||
Indication :
|
||||
Volumineuse lésion ostéolytique symptomatique du [NOM] [NOM] dans un contexte de néoplasie pulmonaire.
|
||||
RESULTATS :
|
||||
@@ -2249,7 +2249,7 @@ un avis en hépatologie un avis en hépatologie un avis en hépatologie
|
||||
est recommandé. Si la est recommandé. Si la est recommandé. Si la
|
||||
valeur est < : 1,3, il valeur est < 1,3, il valeur est < 1,3, il
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 29 de 31 n?existe pas de maladie n?existe pas de maladie n?existe pas de maladie
|
||||
hépatique sévère. hépatique sévère. hépatique sévère.
|
||||
Dans les autres cas, un Dans les autres cas, un Dans les autres cas, un
|
||||
@@ -2327,7 +2327,7 @@ cardiologique
|
||||
Calcium 2,21 mmol/l 2,16 mmol/l 2,30 mmol/l
|
||||
Calcium corrigé 2,40 mmol/l
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 30 de 31 Estimation du DFG (CKD-
|
||||
114 ml/mn/1.73 m2 114 ml/mn/1.73 m2 101 ml/mn/1.73 m2
|
||||
EPI)
|
||||
@@ -2394,7 +2394,7 @@ Dr. [NOM]
|
||||
Validation et diffusion sous la
|
||||
Dr [NOM] [NOM] [NOM] [NOM]
|
||||
responsabilité du biologiste
|
||||
[NOM]
|
||||
BURTIN
|
||||
Réticulocytes (%) 2,48 %
|
||||
Réticulocytes (#) 87,5 10.9/l
|
||||
Trou anionique 8 9 11
|
||||
@@ -2403,7 +2403,7 @@ TCA ratio 1,09 1,05
|
||||
TP 85 % 109 %
|
||||
Volume plaquettaire moyen 10,0 fl 9,6 fl 10,0 fl
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (02016820 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Episode N. : 23095226 ( MEDECINE PNEUMOLOGIE - PNEUMOLOGIE PHTISIOLOGIE HC ) - Taille: 178 cm - Poids: 77 kg - IMC: 24.302
|
||||
Le 21/06/2023 14 : 29 Page 31 de 31
|
||||
|
||||
|
||||
@@ -2411,8 +2411,8 @@ Nom de naissance : [NOM] IPP : [IPP]
|
||||
Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE]
|
||||
Sexe : Masculin Lieu de naissance: [VILLE]
|
||||
Nationalité : FRANCE [CODE_POSTAL]
|
||||
Adresse : [ADRESSE]: [VILLE]
|
||||
Episode No : [EPISODE]
|
||||
Adresse : [ADRESSE]: BAYONNE
|
||||
Episode No : 23095226
|
||||
Localisation : PNEUMOLOGIE PHTISIOLOGIE HC Médecin courant: DR. [NOM]
|
||||
Date d'admission : 12/06/2023 Heure d'admission: 13:22
|
||||
Date de sortie : 21/06/2023 Heure de sortie: 13:32
|
||||
@@ -2640,7 +2640,7 @@ réévaluation au jour le jour de Mr [NOM]
|
||||
|
||||
Note d'évolution : DR. [NOM]
|
||||
[NOM] 13/06/2023
|
||||
17:09 [NOM] [NOM] [NOM]
|
||||
17:09 CIMENTOPLASTIE [NOM] [NOM]
|
||||
Intervention réalisée sans complication. Comblement satisfaisant de la lésion lytique du [NOM]
|
||||
[NOM].
|
||||
Au retour en chambre, repos en décubitus dorsal pendant 2 heures. En fonction de l'état du
|
||||
@@ -2668,7 +2668,7 @@ PCA de morphine à 5 mg en bolus toutes les 10 minutes si besoin mais sans ttt d
|
||||
moment
|
||||
prescriptions à revoir dans la journée en fonction de son évolution
|
||||
en attente de l'avis du chirurgien orthopédique
|
||||
Note d'évolution : Tess [NOM] 13/06/2023
|
||||
Note d'évolution : Tess PAJOT 13/06/2023
|
||||
05:19 Appel IDE pour douleur brutal bras [NOM] en se retournant dans le lit. ( méta huméral droite
|
||||
connu )
|
||||
A entendu un craquement en se retournant dans le lit.
|
||||
@@ -2986,7 +2986,7 @@ santé: titration: 2
|
||||
à 3 mg toutes les
|
||||
5 min Dose MAX
|
||||
20 mg => avis
|
||||
médical Tess [NOM]
|
||||
médical Tess PAJOT
|
||||
FUNGIZONE 10% SUSP
|
||||
BUV FL 40ML [8] Flacon(s) : 1
|
||||
[NOM](S)
|
||||
@@ -3154,7 +3154,7 @@ Date début : Heure
|
||||
début Prescription Date
|
||||
exécution Heure
|
||||
exécution Statut Docteur Note
|
||||
13/06/2023 : 06:25 Humérus [NOM] F P 13/06/2023 06:31 Réalisé Tess [NOM]
|
||||
13/06/2023 : 06:25 Humérus [NOM] F P 13/06/2023 06:31 Réalisé Tess PAJOT
|
||||
13/06/2023 : 17:58 Humérus [NOM] F P 13/06/2023 18:28 Réalisé [NOM]
|
||||
[NOM]
|
||||
Date : Heure Prescription Docteur Date de
|
||||
@@ -3203,7 +3203,7 @@ MEDICAMENTS : Signé - 1 seule fois 1 seule
|
||||
fois 13/06/2023
|
||||
21:25 [NOM]
|
||||
[NOM]
|
||||
[NOM] : AIDE
|
||||
DESHABILLAGE : AIDE
|
||||
PARTIELLE Signé - 1 seule fois 1 seule
|
||||
fois 13/06/2023
|
||||
21:25 [NOM]
|
||||
@@ -4950,7 +4950,7 @@ Réserve alcaline : 26 mmol/l 23 mmol/l 24 mmol/l
|
||||
Validation et diffusion sous la
|
||||
responsabilité du biologiste : Dr [NOM] [NOM] Dr [NOM] [NOM] Dr. [NOM]
|
||||
[NOM]
|
||||
[NOM]
|
||||
BURTIN
|
||||
Réticulocytes (%) : 2,48 %
|
||||
Réticulocytes (#) : 87,5 10.9/l
|
||||
Trou anionique : 8 9 11
|
||||
|
||||
Binary file not shown.
File diff suppressed because it is too large
Load Diff
@@ -136,921 +136,7 @@
|
||||
{"page": 24, "kind": "NOM", "original": "Julien GUILLEMAUD Dr", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": 24, "kind": "NOM", "original": "Julien GUILLEMAUD Dr", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": 24, "kind": "NOM", "original": "Rémi SEGUES", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "ILHARRAMOUNHO", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "ILHARRAMOUNHO", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "vomissements", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "vomissements", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "vomissements", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "Vomissements", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "vomissements", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "vomissements", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "vomissements", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "vomissements", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "ENCEPHALIQUE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "ENCEPHALIQUE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "Marie-Elise", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "Marie-Elise", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "Marie-Elise", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "Marie-Elise", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "ETCHEVERRY", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "ETCHEVERRY", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "ETCHEVERRY", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "ETCHEVERRY", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "ETCHEVERRY", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "ETCHEVERRY", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "ETCHEVERRY", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "ETCHEVERRY", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "GUILLEMAUD", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "GUILLEMAUD", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "GUILLEMAUD", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "GUILLEMAUD", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "GUILLEMAUD", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "GUILLEMAUD", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
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|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "TIBLE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "TXOMIN", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "GUILLEMAUD", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "SCHMITT", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Services", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Anahi", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "DAMESTOY", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Julien", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "DIDAILLER", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "BIENNASSIS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Maialen", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "PETRIAT", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Béta", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "EVENDOLEVENDOLEVENDOL", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Picamilh", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "NEMBUTAL", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Margaux", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Aude", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "VOMISSEMENTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "LARROUY", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "PUGET", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Sophie", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "SEGUES", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "GOURNAY", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Charlotte", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "DUBREL", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "ENCEPHALIQUE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "GLASGOW", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Cecile", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Axel", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "VILLE_GLOBAL", "original": "BAYONNE CEDEX", "placeholder": "[VILLE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "VILLE_GLOBAL", "original": "BOUCAU", "placeholder": "[VILLE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64109 BAYONNE CEDEX", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "Code Postal: 64340", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64340", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64100 BAYONNE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "EPISODE_GLOBAL", "original": "23074384", "placeholder": "[EPISODE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "4 RUE PONTRIQUE", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "1 RUE JOSEPH ST ANDRÉ\tVille de résidence", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "1 RUE JOSEPH ST ANDRÉ Ville de résidence", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "LOEB BP 8", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "MAISON ST JOSEPH 1 RUE JOSEPH ST ANDRÉ", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "13, Avenue de l'Interne J", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "DATE_NAISSANCE_GLOBAL", "original": "Date de naissance: 08/01/2015", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "DATE_NAISSANCE_GLOBAL", "original": "ne le 18/04/2023", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ETAB_GLOBAL", "original": "CMPP", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ETAB_GLOBAL", "original": "unité de Médecine hors SC", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ETAB_GLOBAL", "original": "CHU", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "TEL_GLOBAL", "original": "001141124", "placeholder": "[TEL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "TEL_GLOBAL", "original": "001141879", "placeholder": "[TEL]", "bbox_hint": null}
|
||||
|
||||
@@ -11,7 +11,7 @@ Sexe : Masculin Lieu de naissance: [VILLE]
|
||||
Nationalité : FRANCE [CODE_POSTAL]
|
||||
Adresse : MAISON ST JOSEPH [ADRESSE]: [NOM]
|
||||
Détails épisode
|
||||
Episode No : [EPISODE]
|
||||
Episode No : 23074384
|
||||
Localisation : PEDIATRIE GENERALE Médecin courant: DR. [NOM]
|
||||
Date d'admission : 15/04/2023 Heure d'admission: 13:07
|
||||
Date de sortie : 20/04/2023 Heure de sortie: 18:03
|
||||
@@ -54,7 +54,7 @@ Principal actif R41.0 Désorientation, sans précision [CMA2] 15/04/2023 17 : 52
|
||||
Antécédents (texte libre)
|
||||
Type de note Nom Date Heure Note
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 1 de 25 Aucune donnée
|
||||
renseignée
|
||||
Antécédents habitus (texte libre)
|
||||
@@ -73,7 +73,7 @@ PA
|
||||
52 59 54 57 55 49
|
||||
Diastolique
|
||||
[NOM]
|
||||
[NOM] [NOM] EVENDOLEVENDOL EVS [NOM] [NOM] [NOM] [NOM]
|
||||
[NOM] EVENDOLEVENDOLEVENDOL EVENDOLEVENDOL EVS [NOM] [NOM] [NOM] [NOM]
|
||||
douleur
|
||||
Score au
|
||||
0 0 0 0 0 0 0 0 0 0 0
|
||||
@@ -136,7 +136,7 @@ O²
|
||||
[NOM] 15
|
||||
Transit
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 2 de 25 Glycémie
|
||||
capillaire
|
||||
Observations médicales
|
||||
@@ -202,7 +202,7 @@ Absence de prise de contraste méningée. Absence de disparité de calibre des a
|
||||
Le ruban cortical est fin et régulier. Absence d'anomalie décelée de la morphologie et du signal
|
||||
du vermis et des hémisphères cérébelleux.
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 3 de 25 Les citernes de la fosse postérieure et les angles ponto-cérébelleux sont libres. Absence de signal
|
||||
pathologique du tronc cérébral. Absence d'anomalie de la jonction cervico-occipitale.
|
||||
CONCLUSION : IRM encéphalique sans particularité pathologique ce jour. N° d'examen :
|
||||
@@ -252,7 +252,7 @@ Bilan complémentaire ce jour : ionogramme équilibré, EPS normale, TSH normale
|
||||
Anti TPO anti Tyroglobuline en cours AAN en cours
|
||||
PCR multiplex en cours
|
||||
Poursuite surveillance clinique en hospitalisation
|
||||
Pierre-[NOM] 17/04/2023 PCR multiplex à réaliser sur le LCR (David Leyssenne)
|
||||
Pierre-Axel 17/04/2023 PCR multiplex à réaliser sur le LCR (David Leyssenne)
|
||||
Note d'évolution
|
||||
[NOM] 17 : 48 IRMc demandée
|
||||
Motif d'hospitalisation : Bilan de confusion
|
||||
@@ -260,7 +260,7 @@ Antécédents personnels :
|
||||
- Dyslexie et dysorthographie suivi ?
|
||||
Antécédents familiaux : Aucun
|
||||
Traitement en cours : Aucun
|
||||
Histoire de la Pierre-[NOM] 17/04/2023 Allergies connues : Aucune
|
||||
Histoire de la Pierre-Axel 17/04/2023 Allergies connues : Aucune
|
||||
maladie [NOM] 16 : 49
|
||||
Vaccinations : A jour
|
||||
Histoire de la maladie :
|
||||
@@ -271,7 +271,7 @@ cloniques. Intervention du SMUR : fièvre à 38.5°C, conclusion : délire fébr
|
||||
- 15/04 : persistance d'un tableau confusionnel avec propos incohérents, désorientation temporo-
|
||||
spatiale, et apparition de clonies de membres supérieurs. De plus, malaise d'allure vagal avec
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 4 de 25 perte de connaissance brève vers 4h du matin motivant la consultation aux urgences pédiatriques.
|
||||
Pas de diarrhée. Pas de perte de poids.
|
||||
- Aux urgences : apyrétique à l'entrée, hémodynamique stable, pas de détresse respiratoire.
|
||||
@@ -337,7 +337,7 @@ A102628790
|
||||
Synthèse :
|
||||
Traitement de sortie : aucun
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 5 de 25 Points à suivre :
|
||||
- Examen neurologique
|
||||
- Développement psychomoteur
|
||||
@@ -352,7 +352,7 @@ RCA limites
|
||||
Pas de sd cérébelleux
|
||||
paires crâniennes ok
|
||||
Pas de sd méningé
|
||||
Pierre-[NOM] 17/04/2023
|
||||
Pierre-Axel 17/04/2023
|
||||
Note d'évolution pas de déficit senstif, difficulté à la marche peut être léger déficit 4+/5 des releveurs
|
||||
[NOM] 15 : 32
|
||||
=< poursuite aciclovir en attente résultats pcr
|
||||
@@ -405,11 +405,11 @@ Histoire de la 15/04/2023 Traitement en cours : Aucun
|
||||
maladie 14 : 01 Allergies connues : Aucune
|
||||
Vaccinations : A jour
|
||||
Histoire de la maladie :
|
||||
-[NOM] depuis jeudi. Apparition de fièvre vendredi. Vendredi soir : une crise d'environ 5
|
||||
-Vomissements depuis jeudi. Apparition de fièvre vendredi. Vendredi soir : une crise d'environ 5
|
||||
min avec agitation et propos incohérents. Pas de mouvements tonico-cloniques. Intervention du
|
||||
SMUR : fièvre à 38.5°C => délire fébrile.
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 6 de 25 -Ce matin : propos toujours incohérents, quelques clonies des membres supérieurs. 1 malaise
|
||||
d'allure vagal ce matin, avec perte de connaissance brève et retour à la conscience rapide.
|
||||
-Alimentation : un peu d'eau sucrée depuis 48h + une glace à l'eau ce matin. Pas de
|
||||
@@ -474,7 +474,7 @@ respiratoire
|
||||
Notes paramédicales
|
||||
Type de note Nom Date Note
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 7 de 25 [NOM] 20/04/2023
|
||||
Note IDE Patient sortant après passage du Dr [NOM], sera revu en consult
|
||||
[NOM] 18 : 02
|
||||
@@ -546,7 +546,7 @@ hydratation en cours
|
||||
Note IDE [NOM] [NOM]
|
||||
21 : 14 Arrêt ATV. IRM demandé.
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 8 de 25 Neuro : Pas de mouvements anormaux mais reste ralenti.
|
||||
A beaucoup dormi aujourd'hui suite à la prémédication.
|
||||
Douleur : s'est plaint de céphalées. ATG fait vers 17h, mieux ensuite.
|
||||
@@ -616,29 +616,29 @@ BIONOLYTE G5 INJ FPE modifié. Le débit
|
||||
ML par 1 hrs.
|
||||
Voie d`administration : ORALE
|
||||
Statut des prescriptions : Signé
|
||||
PARACETAMOL [NOM] 1 DOSE(S) Pierre-[NOM]
|
||||
PARACETAMOL [NOM] 1 DOSE(S) Pierre-Axel
|
||||
- Normal 18/04/2023 11 : 54 20/04/2023 17:54
|
||||
SOL BUV KILO [NOM]
|
||||
Statut des prescriptions : Réalisé
|
||||
ATARAX 0,2G/100ML
|
||||
- 1 seule fois 1 seule Pierre-[NOM]
|
||||
- 1 seule fois 1 seule Pierre-Axel
|
||||
SIROP FL 200ML [200] 25 mg 18/04/2023 09 : 40 18/04/2023 10:00
|
||||
fois [NOM]
|
||||
Flacon(s)
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 9 de 25 MELATONINE 2MG - 1 seule fois 1 seule DR. [NOM]
|
||||
2 GEL 17/04/2023 12 : 06 17/04/2023 14:36
|
||||
GELULE fois [NOM]
|
||||
MELATONINE -
|
||||
MELATONINE GEL - 1 seule fois 1 seule Pierre-[NOM]
|
||||
MELATONINE GEL - 1 seule fois 1 seule Pierre-Axel
|
||||
6 mg 18/04/2023 09 : 39 18/04/2023 10:00
|
||||
[NOM] [NOM] , fois [NOM]
|
||||
PREMEDIC [NOM] , fois [NOM]
|
||||
AMPPMAN0104
|
||||
MELATONINE -
|
||||
MELATONINE GEL - 1 seule fois 1 seule DR. [NOM]
|
||||
6 mg 20/04/2023 11 : 00 20/04/2023 11:30
|
||||
[NOM] [NOM] , fois [NOM]
|
||||
PREMEDIC [NOM] , fois [NOM]
|
||||
AMPPMAN0104
|
||||
Voie d`administration : RECTALE
|
||||
Statut des prescriptions : Réalisé
|
||||
@@ -718,7 +718,7 @@ TA, FR, T°, Glyc, Miction, Réalisé 4h ... 16h 20h]
|
||||
17 : 53 [NOM]
|
||||
Transit) Normal
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 10 de 25 Notes du
|
||||
professionel
|
||||
10 Jours - Ttes les 3H
|
||||
@@ -734,7 +734,7 @@ TRANSIT/
|
||||
soir nuit Normal 17 : 53 [NOM]
|
||||
SURV
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 11 de 25 Plan de soins Jour J du 20/04/2023 07h00 au 21/04/2023 07h00
|
||||
Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
|
||||
[NOM] [NOM]
|
||||
@@ -811,14 +811,14 @@ Notes de professionel de santé : 09:44
|
||||
Admin le 20/04/2023 à
|
||||
MAX 1G/ INJ
|
||||
15 : 44
|
||||
[NOM] [NOM]-
|
||||
Réalisé — MELATONINE GEL [NOM] [NOM]
|
||||
[NOM] Marie-
|
||||
Réalisé — MELATONINE GEL PREMEDIC [NOM]
|
||||
[NOM] - MG gelule - Dose 6 mg - ORALE - 1 Début le 20/04/2023 à
|
||||
seule fois - 1ère dose : 20/04/2023 @ 11:00 11:00 11:30 * 6 mg
|
||||
Fin le 20/04/2023 à
|
||||
11 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 12 de 25 Admin le 20/04/2023 à
|
||||
11 : 30
|
||||
[NOM] Pierre-
|
||||
@@ -925,7 +925,7 @@ E
|
||||
05 : 54
|
||||
Admin le 20/04/2023 à
|
||||
17 : 54
|
||||
[NOM] [NOM]-
|
||||
[NOM] Marie-
|
||||
[NOM]
|
||||
Réalisé — [NOM] 60MG - 60MG Début le 20/04/2023 à
|
||||
suppositoire - Dose 120 mg - RECTALE - 1 seule 11 : 00 11:30 * 120
|
||||
@@ -966,7 +966,7 @@ Réalisé — DOULEUR : SURV - Ttes les 6h [2h
|
||||
@ 17 : 53 Début le 15/04/2023 à 02:00 * 1
|
||||
Notes de professionel de santé : 17:53
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 13 de 25 Fin le 25/04/2023 à
|
||||
DE 0-6 ans : EVENDOL A PARTIR de 6
|
||||
14 : 00
|
||||
@@ -1043,7 +1043,7 @@ Réalisé — KT COURT : SURV. - Ttes les 8H [6h [NOM] [NOM]
|
||||
Notes de professionel de santé : Fin le 22/04/2023 à
|
||||
14 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 14 de 25 surv perméable/non inflammatoire/pas de Admin le 20/04/2023 à
|
||||
diffusion/pas d'hématome 14 : 00
|
||||
Réalisé — KT COURT : SURV. - Ttes les 8H [6h [NOM] [NOM]
|
||||
@@ -1121,7 +1121,7 @@ Notes de professionel de santé : 17:00
|
||||
" Conscience/pupilles/comportement" Admin le 20/04/2023 à
|
||||
17 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 15 de 25 [NOM] [NOM]
|
||||
Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à
|
||||
3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53
|
||||
@@ -1193,7 +1193,7 @@ Date Début : 15/04/2023 @ 17:53 Fin le 25/04/2023 à 12:00 * 1
|
||||
Admin le 20/04/2023 à
|
||||
12 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 16 de 25 Plan de soins Jour J + 1 du 21/04/2023 07h00 au 22/04/2023 07h00
|
||||
Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
|
||||
[NOM] [NOM]
|
||||
@@ -1288,7 +1288,7 @@ Signé — PARACETAMOL [NOM] SOL BUV - [NOM] Pierre-
|
||||
Fin le 28/04/2023 à
|
||||
05 : 54
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 17 de 25 Admin le 20/04/2023 à
|
||||
17 : 54
|
||||
[NOM] Pierre-
|
||||
@@ -1398,7 +1398,7 @@ Réalisé — [NOM] : SURV. - Ttes les 3H [NOM] [NOM]
|
||||
Fin le 22/04/2023 à
|
||||
17 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 18 de 25 Admin le 20/04/2023 à
|
||||
17 : 00
|
||||
[NOM] [NOM]
|
||||
@@ -1478,7 +1478,7 @@ Admin le 20/04/2023 à
|
||||
diffusion/pas d'hématome
|
||||
14 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 19 de 25 [NOM] [NOM]
|
||||
Réalisé — SIGNES VITAUX (Pls, TA, FR, Début le 15/04/2023 à
|
||||
T°, Glyc, Miction, Transit) - Ttes les 4H [0h 17 : 53
|
||||
@@ -1550,7 +1550,7 @@ Notes de professionel de santé : 17:00
|
||||
" Conscience/pupilles/comportement" Admin le 20/04/2023 à
|
||||
17 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 20 de 25 [NOM] [NOM]
|
||||
Réalisé — SURV. NEUROLOGIQUE TTES LES Début le 15/04/2023 à
|
||||
3H - Ttes les 3H [2h 5h ... 20h 23h] - 10 Jours- 17 : 53
|
||||
@@ -1624,7 +1624,7 @@ Matricule INS :
|
||||
Examen du : 15/04/2023
|
||||
Compte-rendu validé électroniquement par Dr [NOM] le 15/04/2023
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 21 de 25 SCANNER CEREBRAL
|
||||
Indication :
|
||||
Confusion fébrile depuis 48 heures. Recherche de signe d'HTIC avant ponction lombaire
|
||||
@@ -1673,7 +1673,7 @@ Sur les séquences axiales pondérées T2 et FLAIR, on note un respect des struc
|
||||
semble pas exister d'anomalie focalisée du signal de la substance blanche. Le système ventriculaire est en place, de taille normale.
|
||||
Absence de décollement cranio-encéphalique. Jonction cervico-occipitale sans particularité.
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 22 de 25 Dr [NOM]
|
||||
Technique :
|
||||
Cet examen rendu anonyme est accessible sur le site WEB de l'établissement pour une durée de 10 mois : www.ch-cote-basque.fr
|
||||
@@ -1720,7 +1720,7 @@ Cet examen rendu anonyme est accessible sur le site WEB de l'établissement pour
|
||||
N° d'examen : A102628790
|
||||
[DATE_NAISSANCE]
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 23 de 25 Résultats de laboratoire
|
||||
18/04/2023 09 : 45 16/04/2023 20:56 16/04/2023 20:56 16/04/2023 20:56 16/04/2023 20:56
|
||||
Résultat de labo
|
||||
@@ -1790,7 +1790,7 @@ interprété par Dr [NOM]
|
||||
[NOM] 1 3,2 g/l
|
||||
[NOM] 2 2,8 g/l
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 24 de 25 Polynucléaires neutrophiles
|
||||
40,0 % 64,5 %
|
||||
(%)
|
||||
@@ -1858,7 +1858,7 @@ Trou anionique 11
|
||||
Volume plaquettaire moyen 10,0 fl 9,3 fl
|
||||
Compte-rendu CERBA rslt33598833.tif
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (15000536 )
|
||||
Episode N. : [EPISODE] ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Episode N. : 23074384 ( MEDECINE PEDIATRIE - PEDIATRIE GENERALE ) - Taille: 125 cm - Poids: 25.2 kg - IMC: 16.128
|
||||
Le 20/04/2023 18 : 29 Page 25 de 25
|
||||
|
||||
|
||||
@@ -1867,7 +1867,7 @@ Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE]
|
||||
Sexe : Masculin Lieu de naissance: [VILLE]
|
||||
Nationalité : FRANCE [CODE_POSTAL]
|
||||
Adresse : MAISON ST JOSEPH [ADRESSE]: [NOM]
|
||||
Episode No : [EPISODE]
|
||||
Episode No : 23074384
|
||||
Localisation : PEDIATRIE GENERALE Médecin courant: DR. [NOM]
|
||||
Date d'admission : 15/04/2023 Heure d'admission: 13:07
|
||||
Date de sortie : 20/04/2023 Heure de sortie: 18:03
|
||||
@@ -2049,12 +2049,12 @@ Bilan complémentaire ce jour : ionogramme équilibré, EPS normale, TSH normale
|
||||
Anti TPO anti Tyroglobuline en cours AAN en cours
|
||||
PCR multiplex en cours
|
||||
Poursuite surveillance clinique en hospitalisation
|
||||
Note d'évolution : Pierre-[NOM]
|
||||
Note d'évolution : Pierre-Axel
|
||||
[NOM] 17/04/2023
|
||||
17:48 PCR multiplex à réaliser sur le LCR (David Leyssenne)
|
||||
IRMc demandée
|
||||
|
||||
Note d'évolution : Pierre-[NOM]
|
||||
Note d'évolution : Pierre-Axel
|
||||
[NOM] 17/04/2023
|
||||
15:32 Persistance d'un ralentissement idéo moteur avec quelques incohérence temporo spatiales
|
||||
ROTS perçus facilement aux MS mais difficilement trouvés au MI
|
||||
@@ -2255,12 +2255,12 @@ en cours est : 30
|
||||
ML par 1 hrs. [NOM] [NOM]
|
||||
PARACETAMOL [NOM]
|
||||
SOL BUV : 1 DOSE(S)
|
||||
KILO - Normal 18/04/2023 11:54 20/04/2023 17:54 Pierre-[NOM]
|
||||
KILO - Normal 18/04/2023 11:54 20/04/2023 17:54 Pierre-Axel
|
||||
[NOM]
|
||||
ATARAX 0,2G/100ML
|
||||
SIROP FL 200ML [200]
|
||||
Flacon(s) : 25 mg - 1 seule fois 1 seule
|
||||
fois 18/04/2023 09:40 18/04/2023 10:00 Pierre-[NOM]
|
||||
fois 18/04/2023 09:40 18/04/2023 10:00 Pierre-Axel
|
||||
[NOM]
|
||||
|
||||
MELATONINE 2MG
|
||||
@@ -2269,13 +2269,13 @@ fois 17/04/2023 12:06 17/04/2023 14:36 DR. [NOM]
|
||||
[NOM]
|
||||
MELATONINE -
|
||||
MELATONINE GEL
|
||||
[NOM] [NOM] ,
|
||||
PREMEDIC [NOM] ,
|
||||
AMPPMAN0104 : 6 mg - 1 seule fois 1 seule
|
||||
fois 18/04/2023 09:39 18/04/2023 10:00 Pierre-[NOM]
|
||||
fois 18/04/2023 09:39 18/04/2023 10:00 Pierre-Axel
|
||||
[NOM]
|
||||
MELATONINE -
|
||||
MELATONINE GEL
|
||||
[NOM] [NOM] ,
|
||||
PREMEDIC [NOM] ,
|
||||
AMPPMAN0104 : 6 mg - 1 seule fois 1 seule
|
||||
fois 20/04/2023 11:00 20/04/2023 11:30 DR. [NOM]
|
||||
[NOM]
|
||||
@@ -2538,7 +2538,7 @@ DOSE(S)
|
||||
KILO
|
||||
Réalisé — [NOM] 60MG - 60MG
|
||||
suppositoire - Dose 120 mg - RECTALE - 1 seule
|
||||
fois - 1ère dose : 20/04/2023 @ 11:00 [NOM] [NOM]-
|
||||
fois - 1ère dose : 20/04/2023 @ 11:00 [NOM] Marie-
|
||||
[NOM]
|
||||
Début le 20/04/2023 à
|
||||
11:00
|
||||
|
||||
Binary file not shown.
Binary file not shown.
@@ -118,742 +118,4 @@
|
||||
{"page": 19, "kind": "DATE_NAISSANCE", "original": "née le 12/06/1971", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
||||
{"page": 19, "kind": "ETAB", "original": "Service Madame BEDOUET MARIE-LINE", "placeholder": "[MASK]", "bbox_hint": null}
|
||||
{"page": 19, "kind": "NOM", "original": "Marie LACLAU-LACROUTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MARIE-LINE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MARIE-LINE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MARIE-LINE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MARIE-LINE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MARIE-LINE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MARIE-LINE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MARIE-LINE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_EXTRACTED", "original": "MARIE-LINE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
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|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "MATERNOWSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "LACLAU-LACROUTS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "LACLAU", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Margot", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Lou", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "NORAIS", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Jollin", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "MARIE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Virginie", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "CAZENAVE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "JOBERT", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "GONTIER", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Pierre", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Georges", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "MARIE-LINE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "QUESNEL", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "KASPARIAN", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Samuel", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "NAUSEE", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "Marine", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "NOM_GLOBAL", "original": "SEGUES", "placeholder": "[NOM]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "VILLE_GLOBAL", "original": "PARIS", "placeholder": "[VILLE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "VILLE_GLOBAL", "original": "BOUCAU", "placeholder": "[VILLE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64109 BAYONNE CEDEX", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "Code Postal: 64340", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64340", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "CODE_POSTAL_GLOBAL", "original": "64100 BAYONNE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "EPISODE_GLOBAL", "original": "23183041", "placeholder": "[EPISODE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "4 RUE DU PETIT NANOT", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "4 RUE DU PETIT NANOT Ville de résidence", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "4 RUE DU PETIT NANOT\tVille de résidence", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "1, PLACE PEREIRE", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "LOEB BP 8", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ADRESSE_GLOBAL", "original": "13, Avenue de l'Interne J", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "DATE_NAISSANCE_GLOBAL", "original": "Date de naissance: 12/06/1971", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "DATE_NAISSANCE_GLOBAL", "original": "née le 12/06/1971", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "TEL_GLOBAL", "original": "001205621", "placeholder": "[TEL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "TEL_GLOBAL", "original": "06.45.55.95.38", "placeholder": "[TEL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "TEL_GLOBAL", "original": "0617381939", "placeholder": "[TEL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "TEL_GLOBAL", "original": "0634226193", "placeholder": "[TEL]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ETAB_GLOBAL", "original": "unité de Chirurgie hors SC", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
||||
{"page": -1, "kind": "ETAB_GLOBAL", "original": "Service Madame BEDOUET MARIE-LINE", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
||||
|
||||
@@ -11,7 +11,7 @@ Sexe : Féminin Lieu de naissance: [VILLE]
|
||||
Nationalité : FRANCE [CODE_POSTAL]
|
||||
Adresse : [ADRESSE]: [NOM]
|
||||
Détails épisode
|
||||
Episode No : [EPISODE]
|
||||
Episode No : 23183041
|
||||
Localisation : CHIRURGIE VISCERALE Médecin courant: DR. [NOM]
|
||||
Date d'admission : 22/09/2023 Heure d'admission: 19:22
|
||||
Date de sortie : 25/09/2023 Heure de sortie: 13:49
|
||||
@@ -63,7 +63,7 @@ Date de sortie des urgences 23/09/2023
|
||||
Heure de sortie des Urgences 01 : 46
|
||||
US de destination US Chirurgie Viscérale
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 1 de 20 UF de destination CHIRURGIE VISCERALE
|
||||
Diagnostic aux urgences
|
||||
Type Etat Code Date
|
||||
@@ -140,7 +140,7 @@ Transit Gaz Gaz Absence Gaz Absence Absence Absence Absence Absence
|
||||
Observations médicales
|
||||
Type d'observation Nom Date Commentaires
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 2 de 20 Paul [NOM] 25/09/2023
|
||||
Note d'évolution ATBg en cours
|
||||
[NOM] 09 : 33
|
||||
@@ -213,7 +213,7 @@ Pas de troubles du transit
|
||||
Pas de prise d'OH
|
||||
Pas d'atcd de calcul biliaire ou rénal
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 3 de 20 Antécédents
|
||||
Bypass gastrique
|
||||
Traitements
|
||||
@@ -273,7 +273,7 @@ surveillance 08 : 19 23:51 15:22 09:15 05:16 23:00 20:22 18:00 08:57 04:14 01:54
|
||||
Température 36,30 37,10 36,40 37,50 37 36,60 36,90 37 35,90 35,70 35,60 35,30 35,30
|
||||
Pouls 81 78 76 76 70 75 72 78 63 82 66
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 4 de 20 PA
|
||||
107 144 120 106 109 107 110 125 136 143 143
|
||||
Systolique
|
||||
@@ -342,7 +342,7 @@ Digestif :
|
||||
-Absence de nausées/rots/vomissements
|
||||
Elimination :
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 5 de 20 -à uriné
|
||||
Hmd :
|
||||
-Constantes stables
|
||||
@@ -407,7 +407,7 @@ santé : à diluer
|
||||
dans 100ML de
|
||||
NACL ou G5%
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 6 de 20 METOCLOPRAMIDE CHL Le débit en cours
|
||||
REN 10MG/2ML INJ [100] 1 AMP - Normal 22/09/2023 21 : 48 25/09/2023 05:50 est : 6 ML par 1 [NOM] [NOM]
|
||||
Ampoule(s) hrs.
|
||||
@@ -496,13 +496,13 @@ collection
|
||||
23/09/2023 01 : 30 Hémoculture Flacons 3 et 4 [NOM] [NOM]
|
||||
01 : 33
|
||||
Pièce opératoire ( Atlantic- 23/09/2023
|
||||
23/09/2023 16 : 16 [NOM] [NOM]
|
||||
23/09/2023 16 : 16 [NOM] COATSALIOU
|
||||
Pathologie) 16 : 16
|
||||
Ionogramme ( Na, K, CL, créat,
|
||||
25/09/2023 08 : 07 Paul [NOM] [NOM]
|
||||
glucose )
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 7 de 20 Transaminases ASAT + ALAT sang
|
||||
25/09/2023 08 : 07 Paul [NOM] [NOM]
|
||||
( dosage )
|
||||
@@ -595,7 +595,7 @@ Transaminases ASAT + 25/09/2023 Paul [NOM]
|
||||
Signé - Presc. de Sortie
|
||||
ALAT sang ( dosage ) 08 : 07 [NOM]
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 8 de 20 Plan de soins Jour J du 25/09/2023 07h00 au 26/09/2023 07h00
|
||||
Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
|
||||
Signé — CEFOTAXIME PAN 1 G PDR INJ - [NOM] [NOM]
|
||||
@@ -681,7 +681,7 @@ Signé — PHLOROGLUCINOL ARW
|
||||
solution (4 mL) - Dose 80 mg - sur 20 min - Début le 23/09/2023 à mg
|
||||
INTRAVEINEUSE Discontinue - Toutes les 6 00 : 33
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 9 de 20 Heure(s) Si besoin - Début presc. : 23/09/2023 @
|
||||
00 : 33 Fin le 24/10/2023 à
|
||||
si douleur abdo 02 : 35
|
||||
@@ -767,7 +767,7 @@ Signé — OXYNORMORO 10MG CPR DISP
|
||||
Toutes les 2 Heure(s) Si besoin - Début presc. : Début le 23/09/2023 à CPR
|
||||
23/09/2023 @ 01 : 30 01:30
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 10 de 20 Fin le 26/09/2023 à
|
||||
si douleur intense non soulagée par paracetamol 01 : 53
|
||||
Admin le 25/09/2023 à
|
||||
@@ -861,7 +861,7 @@ e 23/10/2023 à
|
||||
1 G2 E : 0 L0 * 2
|
||||
12 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 11 de 20 Admin le 25/09/2023 à
|
||||
12 : 00
|
||||
[NOM] [NOM]
|
||||
@@ -937,7 +937,7 @@ Réalisé — LIT : REFECTION COMPLETE [NOM] Xabi
|
||||
23/09/2023 @ 07 : 00 Début le 23/09/2023 à 08:00 * 1
|
||||
07 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 12 de 20 Fin le 29/09/2023 à
|
||||
08 : 00
|
||||
Admin le 25/09/2023 à
|
||||
@@ -1011,7 +1011,7 @@ Réalisé — DOULEUR : SURV - Ttes les 6h [2h Début le 23/09/2023 à
|
||||
Admin le 25/09/2023 à
|
||||
08 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 13 de 20 Plan de soins Jour J + 1 du 26/09/2023 07h00 au 27/09/2023 07h00
|
||||
Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
|
||||
Signé — CEFOTAXIME PAN 1 G PDR INJ - [NOM] [NOM]
|
||||
@@ -1093,7 +1093,7 @@ si douleur abdo Admin le 25/09/2023 à
|
||||
08 : 35
|
||||
Notes de professionel de santé :
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 14 de 20 A préparer dans 100 mL de NaCl 0,9%
|
||||
Signé — PHLOROGLUCINOL ARW
|
||||
40 MG/0,04 MG INJ - 40MG + 0.04MG [NOM] [NOM]
|
||||
@@ -1190,7 +1190,7 @@ midi soir - 1ère dose : 23/09/2023 @ 19:00 15:11 CPR
|
||||
Fin le 23/10/2023 à
|
||||
12 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 15 de 20 Admin le 25/09/2023 à
|
||||
12 : 00
|
||||
[NOM] [NOM]
|
||||
@@ -1265,7 +1265,7 @@ goûter soir - pendant 7 Jour(s)- Date Début : 07:00
|
||||
Admin le 25/09/2023 à
|
||||
12 : 00
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 16 de 20 [NOM] Xabi
|
||||
[NOM]
|
||||
Réalisé — REPAS : AUTONOME - Matin midi Début le 24/09/2023 à
|
||||
@@ -1338,7 +1338,7 @@ Compte-rendu validé électroniquement par RAOULT Julien le 23/09/2023
|
||||
SCANNER ABDOMINO-PELVIEN
|
||||
Indication :
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 17 de 20 : 52 ans
|
||||
Recherche : perforation? saignement ?
|
||||
Protocole :
|
||||
@@ -1399,7 +1399,7 @@ Sensible Sensible
|
||||
CEFOTAXIME CEFOTAXIME
|
||||
Sensible Sensible
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 18 de 20 CEFTAZIDIME CEFTAZIDIME
|
||||
Sensible Sensible
|
||||
ERTAPENEME ERTAPENEME
|
||||
@@ -1479,7 +1479,7 @@ Non conformité validé initialement par
|
||||
responsabilité du biologiste
|
||||
Lettres
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 19 de 20 Date
|
||||
Type Texte Utilisateur
|
||||
d'impression
|
||||
@@ -1501,7 +1501,7 @@ Bien confraternellement.
|
||||
DR. [NOM]
|
||||
10101421062
|
||||
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] (10027557 )
|
||||
Episode N. : [EPISODE] ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Episode N. : 23183041 ( CHIRURGIE VISCERALE - CHIRURGIE VISCERALE ) - Taille: 157 cm - Poids: 69 kg - IMC: 27.993
|
||||
Le 25/09/2023 15 : 33 Page 20 de 20
|
||||
|
||||
|
||||
@@ -1510,7 +1510,7 @@ Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE]
|
||||
Sexe : Féminin Lieu de naissance: [VILLE]
|
||||
Nationalité : FRANCE [CODE_POSTAL]
|
||||
Adresse : [ADRESSE]: [NOM]
|
||||
Episode No : [EPISODE]
|
||||
Episode No : 23183041
|
||||
Localisation : CHIRURGIE VISCERALE Médecin courant: DR. [NOM]
|
||||
Date d'admission : 22/09/2023 Heure d'admission: 19:22
|
||||
Date de sortie : 25/09/2023 Heure de sortie: 13:49
|
||||
@@ -1934,7 +1934,7 @@ collection Note
|
||||
23/09/2023 : 01:30 Hémoculture Flacons 3 et 4 [NOM] [NOM] 23/09/2023
|
||||
01:33
|
||||
23/09/2023 : 16:16 Pièce opératoire ( Atlantic-
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||||
Pathologie) [NOM] [NOM] 23/09/2023
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||||
Pathologie) [NOM] COATSALIOU 23/09/2023
|
||||
16:16
|
||||
25/09/2023 : 08:07 Ionogramme ( Na, K, CL, créat,
|
||||
glucose ) Paul [NOM] [NOM]
|
||||
|
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Binary file not shown.
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Reference in New Issue
Block a user