fix(phase2): Élimination FP cross-line + word boundaries — 0 fuite, 0 FP médical

- Remplace \s+ par [ \t]+ dans 11 regex d'extraction de noms (empêche capture cross-line de médicaments)
- Ajoute \b word boundaries dans RE_PERSON_CONTEXT (empêche "PDR" de matcher "DR")
- Ajoute filtrage _MEDICAL_STOP_WORDS_SET dans selective_rescan._rescan_person
- Ajoute stop words : labos pharma (MYL/VTS/ARW/PAN/MSO), dosages (FAIBLE/FORT), anatomie imagerie (CEREBRAL/ABDOMINO-PELVIEN)
- Filtre stop words dans _add_name_force et _add_tokens_force_first
- Mise à jour baseline regression_tests/ avec 29 fichiers du batch audit 30

Co-Authored-By: Claude Opus 4.6 <noreply@anthropic.com>
This commit is contained in:
2026-03-08 11:24:22 +01:00
parent e967a67052
commit 8629a0cda0
91 changed files with 64855 additions and 47367 deletions

View File

@@ -191,7 +191,8 @@ RE_EMAIL = re.compile(r"[A-Za-z0-9._%+-]+@[A-Za-z0-9.-]+\.[A-Za-z]{2,}")
RE_TEL = re.compile(r"(?<!\d)(?:\+33\s?|0)\d(?:[\s.\-]?\d){8}(?!\d)") RE_TEL = re.compile(r"(?<!\d)(?:\+33\s?|0)\d(?:[\s.\-]?\d){8}(?!\d)")
RE_TEL_COMPACT = re.compile(r"(?<!\d)0[1-9]\d{8}(?!\d)") RE_TEL_COMPACT = re.compile(r"(?<!\d)0[1-9]\d{8}(?!\d)")
RE_IBAN = re.compile(r"\b[A-Z]{2}\d{2}(?:\s?[A-Z0-9]{4}){3,7}(?:\s?[A-Z0-9]{1,4})\b") RE_IBAN = re.compile(r"\b[A-Z]{2}\d{2}(?:\s?[A-Z0-9]{4}){3,7}(?:\s?[A-Z0-9]{1,4})\b")
RE_IPP = re.compile(r"\bIPP\s*[:\-]?\s*([A-Za-z0-9]{6,})\b", re.IGNORECASE) RE_IPP = re.compile(r"\b(?:I\.?P\.?P\.?|IPP|N°\s*Ipp)\s*[:\-]?\s*([A-Za-z0-9]{6,})\b", re.IGNORECASE)
RE_CSULT = re.compile(r"\b(?:N°\s*Csult|N°\s*Interv)\s*[:\-]?\s*(\d{6,})\b", re.IGNORECASE)
RE_FINESS = re.compile(r"\b(?:N°\s*)?FINESS?\s*[:\-]?\s*(\d{9})\b", re.IGNORECASE) RE_FINESS = re.compile(r"\b(?:N°\s*)?FINESS?\s*[:\-]?\s*(\d{9})\b", re.IGNORECASE)
RE_OGC = re.compile(r"\b(?:N°\s*)?OGC\s*[:\-]?\s*([A-Za-z0-9\-]{1,})\b", re.IGNORECASE) RE_OGC = re.compile(r"\b(?:N°\s*)?OGC\s*[:\-]?\s*([A-Za-z0-9\-]{1,})\b", re.IGNORECASE)
RE_RPPS = re.compile(r"\b(?:N°\s*)?RPPS\s*[:\-]?\s*(\d{8,11})\b", re.IGNORECASE) RE_RPPS = re.compile(r"\b(?:N°\s*)?RPPS\s*[:\-]?\s*(\d{8,11})\b", re.IGNORECASE)
@@ -294,8 +295,12 @@ _MEDICAL_STOP_WORDS_SET = {
"meropenem", "imipenem", "clindamycine", "doxycycline", "meropenem", "imipenem", "clindamycine", "doxycycline",
"azithromycine", "clarithromycine", "cotrimoxazole", "bactrim", "azithromycine", "clarithromycine", "cotrimoxazole", "bactrim",
"polyionique", "propranolol", "apidra", "solostar", "polyionique", "propranolol", "apidra", "solostar",
# Suffixes laboratoires pharmaceutiques # Noms et suffixes laboratoires pharmaceutiques
"arw", "myl", "myp", "arg", "teva", "bga", "agt", "arw", "myl", "myp", "arg", "teva", "bga", "agt",
"mylan", "biogaran", "arrow", "sandoz", "zentiva", "cristers",
"accord", "viatris", "ranbaxy", "ratiopharm", "almus", "qualimed",
"evolugen", "alter", "zydus", "medisol", "substipharm",
"sdz", "bgr", "egt", "rnb",
# Formes galéniques / voies d'administration # Formes galéniques / voies d'administration
"cpr", "sachet", "orale", "oral", "sol", "buv", "stylo", "flexpen", "cpr", "sachet", "orale", "oral", "sol", "buv", "stylo", "flexpen",
"flestouch", "kwikpen", "inj", "susp", "gelule", "comprime", "flestouch", "kwikpen", "inj", "susp", "gelule", "comprime",
@@ -374,6 +379,9 @@ _MEDICAL_STOP_WORDS_SET = {
"montelukast", "rosuvastatine", "montelukast", "rosuvastatine",
# Abréviations pharma courtes # Abréviations pharma courtes
"cpr", "sol", "bic", "agt", "poche", "inhal", "cpr", "sol", "bic", "agt", "poche", "inhal",
# Termes chirurgicaux/cliniques FP
"cure", "endocrine", "operatoire", "opératoire", "realisee", "réalisée",
"gauche", "droit", "droite", "face", "profil",
# Faux positifs EDS supplémentaires # Faux positifs EDS supplémentaires
"psy", "inhales", "inhalés", "kwikpen", "lansoprazole", "tiorfan", "smecta", "psy", "inhales", "inhalés", "kwikpen", "lansoprazole", "tiorfan", "smecta",
"axa", "ttt", "anionique", "abdomino", "cod", "omi", "urg", "med", "axa", "ttt", "anionique", "abdomino", "cod", "omi", "urg", "med",
@@ -444,6 +452,20 @@ _MEDICAL_STOP_WORDS_SET = {
"thermie", "alim", "alimentation", "admin", "thermie", "alim", "alimentation", "admin",
# Médicaments/tests labo capturés par patterns soignants # Médicaments/tests labo capturés par patterns soignants
"biprofenid", "bi-profenid", "phosphatase", "phosphatases", "biprofenid", "bi-profenid", "phosphatase", "phosphatases",
"ecbu", "suppo", "suppositoire", "mucite", "microlax", "normacol",
"ciprofloxacine", "lavement", "desinfection", "désinfection",
"avaler", "rachis", "lombaire", "thoraco-lombaire",
"cérébrale", "cerebrale", "cérébral", "cerebral", "hépatique", "hepatique",
"thoracique", "abdominale", "abdominal", "pelvienne", "pelvien", "médullaire",
# Dosages et labos pharma (FP fréquents dans prescriptions Trackare)
"faible", "fort", "forte",
"myl", "mylan", "sandoz", "teva", "arrow", "biogaran", "zentiva", "eg",
"arw", "pan", "mso", "bgn", "ratiopharm", "accord", "vts", "viatris",
"abdomino-pelvien", "abdomino", "pelvien", "thoraco-abdominal",
"entree", "entrée", "continu", "continue",
"morphine", "claforan", "skenan", "actiskenan",
# Fragments de noms de médicaments (pdfplumber split)
"sium", "pegic", "fenid", "profenid",
# Termes structurels trackare # Termes structurels trackare
"transmissions", "transmission", "releve", "relevé", "transmissions", "transmission", "releve", "relevé",
"objectif", "objectifs", "evaluation", "évaluation", "objectif", "objectifs", "evaluation", "évaluation",
@@ -507,11 +529,11 @@ _MEDICAL_STOP_WORDS = (
# Un token de nom : commence par majuscule, lettres/tirets/apostrophes (PAS d'espace ni de point) # Un token de nom : commence par majuscule, lettres/tirets/apostrophes (PAS d'espace ni de point)
_PERSON_TOKEN = r"[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇa-zéèàùâêîôûäëïöüç\-\']+" _PERSON_TOKEN = r"[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇa-zéèàùâêîôûäëïöüç\-\']+"
RE_PERSON_CONTEXT = re.compile( RE_PERSON_CONTEXT = re.compile(
r"(?:(?:Dr\.?|DR\.?|Docteur|Pr\.?|Professeur|Mme|MME|Madame|M\.|Mr\.?|Monsieur" r"(?:(?:\bDr\.?|\bDR\.?|\bDocteur|\bPr\.?|\bProfesseur|\bMme|\bMME|\bMadame|\bM\.|\bMr\.?|\bMonsieur"
r"|Nom\s*:\s*" r"|\bNom[ \t]*:[ \t]*"
r"|Rédigé\s+par|Validé\s+par|Signé\s+par|Saisi\s+par|Réalisé\s+par" r"|\bRédigé[ \t]+par|\bValidé[ \t]+par|\bSigné[ \t]+par|\bSaisi[ \t]+par|\bRéalisé[ \t]+par"
r")\s+)" r")[ \t]+)"
rf"({_PERSON_TOKEN}(?:\s+{_PERSON_TOKEN}){{0,2}})" # Max 3 mots rf"({_PERSON_TOKEN}(?:[ \t]+{_PERSON_TOKEN}){{0,2}})" # Max 3 mots, pas de newline
) )
# Noms en MAJUSCULES dans des listes virgulées (ex: "le Dr X, Y, LAZARO") # Noms en MAJUSCULES dans des listes virgulées (ex: "le Dr X, Y, LAZARO")
@@ -561,8 +583,8 @@ RE_EXTRACT_CONTACT = re.compile(
r"(?:\s+([A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇa-zéèàùâêîôûäëïöüç\-\']+))?", r"(?:\s+([A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇa-zéèàùâêîôûäëïöüç\-\']+))?",
) )
RE_EXTRACT_REDIGE = re.compile( RE_EXTRACT_REDIGE = re.compile(
r"(?:Rédigé|Validé|Signé|Saisi)\s+par\s+" r"(?:Rédigé|Validé|Signé|Saisi)[ \t]+par[ \t]+"
rf"((?:{_UC_NAME_TOKEN})(?:\s+(?:{_UC_NAME_TOKEN}))*)", rf"((?:{_UC_NAME_TOKEN})(?:[ \t]+(?:{_UC_NAME_TOKEN})){{0,2}})",
) )
# Token nom composé : JEAN-PIERRE, CAZELLES-BOUDIER, etc. # Token nom composé : JEAN-PIERRE, CAZELLES-BOUDIER, etc.
_UC_COMPOUND = r"[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,}(?:-[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,})*" _UC_COMPOUND = r"[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,}(?:-[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,})*"
@@ -573,22 +595,34 @@ RE_EXTRACT_MME_MR = re.compile(
) )
_INITIAL_OPT = r"(?:[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]\.\s*(?:-?\s*[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]\.\s*)?)?" _INITIAL_OPT = r"(?:[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]\.\s*(?:-?\s*[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]\.\s*)?)?"
RE_EXTRACT_DR_DEST = re.compile( RE_EXTRACT_DR_DEST = re.compile(
r"(?:DR\.?|Dr\.?|Docteur)\s+" r"(?:DR\.?|Dr\.?|Docteur)[ \t]+"
+ _INITIAL_OPT + + _INITIAL_OPT +
rf"((?:{_UC_NAME_TOKEN})(?:\s+(?:{_UC_NAME_TOKEN}))*)", rf"((?:{_UC_NAME_TOKEN})(?:[ \t]+(?:{_UC_NAME_TOKEN})){{0,2}})",
) )
# Noms du personnel médical après un rôle : "Aide : Marie-Paule BORDABERRY" # Noms du personnel médical après un rôle : "Aide : Marie-Paule BORDABERRY"
RE_EXTRACT_STAFF_ROLE = re.compile( RE_EXTRACT_STAFF_ROLE = re.compile(
r"(?:Aide|Infirmière?|IDE|IADE|IBODE|ASH?|Cadre\s+Infirmier" r"(?:Aide|Infirmière?|IDE|IADE|IBODE|ASH?|Cadre[ \t]+Infirmier"
r"|Prescripteur|Prescrit\s+par|Exécut[ée]\s+par|Réalisé\s+par)\s*:?\s*" r"|Prescripteur|Prescrit[ \t]+par|Exécut[ée][ \t]+par|Réalisé[ \t]+par)[ \t]*:?[ \t]*"
r"((?:[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][a-zéèàùâêîôûäëïöüç]+(?:\s*-\s*[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][a-zéèàùâêîôûäëïöüç]+)?\s+)?" r"((?:[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][a-zéèàùâêîôûäëïöüç]+(?:[ \t]*-[ \t]*[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][a-zéèàùâêîôûäëïöüç]+)?[ \t]+)?"
r"(?:[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,}[\-]?)(?:[\s\-]+[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,}){0,2})", r"(?:[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,}[\-]?)(?:[ \t\-]+[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,}){0,2})",
) )
# "Pr DUVAL", "Pr. J.-M. DUVAL", "Professeur DUVAL" # "Pr DUVAL", "Pr. J.-M. DUVAL", "Professeur DUVAL"
RE_EXTRACT_PR = re.compile( RE_EXTRACT_PR = re.compile(
r"(?:Pr\.?|Professeur)\s+" r"(?:Pr\.?|Professeur)[ \t]+"
+ _INITIAL_OPT + + _INITIAL_OPT +
rf"((?:{_UC_NAME_TOKEN})(?:\s+(?:{_UC_NAME_TOKEN}))*)", rf"((?:{_UC_NAME_TOKEN})(?:[ \t]+(?:{_UC_NAME_TOKEN})){{0,2}})",
)
# "Opérateur : Docteur X. NOM", "Anesthésiste(s) Docteur J. NOM",
# "Opérateur : Dr J.-M. NOM", "Anesthésiste : NOM"
RE_EXTRACT_OPERATEUR = re.compile(
r"(?:Op[ée]rateur|Anesth[ée]siste\(?s?\)?|Chirurgien)[ \t]*:?[ \t]*"
r"(?:(?:Docteur|Dr\.?|Pr\.?)[ \t]+)?"
+ _INITIAL_OPT +
rf"((?:{_UC_COMPOUND})(?:[ \t]+(?:{_UC_COMPOUND})){{0,2}})",
)
# Téléphone avec extension slash : 05.59.44.38.32/34
RE_TEL_SLASH = re.compile(
r"(?<!\d)(?:\+33\s?|0)\d(?:[\s.\-]?\d){8}(?:/\d{1,4})(?!\d)"
) )
CID_PATTERN = re.compile(r"\(cid:\d+\)") CID_PATTERN = re.compile(r"\(cid:\d+\)")
@@ -596,7 +630,7 @@ CID_PATTERN = re.compile(r"\(cid:\d+\)")
# --- Nouvelles regex : dates, adresses, âges, dossiers --- # --- Nouvelles regex : dates, adresses, âges, dossiers ---
_MOIS_FR = r"(?:janvier|février|mars|avril|mai|juin|juillet|août|septembre|octobre|novembre|décembre)" _MOIS_FR = r"(?:janvier|février|mars|avril|mai|juin|juillet|août|septembre|octobre|novembre|décembre)"
RE_DATE_NAISSANCE = re.compile( RE_DATE_NAISSANCE = re.compile(
r"(?:n[ée]+\s+le|date\s+de\s+naissance|DDN)\s*[:\-]?\s*" r"(?:\bn[ée]+(?:\(?e?\)?)?\s+le|date\s+de\s+naissance|DDN)\s*[:\-]?\s*"
r"(\d{1,2}[\s/.\-]\d{1,2}[\s/.\-]\d{2,4}|\d{1,2}\s+" + _MOIS_FR + r"\s+\d{4})", r"(\d{1,2}[\s/.\-]\d{1,2}[\s/.\-]\d{2,4}|\d{1,2}\s+" + _MOIS_FR + r"\s+\d{4})",
re.IGNORECASE, re.IGNORECASE,
) )
@@ -947,6 +981,10 @@ def _mask_admin_label(line: str, audit: List[PiiHit], page_idx: int) -> str:
if m: if m:
val = m.group(1); audit.append(PiiHit(page_idx, "IPP", val, PLACEHOLDERS["IPP"])) val = m.group(1); audit.append(PiiHit(page_idx, "IPP", val, PLACEHOLDERS["IPP"]))
return RE_IPP.sub(lambda _: f"IPP : {PLACEHOLDERS['IPP']}", line) return RE_IPP.sub(lambda _: f"IPP : {PLACEHOLDERS['IPP']}", line)
m = RE_CSULT.search(line)
if m:
val = m.group(1); audit.append(PiiHit(page_idx, "DOSSIER", val, PLACEHOLDERS["DOSSIER"]))
return RE_CSULT.sub(lambda _: f"N° : {PLACEHOLDERS['DOSSIER']}", line)
m = RE_RPPS.search(line) m = RE_RPPS.search(line)
if m: if m:
val = m.group(1); audit.append(PiiHit(page_idx, "RPPS", val, PLACEHOLDERS["RPPS"])) val = m.group(1); audit.append(PiiHit(page_idx, "RPPS", val, PLACEHOLDERS["RPPS"]))
@@ -975,6 +1013,7 @@ def _mask_line_by_regex(line: str, audit: List[PiiHit], page_idx: int, cfg: Dict
def _repl_tel(m: re.Match) -> str: def _repl_tel(m: re.Match) -> str:
audit.append(PiiHit(page_idx, "TEL", m.group(0), PLACEHOLDERS["TEL"])) audit.append(PiiHit(page_idx, "TEL", m.group(0), PLACEHOLDERS["TEL"]))
return PLACEHOLDERS["TEL"] return PLACEHOLDERS["TEL"]
line = RE_TEL_SLASH.sub(_repl_tel, line) # slash d'abord (plus spécifique)
line = RE_TEL.sub(_repl_tel, line) line = RE_TEL.sub(_repl_tel, line)
line = RE_TEL_COMPACT.sub(_repl_tel, line) line = RE_TEL_COMPACT.sub(_repl_tel, line)
@@ -1140,6 +1179,7 @@ def _mask_critical_in_key(key: str, audit: List[PiiHit], page_idx: int) -> str:
def _repl_tel(m: re.Match) -> str: def _repl_tel(m: re.Match) -> str:
audit.append(PiiHit(page_idx, "TEL", m.group(0), PLACEHOLDERS["TEL"])) audit.append(PiiHit(page_idx, "TEL", m.group(0), PLACEHOLDERS["TEL"]))
return PLACEHOLDERS["TEL"] return PLACEHOLDERS["TEL"]
key = RE_TEL_SLASH.sub(_repl_tel, key)
key = RE_TEL.sub(_repl_tel, key) key = RE_TEL.sub(_repl_tel, key)
key = RE_TEL_COMPACT.sub(_repl_tel, key) key = RE_TEL_COMPACT.sub(_repl_tel, key)
def _repl_email(m: re.Match) -> str: def _repl_email(m: re.Match) -> str:
@@ -1200,6 +1240,9 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
return return
if tok.lower() in _FORCE_EXCLUDE: if tok.lower() in _FORCE_EXCLUDE:
return return
# Filtre supplémentaire : ne pas force-add les mots médicaux connus
if tok.lower() in _MEDICAL_STOP_WORDS_SET:
return
names.add(tok) names.add(tok)
force_names.add(tok) force_names.add(tok)
@@ -1324,10 +1367,10 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
# --- Noms soignants sur la même ligne que "Note d'évolution" (ex: "Note d'évolution LACLAU-") --- # --- Noms soignants sur la même ligne que "Note d'évolution" (ex: "Note d'évolution LACLAU-") ---
for m in re.finditer( for m in re.finditer(
r"Note\s+(?:IDE|AS|d'[ée]volution|m[ée]dicale|kin[ée])\s+" r"Note[ \t]+(?:IDE|AS|d'[ée]volution|m[ée]dicale|kin[ée])[ \t]+"
r"(?:DR\.?\s+)?" r"(?:DR\.?[ \t]+)?"
r"([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]+)" r"([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]+)"
r"(?:\s+([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]+))?", r"(?:[ \t]+([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]+))?",
full_text full_text
): ):
for g in (m.group(1), m.group(2)): for g in (m.group(1), m.group(2)):
@@ -1337,9 +1380,10 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
_add_name_force(tok) _add_name_force(tok)
# --- "Signé" suivi directement d'un nom de soignant (ex: "Signé LARRIEU-") --- # --- "Signé" suivi directement d'un nom de soignant (ex: "Signé LARRIEU-") ---
# IMPORTANT: [ \t]+ (pas \s+) pour éviter de capturer les médicaments sur la ligne suivante
for m in re.finditer( for m in re.finditer(
r"Signé\s+(?!—|par\b)([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]+)" r"Signé[ \t]+(?!—|par\b)([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]+)"
r"(?:\s+([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]+))?", r"(?:[ \t]+([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]+))?",
full_text full_text
): ):
for g in (m.group(1), m.group(2)): for g in (m.group(1), m.group(2)):
@@ -1350,9 +1394,9 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
# --- "Signé —" + médicament + nom soignant (ex: "Signé — PARACETAMOL BBM 1000 MG INJ NARZABAL") --- # --- "Signé —" + médicament + nom soignant (ex: "Signé — PARACETAMOL BBM 1000 MG INJ NARZABAL") ---
for m in re.finditer( for m in re.finditer(
r"Signé\s+—\s+.*(?:INJ|COMP|GEL|PDR|SOL|PERF|SUSP|CAPS|CREM|SACHET|SIROP)\s+[-]?\s*" r"Signé[ \t]+—[ \t]+.*(?:INJ|COMP|GEL|PDR|SOL|PERF|SUSP|CAPS|CREM|SACHET|SIROP)[ \t]+[-]?[ \t]*"
r"([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]{2,})" r"([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]{2,})"
r"(?:\s+([A-ZÉÈÀÙÂÊÎÔÛ][a-zéèàùâêîôûäëïöüç]{2,}))?", r"(?:[ \t]+([A-ZÉÈÀÙÂÊÎÔÛ][a-zéèàùâêîôûäëïöüç]{2,}))?",
full_text full_text
): ):
for g in (m.group(1), m.group(2)): for g in (m.group(1), m.group(2)):
@@ -1363,7 +1407,7 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
# --- Noms soignants après conditionnement médicament (ex: "Flacon(s) LACROUTS") --- # --- Noms soignants après conditionnement médicament (ex: "Flacon(s) LACROUTS") ---
for m in re.finditer( for m in re.finditer(
r"(?:Flacon|Ampoule|Seringue|Poche|Comprim[ée]|Gélule|Sachet)(?:\(s\))?\s+" r"(?:Flacon|Ampoule|Seringue|Poche|Comprim[ée]|Gélule|Sachet)(?:\(s\))?[ \t]+"
r"([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]{2,})", r"([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]{2,})",
full_text full_text
): ):
@@ -1373,8 +1417,8 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
# --- "DR." / "DR" suivi d'un prénom seul (ex: "DR. Ute", "DR. Tam") dans les prescriptions --- # --- "DR." / "DR" suivi d'un prénom seul (ex: "DR. Ute", "DR. Tam") dans les prescriptions ---
for m in re.finditer( for m in re.finditer(
r"DR\.?\s+([A-ZÉÈÀÙÂÊÎÔÛ][a-zéèàùâêîôûäëïöüç]{2,})" r"DR\.?[ \t]+([A-ZÉÈÀÙÂÊÎÔÛ][a-zéèàùâêîôûäëïöüç]{2,})"
r"(?:\s+([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]+))?", r"(?:[ \t]+([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]+))?",
full_text full_text
): ):
for g in (m.group(1), m.group(2)): for g in (m.group(1), m.group(2)):
@@ -1387,9 +1431,9 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
# Format Trackare : actions de soins suivies de "HH:MM NOM" ou "HH : MM NOM" # Format Trackare : actions de soins suivies de "HH:MM NOM" ou "HH : MM NOM"
# Pattern restrictif : nom ALL-CAPS de 4+ lettres, filtre stop words (pattern bruyant) # Pattern restrictif : nom ALL-CAPS de 4+ lettres, filtre stop words (pattern bruyant)
for m in re.finditer( for m in re.finditer(
r"\d{1,2}\s*:\s*\d{2}\s+" r"\d{1,2}[ \t]*:[ \t]*\d{2}[ \t]+"
r"([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛ\-]{3,})" r"([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛ\-]{3,})"
r"(?:\s+([A-ZÉÈÀÙÂÊÎÔÛ][a-zéèàùâêîôûäëïöüç]{2,}))?", r"(?:[ \t]+([A-ZÉÈÀÙÂÊÎÔÛ][a-zéèàùâêîôûäëïöüç]{2,}))?",
full_text full_text
): ):
for g in (m.group(1), m.group(2)): for g in (m.group(1), m.group(2)):
@@ -1415,13 +1459,15 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
return filtered, hits, force_names return filtered, hits, force_names
def _extract_document_names(full_text: str, cfg: Dict[str, Any]) -> set: def _extract_document_names(full_text: str, cfg: Dict[str, Any]) -> Tuple[set, set]:
"""Pré-scan du document brut pour extraire les noms de personnes """Pré-scan du document brut pour extraire les noms de personnes
depuis les champs structurés (Patient, Rédigé par, etc.). depuis les champs structurés (Patient, Rédigé par, etc.).
Retourne un ensemble de tokens (mots) à masquer globalement.""" Retourne (names, force_names) : ensemble de tokens à masquer,
et sous-ensemble qui bypass les stop words."""
wl_sections = set((cfg.get("whitelist", {}) or {}).get("sections_titres", []) or []) wl_sections = set((cfg.get("whitelist", {}) or {}).get("sections_titres", []) or [])
wl_phrases = set((cfg.get("whitelist", {}) or {}).get("noms_maj_excepts", []) or []) wl_phrases = set((cfg.get("whitelist", {}) or {}).get("noms_maj_excepts", []) or [])
names: set = set() names: set = set()
force_names: set = set()
def _add_tokens(match_str: str): def _add_tokens(match_str: str):
for token in match_str.split(): for token in match_str.split():
@@ -1434,6 +1480,17 @@ def _extract_document_names(full_text: str, cfg: Dict[str, Any]) -> set:
continue continue
names.add(token) names.add(token)
def _add_tokens_force_all(match_str: str):
"""Bypass stop words pour TOUS les tokens (contexte Patient: très fiable)."""
for token in match_str.split():
token = token.strip(" .-'")
if len(token) < 2:
continue
if token.upper() in wl_sections or token in wl_phrases:
continue
names.add(token)
force_names.add(token)
def _add_tokens_force_first(match_str): def _add_tokens_force_first(match_str):
"""Comme _add_tokens mais force le 1er token (contexte Dr/Mme fort).""" """Comme _add_tokens mais force le 1er token (contexte Dr/Mme fort)."""
tokens = match_str.split() tokens = match_str.split()
@@ -1441,21 +1498,20 @@ def _extract_document_names(full_text: str, cfg: Dict[str, Any]) -> set:
token = token.strip(" .-'") token = token.strip(" .-'")
if len(token) < 2: if len(token) < 2:
continue continue
if i == 0:
# Premier token après Dr/Mme : toujours un nom, bypass stop words
if token.upper() not in wl_sections:
names.add(token)
else:
if len(token) < 3:
continue
if token.upper() in wl_sections or token in wl_phrases: if token.upper() in wl_sections or token in wl_phrases:
continue continue
if token.lower() in _MEDICAL_STOP_WORDS_SET: if token.lower() in _MEDICAL_STOP_WORDS_SET:
continue continue
if i == 0:
# Premier token après Dr/Mme : contexte fiable
names.add(token)
else:
if len(token) < 3:
continue
names.add(token) names.add(token)
for m in RE_EXTRACT_PATIENT.finditer(full_text): for m in RE_EXTRACT_PATIENT.finditer(full_text):
_add_tokens(m.group(1)) _add_tokens_force_all(m.group(1))
for m in RE_EXTRACT_REDIGE.finditer(full_text): for m in RE_EXTRACT_REDIGE.finditer(full_text):
_add_tokens(m.group(1)) _add_tokens(m.group(1))
for m in RE_EXTRACT_MME_MR.finditer(full_text): for m in RE_EXTRACT_MME_MR.finditer(full_text):
@@ -1482,6 +1538,9 @@ def _extract_document_names(full_text: str, cfg: Dict[str, Any]) -> set:
# Pr / Professeur + nom(s) # Pr / Professeur + nom(s)
for m in RE_EXTRACT_PR.finditer(full_text): for m in RE_EXTRACT_PR.finditer(full_text):
_add_tokens_force_first(m.group(1)) _add_tokens_force_first(m.group(1))
# Opérateur / Anesthésiste / Chirurgien + nom(s)
for m in RE_EXTRACT_OPERATEUR.finditer(full_text):
_add_tokens_force_first(m.group(1))
# Extraction des noms dans les listes virgulées après Dr/Docteur # Extraction des noms dans les listes virgulées après Dr/Docteur
# ex: "le Dr DUVAL, MACHELART, CHARLANNE, LAZARO, il a été proposé" # ex: "le Dr DUVAL, MACHELART, CHARLANNE, LAZARO, il a été proposé"
@@ -1509,7 +1568,7 @@ def _extract_document_names(full_text: str, cfg: Dict[str, Any]) -> set:
if len(part) >= 3 and part.lower() not in _MEDICAL_STOP_WORDS_SET: if len(part) >= 3 and part.lower() not in _MEDICAL_STOP_WORDS_SET:
names.add(part) names.add(part)
return names return names, force_names
def _apply_extracted_names(text: str, names: set, audit: List[PiiHit], force_names: set = None) -> str: def _apply_extracted_names(text: str, names: set, audit: List[PiiHit], force_names: set = None) -> str:
@@ -1517,6 +1576,10 @@ def _apply_extracted_names(text: str, names: set, audit: List[PiiHit], force_nam
placeholder = PLACEHOLDERS["NOM"] placeholder = PLACEHOLDERS["NOM"]
_force = force_names or set() _force = force_names or set()
safe_names = {n for n in names if len(n) >= 3 and (n in _force or n.lower() not in _MEDICAL_STOP_WORDS_SET)} safe_names = {n for n in names if len(n) >= 3 and (n in _force or n.lower() not in _MEDICAL_STOP_WORDS_SET)}
# Ajouter un hit global (page=-1) par nom pour la redaction PDF raster
# (un seul hit suffit — redact_pdf_raster cherche le token sur chaque page)
for token in sorted(safe_names, key=len, reverse=True):
audit.append(PiiHit(-1, "NOM_GLOBAL", token, placeholder))
for token in sorted(safe_names, key=len, reverse=True): for token in sorted(safe_names, key=len, reverse=True):
pattern = re.compile(rf"\b{re.escape(token)}\b", re.IGNORECASE) pattern = re.compile(rf"\b{re.escape(token)}\b", re.IGNORECASE)
new_text = [] new_text = []
@@ -1577,7 +1640,7 @@ def anonymise_document_regex(pages_text: List[str], tables_lines: List[List[str]
full_raw = "\n".join(pages_text) + "\n" + "\n".join( full_raw = "\n".join(pages_text) + "\n" + "\n".join(
"\n".join(rows) for rows in tables_lines "\n".join(rows) for rows in tables_lines
) )
extracted_names = _extract_document_names(full_raw, cfg) extracted_names, doc_force_names = _extract_document_names(full_raw, cfg)
# Phase 0b : si document Trackare, extraction renforcée des PII structurés # Phase 0b : si document Trackare, extraction renforcée des PII structurés
is_trackare = _is_trackare_document(full_raw) is_trackare = _is_trackare_document(full_raw)
@@ -1586,6 +1649,8 @@ def anonymise_document_regex(pages_text: List[str], tables_lines: List[List[str]
trackare_names, trackare_hits, trackare_force_names = _extract_trackare_identity(full_raw) trackare_names, trackare_hits, trackare_force_names = _extract_trackare_identity(full_raw)
extracted_names.update(trackare_names) extracted_names.update(trackare_names)
audit.extend(trackare_hits) audit.extend(trackare_hits)
# Fusionner les force_names des deux sources
all_force_names = doc_force_names | trackare_force_names
# Phase 0c : détection FINESS multiline (label et numéro sur lignes séparées, # Phase 0c : détection FINESS multiline (label et numéro sur lignes séparées,
# avec possiblement 0-2 lignes intermédiaires masquées ou vides) # avec possiblement 0-2 lignes intermédiaires masquées ou vides)
@@ -1595,6 +1660,32 @@ def anonymise_document_regex(pages_text: List[str], tables_lines: List[List[str]
for m in _RE_FINESS_MULTILINE.finditer(full_raw): for m in _RE_FINESS_MULTILINE.finditer(full_raw):
audit.append(PiiHit(-1, "FINESS", m.group(1), PLACEHOLDERS["FINESS"])) audit.append(PiiHit(-1, "FINESS", m.group(1), PLACEHOLDERS["FINESS"]))
# Phase 0d : date de naissance multiline (label et date sur lignes séparées)
# Ex: "Né(e) le :\n07/04/1943" ou "Date de naissance\n01/02/1950"
_RE_DATE_NAISSANCE_MULTILINE = re.compile(
r"(?:\bn[ée]+(?:\(?e?\)?)?\s+le|date\s+de\s+naissance|DDN)\s*[:\-]?\s*\n\s*"
r"(\d{1,2}[/.\-]\d{1,2}[/.\-]\d{2,4})",
re.IGNORECASE,
)
for m in _RE_DATE_NAISSANCE_MULTILINE.finditer(full_raw):
audit.append(PiiHit(-1, "DATE_NAISSANCE", m.group(1), PLACEHOLDERS["DATE_NAISSANCE"]))
# Phase 0e : IPP multiline (N°Ipp :\n20023294 ou I.P.P. :\nS1032021)
_RE_IPP_MULTILINE = re.compile(
r"(?:I\.?P\.?P\.?|IPP|N°\s*Ipp)\s*[:\-]?\s*\n\s*([A-Za-z0-9]{6,})\b",
re.IGNORECASE,
)
for m in _RE_IPP_MULTILINE.finditer(full_raw):
audit.append(PiiHit(-1, "IPP", m.group(1), PLACEHOLDERS["IPP"]))
# Phase 0f : DEMANDE N° multiline (DEMANDE N°\n2300261164)
_RE_DEMANDE_MULTILINE = re.compile(
r"DEMANDE\s+N[°o]?\s*\n\s*(\d{8,})",
re.IGNORECASE,
)
for m in _RE_DEMANDE_MULTILINE.finditer(full_raw):
audit.append(PiiHit(-1, "DOSSIER", m.group(1), PLACEHOLDERS["DOSSIER"]))
# Phase 1 : masquage ligne par ligne (regex classiques) # Phase 1 : masquage ligne par ligne (regex classiques)
out_pages: List[str] = [] out_pages: List[str] = []
for i, page_txt in enumerate(pages_text): for i, page_txt in enumerate(pages_text):
@@ -1620,7 +1711,7 @@ def anonymise_document_regex(pages_text: List[str], tables_lines: List[List[str]
# Phase 2 : application globale des noms extraits (rattrapage) # Phase 2 : application globale des noms extraits (rattrapage)
if extracted_names: if extracted_names:
text_out = _apply_extracted_names(text_out, extracted_names, audit, force_names=trackare_force_names) text_out = _apply_extracted_names(text_out, extracted_names, audit, force_names=all_force_names)
# Phase 2b : application globale des PiiHit (EPISODE, RPPS, FINESS) # Phase 2b : application globale des PiiHit (EPISODE, RPPS, FINESS)
text_out = _apply_trackare_hits_to_text(text_out, audit) text_out = _apply_trackare_hits_to_text(text_out, audit)
@@ -1806,6 +1897,7 @@ def selective_rescan(text: str, cfg: Dict[str, Any] | None = None) -> str:
protected, kept = strip_tables(text) protected, kept = strip_tables(text)
# PII critiques (comme avant) # PII critiques (comme avant)
protected = RE_EMAIL.sub(PLACEHOLDERS["EMAIL"], protected) protected = RE_EMAIL.sub(PLACEHOLDERS["EMAIL"], protected)
protected = RE_TEL_SLASH.sub(PLACEHOLDERS["TEL"], protected)
protected = RE_TEL.sub(PLACEHOLDERS["TEL"], protected) protected = RE_TEL.sub(PLACEHOLDERS["TEL"], protected)
protected = RE_TEL_COMPACT.sub(PLACEHOLDERS["TEL"], protected) protected = RE_TEL_COMPACT.sub(PLACEHOLDERS["TEL"], protected)
protected = RE_IBAN.sub(PLACEHOLDERS["IBAN"], protected) protected = RE_IBAN.sub(PLACEHOLDERS["IBAN"], protected)
@@ -1846,6 +1938,10 @@ def selective_rescan(text: str, cfg: Dict[str, Any] | None = None) -> str:
tokens = [t for t in span.split() if t] tokens = [t for t in span.split() if t]
if len(tokens) == 1 and len(tokens[0]) <= 3: if len(tokens) == 1 and len(tokens[0]) <= 3:
return raw return raw
# Filtrer les termes médicaux (stop words)
clean = [t for t in tokens if t.lower() not in _MEDICAL_STOP_WORDS_SET]
if not clean:
return raw
return raw.replace(span, PLACEHOLDERS["NOM"]) return raw.replace(span, PLACEHOLDERS["NOM"])
protected = RE_PERSON_CONTEXT.sub(_rescan_person, protected) protected = RE_PERSON_CONTEXT.sub(_rescan_person, protected)
res = list(protected) res = list(protected)
@@ -1971,7 +2067,7 @@ def redact_pdf_vector(original_pdf: Path, audit: List[PiiHit], out_pdf: Path, oc
compact = re.sub(r"\s+", "", token) compact = re.sub(r"\s+", "", token)
if compact != token: if compact != token:
rects = page.search_for(compact) rects = page.search_for(compact)
if not rects and " " in token and h.kind in {"NOM", "NOM_EXTRACTED", "NER_PER", "EDS_NOM"}: if not rects and " " in token and h.kind in {"NOM", "NOM_GLOBAL", "NOM_EXTRACTED", "NER_PER", "EDS_NOM"}:
for word in token.split(): for word in token.split():
word = word.strip(" .-'") word = word.strip(" .-'")
if len(word) < 5 or word.lower() in _MEDICAL_STOP_WORDS_SET: if len(word) < 5 or word.lower() in _MEDICAL_STOP_WORDS_SET:
@@ -2074,7 +2170,7 @@ def redact_pdf_raster(original_pdf: Path, audit: List[PiiHit], out_pdf: Path, dp
if not found and h.kind in {"NIR", "IBAN", "TEL", "VLM_TEL", "VLM_NIR"}: if not found and h.kind in {"NIR", "IBAN", "TEL", "VLM_TEL", "VLM_NIR"}:
compact = re.sub(r"\s+", "", token) compact = re.sub(r"\s+", "", token)
found = page.search_for(compact) found = page.search_for(compact)
if not found and " " in token and h.kind in {"NOM", "NOM_EXTRACTED", "NER_PER", "EDS_NOM", if not found and " " in token and h.kind in {"NOM", "NOM_GLOBAL", "NOM_EXTRACTED", "NER_PER", "EDS_NOM",
"VLM_NOM", "VLM_ETAB", "VLM_SERVICE"}: "VLM_NOM", "VLM_ETAB", "VLM_SERVICE"}:
for word in token.split(): for word in token.split():
word = word.strip(" .-'") word = word.strip(" .-'")
@@ -2359,13 +2455,13 @@ def process_pdf(
# 4b) Propagation globale SÉLECTIVE : uniquement pour les PII critiques # 4b) Propagation globale SÉLECTIVE : uniquement pour les PII critiques
# Les PII critiques (DATE_NAISSANCE, NIR, IPP, EMAIL) sont propagés sur toutes les pages # Les PII critiques (DATE_NAISSANCE, NIR, IPP, EMAIL) sont propagés sur toutes les pages
# pour éviter les fuites sur les documents multi-pages (ex: CRO) # pour éviter les fuites sur les documents multi-pages (ex: CRO)
_CRITICAL_PII_TYPES = {"DATE_NAISSANCE", "NIR", "IPP", "EMAIL", "force_term", "force_regex", "FINESS"} _CRITICAL_PII_TYPES = {"DATE_NAISSANCE", "NIR", "IPP", "EMAIL", "force_term", "force_regex", "FINESS", "DOSSIER"}
_global_pii: Dict[str, set] = {} _global_pii: Dict[str, set] = {}
for h in anon.audit: for h in anon.audit:
# Collecter TOUS les types pour analyse, mais ne propager que les critiques # Collecter TOUS les types pour analyse, mais ne propager que les critiques
if h.kind in {"TEL", "EMAIL", "ADRESSE", "CODE_POSTAL", "EPISODE", "RPPS", "VILLE", "ETAB", if h.kind in {"TEL", "EMAIL", "ADRESSE", "CODE_POSTAL", "EPISODE", "RPPS", "VILLE", "ETAB",
"VLM_SERVICE", "VLM_ETAB", "DATE_NAISSANCE", "NIR", "IPP", "VLM_SERVICE", "VLM_ETAB", "DATE_NAISSANCE", "NIR", "IPP", "DOSSIER",
"force_term", "force_regex", "FINESS"}: "force_term", "force_regex", "FINESS"}:
# Traitement spécial pour DATE_NAISSANCE : extraire la date pure et générer toutes les variations # Traitement spécial pour DATE_NAISSANCE : extraire la date pure et générer toutes les variations
if h.kind == "DATE_NAISSANCE": if h.kind == "DATE_NAISSANCE":

View File

@@ -18,11 +18,15 @@ blacklist:
force_mask_terms: force_mask_terms:
- CENTRE HOSPITALIER COTE BASQUE - CENTRE HOSPITALIER COTE BASQUE
- CENTRE HOSPITALIER DE LA COTE BASQUE - CENTRE HOSPITALIER DE LA COTE BASQUE
- POLYCLINIQUE COTE BASQUE SUD
- POLYCLINIQUE CÔTE BASQUE SUD
- CHCB - CHCB
- '640780417'
- 'Dates du séjour :' - 'Dates du séjour :'
- CONCERTATION - CONCERTATION
force_mask_regex: force_mask_regex:
- 'Centre\s+Hospitalier\s+(?:de\s+(?:la\s+)?)?C[oôÔ]te\s+Basque' - 'Centre\s+Hospitalier\s+(?:de\s+(?:la\s+)?)?C[oôÔ]te\s+Basque'
- 'Polyclinique\s+C[oôÔ]te\s+Basque\s+Sud'
kv_labels_preserve: kv_labels_preserve:
- FINESS - FINESS
- IPP - IPP

View File

@@ -1,46 +0,0 @@
{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "6 AVENUE D ESPAGNE RES UDABERRI", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Unité Médecine Ambulatoire HDJ", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Dorothée NIVET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "José ZULAICA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64250 CAMBO LES BAINS", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "TEL", "original": "05.59.93.72.74", "placeholder": "[TEL]", "bbox_hint": null}
{"page": 0, "kind": "TEL", "original": "0615204864", "placeholder": "[TEL]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "6 AVENUE D ESPAGNE RES", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64250 CAMBO LES", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "TEL", "original": "06.15.20.48.64", "placeholder": "[TEL]", "bbox_hint": null}
{"page": 0, "kind": "TEL", "original": "06.15.20.48.64", "placeholder": "[TEL]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 06/06/1967", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Mathilde", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Tam KHUONG", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Madeleine", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Felix", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "SSR Annie ENia", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 1, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 06/06/1967", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Boube", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Felix", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Mathilde", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 06/06/1967", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 3, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 06/06/1967", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "IPP", "original": "03017203", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 06/06/1967", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "VILLE", "original": "KENDIRA", "placeholder": "[VILLE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "Code Postal: 64250", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "6 AVENUE D ESPAGNE RES UDABERRI\tVille de résidence", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Unité Médecine Ambulatoire HDJ\tMédecin courant", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Dorothée NIVET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "TEL", "original": "05.59.93.72.74", "placeholder": "[TEL]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64250 CAMBO LES BAINS", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "TEL", "original": "0615204864", "placeholder": "[TEL]", "bbox_hint": null}
{"page": 0, "kind": "TEL", "original": "06.15.20.48.64", "placeholder": "[TEL]", "bbox_hint": null}
{"page": 0, "kind": "TEL", "original": "06.15.20.48.64", "placeholder": "[TEL]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "6 AVENUE D ESPAGNE RES\nUDABERRI ", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64250 CAMBO LES\nBAINS FRANCE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "SSR Annie ENia\nIctère", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Mathilde BOUBE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Tam KHUONG HUU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Madeleine HAZARD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Felix GOUTORBE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Boube", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Felix GOUTORBE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Mathilde BOUBE", "placeholder": "[NOM]", "bbox_hint": null}

View File

@@ -1,611 +0,0 @@
N° Finess
[VILLE]
*[FINESS]*
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
[FINESS]
POLE MEDECINE INTERNE - [MASK] :
[NOM]
IPP :
[IPP]
Nom et Prénom :
[NOM] [NOM]
Date de naissance :
[DATE_NAISSANCE]
Sexe :
Masculin
Lieu de naissance :
[VILLE]
Nationalité :
ALGERIE
Code Postal :
[CODE_POSTAL]
Adresse :
[ADRESSE]
Ville de résidence :
[VILLE]
Détails épisode
Episode No :
[NDA]
Localisation :
[VILLE]
Médecin courant :
DR. [NOM]
Date d'admission :
12/10/2023
Heure d'admission :
09 : 27
Date de sortie :
16/11/2023
Heure de sortie :
08 : 00
Médecin traitant
Nom
Adresse
Téléphone
DR. [NOM]
[ADRESSE] [CODE_POSTAL]
[TEL]
Liste des contacts
Type de contact
Relation
Nom
Prénom
Adresse
Tél. domicile
Tél.
professionel
Mobile
Personne à prévenir
(Trakcare)
[NOM]
[NOM]
[NOM]
[TEL]
[ADRESSE]
[NOM] [CODE_POSTAL]
[NOM] FRANCE
Personne à prévenir
(Clinicom)
[NOM]
[NOM]
[TEL]
[TEL]
Alertes
Catégorie
Alerte
Date début
Date
expiration
Message
Staphylocoque
doré résistant à la
méticilline (SARM)
03/04/2023
Mettre en place les précautions complémentaires
contact"C"depistage réalisé le 30/03/2023
BMR
Antécédents (texte libre)
Type de note
Nom
Date
Heure
Note
Aucune donnée
renseignée
Antécédents habitus (texte libre)
Type de note
Nom
Date
Heure
Note
Aucune donnée
renseignée
Signes vitaux
Item de
surveillance
02/11/2023
12 : 00
02/11/2023
09 : 51
19/10/2023
14 : 57
19/10/2023
14 : 30
19/10/2023
14 : 14
19/10/2023
10 : 07
12/10/2023
12 : 14
12/10/2023
09 : 47
Glycémie
capillaire
1,22
1,82
3
2,52
1,10
Température
36,60
36,70
36,50
36,50
Pouls
90
81
84
81
PA
Systolique
133
139
129
141
PA
Diastolique
67
64
68
63
Saturation
100
99
100
99
Ventilation
spontanée
Air
ambiant
Ventilation
spontanée
Air
ambiant
Ventilation
spontanée
Air
ambiant
Ventilation
spontanée
Air
ambiant
Ventilation
Poids/Taille
Item de
surveillance
02/11/2023
09 : 43
19/10/2023
14 : 24
12/10/2023
13 : 48
12/10/2023
09 : 48
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : [NDA] ( POLE MEDECINE INTERNE - [MASK] ) - Taille: 168 cm - Poids: 97.8 kg - IMC: 34.651
Le 04/12/2023 16 : 38
Page 1 de 4 Poids [kg]
97,80
86,20
84,80
94,70
Taille [cm]
168
168
168
Indice
de masse
corporelle
34,65
30,54
33,55
Surface
corporelle
2,07
1,96
2,04
Surv. Isolement et Contention
Item de
surveillance
02/11/2023
09 : 51
19/10/2023
14 : 57
19/10/2023
10 : 07
12/10/2023
09 : 47
Température
36,60
36,70
36,50
36,50
Pouls
90
81
84
81
PA
Systolique
133
139
129
141
PA
Diastolique
67
64
68
63
Saturation
100
99
100
99
Surv. Contention
Item de
surveillance
02/11/2023
12 : 00
02/11/2023
09 : 51
19/10/2023
14 : 57
19/10/2023
14 : 30
Observations médicales
Note d'évolution
DR. [NOM]
[NOM]
02/11/2023
10 : 54
Note d'évolution
DR. [NOM]
[NOM]
19/10/2023
10 : 08
Note d'évolution
DR. [NOM]
[NOM]
12/10/2023
15 : 01
Note d'évolution
DR. [NOM]
[NOM]
12/10/2023
11 : 17
Surveillance Psychiatrie
Item de
surveillance
02/11/2023
09 : 51
19/10/2023
14 : 57
19/10/2023
10 : 07
12/10/2023
09 : 47
Température
36,60
36,70
36,50
36,50
Pouls
90
81
84
81
PA
Systolique
133
139
129
141
PA
Diastolique
67
64
68
63
Saturation
100
99
100
99
Notes paramédicales
19/10/2023
14 : 14
19/10/2023
10 : 07
12/10/2023
12 : 14
12/10/2023
09 : 47
Ponction ascite évacuatrice d'un liquide citrin dans le cadre d'une décompensation oesdemto-
ascite en lien avec un CHC sur cirrhose, hospitalisé au [ETABLISSEMENT]
Ictère conjonctival, pas d'encéphalopathie, cohérent, abomen tendu mais dépressible
3.5L il y 15 jours
prochaine ponction dans 10 jours
est toujours a [VILLE] en soins palliatif
episode d'encephalopathie il y a qq jour car a eu du lexomyl
ce jour orienté, non encephalopathe
ponction d'ascite
Pas d'argument clinique pour une gale.
Pas de sillon, pas de sarcopte en dermosocpie.
Prurit imputable à l'ictere, pas de bilan complémentaire pour le moment.
Mise en place de soins locaux par sensinol lait apaisant , une fois par jour.
Pas de mise en place de dermocorticoïdes dans l'immédiat.
Le 12/10/23
Vient pour une nouvelle PLA évacuatrice dans le cadre de la prise en charge de sa cirrhose
associée à un CHC en soins palliatifs à [VILLE]
Suspicion de galle : avis dermato demandé
Glycémie
capillaire
1,22
1,82
3
2,52
1,10
Température
36,60
36,70
36,50
36,50
Pouls
90
81
84
81
PA
Systolique
133
139
129
141
PA
Diastolique
67
64
68
63
Saturation
100
99
100
99
Type d'observation
Nom
Date
Commentaires
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : [NDA] ( POLE MEDECINE INTERNE - [MASK] ) - Taille: 168 cm - Poids: 97.8 kg - IMC: 34.651
Le 04/12/2023 16 : 38
Page 2 de 4 Type de note
Nom
Date
Note
HDJ GASTRO : DR [NOM].
Pose d'une VVP surveillance, ablation,
Ponction d'ascite = 9l d'ascite compensée par 3 flacons d'albumine 20g à 5l- 7l- 9l = bonne
tolérance,
CS IDE [NOM],
RDV dans 10 jours donné.
Note IDE
[NOM] [NOM]
02/11/2023
14 : 31
IDE éduc diabéto : Glycémies au dessus de l'objectif pendant une dizaine de jours mais à
l'objectif depuis 3 jours (TIR 38% sur 7 jours). Je ne modifie donc pas le protocole pour le
moment. A réévaluer lors d'une prochaine HDJ.
Note IDE
[NOM]
[NOM]
02/11/2023
10 : 40
hdj gastro
vient pour ponction ascite
vu par dr [NOM] [NOM]
évacuation de 3l700 d'ascite : pas de compensation
Note IDE
[NOM] [NOM]
19/10/2023
16 : 07
vu par IDE diabéto
glycémie de 12 h faite : 10 ui insuline rapide faite suivant protocole
prochain rendez vous donné dans 15 jours
IDE [NOM]
appel ce jour pour refaire le points sur son diabete
Protocole changé par [NOM] au vu d'hypos et d'une perte d'appétit.
Ce jour, l'établissement lui fait 15 ui de lente et 10 de rapide matin et midi et 14 le soir +
protocole d'adaptation.
Sur sons FSL2 depuis le changement de protocole les glycémies sont en amélioration avec une
cible à 72 % et pas d'hypos.
Je préconise de baisser la lente à 14 car encore un peu limite par moment la nuit .
Note IDE
[NOM] [NOM]
19/10/2023
11 : 45
On continue ce protocole et on le revoit dans 15j
hdj gastro
vient pour ponction ascite
vu par dr [NOM]
9 l évacué
pose vvp
compensation albumine faite suivant protocole
surv cstes
surv poids
Note IDE
[NOM] [NOM]
12/10/2023
14 : 38
rdv la semaine prochaine donné
vient d'[NOM] qui suspecte une gale : vu par dermato : pas de gale : transmissions faite pour
[NOM] [NOM]
patient diabétique : surv glyclémie : insuline rapide faite à midi
Traitements médicamenteux
Prescription
Dose
Fréquence
Date de début
Date de dernière
administration
Note
Docteur
[NOM] d`administration : INTRAVEINEUSE
Statut des prescriptions : Réalisé
Le débit a été
modifié. Le débit
en cours est : 200
par .
VIALEBEX 200MG/
ML SOL INJ 100ML [1]
Flacon(s)
1 Flacon(s)
- 1 seule fois 1 seule
fois
12/10/2023 10 : 56
12/10/2023 14 : 33
DR. [NOM]
[NOM]
Le débit a été
modifié. Le débit
en cours est : 400
par . Notes du
professionel de
santé : à partir de
5L
VIALEBEX 200MG/
ML SOL INJ 100ML [1]
Flacon(s)
DR. [NOM]
[NOM]
2 FLACON
- URGENT Urgent
02/11/2023 10 : 54
02/11/2023 14 : 27
Prescriptions de soins
Prescription
Dose
Statut
Fréquence
Date de début
Quantité administrée
Note
Docteur
[NOM]
- 1 seule fois 1 seule
fois
19/10/2023
10 : 07
[NOM]
[NOM]
DESINFECTION
ENVIRONNEMENT
PATIENT
Signé
- 1 seule fois 1 seule
fois
12/10/2023
09 : 48
[NOM]
[NOM]
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : [NDA] ( POLE MEDECINE INTERNE - [MASK] ) - Taille: 168 cm - Poids: 97.8 kg - IMC: 34.651
Le 04/12/2023 16 : 38
Page 3 de 4 DESINFECTION
ENVIRONNEMENT
PATIENT
Signé
- 1 seule fois 1 seule
fois
19/10/2023
10 : 07
[NOM]
[NOM]
REPAS : AUTONOME
Signé
- 1 seule fois 1 seule
fois
19/10/2023
10 : 07
[NOM]
[NOM]
BRACELET
IDENTIFICATION
Réalisé
- 1 seule fois 1 seule
fois
12/10/2023
09 : 48
[NOM]
[NOM]
BRACELET
IDENTIFICATION
Réalisé
- 1 seule fois 1 seule
fois
02/11/2023
09 : 43
[NOM]
[NOM]
DESINFECTION
ENVIRONNEMENT
PATIENT
Réalisé
- 1 seule fois 1 seule
fois
02/11/2023
09 : 43
[NOM]
[NOM]
INSTALLATION DU
PATIENT (arrivée)
Réalisé
- 1 seule fois 1 seule
fois
12/10/2023
09 : 48
[NOM]
[NOM]
INSTALLATION DU
PATIENT (arrivée)
Réalisé
- 1 seule fois 1 seule
fois
19/10/2023
10 : 07
[NOM]
[NOM]
INSTALLATION DU
PATIENT (arrivée)
Réalisé
- 1 seule fois 1 seule
fois
02/11/2023
09 : 43
[NOM]
[NOM]
REPAS : AUTONOME
Réalisé
- 1 seule fois 1 seule
fois
12/10/2023
09 : 48
[NOM]
[NOM]
REPAS : AUTONOME
Réalisé
- 1 seule fois 1 seule
fois
02/11/2023
09 : 43
[NOM]
[NOM]
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : [NDA] ( POLE MEDECINE INTERNE - [MASK] ) - Taille: 168 cm - Poids: 97.8 kg - IMC: 34.651
Le 04/12/2023 16 : 38
Page 4 de 4

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@@ -0,0 +1,178 @@
[MASK]
LABORATOIRE de BIOLOGIE MEDICALE
[ADRESSE] [CODE_POSTAL] BAYONNE - Tel : [TEL]
Microbiologie Dr [NOM]
Hématologie
Dr [NOM] (chef de service)
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Biochimie
Dr [NOM]
Dr [NOM]
Assistante
Dr [NOM]
Diffusé le :
à
Compte rendu Complet
05/12/2023
10.40
[NOM] [NOM] [NOM]
Nom usuel :
[DATE_NAISSANCE]
[NOM]
URGENCES
75 a
DDN :
Sexe :
F
23232115
IPP :
[IPP]
N° venue :
DEMANDE N°
[DOSSIER]
Prescrit le :
03/12/2023 11 : 44
Par : [NOM] [NOM]
Prélevé le :
03/12/2023 11 : 47
Par : [NOM] [NOM]
Reçu le :
03/12/2023 12 : 10
Résultat
Borne
BACTERIOLOGIE
Examen(s) de microbiologie ci-dessous rendu(s) sous accréditation (1) sauf mention contraire
ECBU - Milieu de jet
Cytologie
Leucocytes
3388 /µL
<10
Automate Iris IQ 200 Select (Beckman-Coulter)
Hématies
17 /µL
<10
Automate Iris IQ 200 Select (Beckman-Coulter)
Cellules épithéliales
Présence
Culture et identification
Identification réalisée sur Maldi Biotyper, Vitek2, gélose chromogène ou agglutination
>= 1.10*6 UFC/mL Citrobacter braakii
Béta-lactamines : Céphalosporinase. L'utilisation éventuelle de la colistine pour le traitement de ce germe nécessite la mesure
de la CMI. Veuillez prévenir le laboratoire. Antibiogramme réalisé en milieu solide par diffusion Interprétation selon les
recommandations du CA-SFM 2022 L'utilisation d'une C3G sensible in-vitro en monothérapie est déconseillée pour ce type de
bactéries car elle expose au risque de sélection de mutants résistants.
>= 1.10*6 UFC/mL Escherichia coli
Béta-lactamines : Pénicillinase de haut niveau. Antibiogramme réalisé en milieu liquide sur Vitek2 Interprétation selon les
recommandations du CA-SFM 2022
Conclusion
Données microbiologiques en faveur d'une infection urinaire
(1) analyse référencée sous
Compte-rendu :
Complet
ACCREDITATION COFRAC
Validé et diffusé sous la responsabilité du biologiste :
Page 1/2
Dr. [NOM]
N° 8-3188
Portée disponible sur
[ETABLISSEMENT] [NOM] [NOM] [NOM]
Nom usuel :
[NOM]
DDN :
SEXE :
[DATE_NAISSANCE]
F
DEMANDE N°
[DOSSIER]
Résultat
Antibiogramme
.
Citrobacter braakii
AMOXICILLINE
Résistant
AMOX+ AC.CLAVU (pour CYSTITE)
Résistant
AMOXICILLINE + AC.CLAVULANIQUE Résistant
TICARCILLINE
Sensible à posologie standard
TICARCILLINE + AC.CLAVULANIQUE Sensible à posologie standard
PIPERACILLINE
Sensible à posologie standard
PIPERACILLINE + TAZOBACTAM
Sensible à posologie standard
MECILLINAM
Résistant
CEFOTAXIME
Sensible à posologie standard
ERTAPENEME
Sensible à posologie standard
IMIPENEME
Sensible à posologie standard
MEROPENEME
Sensible à posologie standard
AMIKACINE
Sensible à posologie standard
TOBRAMYCINE
Sensible à posologie standard
GENTAMICINE
Sensible à posologie standard
NORFLOXACINE
Sensible à posologie standard
CIPROFLOXACINE
Sensible à posologie standard
TRIMETHOPRIME + SULFAMIDES
Sensible à posologie standard
FOSFOMYCINE
Sensible à posologie standard
FURANES
Résistant
Escherichia coli
AMOXICILLINE
Résistant
AMOXICILLINE + AC.CLAVULANIQUE Résistant
TICARCILLINE
Résistant
TEMOCILLINE
Sensible à forte posologie
PIPERACILLINE + TAZOBACTAM
Sensible à posologie standard
MECILLINAM
Résistant
CEFOXITINE
Sensible à posologie standard
CEFTRIAXONE
Sensible à posologie standard
ERTAPENEME
Sensible à posologie standard
AMIKACINE
Sensible à posologie standard
GENTAMICINE
Sensible à posologie standard
ACIDE NALIDIXIQUE
Sensible à posologie standard
OFLOXACINE
Sensible à posologie standard
TRIMETHOPRIME + SULFAMIDES
Sensible à posologie standard
FOSFOMYCINE
Sensible à posologie standard
FURANES
Sensible à posologie standard
URGENCES
Borne
CMI (mg/l)
CMI (mg/l)
(1) analyse référencée sous
Compte-rendu :
Complet
ACCREDITATION COFRAC
N° 8-3188
Portée disponible sur
[ETABLISSEMENT]
Validé et diffusé sous la responsabilité du biologiste :
Page 2/2
Dr. [NOM]

View File

@@ -0,0 +1,200 @@
[MASK]
Anesthésiste : Dr [NOM]
DOSSIER DE CONSULTATION
(modifié le 24/04/2023)
Date :
24/04/23
Nom :
M. [NOM]
Né(e) le :
[DATE_NAISSANCE]
72 ans
N°Ipp :
[IPP]
N° : [DOSSIER] /
Nom naiss. :
[DOSSIER]
Poids : 85 kg
Taille : 172 cm
B.M.I. : 28.7
Profession :
Adresse :
[ADRESSE]
[CODE_POSTAL]
N° Tél : [TEL]
à
[TEL]
Spécialiste :
Date d'Intervention : 25/04/2023
Médecin traitant :
Motif d'admission : NÉPHRO [NOM]
Opérateur : Dr [NOM]
Prévenir :
Mémo :
Anesthésiste prévu(e) en salle d'opération :
Ambulatoire
Urgence
Entrée le jour de l'intervention
Hospit. < 30 jours
Obstétrique
CHIR.UROLOGIE C2
Hospitalisé(e) le :
à :
Service :
__ : __
__/__/__
Antécédents / Traitements
Examen [ETABLISSEMENT] / Prescriptions
ATCD chirurgicaux :
. Autres/1 Tendon rotulien
ATCD cardio-vasculaires :
. Derniers examens/Epreuve d'effort
2020 : normale
ATCD pulmonaires :
. Tabac/Actif 1 paquet/sem
ATCD médicaux : RAS
Interrogatoire / Autorisation /
Latéralité :
. Côté vérifié avec le patient/Gauche
. Vu seul
. Patient apte à exprimer sa volonté et
participe à la décision
Histoire de la maladie
HDM : lésion de l'uretère
lombaire-pelvien (carcinome urothélial)
avec dilatation des cavités
pyélocalicielles gauches en amont
Examen clinique :
. Capacité d'effort/> 10/ Sportif
régulier marche active
. Etat général/ Excellent
. Cardio-vasculaire/
Asymptomatique/Auscultation
cardiaque/ Normale sans souffle
. Respiratoire asymptomatique
Examen général :
Homme, Poids : 85 Kg, Taille : 172 cm ,
B.S.A. : 2 m², B.M.I. : 28.7
Etat dentaire / Prothèse :
Etat dentaire : Bon, Implants
Informations données au patient :
. Information Transfusion
. Intervention brève sur sevrage
tabagique
. Techniques Anesthésiques
Technique d'anesthésie envisagée :
Anesthésie : AG avec IOT + Infiltration
chirurgicale
Protocole : AG DIP-SUF-ESM-BRI
Antibioprophylaxie : selon protocole
Commentaire : bloc paravertébral T10
indiqué (expliqué si besoin)
Allergie : RAS
Intubation :
. Mallampati 2
. Distance Interincisive : >35mm
. Distance thyromentonière : >65mm
. Mobilité cervicale : diminuée
Synthèse pré-opératoire :
<< Pas de traitement >>
ED Consultation effectuée et complétée
avec celle de Saint PALAIS
Programmation opératoire : maintenue
<< Pas de traitement >>
Risques - classe ASA :
. Classe ASA : ASA2
Prescription biologique :
Récent(s) :
- Autre [le 17/04 Na : 144 K: 4.6 Créat:
80 DFG : 84 Hb: 14.4 Plaquettes:
195000 TP TCK normaux carte de
groupe perso vue RAI neg du 17/04
PCR covid neg du 22/04]
Prescription examens :
Prescrit(s) :
- E.C.G.
Consigne(s) IDE :
A jeun le 25/04/2023 à 00 : 00
Merci de proposer un café, un thé sucré
sans lait, de l'eau plate, ou un jus sans
pulpe, d'un volume de 400 ml, deux
heures avant l'heure de la chirurgie.
Récupérer carte groupe et RAI et faire
un dossier transfusionnel
Merci de réaliser un ECG
Préparations :
pré-opératoire :
. Vidéolaryngoscopie - Glidescope
Dossier de consultation
Le 24 Avril 2023 17 : 07
Page :
1/2 Anesthésiste : Dr [NOM]
DOSSIER DE CONSULTATION
(modifié le 24/04/2023)
Date :
24/04/23
Nom :
M. [NOM]
Né(e) le :
[DATE_NAISSANCE]
72 ans
N°Ipp :
[IPP]
N° : [DOSSIER] /
Nom naiss. :
[DOSSIER]
Poids : 85 kg
Taille : 172 cm
B.M.I. : 28.7
Profession :
Adresse :
[ADRESSE]
[CODE_POSTAL]
N° Tél : [TEL]
(Bienvenu)
per-opératoire :
. Baby-Noradrénaline
. BIS (Voie veineuse X 2)
. Monitorage curarisation
. Réchauffement Patient (Couverture
chauffante placée sous le (a) patient(e))
post-opératoire : CI AINS
Dossier de consultation
Le 24 Avril 2023 17 : 07
Page :
2/2 Anesthésiste : Dr [NOM]
Prémédication
IPP : [IPP]
Patient : [NOM] [NOM] [DATE_NAISSANCE]
N° : [DOSSIER]
Né(e) le : [DATE_NAISSANCE]
72 ans
Date :
24/04/2023 16 : 41
Consigne(s) IDE
PREPARATIONS
A jeun le 25/04/2023 à 00 : 00
Merci de proposer un café, un thé sucré sans lait, de l'eau plate, ou un jus sans pulpe,
d'un volume de 400 ml, deux heures avant l'heure de la chirurgie.
Récupérer carte groupe et RAI et faire un dossier transfusionnel
Merci de réaliser un ECG
- PRE-Opératoires : Vidéolaryngoscopie - Glidescope [Bienvenu]
- PER-Opératoires : Baby-Noradrénaline, BIS [Voie veineuse X 2], Monitorage
curarisation, Réchauffement Patient [Couverture chauffante placée sous le (a) patient(e)]
- POST-Opératoires : CI AINS
Prémédication
Nom du médicament, dosage, posologie
Durée (j)
Soir J-1
Matin J 0
Midi J 0
Coucher J-1
Paracetamol 1g PO
1
1
Date / Heure
Validation IDE
Prémédication
Le 24 Avril 2023 17 : 07
Page :
1/1

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[MASK]
Anesthésiste : Dr [NOM]
DOSSIER DE CONSULTATION
(modifié le 02/04/2023)
Date :
29/03/23
Nom :
M. [NOM]
Né(e) le :
[DATE_NAISSANCE]
71 ans
N°Ipp :
[IPP]
N° : [DOSSIER] /
Nom naiss. :
[DOSSIER]
Poids : 87 kg
Taille : 169 cm
B.M.I. : 30.5
Profession :
Adresse :
[ADRESSE]
[CODE_POSTAL]
N° Tél : [TEL]
à
12 : 14
Spécialiste :
Date d'Intervention : 03/04/2023
Médecin traitant :
Motif d'admission : HOLEP
Opérateur : Dr [NOM]
Prévenir :
Mémo :
Anesthésiste prévu(e) en salle d'opération :
Ambulatoire
Urgence
Entrée le jour de l'intervention
Hospit. < 30 jours
Obstétrique
Hospitalisé(e) le :
à :
Service :
__ : __
__/__/__
Thrombo-embolique : Risque Majeur
Classe ASA : ASA3
ATCD médicaux : Néphro-uro, Rein unique
Antécédents / Traitements
Examen [ETABLISSEMENT] / Prescriptions
ATCD chirurgicaux :
. Ostéosynthèse clavicule gauche puis
broche enlevée
. Urinaire colique néphretique avec pose
de JJ 2020
. Autres/1 endarterectomie carotidienne
D 2021 post AVC
ATCD cardio-vasculaires :
. HTA/Bithérapie
. Artériopathie/Carotides
. Hypercholestérolémie
. Sous antiagrégant
. Derniers examens/Echo 01/2021 : VG
non dilaté non hypertrophié, fct
systolique et diastolique nle. FEVG 72%.
Pas de valvulopathies. Cavités Dtes non
dilatées
ATCD pulmonaires : rhum des foins
. Apnées du sommeil/appareillées
depuis > 1 an presque : suivi Dr [NOM]
. Tabac/Sevré depuis 10 PA sevré il y a
20 ans
. Examens paracliniques récents/EFR
11/2022 : VEMS à 124% de la normale,
le Tiffeneau est en augmentation de 1%
à 111%. La CPT est à 91%.
ATCD médicaux :
. Néphro-uro/Hypertrophie prostate
/Rein unique
. Endocrino-métabolique/Obésité
surpoids
. Neurologique/AVC 2 AVC ischémiques
: 2020 et 01/2021.
Cs neuro 11/2022 Dr [NOM] : élocution
plus harmonieuse. Amélioration
progressive de la paralysie faciale
gauche + intègre mieux son membre
supérieur gauche pourtant déficitaire en
distal/ Séquelles légère faiblesse main G
4/5 + hémiface G
. Ophtalmologique/Glaucome/ Angle
ouvert
. Toxiques/Alcool/ Chronique 2 verres de
vin/j
. Autres/1 psoriasis avec tt topique
Examen clinique : chantait beaucoup,
a repris de plus en plus apès son AVC
. Etat général/Pas de troubles cognitifs
évidents
. Capacité d'effort/ 4 à 7 actif : a repris
ses activités quotidiennes
. Pas de virose récente schéma vaccinal
complet
. Pas de symptome cardio-vasculaire,
auscultation normale
Hémostase clinique :
. Traitement modifiant
l'hémostase/Aspirine relais
75mg/j/Clopidogrel arret J-5
. Anamnèse normale hemstop=0
. Hémostase normale en 2021
Examen général :
Homme, Poids : 87 Kg, Taille : 169 cm ,
B.S.A. : 2 m², B.M.I. : 30.5
Fréquence cardiaque : 68
SaO2 : 97
Pression artérielle : 134 / 62
Signe(s) particulier(s) : Barbe
Ronflement
. Abord(s) veineux : A priori sans
problème
Etat dentaire / Prothèse :
Etat dentaire : Bon; aucune prothèse
Etat oculaire : aucune prothèse
Etat auditif : aucune prothèse
Informations données au patient :
. Accord modalités d'anesthésie
proposées
. Brochure d'information remise au
patient
. Complications péri- et postopératoires
. Information Transfusion
. Informations bien comprises
. Rapport bénéfice/risque expliqué
. Risque dentaire expliqué
. Techniques Anesthésiques
Technique d'anesthésie envisagée :
Anesthésie : AG avec masque laryngé
Protocole : AG DIP-SUF
Antibioprophylaxie : selon protocole
Commentaire : revoir ECBU
Dossier de consultation
Le 02 Avril 2023 17 : 30
Page :
1/3 Anesthésiste : Dr [NOM]
DOSSIER DE CONSULTATION
(modifié le 02/04/2023)
Date :
29/03/23
Nom :
M. [NOM]
Né(e) le :
[DATE_NAISSANCE]
71 ans
N°Ipp :
[IPP]
N° : [DOSSIER] /
Nom naiss. :
[DOSSIER]
Poids : 87 kg
Taille : 169 cm
B.M.I. : 30.5
Profession :
Adresse :
[ADRESSE]
[CODE_POSTAL]
N° Tél : [TEL]
Interrogatoire / Autorisation /
Latéralité :
. Vu seul
. Patient apte à exprimer sa volonté et
participe à la décision
. Consentement éclairé/Vu et présent
dans le dossier
Plus ...
ATCD Chirurgicaux :
.THROMBOENDART CAROTIDIENNE
(14/01/2021)
ATCD Anesthésiques :
.AG avec IOT (14/01/2021)
Histoire de la maladie
Deficit moteur du Mb > G en cours de
recupération
Déficit moteur du Mb < G et PF gauche
centrale constaté lors de la consultation,
a réévaluer
Allergie : RAS
Intubation :
. Mallampati 2
. Distance Interincisive : >35mm
. Distance thyromentonière : >65mm
. Mobilité cervicale : normale
barbe !!!
cou court et double menton
Synthèse pré-opératoire :
Programmation opératoire : maintenue
Traitement(s) :
Traitement(s) en cours :
. PLAVIX cp enrobé 75 mg : 50[HOP]
(CP) // PO [suspendu le 01/04/2023],
Matin (1)
. amlodipine 10mg (CP) // Articulaire,
Matin (1), A continuer le matin
. azarga 10/5 (goutte), Matin (1), A
continuer le matin
. crestor (mg) // PO, Soir (10)
. DIPROSALIC lotion : fl 15 g
(<inconnue>), Soir (1)
. ESIDREX cp séc 25 mg : 20 (CP),
Matin (1)
. ezetimibbe 10mg (CP) // PO, Soir (1),
A continuer jusqu'à la veille au soir
. ISOPTINE cp enrobé séc LP Ad 240 mg
: 30 (CP) // PO, Matin (1), A continuer
le matin
. lansoprazole (mg), Matin (15)
. monoprost (goutte) ( Oeil G ) , Soir
(1), A continuer jusqu'à la veille au soir
. prmixon 160mg (CP) // PO, Matin (1),
Soir (1), A continuer jusqu'à la veille au
soir, A continuer le matin
. urorec 8mg (CP) // PO, Soir (1), A
continuer jusqu'à la veille au soir
Ajout/Modification de traitement(s)
:
. kardegic 75mg , Matin (1)
Risques - classe ASA :
. Classe ASA : ASA3
. Thrombo-embolique : Risque
Majeur !
. Intubation : RAS
. Ventilation : A priori sans difficulté
Prescription biologique :
Résultat(s) récent(s) (N : Normal,
A : Anormal) :
- Créat / DFG( N ) [104 µmol/L 62
ml/min/m2]
- HbA1c( N ) [5.1%]
- Ionogramme( N ) [Na 144 K 4.4]
- NFS / Hémoglobine( N ) [13.8 g/dl]
- Plaquettes( N ) [179 G/L]
Prescrit(s) :
- Groupe sanguin, Rh, 2 déterminations
- R.A.I.
- PCR COVID 19
Récent(s) :
- Date des examens [01/2023]
- PCR COVID 19 [negative 11/01]
Prescription examens :
Récent(s) :
- Echo cardiaque [ETT récente normale,
CR non vu.]
Transfusion :
. Intervention à risque
hémorragique/intermédiaire
Consigne(s) IDE :
A jeun le 06/04/2023 à 00 : 00
Merci de proposer un café, un thé sucré
sans lait, de l'eau plate, ou un jus sans
pulpe, d'un volume de 400 ml, deux
heures avant l'heure de la chirurgie.
PCR COVID à récupérer
Paracétamol 1gr per os en
pré-médication
Vérifier arret clopidogrel
Préparations :
per-opératoire :
Dossier de consultation
Le 02 Avril 2023 17 : 30
Page :
2/3 Anesthésiste : Dr [NOM]
DOSSIER DE CONSULTATION
(modifié le 02/04/2023)
Date :
29/03/23
Nom :
M. [NOM]
Né(e) le :
[DATE_NAISSANCE]
71 ans
N°Ipp :
[IPP]
N° : [DOSSIER] /
Nom naiss. :
[DOSSIER]
Poids : 87 kg
Taille : 169 cm
B.M.I. : 30.5
Profession :
Adresse :
[ADRESSE]
[CODE_POSTAL]
N° Tél : [TEL]
. Baby-Noradrénaline
. Réchauffement Patient
VISITE PRE-ANESTHESIQUE
Date :
02/04/2023 15 : 02
Anesthésiste :
Dr [NOM]
VPA / Eléments nouveaux (MAR)
Gpe + rai + coag + ecg ok
PCR covid non faite, prescrit ce jour (ASA 3 et ventilation mécanique)
Relai plavix ok (arrêt J-5 plavix relai par kardegic)
Dossier de consultation
Le 02 Avril 2023 17 : 30
Page :
3/3 Anesthésiste : Dr [NOM]
Prémédication
IPP : [IPP]
Patient : [NOM] [NOM] [DATE_NAISSANCE]
N° : [DOSSIER]
Né(e) le : [DATE_NAISSANCE]
71 ans
Date :
29/03/2023 11 : 40
Consigne(s) IDE
PREPARATIONS
A jeun le 06/04/2023 à 00 : 00
Merci de proposer un café, un thé sucré sans lait, de l'eau plate, ou un jus sans pulpe,
d'un volume de 400 ml, deux heures avant l'heure de la chirurgie.
PCR COVID à récupérer
Paracétamol 1gr per os en pré-médication
Vérifier arret clopidogrel
- PER-Opératoires : Baby-Noradrénaline, Réchauffement Patient
Prémédication
Nom du médicament, dosage, posologie
Durée (j)
Soir J-1
Matin J 0
Midi J 0
Coucher J-1
Paracetamol 1g PO
1
Date / Heure
Validation IDE
Prescription selon ordonnance du médecin traitant
Adaptation du traitement personnel
Midi J 0
Coucher J-1
Nom du médicament, dosage, posologie
Soir J-1
Arrêt
Matin J 0
ISOPTINE cp enrobé séc LP Ad 240 mg : 30 // CP - PO -, Matin:1, A continuer
le matin
1 CP
PLAVIX cp enrobé 75 mg : 50[HOP] // CP - PO - , Matin:1
01/04/2023
amlodipine 10mg // CP - Articulaire -, Matin : 1, A continuer le matin
1 CP
azarga 10/5 // goutte, Matin : 1, A continuer le matin
1 goutte
crestor // mg - PO -, Soir : 10
10 mg
ezetimibbe 10mg // CP - PO -, Soir : 1, A continuer jusqu'à la veille au soir
1 CP
kardegic 75mg //, Matin : 1
monoprost // goutte [Oeil G], Soir : 1, A continuer jusqu'à la veille au soir
1 goutte
prmixon 160mg // CP - PO -, Matin : 1, Soir:1, A continuer jusqu'à la veille au soir,
A continuer le matin
1 CP
1 CP
urorec 8mg // CP - PO -, Soir : 1, A continuer jusqu'à la veille au soir
1 CP
Prémédication
Le 02 Avril 2023 17 : 30
Page :
1/2 Anesthésiste : Dr [NOM]
Prémédication
IPP : [IPP]
Patient : [NOM] [NOM] [DATE_NAISSANCE]
N° : [DOSSIER]
Né(e) le : [DATE_NAISSANCE]
71 ans
Date :
29/03/2023 11 : 40
Date / Heure
Validation IDE
Prémédication
Le 02 Avril 2023 17 : 30
Page :
2/2

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[MASK]
Anesthésiste : Dr [NOM]
DOSSIER DE CONSULTATION
(modifié le 03/09/2023)
Date :
24/08/23
Nom :
M. [NOM]
Né(e) le :
[DATE_NAISSANCE]
60 ans
N°Ipp :
[IPP]
N° : [DOSSIER] /
Nom naiss. :
[DOSSIER]
Poids : 88 kg
Taille : 158 cm
B.M.I. : 35.3
Profession :
Adresse :
N° Tél :
à
12 : 11
Spécialiste :
Date d'Intervention : 04/09/2023
Médecin traitant :
Motif d'admission : EVENTRATION LAPARO AVEC PLAQUE
Opérateur :
Prévenir :
Mémo :
Anesthésiste prévu(e) en salle d'opération :
Ambulatoire
Urgence
Entrée le jour de l'intervention
Hospit. < 30 jours
Obstétrique
Hospitalisé(e) le :
à :
Service :
__ : __
__/__/__
Classe ASA : ASA3
Antécédents / Traitements
Examen [ETABLISSEMENT] / Prescriptions
ATCD chirurgicaux :
. Arthroscopie
. Fibroscopie Coloscopie
. Autres/1 Colostomie de décharge en
fév 2019 sur tumeur colique
pré-occlusive. Chimio néo adjuvante (6
séances dont la dernière il y a un
mois))/2 Colectomie 7-2019/3
hépatectomie dte 2019/4 exerese
atypique lesion pulm inf gche
ATCD cardio-vasculaires :
. HTA/Bithérapie
. Derniers examens/ECG rythme sinusal
69bpm, PR 210ms, bloc de branche
droit complet, hemibloc ant gauche
. Consultation cardio Dr [NOM] 04/23 :
FEVG normale,
ATCD pulmonaires :
. Examens paracliniques récents/EFR
01/08/2023 : VEMS 2.67 tiffeneau
104%
. Tabac/Sevré depuis 20ans
ATCD médicaux : NON
. Digestifs/Intestin Néo du colon 2019
chir + chimio
3 lessions hepatique
. Endocrino-métabolique/Diabète/
HbA1c 6.5%
Interrogatoire / Autorisation /
Latéralité : NON
. Vu seul
. Patient apte à exprimer sa volonté et
participe à la décision
. Consentement éclairé/À récupérer
Plus ...
ATCD Chirurgicaux :
.COLOSCOPIE SOUS AG (10/05/2023)
ATCD Anesthésiques :
.AG avec masque laryngé [D036]
(10/05/2023)
Examen clinique :
. Etat général/Bon bonne recuperation
post op, bonne tolérance chimio
. Capacité d'effort/ 4 à 7
. Cardio-vasculaire/
Asymptomatique/Auscultation
cardiaque/ Normale
. Pas de virose récente 3doses
Hémostase clinique : RAS
Autre(s) examen(s) ...
Cardio-pulmonaire :
. Asymptomatique
. Auscultation cardiaque/ Normale
. Auscultation pulmonaire/ Normale
Examen général :
Homme, Poids : 88 Kg, Taille : 158 cm ,
B.S.A. : 1.9 m², B.M.I. : 35.3
Etat dentaire / Prothèse :
Etat dentaire : Bon; aucune prothèse
Etat oculaire : aucune prothèse
Etat auditif : aucune prothèse
Informations données au patient :
. Accord modalités d'anesthésie
proposées
. Brochure d'information remise au
patient
. Complications péri- et postopératoires
. Information Transfusion
. Informations bien comprises
. Rapport bénéfice/risque expliqué
. Risque dentaire expliqué
. Techniques Anesthésiques
Technique d'anesthésie envisagée :
Anesthésie : AG avec IOT +
Anesthésie/analgésie périmédullaire
Protocole : AG DIP-SUF-ESM-BRI + APD
thoracique
Antibioprophylaxie : selon protocole
Commentaire : APD validée avec
chirurgien
Allergie :
. Réaction rapportée par le
patient/Urticaire vegetaux
1 episode important avec TTT
Intubation :
. Mallampati 1
. Mobilité cervicale : normale
Synthèse pré-opératoire :
Programmation opératoire : maintenue
Dossier de consultation
Le 03 Septembre 2023 17 : 32
Page :
1/2 Anesthésiste : Dr [NOM]
DOSSIER DE CONSULTATION
(modifié le 03/09/2023)
Date :
24/08/23
Nom :
M. [NOM]
Né(e) le :
[DATE_NAISSANCE]
60 ans
N°Ipp :
[IPP]
N° : [DOSSIER] /
Nom naiss. :
[DOSSIER]
Poids : 88 kg
Taille : 158 cm
B.M.I. : 35.3
Profession :
Adresse :
N° Tél :
corticothérapie
Traitement(s) :
Traitement(s) en cours :
. indapamide 2.5mg (CP) // PO, Matin
(1)
. perindopril 10mg (CP) // PO, Matin (1)
Risques - classe ASA :
. Classe ASA : ASA3
. Intubation : RAS
. Thrombo-embolique : Risque Mineur
Prescription biologique :
Résultat(s) (N : Normal, A:Anormal) :
- TP TCA( N ) [TP 104% TCA r 0.95]
- 24/08/2023 : R.A.I.( N )
Résultat(s) récent(s) (N : Normal,
A : Anormal) :
- Groupe sanguin, Rh, 2
déterminations( N ) [carte perso ok ds
dossier transfu]
- Ionogramme( N ) [139 4.0
06/06/2023]
- NFS / Hémoglobine( N ) [14.7
06/06/2023]
- Plaquettes( N ) [224000 06/06/2023]
Prescrit(s) :
- Créat / DFG
- Ionogramme
Consigne(s) IDE :
A jeun le 04/09/2023 à 00 : 00
Jeune pré-opératoire : solides H-6,
liquides clairs H-2 (eau, thé/café sans
lait, jus de fruit sans pulpe)
Préparations :
pré-opératoire :
. [NOM]
VISITE PRE-ANESTHESIQUE
Date :
03/09/2023 17 : 29
Anesthésiste :
Dr [NOM]
VPA / Eléments nouveaux (MAR)
dossier complet notamment dossier transfu
patient non vu car non arrivé lors de mon passage
Dossier de consultation
Le 03 Septembre 2023 17 : 32
Page :
2/2 Anesthésiste : Dr [NOM]
Prémédication
IPP : [IPP]
Patient : [NOM] [NOM] [DATE_NAISSANCE]
N° : [DOSSIER]
Né(e) le : [DATE_NAISSANCE]
60 ans
Date :
24/08/2023 10 : 41
Consigne(s) IDE
PREPARATIONS
A jeun le 04/09/2023 à 00 : 00
Jeune pré-opératoire : solides H-6, liquides clairs H-2 (eau, thé/café sans lait, jus de fruit
sans pulpe)
- PRE-Opératoires : GOXOAN
Prémédication
Nom du médicament, dosage, posologie
Durée (j)
Soir J-1
Matin J 0
Midi J 0
Coucher J-1
Paracetamol 1g PO
1
Profenid LP 100mg PO
1
Date / Heure
Validation IDE
Prescription selon ordonnance du médecin traitant
Adaptation du traitement personnel
Nom du médicament, dosage, posologie
Soir J-1
Arrêt
Matin J 0
Midi J 0
Coucher J-1
indapamide 2.5mg CP, Matin : 1
perindopril 10mg CP, Matin : 1
Date / Heure
Validation IDE
Prémédication
Le 03 Septembre 2023 17 : 32
Page :
1/1

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@@ -1,108 +0,0 @@
{"page": 0, "kind": "NOM", "original": "Aurélie VALADE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Céline BELLEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Catherine DIDAILLER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Hélène LANGLOIS MEURINNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Claudine EMBAREK", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Mathilde LE GALL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Aurélie VALADE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Alice MANAUD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Elise BADOUR", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Marie DUBREL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Leire ETCHANDY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Fanny HENAFF", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Céline BELLEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Leire ETCHANDY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Fanny HENAFF", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Violette SUC", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Kaiet ECHEVERRIA-ARRUTY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Philippe JOUVENCEL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Hélène LANGLOIS MEURINNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Gaël MAZEIRAS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Justine LABAT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Chloé LAPEYRE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Camille OGER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Caroline DE BARBEYRAC", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Maeva GRONDARD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Catherine DIDAILLER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Claudine EMBAREK", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Julie ALSUGUREN", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Leïla LAZARO", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Serge RIVERA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Marie-Elise PICAMILH", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Léna MARIOTTE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Charlotte PETRIAT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Pierre-Marie DUBOUE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Christel BUZENET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Sabrina DUBOIS-ZUAZO", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Sophie NAUDION", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Marine LEGENDRE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Julien VAN-GILS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Véronique OYHARCABAL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Agnès PUEL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Stéphane DEBELLEIX", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Valérie TERRIER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "SKILBECQ", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "JUZAN", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Pôle Femme - Mère - Enfant", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "COQUEL GAELLE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "39 RUE BERNARD DE CORAL", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64122 URRUGNE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "né le 15/01/2017", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Service de Pédiatrie Générale - HDJ - Urgences Pédiatriques - UHCD", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Service de Néonatologie - Réanimation Néonatale - Soins Continus Pédiatriques", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "IPP", "original": "17001141", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 0, "kind": "EPISODE", "original": "23066188", "placeholder": "[EPISODE]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Aurélie VALADE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Céline BELLEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Catherine DIDAILLER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Hélène LANGLOIS MEURINNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Claudine EMBAREK", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Mathilde LE GALL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Aurélie VALADE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Alice MANAUD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Elise BADOUR", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Marie DUBREL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Leire ETCHANDY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Fanny HENAFF", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Céline BELLEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Leire ETCHANDY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Fanny HENAFF", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Violette SUC", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Kaiet ECHEVERRIA-ARRUTY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Philippe JOUVENCEL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Hélène LANGLOIS MEURINNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Gaël MAZEIRAS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Justine LABAT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Chloé LAPEYRE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Camille OGER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Caroline DE BARBEYRAC", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Maeva GRONDARD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Catherine DIDAILLER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Claudine EMBAREK", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Julie ALSUGUREN", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Leïla LAZARO", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Serge RIVERA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Marie-Elise PICAMILH", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Léna MARIOTTE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Charlotte PETRIAT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Pierre-Marie DUBOUE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Christel BUZENET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Sabrina DUBOIS-ZUAZO", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Sophie NAUDION", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Marine LEGENDRE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Julien VAN-GILS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Véronique OYHARCABAL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Agnès PUEL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Stéphane DEBELLEIX", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Valérie TERRIER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "SKILBECQ", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "JUZAN", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Pôle Femme - Mère - Enfant", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "PICAMILH Marie-Elise", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "COQUEL Gaelle", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Service de Pédiatrie Générale - HDJ - Urgences Pédiatriques - UHCD", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Service de Néonatologie - Réanimation Néonatale - Soins Continus Pédiatriques", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "IPP", "original": "17001141", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 1, "kind": "EPISODE", "original": "23066188", "placeholder": "[EPISODE]", "bbox_hint": null}

View File

@@ -1,250 +0,0 @@
N° Finess
[FINESS]
Chef de Pôle :
Dr [NOM]
Chef de Service - Urgences [NOM]
et Pédiatrie Générale et [NOM] :
Dr [NOM] Urgences
Dr [NOM] - Pédiatrie
Dr [NOM] -
[NOM]
Pédiatrie de Maternité :
Dr [NOM]
Consultation dEndocrino-Diabétologie :
Dr [NOM]
Dr [NOM]
Consultation [NOM] :
Dr [NOM]
Consultation dHémato-Cancérologie :
Dr [NOM]
Dr [NOM]
Consultation de Rhumatologie :
Dr [NOM]
Consultation de Médecine de l'Adolescent :
Dr [NOM]
Urgences [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
[NOM], Réanimation Néonatale :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Consultation de Néphropédiatrie :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Consultation de Neuropédiatrie :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Consultation de Pneumopédiatrie :
Dr [NOM]
Consultation de Cardiopédiatrie :
Dr [NOM]
[NOM]
Dr [NOM] - Dermatologie
Dr [NOM] - Maternité
Dr [NOM], Dr [NOM]
et Dr [NOM] - Génétique
Dr [NOM] -
Rhumato-immunologie
Dr [NOM] - Gynécopédiatrie/Maternité
Dr [NOM] - Pneumologie
Cadre Infirmier Supérieur du Pôle :
Mme [NOM]
Cadres Infirmiers :
Mr K. [NOM] Générale
Mme C. [NOM] Urgences UHCD et HDJ
Mme J. [NOM] - [NOM]
Psychomotricienne :
Mme A. [NOM]
Orthophonistes :
Mme M-L. [NOM]
Mme M. [NOM]
Psychologues :
Mme E. [NOM]
Mme C. [NOM]
Mme L. [NOM]
Neuropsychologues :
Mme N. [NOM]
Mme M.[NOM]
Assistantes Sociales :
Mme Z. [NOM]
Mme M. [NOM]
Mme J. [NOM]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
Bayonne, le 05/04/2023
DR [NOM]
[ADRESSE]
[CODE_POSTAL]
Mon cher confrère,
Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 02/04/2023 au 05/04/2023 pour le motif
suivant :
-
Méningite à Entérovirus
Antécédents personnels :
Migraine frontale, environ 2 épisodes par mois cédant à la prise de paracétamol et AINS
Antécédents familiaux :
Terrain migraineux chez le père et la mère. Traitement de fond auparavant chez la mère arrêté, prend AINS et triptans en
cas de crise. AINS simple chez le père
Allergies : non.
Vaccination : rappel des 6 ans à faire.
Traitements habituels :
- Paracétamol et AINS si céphalées.
Traitements reçus en hospitalisation :
- Réhydratation parentérale IV par Bionolyte G5 pendant 48h.
- Traitement antalgique par paracétamol, Nubain et Advil.
- Traitement par 1 injection de Caféine dans le cadre d'un syndrome post-PL d'évolution favorable.
- Une antibiothérapie a été mise en place par Cefotaxime par voie iv pendant 48 heures, interrompue après réception des
résultats de la ponction lombaire.
Examens complémentaires pertinents :
Biologie du 02/04 : leucocytes 8.7 G/L, CRP 53 mg/l, ionogramme normal.
Hémoculture sur VVP du 02/04 : negative à H48
Ponction lombaire : Glycorachie 0.67 g/L, protéinorachie 0.33 g/L, 14 éléments, culture négative à 48h.
Analyse du LCR :
* PCR HSV : négative
* PCR Entérovirus : positive
Synthèse du séjour : méningite à Entérovirus d'évolution favorable après antalgie par paracétamol, Nubain et
AINS.
Décision dun retour à domicile. Poids de sortie : 19.4 Kgs.
Traitement de sortie : Doliprane et advil si besoin.
A Prévoir : contrôle clinique par le médecin traitant.
Parents informés de la démarche diagnostique et thérapeutique.
Document remis en mains propres aux parents le jour de la sortie.
Evènements indésirables :
- Transfusions : non
- Produits dérivés du sang : non
- BMR / BHRe / LHR : non
- Découverte de BMR / BHRe / BHR : non
- Pose DMI : non
[MASK]
[MASK]
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (PEDIATRIE GENERALE)
V1 - Imprimé le 08/04/2025 à 10 : 21 par
Page(s) : 1 sur 2 N° Finess
[FINESS]
Chef de Pôle :
Dr [NOM]
Chef de Service - Urgences [NOM]
et Pédiatrie Générale et [NOM] :
Dr [NOM] Urgences
Dr [NOM] - Pédiatrie
Dr [NOM] -
[NOM]
Pédiatrie de Maternité :
Dr [NOM]
Consultation dEndocrino-Diabétologie :
Dr [NOM]
Dr [NOM]
Consultation [NOM] :
Dr [NOM]
Consultation dHémato-Cancérologie :
Dr [NOM]
Dr [NOM]
Consultation de Rhumatologie :
Dr [NOM]
Consultation de Médecine de l'Adolescent :
Dr [NOM]
Urgences [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
[NOM], Réanimation Néonatale :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Consultation de Néphropédiatrie :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Consultation de Neuropédiatrie :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Consultation de Pneumopédiatrie :
Dr [NOM]
Consultation de Cardiopédiatrie :
Dr [NOM]
[NOM]
Dr [NOM] - Dermatologie
Dr [NOM] - Maternité
Dr [NOM], Dr [NOM]
et Dr [NOM] - Génétique
Dr [NOM] -
Rhumato-immunologie
Dr [NOM] - Gynécopédiatrie/Maternité
Dr [NOM] - Pneumologie
Cadre Infirmier Supérieur du Pôle :
Mme [NOM]
Cadres Infirmiers :
Mr K. [NOM] Générale
Mme C. [NOM] Urgences UHCD et HDJ
Mme J. [NOM] - [NOM]
Psychomotricienne :
Mme A. [NOM]
Orthophonistes :
Mme M-L. [NOM]
Mme M. [NOM]
Psychologues :
Mme E. [NOM]
Mme C. [NOM]
Mme L. [NOM]
Neuropsychologues :
Mme N. [NOM]
Mme M.[NOM]
Assistantes Sociales :
Mme Z. [NOM]
Mme M. [NOM]
Mme J. [NOM]
[NOM]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[NOM]
Les consignes d'usage ont été remises.
Bien confraternellement,
Docteur [NOM] [NOM]
*[TEL]*
[TEL]
Liste des destinataires :
DR. [NOM]
[NOM]
[NOM]
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (PEDIATRIE GENERALE)
V1 - Imprimé le 08/04/2025 à 10 : 21 par
Page(s) : 2 sur 2

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@@ -1,108 +0,0 @@
{"page": 0, "kind": "NOM", "original": "Aurélie VALADE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Céline BELLEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Catherine DIDAILLER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Hélène LANGLOIS MEURINNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Claudine EMBAREK", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Mathilde LE GALL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Aurélie VALADE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Alice MANAUD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Elise BADOUR", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Marie DUBREL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Leire ETCHANDY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Fanny HENAFF", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Céline BELLEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Leire ETCHANDY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Fanny HENAFF", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Violette SUC", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Kaiet ECHEVERRIA-ARRUTY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Philippe JOUVENCEL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Hélène LANGLOIS MEURINNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Gaël MAZEIRAS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Justine LABAT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Chloé LAPEYRE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Camille OGER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Caroline DE BARBEYRAC", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Maeva GRONDARD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Catherine DIDAILLER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Claudine EMBAREK", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Julie ALSUGUREN", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Leïla LAZARO", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Serge RIVERA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Marie-Elise PICAMILH", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Léna MARIOTTE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Charlotte PETRIAT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Pierre-Marie DUBOUE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Christel BUZENET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Sabrina DUBOIS-ZUAZO", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Sophie NAUDION", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Marine LEGENDRE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Julien VAN-GILS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Véronique OYHARCABAL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Agnès PUEL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Stéphane DEBELLEIX", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Valérie TERRIER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "SKILBECQ", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "JUZAN", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 0, "kind": "ETAB", "original": "Pôle Femme - Mère - Enfant", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "12 PLACE GRAMONT", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64000 PAU", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "né le 18/01/2008", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Service de Pédiatrie Générale - HDJ - Urgences Pédiatriques - UHCD", "placeholder": "[MASK]", "bbox_hint": null}
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{"page": 0, "kind": "EPISODE", "original": "23079402", "placeholder": "[EPISODE]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Aurélie VALADE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Céline BELLEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Catherine DIDAILLER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Hélène LANGLOIS MEURINNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Claudine EMBAREK", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Mathilde LE GALL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Aurélie VALADE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Alice MANAUD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Elise BADOUR", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Marie DUBREL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Leire ETCHANDY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Fanny HENAFF", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Céline BELLEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Leire ETCHANDY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Fanny HENAFF", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Violette SUC", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Kaiet ECHEVERRIA-ARRUTY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Philippe JOUVENCEL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Hélène LANGLOIS MEURINNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Gaël MAZEIRAS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Justine LABAT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Chloé LAPEYRE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Camille OGER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Caroline DE BARBEYRAC", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Maeva GRONDARD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Catherine DIDAILLER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Claudine EMBAREK", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Julie ALSUGUREN", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Leïla LAZARO", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Serge RIVERA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Marie-Elise PICAMILH", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Léna MARIOTTE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Charlotte PETRIAT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Pierre-Marie DUBOUE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Christel BUZENET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Sabrina DUBOIS-ZUAZO", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Sophie NAUDION", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Marine LEGENDRE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Julien VAN-GILS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Véronique OYHARCABAL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Agnès PUEL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Stéphane DEBELLEIX", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Valérie TERRIER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "SKILBECQ", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "JUZAN", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Pôle Femme - Mère - Enfant", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "PICAMILH Marie-Elise", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "PORTET Guillaume", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "TOULOUZET JOSH", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Service de Pédiatrie Générale - HDJ - Urgences Pédiatriques - UHCD", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Service de Néonatologie - Réanimation Néonatale - Soins Continus Pédiatriques", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "IPP", "original": "23009267", "placeholder": "[IPP]", "bbox_hint": null}
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View File

@@ -1,273 +0,0 @@
N° Finess
[FINESS]
Chef de Pôle :
Dr [NOM]
Chef de Service - Urgences [NOM]
et Pédiatrie Générale et [NOM] :
Dr [NOM] Urgences
Dr [NOM] - Pédiatrie
Dr [NOM] -
[NOM]
Pédiatrie de Maternité :
Dr [NOM]
Consultation dEndocrino-Diabétologie :
Dr [NOM]
Dr [NOM]
Consultation [NOM] :
Dr [NOM]
Consultation dHémato-Cancérologie :
Dr [NOM]
Dr [NOM]
Consultation de Rhumatologie :
Dr [NOM]
Consultation de Médecine de l'Adolescent :
Dr [NOM]
Urgences [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
[NOM], Réanimation Néonatale :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Consultation de Néphropédiatrie :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Consultation de Neuropédiatrie :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Consultation de Pneumopédiatrie :
Dr [NOM]
Consultation de Cardiopédiatrie :
Dr [NOM]
[NOM]
Dr [NOM] - Dermatologie
Dr [NOM] - Maternité
Dr [NOM], Dr [NOM]
et Dr [NOM] - Génétique
Dr [NOM] -
Rhumato-immunologie
Dr [NOM] - Gynécopédiatrie/Maternité
Dr [NOM] - Pneumologie
Cadre Infirmier Supérieur du Pôle :
Mme [NOM]
Cadres Infirmiers :
Mr K. [NOM] Générale
Mme C. [NOM] Urgences UHCD et HDJ
Mme J. [NOM] - [NOM]
Psychomotricienne :
Mme A. [NOM]
Orthophonistes :
Mme M-L. [NOM]
Mme M. [NOM]
Psychologues :
Mme E. [NOM]
Mme C. [NOM]
Mme L. [NOM]
Neuropsychologues :
Mme N. [NOM]
Mme M.[NOM]
Assistantes Sociales :
Mme Z. [NOM]
Mme M. [NOM]
Mme J. [NOM]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
Bayonne, le 25/04/2023
M [NOM] [NOM]
[ADRESSE]
[CODE_POSTAL]
Mon cher confrère,
Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 22/04/2023 au 25/04/2023 pour le motif
suivant :
-
Découverte de syndrome néphrotique impur.
Antécédents personnels : aucun
Antécédents familiaux : aucun
Allergies : non.
Vaccination : à jour
Traitements habituels : aucun
Histoire de la maladie : Adolescent de 15.5 ans sans antécédent, adressé aux urgences le 22/04 pour syndrome œdémateux
d'évolution aigue. Début la semaine précédente par œdèmes des paupières, puis, œdèmes des MI et abdominal depuis le
17/04.
AEG depuis 5 jours avec dyspnée modérée à l'effort.
Pas de notion d'hyperthermie, ni vaccination. Bronchite il y a 10 jours sous ttt symptomatique.
A l'examen clinique aux urgences le 22/04 :
Poids habituel : 64kg; poids à l'arrivée aux urgences le 22/04 : 82.5 kg (+ 18.5 kg)
apyrétique, pas de syndrome infectieux
syndrome œdémateux avec œdèmes déclives prenant le godet remontant jusqu'aux genoux et œdèmes des lombes
auscultation CP : pas de crépitants, pas de diminution du MV
BDC réguliers, pas de souffle
pas de signe d'OAP, pas de signe de TVP
pas de douleur lombaire, pas d'hématurie macro
Examens complémentaires pertinents :
* Biologie :
Na 134mmol/l, K 3.9 mmol/L
créatininémie à 88 µmol/L
albumine 23.7 g/L
protéinurie/creatininurie : 600 ; proténiurie sur échantillon 11.5 g/L
NFS : G 10.3 G/L Hb 15 g/dL, plaquette 345 G/L
bilan hépatique normal, proBNP 455 ng/L
hypertriglycéridémie à 2.69 g/L.
Critères d'anticoagulation préventive : DDimères > 1000, fibrinogène > 6 g/L , AT3 77%
*Radiologique :
- Echo-doppler des reins : N° d'examen : RAD[TEL]
Les reins sont mesurés à 11 cm à droite, 11,8 cm à gauche. Leurs contours sont réguliers. La différenciation
corticomédullaire est visualisée de façon bilatérale, atténuée. Absence d'anomalie parenchymateuse focale. Absence de
modification du volume des systèmes excréteurs. L'enregistrement doppler met en évidence un spectre artériel de type
basse résistance tant en intrarénal qu'au niveau du hile. L'enregistrement veineux est correct tant en intrarénal qu'au
niveau du hile. Confirmation
d'un épanchement pleural et péritonéal significatif.
CONCLUSION : Absence d'argument en faveur d'une thrombose veineuse rénale
Traitements reçus en hospitalisation :
Début du protocole de prise en charge du SN pédiatrique le 23/04 avec :
- Corticothérapie par PREDNISONE 60 mg par jour sous couvert d'une protection gastrique par INEXIUM 20 mg.
- Mise en place d'antihypertenseur devant l'HTA par RAMIPRIL 2.5 mg .
- Anticoagulation préventive par LOVENOX SC 0.4 mL/j
- FUROSEMIDE 40 mg IVD administrer une fois relancer la diurèse.
- Régime hypo-sodé/ hypo-sucré et restriction hydrique à 500 mL /jour.
[MASK]
[MASK]
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (Pédia Surv continue (hors Nné))
V1 - Imprimé le 11/04/2025 à 09 : 19 par
Page(s) : 1 sur 2 N° Finess
[FINESS]
Chef de Pôle :
Dr [NOM]
Chef de Service - Urgences [NOM]
et Pédiatrie Générale et [NOM] :
Dr [NOM] Urgences
Dr [NOM] - Pédiatrie
Dr [NOM] -
[NOM]
Pédiatrie de Maternité :
Dr [NOM]
Consultation dEndocrino-Diabétologie :
Dr [NOM]
Dr [NOM]
Consultation [NOM] :
Dr [NOM]
Consultation dHémato-Cancérologie :
Dr [NOM]
Dr [NOM]
Consultation de Rhumatologie :
Dr [NOM]
Consultation de Médecine de l'Adolescent :
Dr [NOM]
Urgences [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
[NOM], Réanimation Néonatale :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Consultation de Néphropédiatrie :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Consultation de Neuropédiatrie :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Consultation de Pneumopédiatrie :
Dr [NOM]
Consultation de Cardiopédiatrie :
Dr [NOM]
[NOM]
Dr [NOM] - Dermatologie
Dr [NOM] - Maternité
Dr [NOM], Dr [NOM]
et Dr [NOM] - Génétique
Dr [NOM] -
Rhumato-immunologie
Dr [NOM] - Gynécopédiatrie/Maternité
Dr [NOM] - Pneumologie
Cadre Infirmier Supérieur du Pôle :
Mme [NOM]
Cadres Infirmiers :
Mr K. [NOM] Générale
Mme C. [NOM] Urgences UHCD et HDJ
Mme J. [NOM] - [NOM]
Psychomotricienne :
Mme A. [NOM]
Orthophonistes :
Mme M-L. [NOM]
Mme M. [NOM]
Psychologues :
Mme E. [NOM]
Mme C. [NOM]
Mme L. [NOM]
Neuropsychologues :
Mme N. [NOM]
Mme M.[NOM]
Assistantes Sociales :
Mme Z. [NOM]
Mme M. [NOM]
Mme J. [NOM]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
- Antalgie par Doliprane.
Synthèse du séjour : Syndrome néphrotique impur avec HTA et hématurie microcospique.
Début de la corticothérapie le 23/04
Décision dun transfert dans le service de néphrologie pédiatrique 25/04 à [VILLE] pour rapprochement familial.
Poids de sortie le 25/4 : 77.7 Kgs.
Parents informés de la démarche diagnostique et thérapeutique.
Document remis en mains propres aux parents le jour de la sortie.
Evènements indésirables :
- Transfusions : non
- Produits dérivés du sang : non
- BMR / BHRe / LHR : non
- Découverte de BMR / BHRe / BHR : non
- Pose DMI : non
Les consignes d'usage ont été remises.
Bien confraternellement,
Docteur [NOM] [NOM]
*[TEL]*
[TEL]
Rédigé par [NOM]
Liste des destinataires :
Monsieur [NOM]
[MASK]
[MASK]
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (Pédia Surv continue (hors Nné))
V1 - Imprimé le 11/04/2025 à 09 : 19 par
Page(s) : 2 sur 2

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@@ -1,65 +0,0 @@
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{"page": 0, "kind": "NOM", "original": "Thomas Grellety", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "faudemar@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "BOUBE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "mboube@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "BRUGEL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "mbrugel@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
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{"page": 0, "kind": "EMAIL", "original": "dnivet@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "boui@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Pôle Spécialités Médicales", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Service de Gastro-Entérologie - Oncologie Digestive", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10100532760", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "fprevost@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "IPP", "original": "21020800", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 0, "kind": "EPISODE", "original": "23127286", "placeholder": "[EPISODE]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Christelle Béraut", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Thomas Grellety", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "faudemar@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "BOUBE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "mboube@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "BRUGEL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "mbrugel@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "mcboudier@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "fgoutorbe@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "aguilngar@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "tkhuong-huu@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "dnivet@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "boui@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Pôle Spécialités Médicales", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Service de Gastro-Entérologie - Oncologie Digestive", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "PELLERIN-GUIGNARD Aude", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "PUJOS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "PUJOS Marion", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "RPPS", "original": "10100532760", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "fprevost@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "IPP", "original": "21020800", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 1, "kind": "EPISODE", "original": "23127286", "placeholder": "[EPISODE]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Christelle Béraut", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Thomas Grellety", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "faudemar@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "BOUBE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "mboube@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "BRUGEL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "mbrugel@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "mcboudier@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "fgoutorbe@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "aguilngar@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "tkhuong-huu@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "dnivet@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "boui@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 2, "kind": "ETAB", "original": "Pôle Spécialités Médicales", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 2, "kind": "ETAB", "original": "Service de Gastro-Entérologie - Oncologie Digestive", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "AUDEMAR Franck", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "MEURAT Aurore", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "RPPS", "original": "10100532760", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "fprevost@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "IPP", "original": "21020800", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 2, "kind": "EPISODE", "original": "23127286", "placeholder": "[EPISODE]", "bbox_hint": null}

View File

@@ -1,364 +0,0 @@
N° Finess
[FINESS]
ICANCE - Institut de Cancérologie
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK]. [NOM]
A. Interne Hôpitaux Strasbourg
A. Chef Clinique Ass. Hôpitaux
DESC Oncologie Digestive
Hépato-gastro-entérologue
Oncologue Digestif
[EMAIL]
Praticiens Hospitaliers
Dr M. [NOM]
A. In. Hôpitaux [ETABLISSEMENT]
A. Chef de clinique - Ass Hôpitaux
Hépato-gastro-entérologue
[EMAIL]
Dr M. [NOM]
A. Interne Hôpitaux [ETABLISSEMENT]
A. Ass. Hôpitaux [ETABLISSEMENT]
DESC Cancérologie
Hépato-gastro-entérologue
Oncologue digestif
[EMAIL]
Dr C. [NOM]
A. Interne Hôpitaux Limoges
A. Chef Clinique Ass. Hôpitaux
Hépato-gastro-entérologue
Proctologue
Explorations Fonct. Digestives
[EMAIL]
Dr F. [NOM]
A. In. Hôpitaux [ETABLISSEMENT]
A. Chef de clinique - Ass Hôpitaux
DESC Oncologie Digestive
Proctologue
[EMAIL]
Dr A.[NOM]
A.Interne Hôpitaux Bordeaux
DESC Oncologie Digestive
Hépato-gastro-entérologue
Oncologue Digestif
[EMAIL]
Dr T. [NOM]
A. In. Hôpitaux [ETABLISSEMENT]
A. Chef Clinique Ass. Hôpitaux
Hépato-gastro-entérologue
Proctologue
Explorations Fonct. Digestives
[EMAIL]
Dr D. [NOM]
A. Interne Hôpitaux Bordeaux - Ass.
Hôpitaux
Hépato-gastro-entérologue
[EMAIL]
Dr B. OUI
A. Interne Hôpitaux Bordeaux
A. Chef Clinique - Ass. Hôpitaux
Hépato-gastro-entérologue
[EMAIL]
Unité dHospitalisation
Tel [TEL]
Fax [TEL]
Cadre Infirmier
Mme S. [NOM]
Secrétariat et R.V.
Tel [TEL]
Fax [TEL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
Bayonne, le 04/07/2023
Mon cher confrère,
Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 01/07/2023 au 04/07/2023 pour le motif suivant :
-
MH : douleur anale
ATCD : non
TTT : non
Allergie : NC
HdM : A consulté il y a 2 jours sur douleur anale avec dysurie.
Douleur brutale anale après séance de sport mercredi dans la journée
HSH - dernier rapport datant d'il y a 7 jours, pas d'insertion de CE
Nous avions conclu à une prostatite et débuté la Levofloxacine et une antalgie palier 1 et 3.
Depuis majoration des symptômes, fébrile à 39, anorexie.
Examen clinique :
Douleur EN 9/
Febrile 39°C, TA 13/8 mmHg, FC 120bpm, SpO2 98% en AA
Bdc regulier pas de souffle
MV+/+ pas de bruit surajouté
Abdomen souple dépressible, non dl. Absce de transit depuis 3j.
SFU brulures.
PAs découlement urteral
Examen complémentaires :
Biologie :
Majoration SIB, GB 15G/L, CRP 168
Bilan hépatique subnormal
Fonction rénale normale
Ionogramme sgx normal
Bladder : 600cc
BU : leuco neg
ECBU : en cours
Hémocultures : en cours
SCANNER ABDOMINO-PELVIEN :
Indication :
Suspicion d'abcès prostatique.
Protocole :
Examen réalisé avec injection de produit de contraste.
RESULTATS :
Mise en évidence d'une collection péri rectale mesurée à 3cm associée à une infiltration ?démateuse périrectale.
Prostate de volume préservée. Pas de collection visible prostatique.
Le foie est homogène et non dysmorphique.
Il n'y a pas d'anomalie significative de la vésicule biliaire. Les voies biliaires intra et extra hépatiques sont fines.
Pas d'anomalie du système porte.
Pas d'anomalie du pancréas, de la rate, des reins et des surrénales.
Pas d'adénopathie rétropéritonéale ou coelio-mésentérique de taille significative.
Dr F. [NOM]
RPPS : [RPPS]
Hépato-gastro-entérologue et assistante
nutritive
[EMAIL]
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (MEDECINE GASTRO B2 HC)
V1 - Imprimé le 17/04/2025 à 08 : 31 par
Page(s) : 1 sur 3 N° Finess
[FINESS]
ICANCE - Institut de Cancérologie
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK]. [NOM]
A. Interne Hôpitaux Strasbourg
A. Chef Clinique Ass. Hôpitaux
DESC Oncologie Digestive
Hépato-gastro-entérologue
Oncologue Digestif
[EMAIL]
Praticiens Hospitaliers
Dr M. [NOM]
A. In. Hôpitaux [ETABLISSEMENT]
A. Chef de clinique - Ass Hôpitaux
Hépato-gastro-entérologue
[EMAIL]
Dr M. [NOM]
A. Interne Hôpitaux [ETABLISSEMENT]
A. Ass. Hôpitaux [ETABLISSEMENT]
DESC Cancérologie
Hépato-gastro-entérologue
Oncologue digestif
[EMAIL]
Dr C. [NOM]
A. Interne Hôpitaux Limoges
A. Chef Clinique Ass. Hôpitaux
Hépato-gastro-entérologue
Proctologue
Explorations Fonct. Digestives
[EMAIL]
Dr F. [NOM]
A. In. Hôpitaux [ETABLISSEMENT]
A. Chef de clinique - Ass Hôpitaux
DESC Oncologie Digestive
Proctologue
[EMAIL]
Dr A.[NOM]
A.Interne Hôpitaux Bordeaux
DESC Oncologie Digestive
Hépato-gastro-entérologue
Oncologue Digestif
[EMAIL]
Dr T. [NOM]
A. In. Hôpitaux [ETABLISSEMENT]
A. Chef Clinique Ass. Hôpitaux
Hépato-gastro-entérologue
Proctologue
Explorations Fonct. Digestives
[EMAIL]
Dr D. [NOM]
A. Interne Hôpitaux Bordeaux - Ass.
Hôpitaux
Hépato-gastro-entérologue
[EMAIL]
Dr B. OUI
A. Interne Hôpitaux Bordeaux
A. Chef Clinique - Ass. Hôpitaux
Hépato-gastro-entérologue
[EMAIL]
Unité dHospitalisation
Tel [TEL]
Fax [TEL]
Cadre Infirmier
Mme S. [NOM]
Secrétariat et R.V.
Tel [TEL]
Fax [TEL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
Pas d'épanchement péritonéal.
Pas d'anomalie des structures pelviennes.
CONCLUSION :
Aspect TDM en faveur d'une collection abcédée péri rectale.
Dr [NOM]
[NOM] en charge évolution :
Hydratation Nacl
Antalgie : paracetamol + Morphine
Anthibiothérapie par Ceftriaxone + Flagyl débuté pour abcès péri rectal
SU ?
AU TOTAL : Abcès peri rectal
ATB C3G Flagyl
Suite de la [NOM] en charge en infectiologie. Faute de place hébergé par la Gastroentérologie
Evolution :
Bloc ce jour :
Volumineux abcès en fer à cheval péri-anal, développé au dépens d'une fistule avec le canal anal située à 6h
Prélèvement bactério réalisé
Evacuation de pus en quantité importante
Elastique dans le trajet fistuleux afin de l'abaisser
- Sur le plan urologique : reprise mictionnelle sans difficultés, retrait du KT sus-pubien le 04/07 sans complication.
- Sur le plan digestif : abdomen souple, dépressible et indolore. Difficultés à l'exonération, mise en place de laxatifs.
Réévaluation en consultation dans 2 semaines par le Dr [NOM].
- Sur le plan infectieux : analyse du pus en cours, hémocultures toujours en cours à la sortie. Relai de l'antibiothérapie par
Rocéphine + Flagyl débutée le 01/07 par Augmentin pour 7 jours au total (fin le 08/07/2023).
Décroissance de la CRP à 174 mg/L lors de la sortie (vs 291 à l'entrée).
Surveillance biologique hebdomadaire pour surveiller décroissance CRP.
Sortie le 04/07 du service avec les consignes devant amener à faire reconsulter en urgence : fièvre, douleurs abdominales
intenses, écoulements, rétention aigue d'urine.
Votre patient(e) quitte le service avec :
- Pharmacie :
PARACETAMOL ARW 500MG GELULE [12] Gelule(s) 2 GELULE (ORALE) toutes les 6 heures jusqu'au 14/07/2023 à
6h04
TRAMADOL - TOPALGIC 50MG GELULE 50MG gelule 1 GELULE (ORALE) toutes les 6 heures jusqu'au 11/07/2023
à 6h04
AMOX/AC CLAV SDZ 1G/125MG AD SACH [12] Sachet(s) 1 G (ORALE) matin midi soir
MACROGOL - TRANSIPEG 5,9G PDR [NOM] 5,9G poudre 2 SACHET(S) (ORALE) matin [8h]
Conclusion :
-
Draînage d'un abcès péri-rectal avec fistule anale, suites simples.
Sera revu en consultation par le Dr [NOM] le 20 Juillet 2023 à 15h30 avec un bilan biologique à réaliser au
préalable.
Poursuite de l'antibiothérapie jusqu'au 08/07/2023 pour 7 jours au total.
Dr F. [NOM]
RPPS : [RPPS]
Hépato-gastro-entérologue et assistante
nutritive
[EMAIL]
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (MEDECINE GASTRO B2 HC)
V1 - Imprimé le 17/04/2025 à 08 : 31 par
Page(s) : 2 sur 3 N° Finess
[FINESS]
ICANCE - Institut de Cancérologie
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK]. [NOM]
A. Interne Hôpitaux Strasbourg
A. Chef Clinique Ass. Hôpitaux
DESC Oncologie Digestive
Hépato-gastro-entérologue
Oncologue Digestif
[EMAIL]
Praticiens Hospitaliers
Dr M. [NOM]
A. In. Hôpitaux [ETABLISSEMENT]
A. Chef de clinique - Ass Hôpitaux
Hépato-gastro-entérologue
[EMAIL]
Dr M. [NOM]
A. Interne Hôpitaux [ETABLISSEMENT]
A. Ass. Hôpitaux [ETABLISSEMENT]
DESC Cancérologie
Hépato-gastro-entérologue
Oncologue digestif
[EMAIL]
Dr C. [NOM]
A. Interne Hôpitaux Limoges
A. Chef Clinique Ass. Hôpitaux
Hépato-gastro-entérologue
Proctologue
Explorations Fonct. Digestives
[EMAIL]
Dr F. [NOM]
A. In. Hôpitaux [ETABLISSEMENT]
A. Chef de clinique - Ass Hôpitaux
DESC Oncologie Digestive
Proctologue
[EMAIL]
Dr A.[NOM]
A.Interne Hôpitaux Bordeaux
DESC Oncologie Digestive
Hépato-gastro-entérologue
Oncologue Digestif
[EMAIL]
Dr T. [NOM]
A. In. Hôpitaux [ETABLISSEMENT]
A. Chef Clinique Ass. Hôpitaux
Hépato-gastro-entérologue
Proctologue
Explorations Fonct. Digestives
[EMAIL]
Dr D. [NOM]
A. Interne Hôpitaux Bordeaux - Ass.
Hôpitaux
Hépato-gastro-entérologue
[EMAIL]
Dr B. OUI
A. Interne Hôpitaux Bordeaux
A. Chef Clinique - Ass. Hôpitaux
Hépato-gastro-entérologue
[EMAIL]
Unité dHospitalisation
Tel [TEL]
Fax [TEL]
Cadre Infirmier
Mme S. [NOM]
Secrétariat et R.V.
Tel [TEL]
Fax [TEL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
Les consignes d'usage ont été remises.
Bien confraternellement,
Docteur [NOM]
*[TEL]*
[TEL]
Rédigé par [NOM]
Dr F. [NOM]
RPPS : [RPPS]
Hépato-gastro-entérologue et assistante
nutritive
[EMAIL]
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (MEDECINE GASTRO B2 HC)
V1 - Imprimé le 17/04/2025 à 08 : 31 par
Page(s) : 3 sur 3

View File

@@ -1,251 +0,0 @@
{"page": 0, "kind": "NOM", "original": "Alexia HOURDILLE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10100817005", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Stéphane MARCE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10002815024", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Léa LOPEZ", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10101856135", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Itsaso ODRIOZOLA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10102272209", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Thomas CLAVERIE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10102268702", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Irène MACHELART", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10100858090", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Visal KEO", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10101480506", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Hilaire CHARLANNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10004606595", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Kevin DEVE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10101639580", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Suzanne DEVAUX", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10100163277", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Elisabeth GUINARD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10101096005", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Alice MARNEFFE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10110601324", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Anne BARTEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Irène MACHELART", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "secr.medint@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "PERNAUT CHRYSTELLE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "1 RUE MAGENTA", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "40660 MOLIETS ET MAA", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "né le 14/04/1950", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "PERNAUT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARTINEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "LACRAZ", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARTINEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARTINEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "IPP", "original": "07009798", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 0, "kind": "EPISODE", "original": "23132490", "placeholder": "[EPISODE]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Alexia HOURDILLE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 1, "kind": "RPPS", "original": "10100817005", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Stéphane MARCE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 1, "kind": "RPPS", "original": "10002815024", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Léa LOPEZ", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
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{"page": 1, "kind": "NOM", "original": "Itsaso ODRIOZOLA", "placeholder": "[NOM]", "bbox_hint": null}
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View File

@@ -1,737 +0,0 @@
N° Finess
[FINESS]
RHUMATOLOGIE
Dr [NOM]
Chef de [MASK] [ETABLISSEMENT]
de Paris
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de Lyon
Praticien hospitalier contractuel
RPPS : [RPPS]
Secrétariat : [TEL]
MEDECINE INTERNE ET
IMMUNOLOGIE CLINIQUE
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de
Bordeaux et Bayonne
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Lille
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Assistant spécialiste
RPPS : [RPPS]
Secrétariat : [TEL]
DERMATOLOGIE
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Toulouse
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de
Toulouse
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM]
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM]
Praticien Hospitalier contractuel
Secrétariat : [TEL]
CENTRE DE COMPETENCES
DES MALADIES AUTO IMMUNES
ET AUTO-INFLAMMATOIRES
SYSTEMIQUES RARES :
Médecin coordonnateur :
Dr [NOM]
Secrétariat : [TEL]
[EMAIL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
PÔLE MÉDECINE INTERNE
SERVICE RHUMATOLOGIE - MEDECINE INTERNE
ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE
Bayonne, le 31/07/2023
DR [NOM]
[ADRESSE]
[CODE_POSTAL]
Mon cher confrère,
Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 24/07/2023 au 27/07/2023 pour le motif
suivant :
-
Médecin traitant : Dr [NOM]
Hématologue : Dr [NOM]
Motif d'entrée : Cimentoplastie
Antécédents :
Lithiase rénale sur hypercalciurie suivi par Dr [NOM]
[NOM] monoclonal IgG Kappa 8.5 g/L suivi par Dr [NOM] en cours de bilan
Fracture T5
Chirurgicaux : Lithotritie per cutanée
ALLERGIE : Œdème de Quincke a lamoxicilline
Mode de vie :
Vit avec sa femme, patient autonome
Tabac 5/6 cig par jour. OH occasionnel
Traitements :
ALLOPURINOL 100mg 1.0.0
NEBIVOLOL 5mg 1/2.0.0
KARDEGIC 75mg 1.0.0
HYDROCHLOROTHIAZIDE 25mg 1.0.1
ZYMAD 10000UI 2gt tous les jours
MECIR LP 0.4mg 0.1.1
CITRATE de K 1g 1.1.1
Histoire de la maladie :
Patient suivi pour une MGUS IgG Kappa à 8.5 g/dL par le Dr [NOM] en surveillance sans traitement pour le
moment.
Début mai le patient se plaint de douleur dorsal sans notion de chute ni de traumatisme.
Une radio et un scanner puis une IRM sont réalisées au cours du moi de mai :
- Le scanner du 16/05/23 retrouve : Fracture compression dallure non strictement consolidée étagée du plateau vertébral
supérieur de la pièce du corps vertébrale T5 sans recul du mur postérieur.
- L'IRM du Rachis réalisé le 31/05/23 : Fracture T5 sur os non pathologique.
Patient douloureux mais non hyperalgique, ne prend pas dantalgique.
Pas de sciatalgie ni d'argument pour un syndrome de la queue de cheval.
Dans le contexte son hématologue souhaite réaliser une biopsie afin déliminer définitivement lorigine myélomateuse de la
lésion, une cimentoplastie est organisé dans le même temps a but antalgique.
Hospitalisé en rhumatologie pour cimentoplastie + bilan ostéopathie fragilisante.
Examen clinique :
Apyrétique, pas de défaillance hémodynamique.
BDC régulier, pas de souffle perçu, pas d'omi, pas de douleur thoracique.
MV +/+ pas de bruit surajouté, pas de toux.
Abdomen souple depressible, indolore a la palpation, pas de trouble du transit, pas de SFU.
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (RHUMATOLOGIE)
V1 - Imprimé le 17/04/2025 à 11 : 24 par
Page(s) : 1 sur 3 N° Finess
[FINESS]
RHUMATOLOGIE
Dr [NOM]
Chef de [MASK] [ETABLISSEMENT]
de Paris
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de Lyon
Praticien hospitalier contractuel
RPPS : [RPPS]
Secrétariat : [TEL]
MEDECINE INTERNE ET
IMMUNOLOGIE CLINIQUE
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de
Bordeaux et Bayonne
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Lille
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Assistant spécialiste
RPPS : [RPPS]
Secrétariat : [TEL]
DERMATOLOGIE
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Toulouse
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de
Toulouse
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM]
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM]
Praticien Hospitalier contractuel
Secrétariat : [TEL]
CENTRE DE COMPETENCES
DES MALADIES AUTO IMMUNES
ET AUTO-INFLAMMATOIRES
SYSTEMIQUES RARES :
Médecin coordonnateur :
Dr [NOM]
Secrétariat : [TEL]
[EMAIL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
PÔLE MÉDECINE INTERNE
SERVICE RHUMATOLOGIE - MEDECINE INTERNE
ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE
Douleur élective a la palpation de T5 et des muscle paravertebraux. Pas de déficit sensitivo-moteur ou de paresthésies. Pas
d'irradiation de la douleur.
Pas de céphalées, pas de raideur méningée.
Pas de trouble vésico-sphinctérien.
Examens complémentaires :
Biologie :
Hb 14.5 g/dL, plaquettes 206 G/L, PNN 4.17 G/L
Ionogramme normal en dehors d'une discrète hyponatrémie à 134 mmol/L, calcémie nomrale à 2.25 mmol/L,
hypomagnésémie à 0.67 mmol/L, phosphore normal à 1.12 mmol/L
Vitamine D normale à 44 ng/mL
PTH normale
Créatininémie 49 umol/L avec DFG 103 ml/min
CRP 1 mg/L
Bilan hépatique normal
TP 94 %, TCA ratio 0.94
EPP : [NOM] monoclonal connu et stable à 8.1 g/L
Evolution dans le service :
Patient hospitalisé dans le service pour biopsie et cimentoplastie de T5 suite à une fracture vertébrale de T5 dans un
contexte de gammapathie monoclonale (MGUS IgG kappa) actuellement sous surveillance.
Relecture des images IRM : en faveur d'une origine ostéoporotique de la lésion.
Par ailleurs, dans ce contexte de gammapathie monoclonale : pas d'anémie, fonction rénale normale et pas d'hypercalcémie.
Vertébroplastie de T5 et biopsie réalisée le 25/07/23 sans complication par le Dr [NOM].
Bien soulagé par vertébroplastie.
Réalisation d'un bilan d'ostéopathie fragilisante : pas de carence en vitamine D, bilan phosphocalcique sans particularité,
gammapathie monoclonale connue, TSH normale.
Facteur de risque ostéopathie fragilisante : tabagisme, gammapathie monoclonale, hypercalciurie primitive, pas d'ATCD de
corticothérapie au long cours, pas dATCD personnel ou familiaux de fracture.
Indication à l'initiation d'un traitement anti-ostréoporotique et réalisation d'un perfusion d'ACLASTA le 26/07.
La patient sera revu en consultation dans un mois par le Dr [NOM] avec les résultats de la biopsie osseuse.
Conclusion :
Réalisation d'une cimentoplastie et biopsie de T5.
Lésion d'allure ostéoporotique.
Bilan d'ostéopathie fragilisante normal.
Réalisation d'une première perfusion d'Aclasta 5 mg IV.
Suite et devenir :
DMO à réaliser en externe
Injection d'ACLASTA une fois par an pendant les deux prochaines années puis nouvelle DMO.
Consultation Dr [NOM] avec les résultats de la biopsie osseuse dans un mois.
Traitement de sortie :
inchangé
Les consignes d'usage ont été remises.
Bien confraternellement,
Docteur [NOM] [NOM]
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (RHUMATOLOGIE)
V1 - Imprimé le 17/04/2025 à 11 : 24 par
Page(s) : 2 sur 3 N° Finess
[FINESS]
RHUMATOLOGIE
Dr [NOM]
Chef de [MASK] [ETABLISSEMENT]
de Paris
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de Lyon
Praticien hospitalier contractuel
RPPS : [RPPS]
Secrétariat : [TEL]
MEDECINE INTERNE ET
IMMUNOLOGIE CLINIQUE
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de
Bordeaux et Bayonne
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Lille
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Assistant spécialiste
RPPS : [RPPS]
Secrétariat : [TEL]
DERMATOLOGIE
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Toulouse
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de
Toulouse
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM]
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM]
Praticien Hospitalier contractuel
Secrétariat : [TEL]
CENTRE DE COMPETENCES
DES MALADIES AUTO IMMUNES
ET AUTO-INFLAMMATOIRES
SYSTEMIQUES RARES :
Médecin coordonnateur :
Dr [NOM]
Secrétariat : [TEL]
[EMAIL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
PÔLE MÉDECINE INTERNE
SERVICE RHUMATOLOGIE - MEDECINE INTERNE
ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE
*[RPPS]*
[RPPS]
Liste des destinataires :
DR. [NOM]
DR. [NOM]
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (RHUMATOLOGIE)
V1 - Imprimé le 17/04/2025 à 11 : 24 par
Page(s) : 3 sur 3 N° Finess
[FINESS]
RHUMATOLOGIE
Dr [NOM]
Chef de [MASK] [ETABLISSEMENT]
de Paris
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de Lyon
Praticien hospitalier contractuel
RPPS : [RPPS]
Secrétariat : [TEL]
MEDECINE INTERNE ET
IMMUNOLOGIE CLINIQUE
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de
Bordeaux et Bayonne
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Lille
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Assistant spécialiste
RPPS : [RPPS]
Secrétariat : [TEL]
DERMATOLOGIE
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Toulouse
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de
Toulouse
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM]
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM]
Praticien Hospitalier contractuel
Secrétariat : [TEL]
CENTRE DE COMPETENCES
DES MALADIES AUTO IMMUNES
ET AUTO-INFLAMMATOIRES
SYSTEMIQUES RARES :
Médecin coordonnateur :
Dr [NOM]
Secrétariat : [TEL]
[EMAIL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
PÔLE MÉDECINE INTERNE
SERVICE RHUMATOLOGIE - MEDECINE INTERNE
ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE
Bayonne, le 31/07/2023
DR [NOM]
SERVICE [NOM]
[CODE_POSTAL]
Mon cher confrère,
Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 24/07/2023 au 27/07/2023 pour le motif
suivant :
-
Médecin traitant : Dr [NOM]
Hématologue : Dr [NOM]
Motif d'entrée : Cimentoplastie
Antécédents :
Lithiase rénale sur hypercalciurie suivi par Dr [NOM]
[NOM] monoclonal IgG Kappa 8.5 g/L suivi par Dr [NOM] en cours de bilan
Fracture T5
Chirurgicaux : Lithotritie per cutanée
ALLERGIE : Œdème de Quincke a lamoxicilline
Mode de vie :
Vit avec sa femme, patient autonome
Tabac 5/6 cig par jour. OH occasionnel
Traitements :
ALLOPURINOL 100mg 1.0.0
NEBIVOLOL 5mg 1/2.0.0
KARDEGIC 75mg 1.0.0
HYDROCHLOROTHIAZIDE 25mg 1.0.1
ZYMAD 10000UI 2gt tous les jours
MECIR LP 0.4mg 0.1.1
CITRATE de K 1g 1.1.1
Histoire de la maladie :
Patient suivi pour une MGUS IgG Kappa à 8.5 g/dL par le Dr [NOM] en surveillance sans traitement pour le
moment.
Début mai le patient se plaint de douleur dorsal sans notion de chute ni de traumatisme.
Une radio et un scanner puis une IRM sont réalisées au cours du moi de mai :
- Le scanner du 16/05/23 retrouve : Fracture compression dallure non strictement consolidée étagée du plateau vertébral
supérieur de la pièce du corps vertébrale T5 sans recul du mur postérieur.
- L'IRM du Rachis réalisé le 31/05/23 : Fracture T5 sur os non pathologique.
Patient douloureux mais non hyperalgique, ne prend pas dantalgique.
Pas de sciatalgie ni d'argument pour un syndrome de la queue de cheval.
Dans le contexte son hématologue souhaite réaliser une biopsie afin déliminer définitivement lorigine myélomateuse de la
lésion, une cimentoplastie est organisé dans le même temps a but antalgique.
Hospitalisé en rhumatologie pour cimentoplastie + bilan ostéopathie fragilisante.
Examen clinique :
Apyrétique, pas de défaillance hémodynamique.
BDC régulier, pas de souffle perçu, pas d'omi, pas de douleur thoracique.
MV +/+ pas de bruit surajouté, pas de toux.
Abdomen souple depressible, indolore a la palpation, pas de trouble du transit, pas de SFU.
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (RHUMATOLOGIE)
V1 - Imprimé le 17/04/2025 à 11 : 24 par
Page(s) : 1 sur 3 N° Finess
[FINESS]
RHUMATOLOGIE
Dr [NOM]
Chef de [MASK] [ETABLISSEMENT]
de Paris
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de Lyon
Praticien hospitalier contractuel
RPPS : [RPPS]
Secrétariat : [TEL]
MEDECINE INTERNE ET
IMMUNOLOGIE CLINIQUE
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de
Bordeaux et Bayonne
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Lille
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Assistant spécialiste
RPPS : [RPPS]
Secrétariat : [TEL]
DERMATOLOGIE
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Toulouse
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de
Toulouse
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM]
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM]
Praticien Hospitalier contractuel
Secrétariat : [TEL]
CENTRE DE COMPETENCES
DES MALADIES AUTO IMMUNES
ET AUTO-INFLAMMATOIRES
SYSTEMIQUES RARES :
Médecin coordonnateur :
Dr [NOM]
Secrétariat : [TEL]
[EMAIL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
PÔLE MÉDECINE INTERNE
SERVICE RHUMATOLOGIE - MEDECINE INTERNE
ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE
Douleur élective a la palpation de T5 et des muscle paravertebraux. Pas de déficit sensitivo-moteur ou de paresthésies. Pas
d'irradiation de la douleur.
Pas de céphalées, pas de raideur méningée.
Pas de trouble vésico-sphinctérien.
Examens complémentaires :
Biologie :
Hb 14.5 g/dL, plaquettes 206 G/L, PNN 4.17 G/L
Ionogramme normal en dehors d'une discrète hyponatrémie à 134 mmol/L, calcémie nomrale à 2.25 mmol/L,
hypomagnésémie à 0.67 mmol/L, phosphore normal à 1.12 mmol/L
Vitamine D normale à 44 ng/mL
PTH normale
Créatininémie 49 umol/L avec DFG 103 ml/min
CRP 1 mg/L
Bilan hépatique normal
TP 94 %, TCA ratio 0.94
EPP : [NOM] monoclonal connu et stable à 8.1 g/L
Evolution dans le service :
Patient hospitalisé dans le service pour biopsie et cimentoplastie de T5 suite à une fracture vertébrale de T5 dans un
contexte de gammapathie monoclonale (MGUS IgG kappa) actuellement sous surveillance.
Relecture des images IRM : en faveur d'une origine ostéoporotique de la lésion.
Par ailleurs, dans ce contexte de gammapathie monoclonale : pas d'anémie, fonction rénale normale et pas d'hypercalcémie.
Vertébroplastie de T5 et biopsie réalisée le 25/07/23 sans complication par le Dr [NOM].
Bien soulagé par vertébroplastie.
Réalisation d'un bilan d'ostéopathie fragilisante : pas de carence en vitamine D, bilan phosphocalcique sans particularité,
gammapathie monoclonale connue, TSH normale.
Facteur de risque ostéopathie fragilisante : tabagisme, gammapathie monoclonale, hypercalciurie primitive, pas d'ATCD de
corticothérapie au long cours, pas dATCD personnel ou familiaux de fracture.
Indication à l'initiation d'un traitement anti-ostréoporotique et réalisation d'un perfusion d'ACLASTA le 26/07.
La patient sera revu en consultation dans un mois par le Dr [NOM] avec les résultats de la biopsie osseuse.
Conclusion :
Réalisation d'une cimentoplastie et biopsie de T5.
Lésion d'allure ostéoporotique.
Bilan d'ostéopathie fragilisante normal.
Réalisation d'une première perfusion d'Aclasta 5 mg IV.
Suite et devenir :
DMO à réaliser en externe
Injection d'ACLASTA une fois par an pendant les deux prochaines années puis nouvelle DMO.
Consultation Dr [NOM] avec les résultats de la biopsie osseuse dans un mois.
Traitement de sortie :
inchangé
Les consignes d'usage ont été remises.
Bien confraternellement,
Docteur [NOM] [NOM]
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (RHUMATOLOGIE)
V1 - Imprimé le 17/04/2025 à 11 : 24 par
Page(s) : 2 sur 3 N° Finess
[FINESS]
RHUMATOLOGIE
Dr [NOM]
Chef de [MASK] [ETABLISSEMENT]
de Paris
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de Lyon
Praticien hospitalier contractuel
RPPS : [RPPS]
Secrétariat : [TEL]
MEDECINE INTERNE ET
IMMUNOLOGIE CLINIQUE
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de
Bordeaux et Bayonne
Praticien Hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Lille
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Assistant spécialiste
RPPS : [RPPS]
Secrétariat : [TEL]
DERMATOLOGIE
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Toulouse
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Assistant des Hôpitaux de
Toulouse
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM]
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM]
Praticien Hospitalier contractuel
Secrétariat : [TEL]
CENTRE DE COMPETENCES
DES MALADIES AUTO IMMUNES
ET AUTO-INFLAMMATOIRES
SYSTEMIQUES RARES :
Médecin coordonnateur :
Dr [NOM]
Secrétariat : [TEL]
[EMAIL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
PÔLE MÉDECINE INTERNE
SERVICE RHUMATOLOGIE - MEDECINE INTERNE
ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE
*[RPPS]*
[RPPS]
Liste des destinataires :
DR. [NOM]
DR. [NOM]
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (RHUMATOLOGIE)
V1 - Imprimé le 17/04/2025 à 11 : 24 par
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@@ -1,29 +0,0 @@
{"page": 0, "kind": "NOM", "original": "Christelle Béraut", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Thomas Grellety", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "secr.onco@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "secr.oncogenetique@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "secr.hdjcancero@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Pôle Spécialités Médicales", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Service d'Oncologie Médicale et Oncogénétique", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "LASSERRE SENNE BRIGITTE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "150 ALLEE DE BIELLENAVE", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64200 BASSUSSARRY", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "née le 01/02/1980", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MAJOUFRE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Toulmonde", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "IPP", "original": "23018342", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 0, "kind": "EPISODE", "original": "23173599", "placeholder": "[EPISODE]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Christelle Béraut", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Thomas Grellety", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "secr.onco@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "secr.oncogenetique@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "secr.hdjcancero@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Pôle Spécialités Médicales", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Service d'Oncologie Médicale et Oncogénétique", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "DA SILVA Fabio", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "FRANCOIS Louis", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "LASSERRE SENNE Brigitte", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "IPP", "original": "23018342", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 1, "kind": "EPISODE", "original": "23173599", "placeholder": "[EPISODE]", "bbox_hint": null}

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@@ -1,202 +0,0 @@
N° Finess
[FINESS]
ICANCE - Institut de
Cancérologie Navarre Côte
Basque
Mme [NOM], cadre de
fédération
Dr [NOM],
coordonnateur médical de
fédération
Praticiens Hospitaliers :
Dr T. [NOM]
Oncologie médicale
Chef de [MASK]. [NOM]
Oncologie médicale
Dr G. [NOM]
Oncologie médicale
Dr F. [NOM]
Oncologie médicale
Dr F. DA [NOM]
Oncologie médicale
Dr A. [NOM]
Soins de support oncologiques
Soins palliatifs
Dr T. [NOM]
Oncologie
Tel : [TEL] (secrétariat)
Oncogénétique :
Dr S. [NOM]
Médecin généticien
Mme A. [NOM]
Conseillère en génétique
Cadre de Service :
Mme F. [NOM]
Tel : [TEL]
Hospitalisation conventionnelle :
Renseignements familles
Tel : [TEL]
Secrétariat Oncologie :
Accueil et RDV - Consultations
Tel : [TEL]
[EMAIL]
Secrétariat Oncogénétique :
Tel : [TEL]
[EMAIL]
[ETABLISSEMENT] :
Acceuil et Programmation
Tel : [TEL]
[EMAIL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
Bayonne, le 17/09/2023
DR [NOM]
[ADRESSE]
[CODE_POSTAL]
Mon cher confrère,
Votre patiente [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisée dans le service du 13/09/2023 au 17/09/2023 pour le motif
suivant :
-
Motif d'hospitalisation :
C3 dIVADO (sans vincristine) en néoadjuvant dun rabdomyosarcome de la gencive maxillaire gauche.
Antécédents :
Médicaux : Tumeur du péroné gauche traitée par chirurgie et ZOMETA en 2006.
Traitements habituels :
SERESTA 10 mg
PARACETAMOL 1g : si besoin
OXYCONTIN LP 10 mg : 1-0-1
OXYNORMORO 5mg : si besoin
Allergies :
Aucune
Mode de vie :
Patiente travaillant dans linformatique. Vit seul à [VILLE], 1 sœur qui vit à [VILLE]. Pas denfant.
Activités : Randonnées (dernières semaines seulement quelques balades de 15 minutes devant asthénie), vélo électrique
Histoire de la maladie :
Juillet 2023 : Diagnostic dun rhabdomyosarcome TFCP2 réarrangé de la gencive maxillaire gauche rapidement évolutif.
Chimiothérapie 1ère par IVADo avant chirurgie par le Pr [NOM] avec C1 le 02/08.
Août 2023 : réévaluation par IRM après 2 cures : début débauche thérapeutique. Neuropathie de grade 2. Poursuite pour
deux cures supplémentaires avant geste chirurgical prévu le 23/10/2023.
Par la suite, 5 cures dIVA seront réalisées (idéalement début 2-3 semaines après lexérèse chirurgicale).
Intercure :
Neuropathie de grade 2 : arrêt de la vincristine au J8 et J15.
Nausées grade 1 les 3 jours suivant la chimiothérapie.
Mucite grade 2 dévolution favorable sous fungizone.
Douleurs gingivales prédominant la nuit, avec 2 interdoses la nuit.
Consultation avec le Dr [NOM] (cf histoire de la maladie).
Examen clinique :
Patiente OMS 1, poids relativement stable à 49.8kg
Tachycardie régulière
Pas de signe de décompensation cardiaque
Tumeur bourgeonante de la gencive gauche
Reste de lexamen sans particularité
Examens complémentaires :
Bilan biologique du 11/09/2023 :
Hb 9.7g/dl, PNN 9.8G/L, plq 420G/L
Bilan hépatique normal
Créatinine 64.6µmol/l
Evolution dans le service :
Validation le 13/09 du C3J1 IVADO. Pas de J8 et J15 de Vincristine devant neuropathie grade 2.
Prévention des nausées et vomissements par EMEND tripack, SOLUPRED 5 jours, PRIMPERAN si besoin.
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (ONCOLOGIE HC)
V1 - Imprimé le 22/04/2025 à 10 : 53 par
Page(s) : 1 sur 2 N° Finess
[FINESS]
ICANCE - Institut de
Cancérologie Navarre Côte
Basque
Mme [NOM], cadre de
fédération
Dr [NOM],
coordonnateur médical de
fédération
Praticiens Hospitaliers :
Dr T. [NOM]
Oncologie médicale
Chef de [MASK]. [NOM]
Oncologie médicale
Dr G. [NOM]
Oncologie médicale
Dr F. [NOM]
Oncologie médicale
Dr F. DA [NOM]
Oncologie médicale
Dr A. [NOM]
Soins de support oncologiques
Soins palliatifs
Dr T. [NOM]
Oncologie
Tel : [TEL] (secrétariat)
Oncogénétique :
Dr S. [NOM]
Médecin généticien
Mme A. [NOM]
Conseillère en génétique
Cadre de Service :
Mme F. [NOM]
Tel : [TEL]
Hospitalisation conventionnelle :
Renseignements familles
Tel : [TEL]
Secrétariat Oncologie :
Accueil et RDV - Consultations
Tel : [TEL]
[EMAIL]
Secrétariat Oncogénétique :
Tel : [TEL]
[EMAIL]
[ETABLISSEMENT] :
Acceuil et Programmation
Tel : [TEL]
[EMAIL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
Prévention primaire de la neutropénie fébrile par une injection de PELMEG à J5.
Tachycarde à 120 en fin d'hospitalisation sans signe clinique associé. ECG : tachycardie sinusale.
BS de contrôle 17/09 Hb 8.9 gdl-1 : 1 CGR le 17/09
Traitements de sortie :
Inchangé sauf :
-Majoration OXYCONTIN LP à 15mg le soir, maintien 10mg le matin.
-Bains de bouche bicarbonate de sodium avec SOLUPRED 60mg dans la bouteille
Conclusion :
C3 dIVADO (sans vincristine) en néoadjuvant dun rabdomyosarcome de la gencive maxillaire gauche.
Bonne tolérance immédiate.
Transfusion d'un 1 CGR le 17/09
Prochaine venue dans 3 semaines pour le C4.
Prochains rendez-vous :
C4 le 04/10.
Chirurgie le 23/10.
Prévoir reprise chimiothérapie par IVA 2-3 semaines maximum après la chirurgie.
Les consignes d'usage ont été remises.
Bien confraternellement,
Docteur DA [NOM] [NOM]
*[TEL]*
[TEL]
Rédigé par [NOM]
Liste des destinataires :
DR. [NOM]
Patient(e) : [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (ONCOLOGIE HC)
V1 - Imprimé le 22/04/2025 à 10 : 53 par
Page(s) : 2 sur 2

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@@ -1,260 +0,0 @@
{"page": 0, "kind": "NOM", "original": "Christelle Béraut", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Thomas Grellety", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Emmanuel ELLIE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "eellie@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Christelle BERAUT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Elise ABRAHAM", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "eabraham@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Daniel BONNET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "dbonnet@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Claire LETHROSNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "clethrosne@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Laurence MASSE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "lmasse@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Jean Pierre MATHIEU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "jpmathieu@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Cécilia NOCENT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "cnocent@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Pierre RIGAUD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "prigaud@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Marielle SABATINI", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "msabatini@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Sophie SCHNEIDER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "sschneider@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Marilyn DAVANT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "secr.pneumo@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Pôle Spécialités Médicales", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Service des Maladies Respiratoires et Allergiques", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "KRIEGER ANA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "10 RUE DE TORCY", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "77360 VAIRES SUR MARNE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "née le 17/05/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "RIDEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Kabany Jamal", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "IPP", "original": "23026373", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 0, "kind": "EPISODE", "original": "23194278", "placeholder": "[EPISODE]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Christelle Béraut", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Thomas Grellety", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Emmanuel ELLIE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "eellie@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Christelle BERAUT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Elise ABRAHAM", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "eabraham@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Daniel BONNET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "dbonnet@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Claire LETHROSNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "clethrosne@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Laurence MASSE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "lmasse@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Jean Pierre MATHIEU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "jpmathieu@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Cécilia NOCENT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "cnocent@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Pierre RIGAUD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "prigaud@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Marielle SABATINI", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "msabatini@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Sophie SCHNEIDER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "sschneider@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Marilyn DAVANT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "secr.pneumo@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Pôle Spécialités Médicales", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "Service des Maladies Respiratoires et Allergiques", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 1, "kind": "IPP", "original": "23026373", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 1, "kind": "EPISODE", "original": "23194278", "placeholder": "[EPISODE]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Christelle Béraut", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Thomas Grellety", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Emmanuel ELLIE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "eellie@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Christelle BERAUT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Elise ABRAHAM", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "eabraham@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Daniel BONNET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "dbonnet@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Claire LETHROSNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "clethrosne@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Laurence MASSE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "lmasse@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Jean Pierre MATHIEU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "jpmathieu@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Cécilia NOCENT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "cnocent@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Pierre RIGAUD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "prigaud@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Marielle SABATINI", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "msabatini@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Sophie SCHNEIDER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "sschneider@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Marilyn DAVANT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "EMAIL", "original": "secr.pneumo@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 2, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 2, "kind": "ETAB", "original": "Pôle Spécialités Médicales", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 2, "kind": "ETAB", "original": "Service des Maladies Respiratoires et Allergiques", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 2, "kind": "AGE", "original": "patiente de 79ans", "placeholder": "[AGE]", "bbox_hint": null}
{"page": 2, "kind": "IPP", "original": "23026373", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 2, "kind": "EPISODE", "original": "23194278", "placeholder": "[EPISODE]", "bbox_hint": null}
{"page": 3, "kind": "NOM", "original": "Christelle Béraut", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 3, "kind": "NOM", "original": "Thomas Grellety", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 3, "kind": "NOM", "original": "Emmanuel ELLIE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 3, "kind": "EMAIL", "original": "eellie@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 3, "kind": "NOM", "original": "Christelle BERAUT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 3, "kind": "NOM", "original": "Elise ABRAHAM", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 3, "kind": "EMAIL", "original": "eabraham@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 3, "kind": "NOM", "original": "Daniel BONNET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 3, "kind": "EMAIL", "original": "dbonnet@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
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{"page": 3, "kind": "EMAIL", "original": "clethrosne@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
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{"page": 3, "kind": "EMAIL", "original": "lmasse@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
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{"page": 3, "kind": "EMAIL", "original": "jpmathieu@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
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{"page": 5, "kind": "EMAIL", "original": "clethrosne@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 5, "kind": "NOM", "original": "Laurence MASSE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 5, "kind": "EMAIL", "original": "lmasse@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 5, "kind": "NOM", "original": "Jean Pierre MATHIEU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 5, "kind": "EMAIL", "original": "jpmathieu@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 5, "kind": "NOM", "original": "Cécilia NOCENT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 5, "kind": "EMAIL", "original": "cnocent@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 5, "kind": "NOM", "original": "Pierre RIGAUD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 5, "kind": "EMAIL", "original": "prigaud@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 5, "kind": "NOM", "original": "Marielle SABATINI", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 5, "kind": "EMAIL", "original": "msabatini@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
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{"page": 5, "kind": "EMAIL", "original": "sschneider@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 5, "kind": "NOM", "original": "Marilyn DAVANT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 5, "kind": "EMAIL", "original": "secr.pneumo@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 5, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
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{"page": 6, "kind": "NOM", "original": "Thomas Grellety", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Emmanuel ELLIE", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 6, "kind": "NOM", "original": "Christelle BERAUT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Elise ABRAHAM", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "EMAIL", "original": "eabraham@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Daniel BONNET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "EMAIL", "original": "dbonnet@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Claire LETHROSNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "EMAIL", "original": "clethrosne@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Laurence MASSE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "EMAIL", "original": "lmasse@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Jean Pierre MATHIEU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "EMAIL", "original": "jpmathieu@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Cécilia NOCENT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "EMAIL", "original": "cnocent@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Pierre RIGAUD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "EMAIL", "original": "prigaud@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Marielle SABATINI", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "EMAIL", "original": "msabatini@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Sophie SCHNEIDER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "EMAIL", "original": "sschneider@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Marilyn DAVANT", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 7, "kind": "NOM", "original": "Christelle Béraut", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "NOM", "original": "Thomas Grellety", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "NOM", "original": "Emmanuel ELLIE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "EMAIL", "original": "eellie@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
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{"page": 7, "kind": "NOM", "original": "Elise ABRAHAM", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "EMAIL", "original": "eabraham@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 7, "kind": "NOM", "original": "Daniel BONNET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "EMAIL", "original": "dbonnet@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 7, "kind": "NOM", "original": "Claire LETHROSNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "EMAIL", "original": "clethrosne@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 7, "kind": "NOM", "original": "Laurence MASSE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "EMAIL", "original": "lmasse@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 7, "kind": "NOM", "original": "Jean Pierre MATHIEU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "EMAIL", "original": "jpmathieu@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 7, "kind": "NOM", "original": "Cécilia NOCENT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "EMAIL", "original": "cnocent@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 7, "kind": "NOM", "original": "Pierre RIGAUD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "EMAIL", "original": "prigaud@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 7, "kind": "NOM", "original": "Marielle SABATINI", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "EMAIL", "original": "msabatini@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 7, "kind": "NOM", "original": "Sophie SCHNEIDER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "EMAIL", "original": "sschneider@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 7, "kind": "NOM", "original": "Marilyn DAVANT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 7, "kind": "EMAIL", "original": "secr.pneumo@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
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View File

@@ -1,910 +0,0 @@
N° Finess
[FINESS]
ICANCE - Institut de Cancérologie
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK] [NOM]
[NOM]
[EMAIL]
Cadre de [MASK] [NOM]
Chef de [MASK] [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Praticiens Hospitaliers
Dr [NOM]
Pneumologue
DESC Infectiologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
Médecin du Sport
[EMAIL]
Dr [NOM]
Pneumologue - Allergologue
DESC Réanimation Médicale
[EMAIL]
Dr [NOM]
Pneumologue
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Cadre de Santé :
Mme [NOM]
Tel : [TEL]
Secrétariat Médical
Tel : [TEL]
Tel : [TEL]
[EMAIL]
Hospitalisation
Chambres 3760 à 3772
Tel : [TEL]
Chambres 3773 à 3783
Tel : [TEL]
Explorations Endoscopies
Tel : [TEL]
Centre de Lutte Anti Tuberculeuse
C.L.A.T.
Tel : [TEL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
Bayonne, le 12/10/2023
MME [NOM]
[ADRESSE]
[CODE_POSTAL]
Mon cher confrère,
Votre patiente [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisée dans le service du 09/10/2023 au 10/10/2023 pour le motif
suivant :
-
Dyspnée
-
Motif d'hospitalisation : exacerbation de BPCO
Correspondants :
Médecin traitant : Dr [NOM] (Vaires sur Marne)
Pneumologue : Dr [NOM] (Chesse)
Antécédents :
- BPCO
- Dyslipidémie
- Dépression
- fractures orteils à droite
Allergies :
Aucunes connues
Traitements habituels :
- TRIXEO 5/7.2/160 2-0-2
- Lamictal 50 1-0-1
- Sertraline 50 1-1-0
- Theralene 5 2-0-0
- simvastatine 10 0-0-1
- tedralan LP 200 1-0-1
- oxazepam 10 0-0-1
- cozaar 50 1-0-0
- ventoline 2/j
Mode de vie :
A la retraite , travaillait à la bourse américaine
Récemment en vacances au Portugal, était sur le trajet pour rentrer chez elle en région parisienne
Vit avec son marie , sédentarité importante depuis 6/7 mois dans un contexte d'asthénie : c'est son mari qui s'occupe des
courses de la cuisine et du ménage
A des enfants
Toxiques :
Tabac sevré depuis janvier 2023 , commencé à 17 ans : 30 PA
Pas de canabis
Histoire de la maladie :
Se sent asthénique depuis 6 mois associée à une anorexie sans perte de poids
Etait en vacances au Portugal avec son mari
Présente une dyspnée progressive depuis plusieurs jours sans notion de fièvre mais avec une toux et des crachats
qui deviennent plus abondants et colorés
Cliniquement aux urgences :
A l arrivée FR 32 signes de luttes respi pas de sueurs
finit ses phrases
expiration à lèvres pincées
abdo souple indolore
sibilants bilatéraux+++ pas de crépitants
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par
Page(s) : 1 sur 4 N° Finess
[FINESS]
ICANCE - Institut de Cancérologie
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK] [NOM]
[NOM]
[EMAIL]
Cadre de [MASK] [NOM]
Chef de [MASK] [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Praticiens Hospitaliers
Dr [NOM]
Pneumologue
DESC Infectiologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
Médecin du Sport
[EMAIL]
Dr [NOM]
Pneumologue - Allergologue
DESC Réanimation Médicale
[EMAIL]
Dr [NOM]
Pneumologue
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Cadre de Santé :
Mme [NOM]
Tel : [TEL]
Secrétariat Médical
Tel : [TEL]
Tel : [TEL]
[EMAIL]
Hospitalisation
Chambres 3760 à 3772
Tel : [TEL]
Chambres 3773 à 3783
Tel : [TEL]
Explorations Endoscopies
Tel : [TEL]
Centre de Lutte Anti Tuberculeuse
C.L.A.T.
Tel : [TEL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
PEC initiale aux urgences
--> série de 3 aérosols + Augmentin + solumedrol
Examens complémentaires aux urgences :
Bio :
Hb 13.4 : plaquettes 290 ; leuco 10.2 dont PNN 8.33
Pas de troubles ioniques
CRP 149
PCT 0.09
ASAT 58 : ALAT 32
Cholestase avec GGT 253 : PAL 130
tropo 44 : T pro BNP 273
GDS sous 2L : pH 7.4 ; pO2 102 pCO2 43 bicar 26.5
Microbio :
PCR covid grippe et VRS négative
Radio de thorax :
On ne met pas en évidence de foyer infectieux parenchymateux.
Pas de signe d'épanchement pleural.
Aspect normal de la silhouette cardio-médiastinale. Lésion nodulaire d'allure spiculée en projection de la base droite :
lésion parenchymateuse versus mammaire à confronter à distance un scanner dédiée. De la base droite
ECG : RRS qrs fins pas de trouble de repolarisation pas de s1q3
Transfert en pneumologie pour la suite de la prise en charge
Evolution :
Interrogatoire :
M'explique qu'une dyspnée avec majoration de la quantité et la purulence des crachats depuis quelques jours mais n'y a pas
trop prête attention car elle était en vacances
Consulte aux urgences devant la dyspnée qui est devenue trop importante
Elle m'explique aussi qu'elle présente depuis 6/7 mois une asthénie importante l'empêchant de réaliser seule les AVQ
En parallèle : anorexie sans perte de poids objectivée
Cliniquement à l'arrivée en pneumologie :
Sat 100% sous 1 L aux lunettes
Non dyspnéique au repos
Dyspnée au moindre effort dans un contexte de probable déconditionnement cardio respi
Pas de signes de détresse respiratoire, non polypnéique , pas de tirage
Toux et crachats sales
Pas d'hémoptysie
Auscultation : sibilants avec frein expiratoire
Pas de douleurs thoraciques
Légers OMI prenant le godet
Mollets souples et non douloureux
Pas de plaintes abdominales ni urinaires
CAT :
Tentative de diminution de l'O2 pour sevrage rapide
Poursuite aérosol, Augmentin 1g x 3 et Solupred 40 mg
Intérêt à consulter son pneumologue dans le mois qui arrive avec un scanner thoracique
93% en AA, apyrétique
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par
Page(s) : 2 sur 4 N° Finess
[FINESS]
ICANCE - Institut de Cancérologie
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK] [NOM]
[NOM]
[EMAIL]
Cadre de [MASK] [NOM]
Chef de [MASK] [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Praticiens Hospitaliers
Dr [NOM]
Pneumologue
DESC Infectiologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
Médecin du Sport
[EMAIL]
Dr [NOM]
Pneumologue - Allergologue
DESC Réanimation Médicale
[EMAIL]
Dr [NOM]
Pneumologue
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Cadre de Santé :
Mme [NOM]
Tel : [TEL]
Secrétariat Médical
Tel : [TEL]
Tel : [TEL]
[EMAIL]
Hospitalisation
Chambres 3760 à 3772
Tel : [TEL]
Chambres 3773 à 3783
Tel : [TEL]
Explorations Endoscopies
Tel : [TEL]
Centre de Lutte Anti Tuberculeuse
C.L.A.T.
Tel : [TEL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
Expectoration sale, encombrement prédominant aux bases, non spastique, pas de signes de luttes
Autonome dans les AVQ sans désaturation
transit et appétit conservé
Pas de plaintes
RAD Paris demain si évolution favorable (ordo imprimés dans le dossier)
Poursuite AUGMENTIN/ CTC/ Aerosol
Kiné drainage
TDM thorax et consult pneumo
vaccin grippe
11/10/23 CNE
exacerbation de BPCO aujourd'hui pas encore bien contrôlée
apyrétique, sat correcte
poursuite de la même prise en charge
le mari de la patiente souhaite un rapatriement => doit contacter son assurance pour qu'ils nous appellent
12/10/23 CNE
lettre Dr [NOM] : emphysème sur le scanner avec syndrome obstructif (VEMS à 48% soit 660 ml), distension vraie
associée (CPT : 130%, VR : 230%)
ttt par trimbow nexthaler : 2bX2/j
ce jour la patiente va bien
auscultation : RAS
retour à domicile avec rapatriement demain
Votre patient(e) quitte le service avec :
- Pharmacie :
LACTEOL 340MG PDR [NOM] [10] Sachet(s) 1 SACHET (ORALE) matin midi soir
LOXEN LP 50MG GELULE [60] Gelule(s) 1 GELULE (ORALE) matin soir (8h - 19h)
AMOX/AC CLAV SDZ 1G/125MG AD SACH [12] Sachet(s) 1 G (ORALE) matin midi soir
LAMICTAL 25MG CPR DISP [30] COMPRIME(S) 2 COMPRIME (ORALE) matin soir (8h - 19h)
LOSARTAN EG 50MG CPR [90] COMPRIME(S) 1 COMPRIME (ORALE) matin [8h]
SERESTA 10MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) nuit [21h]
SIMVASTATINE AHL 20MG CPR [28] COMPRIME(S) .5 COMPRIME (ORALE) soir [19h]
THERALENE 5MG CPR [50] COMPRIME(S) 2 COMPRIME (ORALE) matin [8h]
TRIXEO AEROSPHERE 5/7.2MCG INH 120 D [120] REC. UNIDOSE(s) 2 UNIDOSE (INHALEE) en direct matin soir
(8h - 19h)
Conclusion :
-
Exacerbation aigue d'une BPCO post tabagique chez une [AGE] sur probable surinfection bronchique
sans documentation microbiologique d'évolution favorable.
Traitement de sortie :
-AUGMENTIN 1g/8h jusquau 16/10 inclus
-PARACETAMOL 1g/6h si douleurs
-SOLUPRED 40mg le matin jusquau 13/10
Ventoline 5mg/2mL solution inhalée 1 aérosol 3 fois par jour si besoin
Atrovent 0.5mg/1mL solution inhalée 1 aérosol 3 fois par jour si besoin
Location dappareil pour aérosol pneumatique
Poursuit du traitement habituel par ailleurs
Suite de prise en charge :
Kinésithérapie drainage
Vaccination anti grippale
TDM thoracique non injecté low dose
Consultation pneumologue
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par
Page(s) : 3 sur 4 N° Finess
[FINESS]
ICANCE - Institut de Cancérologie
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK] [NOM]
[NOM]
[EMAIL]
Cadre de [MASK] [NOM]
Chef de [MASK] [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Praticiens Hospitaliers
Dr [NOM]
Pneumologue
DESC Infectiologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
Médecin du Sport
[EMAIL]
Dr [NOM]
Pneumologue - Allergologue
DESC Réanimation Médicale
[EMAIL]
Dr [NOM]
Pneumologue
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Cadre de Santé :
Mme [NOM]
Tel : [TEL]
Secrétariat Médical
Tel : [TEL]
Tel : [TEL]
[EMAIL]
Hospitalisation
Chambres 3760 à 3772
Tel : [TEL]
Chambres 3773 à 3783
Tel : [TEL]
Explorations Endoscopies
Tel : [TEL]
Centre de Lutte Anti Tuberculeuse
C.L.A.T.
Tel : [TEL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
Les consignes d'usage ont été remises.
Bien confraternellement,
Docteur [NOM]
*[TEL]*
[TEL]
Liste des destinataires :
Madame [NOM]
Dr [NOM]
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par
Page(s) : 4 sur 4 N° Finess
[FINESS]
ICANCE - Institut de Cancérologie
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK] [NOM]
[NOM]
[EMAIL]
Cadre de [MASK] [NOM]
Chef de [MASK] [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Praticiens Hospitaliers
Dr [NOM]
Pneumologue
DESC Infectiologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
Médecin du Sport
[EMAIL]
Dr [NOM]
Pneumologue - Allergologue
DESC Réanimation Médicale
[EMAIL]
Dr [NOM]
Pneumologue
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Cadre de Santé :
Mme [NOM]
Tel : [TEL]
Secrétariat Médical
Tel : [TEL]
Tel : [TEL]
[EMAIL]
Hospitalisation
Chambres 3760 à 3772
Tel : [TEL]
Chambres 3773 à 3783
Tel : [TEL]
Explorations Endoscopies
Tel : [TEL]
Centre de Lutte Anti Tuberculeuse
C.L.A.T.
Tel : [TEL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
Bayonne, le 12/10/2023
DR [NOM]
[ADRESSE]
[CODE_POSTAL]
DR [NOM]
[ADRESSE]
[CODE_POSTAL]
Mon cher confrère,
Votre patiente [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisée dans le service du 09/10/2023 au 10/10/2023 pour le motif
suivant :
-
Dyspnée
-
Motif d'hospitalisation : exacerbation de BPCO
Correspondants :
Médecin traitant : Dr [NOM] (Vaires sur Marne)
Pneumologue : Dr [NOM] (Chesse)
Antécédents :
- BPCO
- Dyslipidémie
- Dépression
- fractures orteils à droite
Allergies :
Aucunes connues
Traitements habituels :
- TRIXEO 5/7.2/160 2-0-2
- Lamictal 50 1-0-1
- Sertraline 50 1-1-0
- Theralene 5 2-0-0
- simvastatine 10 0-0-1
- tedralan LP 200 1-0-1
- oxazepam 10 0-0-1
- cozaar 50 1-0-0
- ventoline 2/j
Mode de vie :
A la retraite , travaillait à la bourse américaine
Récemment en vacances au Portugal, était sur le trajet pour rentrer chez elle en région parisienne
Vit avec son marie , sédentarité importante depuis 6/7 mois dans un contexte d'asthénie : c'est son mari qui s'occupe des
courses de la cuisine et du ménage
A des enfants
Toxiques :
Tabac sevré depuis janvier 2023 , commencé à 17 ans : 30 PA
Pas de canabis
Histoire de la maladie :
Se sent asthénique depuis 6 mois associée à une anorexie sans perte de poids
Etait en vacances au Portugal avec son mari
Présente une dyspnée progressive depuis plusieurs jours sans notion de fièvre mais avec une toux et des crachats
qui deviennent plus abondants et colorés
Cliniquement aux urgences :
A l arrivée FR 32 signes de luttes respi pas de sueurs
finit ses phrases
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par
Page(s) : 1 sur 4 N° Finess
[FINESS]
ICANCE - Institut de Cancérologie
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK] [NOM]
[NOM]
[EMAIL]
Cadre de [MASK] [NOM]
Chef de [MASK] [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Praticiens Hospitaliers
Dr [NOM]
Pneumologue
DESC Infectiologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
Médecin du Sport
[EMAIL]
Dr [NOM]
Pneumologue - Allergologue
DESC Réanimation Médicale
[EMAIL]
Dr [NOM]
Pneumologue
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Cadre de Santé :
Mme [NOM]
Tel : [TEL]
Secrétariat Médical
Tel : [TEL]
Tel : [TEL]
[EMAIL]
Hospitalisation
Chambres 3760 à 3772
Tel : [TEL]
Chambres 3773 à 3783
Tel : [TEL]
Explorations Endoscopies
Tel : [TEL]
Centre de Lutte Anti Tuberculeuse
C.L.A.T.
Tel : [TEL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
expiration à lèvres pincées
abdo souple indolore
sibilants bilatéraux+++ pas de crépitants
PEC initiale aux urgences
--> série de 3 aérosols + Augmentin + solumedrol
Examens complémentaires aux urgences :
Bio :
Hb 13.4 : plaquettes 290 ; leuco 10.2 dont PNN 8.33
Pas de troubles ioniques
CRP 149
PCT 0.09
ASAT 58 : ALAT 32
Cholestase avec GGT 253 : PAL 130
tropo 44 : T pro BNP 273
GDS sous 2L : pH 7.4 ; pO2 102 pCO2 43 bicar 26.5
Microbio :
PCR covid grippe et VRS négative
Radio de thorax :
On ne met pas en évidence de foyer infectieux parenchymateux.
Pas de signe d'épanchement pleural.
Aspect normal de la silhouette cardio-médiastinale. Lésion nodulaire d'allure spiculée en projection de la base droite :
lésion parenchymateuse versus mammaire à confronter à distance un scanner dédiée. De la base droite
ECG : RRS qrs fins pas de trouble de repolarisation pas de s1q3
Transfert en pneumologie pour la suite de la prise en charge
Evolution :
Interrogatoire :
M'explique qu'une dyspnée avec majoration de la quantité et la purulence des crachats depuis quelques jours mais n'y a pas
trop prête attention car elle était en vacances
Consulte aux urgences devant la dyspnée qui est devenue trop importante
Elle m'explique aussi qu'elle présente depuis 6/7 mois une asthénie importante l'empêchant de réaliser seule les AVQ
En parallèle : anorexie sans perte de poids objectivée
Cliniquement à l'arrivée en pneumologie :
Sat 100% sous 1 L aux lunettes
Non dyspnéique au repos
Dyspnée au moindre effort dans un contexte de probable déconditionnement cardio respi
Pas de signes de détresse respiratoire, non polypnéique , pas de tirage
Toux et crachats sales
Pas d'hémoptysie
Auscultation : sibilants avec frein expiratoire
Pas de douleurs thoraciques
Légers OMI prenant le godet
Mollets souples et non douloureux
Pas de plaintes abdominales ni urinaires
CAT :
Tentative de diminution de l'O2 pour sevrage rapide
Poursuite aérosol, Augmentin 1g x 3 et Solupred 40 mg
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par
Page(s) : 2 sur 4 N° Finess
[FINESS]
ICANCE - Institut de Cancérologie
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK] [NOM]
[NOM]
[EMAIL]
Cadre de [MASK] [NOM]
Chef de [MASK] [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Praticiens Hospitaliers
Dr [NOM]
Pneumologue
DESC Infectiologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
Médecin du Sport
[EMAIL]
Dr [NOM]
Pneumologue - Allergologue
DESC Réanimation Médicale
[EMAIL]
Dr [NOM]
Pneumologue
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Cadre de Santé :
Mme [NOM]
Tel : [TEL]
Secrétariat Médical
Tel : [TEL]
Tel : [TEL]
[EMAIL]
Hospitalisation
Chambres 3760 à 3772
Tel : [TEL]
Chambres 3773 à 3783
Tel : [TEL]
Explorations Endoscopies
Tel : [TEL]
Centre de Lutte Anti Tuberculeuse
C.L.A.T.
Tel : [TEL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
Intérêt à consulter son pneumologue dans le mois qui arrive avec un scanner thoracique
93% en AA, apyrétique
Expectoration sale, encombrement prédominant aux bases, non spastique, pas de signes de luttes
Autonome dans les AVQ sans désaturation
transit et appétit conservé
Pas de plaintes
RAD Paris demain si évolution favorable (ordo imprimés dans le dossier)
Poursuite AUGMENTIN/ CTC/ Aerosol
Kiné drainage
TDM thorax et consult pneumo
vaccin grippe
11/10/23 CNE
exacerbation de BPCO aujourd'hui pas encore bien contrôlée
apyrétique, sat correcte
poursuite de la même prise en charge
le mari de la patiente souhaite un rapatriement => doit contacter son assurance pour qu'ils nous appellent
12/10/23 CNE
lettre Dr [NOM] : emphysème sur le scanner avec syndrome obstructif (VEMS à 48% soit 660 ml), distension vraie
associée (CPT : 130%, VR : 230%)
ttt par trimbow nexthaler : 2bX2/j
ce jour la patiente va bien
auscultation : RAS
retour à domicile avec rapatriement demain
Votre patient(e) quitte le service avec :
- Pharmacie :
LACTEOL 340MG PDR [NOM] [10] Sachet(s) 1 SACHET (ORALE) matin midi soir
LOXEN LP 50MG GELULE [60] Gelule(s) 1 GELULE (ORALE) matin soir (8h - 19h)
AMOX/AC CLAV SDZ 1G/125MG AD SACH [12] Sachet(s) 1 G (ORALE) matin midi soir
LAMICTAL 25MG CPR DISP [30] COMPRIME(S) 2 COMPRIME (ORALE) matin soir (8h - 19h)
LOSARTAN EG 50MG CPR [90] COMPRIME(S) 1 COMPRIME (ORALE) matin [8h]
SERESTA 10MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) nuit [21h]
SIMVASTATINE AHL 20MG CPR [28] COMPRIME(S) .5 COMPRIME (ORALE) soir [19h]
THERALENE 5MG CPR [50] COMPRIME(S) 2 COMPRIME (ORALE) matin [8h]
TRIXEO AEROSPHERE 5/7.2MCG INH 120 D [120] REC. UNIDOSE(s) 2 UNIDOSE (INHALEE) en direct matin soir
(8h - 19h)
Conclusion :
-
Exacerbation aigue d'une BPCO post tabagique chez une [AGE] sur probable surinfection bronchique
sans documentation microbiologique d'évolution favorable.
Traitement de sortie :
-AUGMENTIN 1g/8h jusquau 16/10 inclus
-PARACETAMOL 1g/6h si douleurs
-SOLUPRED 40mg le matin jusquau 13/10
Ventoline 5mg/2mL solution inhalée 1 aérosol 3 fois par jour si besoin
Atrovent 0.5mg/1mL solution inhalée 1 aérosol 3 fois par jour si besoin
Location dappareil pour aérosol pneumatique
Poursuit du traitement habituel par ailleurs
Suite de prise en charge :
Kinésithérapie drainage
Vaccination anti grippale
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par
Page(s) : 3 sur 4 N° Finess
[FINESS]
ICANCE - Institut de Cancérologie
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK] [NOM]
[NOM]
[EMAIL]
Cadre de [MASK] [NOM]
Chef de [MASK] [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Praticiens Hospitaliers
Dr [NOM]
Pneumologue
DESC Infectiologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
Médecin du Sport
[EMAIL]
Dr [NOM]
Pneumologue - Allergologue
DESC Réanimation Médicale
[EMAIL]
Dr [NOM]
Pneumologue
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie
[EMAIL]
Cadre de Santé :
Mme [NOM]
Tel : [TEL]
Secrétariat Médical
Tel : [TEL]
Tel : [TEL]
[EMAIL]
Hospitalisation
Chambres 3760 à 3772
Tel : [TEL]
Chambres 3773 à 3783
Tel : [TEL]
Explorations Endoscopies
Tel : [TEL]
Centre de Lutte Anti Tuberculeuse
C.L.A.T.
Tel : [TEL]
[MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[MASK]
[MASK]
TDM thoracique non injecté low dose
Consultation pneumologue
Les consignes d'usage ont été remises.
Bien confraternellement,
Docteur [NOM]
*[TEL]*
[TEL]
Liste des destinataires :
Madame [NOM]
Dr [NOM]
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM]
Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / N° Episode [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par
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{"page": 0, "kind": "NOM", "original": "Anne BANOS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Clinique des Hôpitaux de Bordeaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Frédéric BAUDUER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Sophie BERNARD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Louise BOUARD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Claudie CAPDUPUY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Prune CROUZAL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Julie GAY", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Delphine MARTINEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Jean-Baptiste ROBIN", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Marielle LE-MECHEC", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Corinne MONNIER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Laurent DAVID", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "secr.hema@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "EMAIL", "original": "hospi.hemato@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Pôle Spécialités Médicales", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Service Hématologie", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Pierre COUDANNE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64240 URT", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "né le 20/02/1981", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "COUDANNE Pierre", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "DATE_NAISSANCE", "original": "né le 20/02/1981", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "COUDANNE Pierre", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "DATE_NAISSANCE", "original": "né le 20/02/1981", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "COUDANNE Pierre", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Sophie BERNARD", "placeholder": "[NOM]", "bbox_hint": null}

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C E N T R E H O S P I T A L I E R D E L A C ÔT E B A S Q U E
 [ADRESSE]Interne [NOM] [NOM] - B.P. 8 [CODE_POSTAL]
[TEL]
*[TEL]*
Médecin Chef de [MASK] [NOM]
Ancien I
nterne des Hôpitaux de Lille
Ancien Chef de [ETABLISSEMENT]
Praticiens Hospitaliers
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM] [NOM]
Dr [NOM]
Dr [NOM]
[NOM] de santé
Mme [NOM]
Cadre de [MASK] [NOM]
Cadre Infirmier
Secteur Conventionnel
Mr [NOM]
Cadre Infirmier
Hospitalisation de Jour
Secrétariat Médical
Consultations :
 : [TEL]
Fax : [TEL]
[EMAIL]
Secr.Hospitalisation Hématologie :
 : [TEL]
Fax : [TEL]
[EMAIL]
Accueil / Programmation
[ETABLISSEMENT] :
 : [TEL]
[MASK]
[MASK]
 Secrétariat : [TEL]/34 - Télécopie : [TEL]
 Secteur Conventionnel- [TEL] -  Secteur protégé : [TEL].
 [ETABLISSEMENT] : Secrétariat [TEL] Télécopie [TEL]
Réf : SB/LL
Bayonne, le 2 avril 2023
Docteur [NOM]
AVENUE [NOM]
[CODE_POSTAL]
Cher Confrère,
Monsieur [NOM], [DATE_NAISSANCE], a été hospitalisé dans le service
d'hématologie du 27 mars au 2 avril 2023 pour 1ère cure de R-CYVE pour un lymphome de
burkitt.
ANTECEDENTS
Médicaux :
Maladie dHashimoto non traitée
Lumbago il y a 5ans
Allergies : NC
Traitements habituels :
BACTRIM FORTE : 1cp/j Lun Me Ve
LEDERFOLINE 25 : 1/sem
VALACICLOVIR 500 : 2/jour
SYMBICORT.
Bilan pré-thérapeutique
Covid 19 : Vaccination à jour dont covid x 3 et infection en juillet 2022
VIH VHB VHC : négatives le 10/02/23.
ETT : FEVG 63%, sans anomalie retrouvé
MODE DE VIE
Médecin généraliste à [VILLE]
Marié, 3 enfants (jumeaux de 10ans, fille de 3ans)
2 chats au domicile, pas de contact avec autre animal
Pas de voyage récent
Pas dintoxication alcoolo-tabagique, pas de drogue
Loisirs : tennis
HISTOIRE DE LA MALADIE
Notion de soins dentaires le 18/01 (détartrage, carie).
Apparition le 21/01 de douleurs lombaires de type sciatalgie tronquée bilatérale dhoraire
inflammatoire, non soulagées par AINS.
Douleur dentaire gauche automédiquée par AUGMENTIN depuis le 26/01. Mise sous
antalgiques pallier 3.
Le 28/01 au soir, sensation de sueurs avec frissons, subfébrile à 38°C.
Majoration des douleurs osseuses.
Le patient consulte aux urgences pour suspicion de spondylodiscite. Aux urgences :
- sur le plan biologique : LDH 1100UI/l, CRP 120mg/l, myélémie à 6%, CMF B sans
anomalie, marqueurs tumoraux négatifs. Monsieur [NOM], [DATE_NAISSANCE] 2
- IRM rachis thoraco-lombaire 01/02 : Il n'y a pas d'atteinte spondylodiscale
dallure infectieuse. Mise en évidence d'un aspect très hétérogène de la trame osseuse de
l'ensemble du rachis. Il existe de multiples lésions se présente en hypersignal en pondération
T2 et se rehaussant après injection. Ces lésions doivent faire rechercher une pathologie
hématologique ou oncologique. Il n'est pas décelé de tassement vertébral. Pas d'épidurite
visible. Pas de compression de la moelle épinière ou des racines de la queue de
cheval. CONCLUSION : L'examen met en évidence de multiples lésions du rachis à
confronter à un bilan étiologique oncologique et hématologique.
- TDM TAP 01/02 : Présence d'un épaississement pariétal de l'iléon situé à environ 10 cm de la
valvule terminale, étendue sur environ 10 cm, concentrique, assez peu sténosante. L'aspect
peut faire évoquer deux étiologies : adénocarcinome de l'iléon ou lymphome. Lésions
ganglionnaires mésentériques associées
Biopsie iléale 03/02/23 (relecture Bordeaux OK) : Lymphome de burkitt avec expression
diffuse et inhabituelle de MUM1.
Réarrangement de MYC en FISH, sans réarrangement de BCL2/BCL6.
Myélogramme (10/02/23) : localisation médullaire d'un lymphome B de haut grade de
malignité, dont l'aspect cytologique est compatible avec un lymphome type Burkitt/ Burkitt
like.
Caryotype médullaire : t(2;8) dans 1 mitose sur 27.
PL (10/02/23) : prot = 0.53 - 2 éléments - Anapth négatif
Le diagnostic de lymphome de Burkitt est posé sur la clinique, l'anatomopathologie, la présence
d'une t(2 : 8) sur la caryotype et d'un réarrangement MYC en FISH.
Au total, Lymphome de Burkitt stade IV, moelle +, SNC-. Traitement selon le protocole
LMB02, bras C3.
COP - J1 = 10/02/23 (1PL)
TDM TAP J7 (16/02/23) : Diminution de la masse tumorale en rapport avec le lymphome de
Burkitt : au niveau de l'atteinte de l'iléon terminal et des adénomégalies ilio caecales satellites.
R-COPADEM J0 = 16/02/23 - Pas de complication en dehors d'une aplasie fébrile non
documentée.
(2PL à J0 et J6)
R-COPADEM n2 J0 = 06/03/23 - (2PL à J0 et J6) - Pas de complication.
Bilan évaluation :
TEP scanner (24/03/23) : Régression de l'atteinte iléale et de l'atteinte ganglionnaire satellite.
Petite régression de l'hépato-splénomégalie sans anomalie métabolique.
Métabolisme ostéomédullaire homogène d'intensité nettement diminuée, d'allure post-
thérapeutique ce jour. Persistance d'un hypermétabolisme focal intense en avant de l'angle
mandibulaire gauche, déjà présent sur l'examen TEP initial et non caractérisable sur les images
TDM non injectées : discuter IRM centrée pour caractérisation.
Myélogramme (27/03/23) : aspect de RC cytologique
IRM ORL (28/03/23 - Dr [NOM]) : Lésion de 9-10 mm centrée sur la commissure
intermaxillaire gauche bien limitée sans infiltration des structures adjacentes, non évolutive
comparativement aux imageries antérieures dont la caractérisation est difficile mais paraissant
atypique pour de l'atteinte lymphomateuse au vu de l'évolutivité. L'hypothèse d'une tumeur
nerveuse reste possible (schwannome). À confronter à l'évolution
INTERCURE
Fièvre vespérale du 22 au 25/03/23 - associée à des diarrhées
Introduction d'Augmentin le 25/03/23 en HDJ
Prélèvement microbio négatifs.
Se sent beaucoup mieux depuis hier. Monsieur [NOM], [DATE_NAISSANCE] 3
BILAN BIOLOGIQUE
27/03/23
Hb = 9.6 - plqt = 418 - GB = 10.4
LDH normales - BHC normal - Préalb = 0.17 - Alb = 39
Créat = 67
EXAMEN PHYSIQUE
PS = 0
Pas de syndrome tumoral palpable
Examen neurologique normal
Auscultation cardiopulmonaire normale.
EVOLUTION HOSPITALISATION
Sur le plan hématologique :
J1C1 R-CYVE le 28/03/23
Rituximab 375 mg/m2 soit 750 mg DT J1
Cytarabine 100mg/12h J1 à J5
Cytarabine HD 2000 mg/m2 soit 4000 mg DT J2 à J5
Etoposide 200mg/m2 soit 400 mg J2 à J5
PL triple (rattrapage COP) le 29/03/23 : 1 élément.
Bonne tolérance de la chimiothérapie.
Sur le plan infectieux
Pas de récidive fébrile en hospitalisation.
TRAITEMENT DE SORTIE
BACTRIM FORTE : 1cp/j Lun Me Ve
LEDERFOLINE 25 : 1/sel
VALACICLOVIR 500 : 2/jour
LANSOPRAZOLE 15 : 1/jour
Duphalac et Paracetamol si besoin
SYMBICORT
CONCLUSION : 1ère cure de R-CYVE pour un lymphome de Burkitt traité dans le
groupe C3 du LMB02.
PROCHAIN RDV :
RAD
HDJ transfusionnels demandés avec fiche de consigne transfusionnelle.
R-CYVE n2 en hospitalisation le 24/04/2023
TEP + IRM post R-CYVE n2 demandés.
Patient informé de la prise en charge thérapeutique et ou sa personne de confiance.
Bien confraternellement.
Docteur [NOM]
Courrier lu et validé par le médecin

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C E N T R E H O S P I T A L I E R D E L A C ÔT E B A S Q U E
[MASK]
*[MASK]*
Praticiens Hospitaliers :
Dr T. [NOM]
Oncologie médicale
Dr F. [NOM]
Oncologie médicale
Dr S. [NOM]
Chirurgie Sénologie-
Gynécologie
Dr L. [NOM]
Chirurgie Sénologie-
Gynécologie
Dr B. [NOM]
Radiologie
Dr A. [NOM]
Radiologie
Dr C. [NOM]
Radiologie
Dr S.[NOM]
Médecin généticien
Mme A. [NOM]
Conseillère en génétique
Cadres de Service :
Mme C. [NOM]
 [TEL]
Mr L. [NOM]
 [TEL]
Secrétariat Médical :
Accueil, Rendez-vous
Mme C. [NOM]
Mme A. [NOM]
 [TEL]
[EMAIL]
 [ADRESSE]Interne [NOM] [NOM] - B.P. 8 [CODE_POSTAL]
[MASK] (Chef de [MASK].[NOM])
 Secrétariat : [TEL] Télécopie : [TEL]
[EMAIL]
CL
Bayonne, le 05 Juin 2023
Docteur [NOM]
[MASK]
[ADRESSE][CODE_POSTAL]
[CODE_POSTAL]
Doubles aux :
Docteur [NOM]
Cabinet Médical [NOM] Egoa
[ADRESSE]
[CODE_POSTAL]
Docteur [NOM]
[NOM]
[ADRESSE][CODE_POSTAL]
[CODE_POSTAL]
Chers Confrères,
Nous avons vu en Hôpital de jour Multidisciplinaire de Sénologie-gynécologie (HMS), le
02/06/2023, Madame [NOM], [DATE_NAISSANCE].
Veuillez trouver ci-joint le compte-rendu.
Docteur [NOM]
Docteur [NOM]
Courrier relu et validé par les médecins
[ETABLISSEMENT] [NOM] [NOM], [DATE_NAISSANCE]
COMPTE-RENDU DE VISITE INITIALE
Date : 02 Juin 2023
Vue par : Docteurs [NOM], [NOM] ainsi que Madame [NOM], IPA
Adressée par : Docteur [NOM] du court séjour gériatrie à la [ETABLISSEMENT] où est
actuellement hospitalisée la patiente.
Motif : patiente vue seule en HMS pour situation complexe nécessitant une prise en charge multidisciplinaire à la
Histoire de la maladie :
Hospitalisation pour douleurs abdominales le 30 Mai 2023 avec nausées, anorexie, et clinopholie depuis cinq jours.
Description dune altération de létat général depuis environ 3 semaines.
Contexte de décompensation cardio-respiratoire associée et poussée dinsuffisance rénale aigue sur insuffisance
rénale chronique.
Scanner TAP retrouvant un syndrome de masse développé au niveau de lutérus avec des nodules de carcinose
péritonéale et micro-nodules pulmonaires. ACE augmenté 32. CA 125 à 190.
Traitement symptomatique par OXYCODONE et corticothérapie.
Antécédents :
Personnels médicaux : diabète non insulio-dépendant, HTA, surpoids, dyslipdémie, hypothyroïdie, insuffisance
rénale chronique.
Personnels chirurgicaux : non connus
Gynécologiques : -
Familiaux : non connus
Traitement :
Allergie : pas dallergie médicamenteuse connue.
Mode de vie : vit habituellement au domicile avec son époux, son fils et sa belle fille.
Jusquà peu de temps, autonome à son domicile mais ne sortait plus à lextérieur.
EXAMEN CLINIQUE PRÉ-THÉRAPEUTIQUE
PS 4 avec patiente qui s'endort lors de l'interrogatoire.
Abdomen pléthorique avec volumineux gâteau épiploïque palpé en lien avec la carcinose péritonéale sans franc syndrome
occlusif.
Douleurs a priori contrôlées depuis 24 h.
Absence de métrorragies rapportées par la patiente.
Mycose buccale avec sècheresse.
INTERVENTIONS ET PROPOSITION DE PRISE EN CHARGE
[AGE] vue pour probable carcinome endométrial d'emblée métastatique au niveau péritonéal et pulmonaire
chez une patiente grabataire.
Sur le plan chirurgical :
Nécessité théorique d'envisager à minima une hystéroscopie pour biopsie afin de prouver la maladie.
Sur le plan oncologique :
Devant la franche altération l'état général et rapidité d'installation, il ne semble pas licite d'envisager une
anatomopathologie, puisqu'aucun projet thérapeutique ne pourra être mené chez cette patiente.
Une prise en charge palliative pure symptomatique est à envisager. [NOM] [NOM], [DATE_NAISSANCE]
Questionnaire Qualité de vie : non rempli ce jour.
Au plan infirmier de pratique avancée : évaluation des besoins en soins de support.
Prochain rendez-vous :
Pas de rendez-vous donné au vu de la prise en charge symptomatique exclusive.
On reste disponible si nécessité.
Docteur [NOM]
Docteur [NOM]
Courrier relu et validé par les médecins

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{"page": 0, "kind": "NOM", "original": "Caroline DOMBRIZ FRADIN", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "15 BIS RUE AMEDEE DUFOURG", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64600 ANGLET", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARIE-THEREZE AGUIRRE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Née le 12/02/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}

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CROp [NOM] - [NOM], [NOM] [NOM]
_______________________________________________________________________________________________________________
Compte rendu opératoire
>>>1 CRO type chirurgie viscérale 06/05/23 10 : 32 (mod. le 12/05/23 12:23 par [NOM] An
LE/ AA
Bayonne, le 11 mai 2023
Docteur [NOM]
[ADRESSE]
[CODE_POSTAL]
Madame [NOM]
[DATE_NAISSANCE]
CHOLECYSTECTOMIE SOUS COELIOSCOPIE
DIAGNOSTIC : Cholécystite aiguë. Patiente admise aux urgences sur des douleurs fébriles de lhypochondre.
cholécystite.
Compte rendu opératoire du 01/05/2023 :
Opérateur : Docteur L. [NOM]
Anesthésiste(s) Docteur J. [NOM]
Aide(s) : L'interne
VOIE DADORD : Laparoscopie
CONSTATATIONS OPERATOIRES :
La vésicule est en réplétion, inflammatoire :
Le foie est daspect normal,
Le canal cystique est court, mais facilement individualisable
Cholangiographie per-opératoire : non
GESTES EFFECTUES :
Création dun pneumopéritoine par open laparoscopie péri-ombilicale. Introduction dun trocart de 10 mm sous
pour insufflation du pneumopéritoine jusquà 12 mm de Hg.
Introduction sous contrôle de la vue dun trocart de 5 mm dans le flanc droit. Dun trocart de 10 mm dans lhyp
dun trocart de 5 mm en position sous-xiphoïdienne pénétrant dans la cavité abdominale à gauche du ligamen
Ponction vésiculaire.
Abord et dissection du triangle de Callot et de linfundibulum vésiculaire permettant dindividualiser le canal cy
du collet vésiculaire ainsi que l'artère cystique.
Section du canal cystique après contrôle du moignon cystique restant par trois clips (HEMOLOCK 10) Section
entre trois (HEMOLOCK 10). Cholécystectomie rétrograde. Extériorisation de la vésicule dans un endosac intr
de 10 mm.
Vérification du lit vésiculaire et réalisation d'hémostase complémentaire ponctuelle.
Vérification de l'artère et du canal cystique clipés qui retrouve une bonne hémostase et l'absence de fuite bilia
Ablation de tous les trocarts sous contrôle la vue ce qui permet de vérifier l'absence de saignement au niveau
ponction.
_______________________________________________________________________________________________________________
Information patient
Page 1
08/04/2025 09 : 50:42 CROp [NOM] - [NOM], [NOM] [NOM]
_______________________________________________________________________________________________________________
Compte rendu opératoire
Exsufflation de l'ensemble du pneumopéritoine.
Fermeture aponévrotique des orifices trocart de 10 mm par un point en X de Vicryl 0.
Fermeture cutanée par agrafes
Drainage : non
Bactériologie : oui
Ponction vésiculaire : oui
Envoi de la pièce opératoire pour examen anatomopathologique : Aspect macroscopique : Présence de calcul
Difficultés per-opératoires : non
_______________________________________________________________________________________________________________
Information patient
Page 2
08/04/2025 09 : 50:42

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{"page": 0, "kind": "NOM", "original": "Stephan GUILHEM-DUCLEON", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "15 BIS RUE AMEDEE DUFOURG", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64600 ANGLET", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Michel PRIOT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Né le 09/06/1953", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "DOUARD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Laurent MASCLE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Magali VERGEZ", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Laurent MASCLE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "DOUARD", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Laurent MASCLE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Magali VERGEZ", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Laurent MASCLE", "placeholder": "[NOM]", "bbox_hint": null}

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CROp Epi - [NOM], [NOM]
_______________________________________________________________________________________________________________
Compte rendu opératoire
>>>1 CRO type chirurgie viscérale 06/06/23 15 : 58 (mod. le 06/06/23 16:03 par [NOM] [NOM] , statut : Rés
LM / EP
Docteur [NOM]
[ADRESSE]
[CODE_POSTAL]
Monsieur [NOM]
[DATE_NAISSANCE]
RTV
Histoire Clinique :
- Patient initialement pris en charge par le Docteur [NOM] pour des hématuries macroscopiques.
- Une échographie fait état d'une lésion polypoïde vésicale.
- Du fait d'une récidive de ses hématuries macroscopiques, on décide d'avancer le geste d'intervention pour e
exploration plus ou moins résection.
Compte-rendu opératoire du 6 juin 2023 :
Opérateur : Docteur [NOM]
Anesthésiste : Docteur [NOM]
Aide(s) [NOM] [NOM], Interne
- Sous anesthésie générale, en position gynécologique, après antibiothérapie péri-opératoire.
- Introduction du résecteur qui réalise une cystoscopie complète et retrouve des méats urétéraux normaux, av
dallure urothéliale près du méat urétéral gauche et d'autres lésions plus planes, suspectes de carcinome in si
- Résections complète des lésions sauf celles du carcinome in situ planes qui sont très nombreuses.
- On parvient néanmoins à réaliser de nombreux prélèvements pour examen histologique.
- Hémostase soigneuse.
- Mise en place d'une sonde Dufour charrière 18 pour irrigation-lavage.
- Les urines sont claires.
Docteur [NOM]
_______________________________________________________________________________________________________________
Information patient
Page 1
15/04/2025 16 : 30:14

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CROp [NOM] - [NOM], [NOM]
_______________________________________________________________________________________________________________
Compte rendu opératoire
>>>CRO neurochirurgie type 22/08/23 14 : 31 (mod. le 22/08/23 14:58 par [NOM] [NOM] , statut
Réf : JF/VA
Bayonne, le 22/08/2023
Dr [NOM]
CABINET [NOM]
Le BOURG
[CODE_POSTAL]
Mr [NOM]
[ADRESSE]
[CODE_POSTAL]
Madame et cher confrère,
Je vous remercie de bien vouloir trouver ci-joint le compte-rendu opératoire concernant votre patient, Mr R
le [DATE_NAISSANCE].
En vous remerciant de votre confiance,
Je vous prie de croire, Madame et cher confrère, à lexpression de mes sentiments confraternellement dé
Docteur [NOM]
Courrier lu et validé par le médecin
COMPTE RENDU OPÉRATOIRE
Date : 22/08/2023 [DOSSIER]
Nom : [NOM] Prénom : [NOM]
Date de naissance : [DATE_NAISSANCE]
Service : Neurochirurgie
CHIRURGIEN : Dr [NOM]
AIDE OPERATOIRE : [NOM] [NOM]
ANESTHÉSISTE : Dr [NOM]
INTERVENTION PRATIQUÉE :
ABLATION DUN SITE DACCES INTRATHECAL POUR DES TESTS A BACLOFENE.
HISTOIRE DE LA MALADIE :
Mr [NOM], [DATE_NAISSANCE], qui est connu pour avoir une tétraparésie spastique suite à une contusion
_______________________________________________________________________________________________________________
Information patient
Page 1
18/04/2025 11 : 54:37 CROp [NOM] - [NOM], [NOM]
_______________________________________________________________________________________________________________
Compte rendu opératoire
est porteur depuis trois semaines dun site daccès intrathécal pour des tests à Baclofène.
Lintervention sétait déroulée sans complication particulière et Mr [NOM] était hospitalisé à [NOM] depui
pour réaliser les tests nécessaires.
Il a présenté une déhiscence de la cicatrice thoraco-lombaire avec le cathéter intrathécal qui était exposé à la
Après discussion collégiale avec nos collègues MPR, Dr [NOM] à [NOM], Mr [NOM] a été transféré dan
neurochirurgie pour ablation du site daccès intrathécal, surtout que lexposition à lair libre du cathéter intrathé
risque important dinfection à type de méningite.
Les avantages de cette intervention ainsi que le risque de complication ont été bien expliqués à Mr [NOM] qu
geste chirurgical.
Protocole opératoire :
Anesthésie générale, position en décubitus latéral gauche, vérification des points dappuis après intubation oro
Vérification des points dappui.
Préparation de la peau selon le protocole habitue à la Bétadine scrub et réalisation de badigeons à la Bétadin
Mise en place des champs en condition stérile.
Reprise de la cicatrice para-ombilicale droite. Dissection sous-cutanée jusquà identification du réservoir. Exté
ce réservoir.
Reprise de la cicatrice thoraco-lombaire qui était inflammatoire sur ses berges et exposition du cathéter intrath
déjà exposé à lair libre en partie.
On enlève le fixateur aponévrotique du cathéter et on sectionne le cathéter intrathécal pour avoir quelques cc
envoyés en étude bactériologique.
Ablation de la partie intrathécale de ce cathéter qui a été envoyée à son tour à létude bactériologique.
Ablation du réservoir avec le cathéter correspondant.
Avivement des berges de la cicatrice thoraco-lombaire jusquà avoir un retour sanguin suffisant et fermeture d
laide de fil à peau en Blair Donati.
Fermeture de lincision para-ombilicale droite à laide de fil à peau en points séparés Blair Donati.
Durée de lintervention : 15 mn
Perte sanguine : négligeable, non compensée
Docteur [NOM]
Courrier lu et validé par le médecin
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CROp [NOM] - [NOM], [NOM]
_______________________________________________________________________________________________________________
Compte rendu opératoire
>>>1 CRO type chirurgie viscérale 13/09/23 14 : 55 (mod. le 13/09/23 15:05 par [NOM] [NOM] , statut : Rés
RG/ JL
Bayonne, le 13/09/2023
Docteur [NOM]
[ADRESSE]
[CODE_POSTAL] BAYONNE
Monsieur [NOM]
[ADRESSE]
[CODE_POSTAL]
Docteur [NOM]
Gastro entérologie
[MASK]
Monsieur [NOM]
[DATE_NAISSANCE]
RESECTION SEGMENTAIRE DE GRELE POUR PROBABLE TUMEUR NEURO ENDOCRINE
Compte rendu opératoire du 12/09/2023 :
Opérateur : Docteur R. [NOM]
Anesthésiste(s) Docteur E. [NOM]
Aide(s) : L'interne
Mise en place dun trocart de 10 mm à lombilic par la technique dopen coelioscopie et insufflation du pneumo
Lexploration de la cavité abdominale retrouve un globe vésical et des adhérences sur le grand épiploon et le f
Mise en place dun trocart de 5 mm en fosse iliaque gauche, dun trocart de 5 mm en para rectal gauche.
On déroule le grêle et on va effectivement retrouver la tumeur environ 30 cm avant la valvule de Bauhin.
Lexploration du reste du grêle est sans particularité.
On va donc réaliser une incision de Pfannenstiel pour extraire le segment de grêle intéressé par la lésion et ré
résection et le rétablissement de la continuité.
Repérage de la lésion.
Exsufflation.
Réalisation dune incision de Pfannenstiel.
Mise en place dune jupe de protection de paroi.
Extériorisation du grêle.
A la palpation on va retrouver la lésion principale mais aussi une petite lésion quelques centimètres à côté.
Section du grêle en zone saine de part et dautre au bistouri électrique.
Section du mésentère en regard ligaturé au Vicryl 2/0.
Rétablissement de la continuité par une anastomose termino-terminale en points séparés de PDS 4/0.
Fermeture de la brèche mésentérique au PDS 4/0.
Réintroduction dans la cavité abdominale.
_______________________________________________________________________________________________________________
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Page 1
22/04/2025 10 : 07:08 CROp [NOM] - [NOM], [NOM]
_______________________________________________________________________________________________________________
Compte rendu opératoire
Fermeture du péritoine au Vicryl 2/0.
Fermeture musculo-aponévrotique au PDS n°1.
Fermeture des orifices de trocarts au Vicryl 0.
Asufil 4/0 en intra dermique et colle sur la peau.
_______________________________________________________________________________________________________________
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{"page": 0, "kind": "NOM", "original": "Anne SEVILLA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64500 CIBOURE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Valerico SANCHEZ", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "10, avenue Layats ", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Polyclinique Côte Basque Sud", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64500 ST JEAN DE LUZ", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Jean-Daniel BADIOLA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "2 Avenue Pierre Larramendy", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64500 ST JEAN DE LUZ", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Andon LAZAROV", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Né le 27/11/1958", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Alessandro FALCHETTI", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Estelle QUEANT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Alessandro FALCHETTI", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Estelle QUEANT", "placeholder": "[NOM]", "bbox_hint": null}

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CROp Epi - [NOM], [NOM]
_______________________________________________________________________________________________________________
Compte rendu opératoire
>>>1 CRO type chirurgie viscérale 16/11/23 14 : 02 (mod. le 27/11/23 15:16 par [NOM] [NOM] , statut : Ré
AL/AF
Docteur [NOM]
Cabinet Médical [NOM] [NOM]
Place Du [NOM]
[CODE_POSTAL]
Docteur [NOM]
[ADRESSE]
[ETABLISSEMENT]
[CODE_POSTAL]
Docteur [NOM]
[NOM]
[ADRESSE]
[CODE_POSTAL]
Monsieur [NOM]
[DATE_NAISSANCE]
PONTAGE FEMORO-POPLITE SOUS ARTICULAIRE
EN VEINE SAPHENE INVERSEE.
Histoire Clinique :
- Il sagit dun patient qui présente une thrombose danévrisme poplité gauche symptomatique avec une ischém
inférieur gauche.
- On propose la réalisation dun pontage fémoro-poplité.
Compte-rendu opératoire du 16.11.2023 :
Opérateur : Docteur [NOM]
Anesthésiste : Docteur [NOM]
Aide(s) *
- Sous anesthésie générale, après désinfection et mise en place de champs opératoires.
- On réalise tout dabord un abord poplité.
- On met sur LAC lartère poplitée en dessous de larticulation.
- On prélève la veine saphène qui est un peu grêle en dessous du genou, on remontera donc le prélèvement d
jusquà la jonction tiers proximal tiers moyen de cuisse.
- On aborde ensuite lartère fémorale au niveau de son segment II.
- Mise sur LAC de cette artère.
- Réalisation dun trajet de tunnélisation entre lincision poplitée et labord de lartère fémorale superficielle pro
- Héparinisation du patient par 3500Ui dHEPARINE non fractionnée.
- Vérification de la veine qui ne présente pas de fuite.
- Les collatérales sont toutes liées au Vicryl 3/0.
- Orientation de la veine par un feutrage.
- On passe alors la veine dans le trajet de tunnélisation.
_______________________________________________________________________________________________________________
Information patient
Page 1
24/04/2025 10 : 03:34 CROp [NOM] - [NOM], [VILLE]
_______________________________________________________________________________________________________________
Compte rendu opératoire
- On réalise tout dabord lanastomose proximale.
- Clampage de lartère fémorale superficielle.
- Artériotomie d1cm.
- Réalisation dune anastomose termino-latérale entre la veine et lartère au Prolène 5/0.
- Mise en charge du pontage qui est bien pulsatile.
- Purge de celui-ci au sérum hépariné.
- Reclampage du pontage.
- Découpe de la veine à la bonne longueur avec la jambe tendue.
- Réalisation après clampage de lartère poplitée dune artériotomie à ce niveau de 1cm également.
- Veinotomie correspondante.
- Anastomose termino-latérale entre la veine et lartère au Prolène 6/0.
- Après purge, déclampage.
- On réalise une bourse au Prolène 5/0 en amont de lanastomose proximale sur lartère fémorale superficielle
- A ce niveau, mise en place dun introducteur de 4French.
- Par cet introducteur, on réalise une artériographie de contrôle qui montre la bonne perméabilité du pontage e
vice anastomotique et la bonne perméabilité du lit distal.
- Après retrait de lintroducteur, fermeture de la bourse.
- Vérification de lhémostase sur toutes les incisions.
- Mise en place de deux Redons qui vont drainer toutes les incisions.
- Fermeture de chaque incision par un Vicryl 0 en sous cutané et par des agrafes à la peau.
_______________________________________________________________________________________________________________
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{"page": 0, "kind": "NOM", "original": "Anthony MURET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "2, ALLÉE DE PLAISANCE", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64600 ANGLET", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARIE BARETS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "10 AVENUE MARECHAL SOULT", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64100 BAYONNE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARIE BARETS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARIE BARETS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Romain BILLON-GRAND", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Date de naissance : 08/12/1952", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "2, ALLÉE DE PLAISANCE\n", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "10 AVENUE MARECHAL SOULT\n", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64600 ANGLET\nMme MARIE BARETS\nRES LE PARADOR", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64100 BAYONNE\nPatient", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Anthony MURET RÉSIDENCE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARIE BARETS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARIE BARETS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Romain BILLON-GRAND", "placeholder": "[NOM]", "bbox_hint": null}

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Courrier [NOM] - [NOM], [NOM] [NOM]
___________________________________________________________________________________________________________________________
Courriers médicaux
>>>A Lettre de sortie 10/04/23 14 : 19 (mod. le 13/04/23 15:58 par [NOM] [NOM], statut : complet)
Ref : RBG/FL
Bayonne, le 12 Avril 2023
Dr [NOM]
[NOM] [NOM] DES [NOM]
[NOM] 9
[ADRESSE]
[CODE_POSTAL]
Mme [NOM]
[NOM] LE [NOM]
[ADRESSE]
[CODE_POSTAL]
Patient(e) : Madame [NOM]
Date de naissance : [DATE_NAISSANCE]
COMPTE RENDU DHOSPITALISATION
Hospitalisation du 07/04/2023 au 10/04/2023
Cher confrère,
Madame [NOM] a été accueillie en urgence dans le service, pour hypertension intracrânienne, sur des héma
sous-duraux chroniques.
Des épisodes de vomissements, et chez nous une asthénie, une tendance confuse et des céphalées.
On la finalement opérée en semi-urgence.
Les suites sont extrêmement simples, avec demblée une patiente beaucoup plus confortable, bien consciente et sans
focal.
Elle sort donc avec de simples soins de pansements, et lablation des sutures à faire à une semaine de lintervention, s
vers le 15 avril.
Je la reverrai dans un mois (le 11/05 à 11h50), munie dun scanner qui est prescrit (rdv le 10/05 à 10h30).
Pas de consigne particulière dici-là.
Je vous remercie de votre confiance et reste à votre disposition.
Mes respects.
Docteur [NOM]
Courrier lu et validé par le médecin
___________________________________________________________________________________________________________________________
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Courrier Epi - [NOM], [NOM]
___________________________________________________________________________________________________________________________
Courriers médicaux
>>>A Lettre de sortie 05/07/23 14 : 17 (mod. le 07/07/23 12:19 par [NOM] [NOM] , statut : Résu non validés)
AD/EP
Bayonne, le 6 juillet 2023
Docteur [NOM]
Centre Médical de la Zup
Quartier Ste Croix
[CODE_POSTAL]
Cher Confrère,
Monsieur [NOM], [DATE_NAISSANCE], a été hospitalisé dans le service du 2 au 5 juillet 2023, pour une tenta
de descente de sonde mono-J dans son Bricker à gauche.
Il avait donc présenté une pyélonéphrite sévère en février, le scanner montrait une majoration importante de la
dilatation et un rein présentant un retard excrétoire.
Jai donc réalisé facilement la ponction de ce rein gauche, la dilatation et l'opacification. Celle-ci montre une absence
totale de passage entre l'uretère gauche et le Bricker. Jai donc réalisé une urétéroscopie descendante, permettant de de
jusqu'en bas de luretère à la jonction urétéro-iléale. Pour autant, aucun passage possible jusqu'au Bricker.
Nous avons donc secondairement tenté une Brickeroscopie pour tenter de retrouver ce passage. Cela a permis de c
un Bricker extrêmement fragile, qui a été très légèrement endommagé au cours de cette Brickeroscopie.
Au total, aucune possibilité de drainage interne par sonde mono-J. Jai laissé une sonde vésicale dans le Bricker pou
assurer la cicatrisation.
L'évolution est favorable, puisqu'il a repris une bonne diurèse par son Bricker sans aucune douleur et un Bricker qui
reste fonctionnel.
Au niveau rénal, jai laissé en place une néphrostomie pour assurer la cicatrisation et permettre le drainage de ce rei
…/…
Finalement après évolution favorable, je lui ai exposé les options possibles désormais :
- premièrement, laisser les choses en l'état et rester porteur de cette néphrostomie. Cette solution paraît invalidante
long terme.
- deuxièmement, réaliser une réfection complète de son Bricker, ce qui impose une nouvelle chirurgie par voie ouver
dans un ventre potentiellement très hostile du fait de ses antécédents. Cette option est surement la meilleure à long terme
avec beaucoup plus de risques péri-opératoires.
- troisième option : retirer la néphrostomie et revenir à l'état préopératoire. Il a bien compris que cela l'amènerait
quoiqu'il en soit à une destruction progressive de son rein gauche et l'exposerait potentiellement à des nouveaux phénom
infectieux. Malgré cela, il est plutôt partisan a priori de cette dernière option.
Jai proposé de le revoir dans quelques semaines, après essai de la situation, porteur de le néphrostomie et nous ve
à ce moment-là si on la retire secondairement.
___________________________________________________________________________________________________________________________
Information patient
Page 1
17/04/2025 09 : 17:42 Courrier Epi - [NOM], [NOM]
___________________________________________________________________________________________________________________________
Courriers médicaux
Bien confraternellement.
Docteur [NOM]
Courrier lu et validé par le médecin
___________________________________________________________________________________________________________________________
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@@ -1,13 +0,0 @@
{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER DE LA COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "LAGARRIGUE Juliette", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "HARIZPE CAMINONDO Bernard", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64120 ST JUST IBARRE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "TEL", "original": "0559378513", "placeholder": "[TEL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "COMAT VINCENT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "QUEANT Estelle", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "LAGARRIGUE Juliette", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "HARIZPE CAMINONDO Bernard", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "CODE_POSTAL", "original": "64120 ST JUST IBARRE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 1, "kind": "TEL", "original": "0559378513", "placeholder": "[TEL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "DE MONTAUDOUIN Jean", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "LAGARRIGUE Juliette", "placeholder": "[NOM]", "bbox_hint": null}

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[MASK]
Anesthésiste : Dr [NOM]
DOSSIER DE CONSULTATION
(modifié le 23/02/2023)
Date :
17/02/23
Nom :
M. [NOM]
Né(e) le :
[DATE_NAISSANCE]
79 ans
N°Ipp :
[TEL]
N? Csult : [IPP] /
Nom naiss. :
23025988
Poids : 65 kg
Taille : 170 cm
B.M.I. : 22.5
Profession :
Adresse :
MAISON [NOM]
[CODE_POSTAL]
N° Tél : [TEL]
à
11 : 55
Spécialiste :
Date d'Intervention : 23/02/2023
Médecin traitant :
Motif d'admission : HOLEP
Opérateur : Dr [NOM]
Prévenir :
Mémo :
Anesthésiste en salle d'opération :
Dr [NOM]
Ambulatoire
Urgence
Entrée le jour de l'intervention
Hospit. < 30 jours
Obstétrique
CHIR.UROLOGIE C2
Hospitalisé(e) le :
à :
Service :
__ : __
__/__/__
Allergie : [pyostacine]
ATCD pulmonaires : Autres problèmes respiratoires : [H° en novembre pour pnp à pyocianique en réa iot, décupération
quasiment ad intrégrum sur le plan respiratoire]
Classe ASA : ASA3
Etat dentaire : Edenté
ATCD cardio-vasculaires : Valvulopathie, RAo : [grad moyen 25 02/25]
Antécédents / Traitements
Examen [ETABLISSEMENT] / Prescriptions
ATCD chirurgicaux :
. Cataracte
. Autres/1 phimosis
ATCD cardio-vasculaires :
. Valvulopathie /RAo grad moyen 25
02/25
. Insuffisance coronaire/Stent 2019 atc
iva proximale , cd occluse
. Trouble du rythme/AFCA clinique
alternance fa et flutter
. Arteriopathie/AOMI
. Derniers examens/Echo fe N cinetique
ok pas de valvulopathie mitro aortique
prvg basses rao gradient moyen 25
cavite droites non dilateees pas d'it vci
souple/ECG 02/23 sinusal 96 bpm bav 1
pr 240 bbdi gche
. Consultation cardio 02/23
Examen clinique :
. Etat general/Altere fragile
. Capacite d?effort/ 4 a 7 marche
quotidienne
. Cardio-vasculaire/
Asymptomatique/Auscultation
cardiaque/ Souffle systolique rao
Hemostase clinique :
. Anamnese normale
. Pas d?indication a un bilan de
coagulation
Examen général :
Homme, Poids : 65 Kg, Taille : 170 cm ,
B.S.A. : 1.8 m², B.M.I. : 22.5
. Jeûne : A jeun
Etat dentaire / Prothèse :
Etat dentaire : Edenté
Informations données au patient :
. Accord modalites d'anesthesie
proposees
. Brochure d'information remise au
patient
. Complications peri- et postoperatoires
. Information Transfusion
. Informations bien comprises
. Rapport benefice/risque explique
. Risque dentaire explique
. Techniques Anesthesiques
Technique d'anesthésie envisagée :
Anesthésie : AG avec masque larynge
Protocole : AG DIP-SUF
Antibioprophylaxie : selon protocole
ATCD pulmonaires :
. Autres problemes respiratoires H?
en novembre pour pnp a
pyocianique en [ETABLISSEMENT]
decuperation quasiment ad
intregrum sur le plan respiratoire
ATCD medicaux :
. Autres/1 escarre pied droit en cours de
cicatrisation
. Endocrino-metabolique/Denutrition
severe/Diabete/ Type 2 8.3% 02/23
. Neurologique/AVC 2015 ischemique
pas de sequelles
Interrogatoire / Autorisation /
Lateralite :
. Vu seul
. Patient apte a exprimer sa volonte et
participe a la decision
Dossier de consultation
Le 28 Février 2023 11 : 28
Page :
1/2 Anesthésiste : Dr [NOM]
DOSSIER DE CONSULTATION
(modifié le 23/02/2023)
Date :
17/02/23
Nom :
M. [NOM]
Né(e) le :
[DATE_NAISSANCE]
79 ans
N°Ipp :
[TEL]
N? Csult : [IPP] /
Nom naiss. :
23025988
Poids : 65 kg
Taille : 170 cm
B.M.I. : 22.5
Profession :
Adresse :
MAISON [NOM]
[CODE_POSTAL]
N° Tél : [TEL]
Allergie : pyostacine
Intubation :
. Mallampati 2
. Distance Interincisive : >35mm
. Distance thyromentonière : >65mm
. Mobilité cervicale : normale
Synthèse pré-opératoire :
Programmation opératoire : maintenue
Traitement(s) :
Traitement(s) en cours :
. xarelto 15 mg [suspendu le
20/02/2023], Matin (1)
. abasaglar (UI), Soir (30), A continuer
jusqu'à la veille au soir
. bisoprolol 1.25 mg (CP), Matin (1), A
continuer le matin
. forxiga 10 mg (CP), Midi (1)
. inexium 20 mg (CP), Soir (1), A
continuer jusqu'à la veille au soir
. januvia 50 mg (CP), Matin (1)
. kaleorid lp 1000 mg (CP), Matin (1),
Soir (1), A continuer jusqu'à la veille au
soir, A continuer le matin
. lercan 20mg (CP), Matin (1), A
continuer le matin
. metformine 500 mg (CP), Matin (1),
Soir (1)
. seresta 10 mg (CP), Soir (1), A
continuer jusqu'à la veille au soir
Risques - classe ASA :
. Classe ASA : ASA3
. Intubation : RAS
. Thrombo-embolique : Risque Moyen
. Ventilation : A priori sans difficulte
Prescription biologique :
Résultat(s) récent(s) (N : Normal,
A : Anormal) :
- Ionogramme( N )
- NFS / Hemoglobine( N )
- Plaquettes( N )
- Creat / DFG( A ) [dfg 38 02/22 (baisse
xarelto en consequence)]
Prescrit(s) :
- E.C.B.U.
- PCR COVID 19
- R.A.I.
- Groupe sanguin, Rh, 2 determinations
[carte de groupe personnelle valide et
verifiee]
Transfusion :
. Intervention a risque
hemorragique/intermediaire
. Carte de groupe/photocopie dans le
dossier
. RAI/prescrite + a recuperer neg 17/02
. Information transfusion donnee
Consigne(s) IDE :
A jeun le 23/02/2023 à 00 : 00
PCR COVID a recuperer
Paracetamol 1gr per os en
pre-medication
Préparations :
per-opératoire :
. BIS
. Baby-Noradrenaline
VISITE PRE-ANESTHESIQUE
Date :
22/02/2023 16 : 59
Anesthésiste :
Dr [NOM]
[NOM] / Eléments nouveaux (MAR)
PCR COVID : neg 21/02
Dossier transfu : gpe x2 ok, rai neg 17/02/23
Cli : evolution favorable de l'escarre du talon selon le patient mais ATBttt par AUGMENTIN jusq'au 19/02 (8 jours au
total) et radio prevue a distanc epour rechercher osteite...
Exam comp : note cs
Jeune : std
Adaptation TTT : derniere prise Xarelto 20/02 - forxiga 22/02 (donc sur-risque theorique d'acidocetose euglicemique a
garder en tete), presc pre-op signee.
Dossier de consultation
Le 28 Février 2023 11 : 28
Page :
2/2 Anesthésiste : Dr [NOM]
[NOM]
I.P.P. : [TEL]
Patient : [NOM] [NOM] [NOM] né(e) le :
N? Interv : [IPP]
[DATE_NAISSANCE]
Né(e) le : [DATE_NAISSANCE]
79 ans
Date :
17/02/2023 09 : 31
Consigne(s) IDE
PREPARATIONS
A jeun le 23/02/2023 à 00 : 00
PCR COVID a recuperer
- PER-Opératoires : BIS, Baby-Noradrenaline
Paracetamol 1gr per os en pre-medication
Prescription selon ordonnance du médecin traitant
Adaptation du traitement personnel
Nom du médicament, dosage, posologie
Soir J-1
Arrêt
Matin J 0
Midi J 0
Coucher J-1
abasaglar // UI, Soir : 30, A continuer jusqu'a la veille au soir
30 UI
bisoprolol 1.25 mg // CP, Matin : 1, A continuer le matin
1 CP
inexium 20 mg // CP, Soir : 1, A continuer jusqu'a la veille au soir
1 CP
kaleorid lp 1000 mg // CP, Matin : 1, Soir:1, A continuer jusqu'a la veille au soir, A
continuer le matin
1 CP
1 CP
lercan 20mg // CP, Matin : 1, A continuer le matin
1 CP
seresta 10 mg // CP, Soir : 1, A continuer jusqu'a la veille au soir
1 CP
Date / Heure
Validation IDE
Prémédication
Le 28 Février 2023 11 : 28
Page :
1/1

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@@ -1,127 +0,0 @@
C E N T R E H O S P I T A L I E R D E L A C ÔT E B A S Q U E
B.P.8 - [CODE_POSTAL] - Tél [TEL]
PÔLE DE CHIRURGIE ANESTHÉSIE BLOC OPÉRATOIRE
[TEL]
*[TEL]*
CHIRURGIE ORTHOPÉDIQUE TRAUMATOLOGIE
____________________________________________________________________________________________________________________________
FINESS juridique : [IPP]
FINESS géographique : [IPP]
Bayonne, le 26/08/2023
Dr M. [NOM]
[NOM]
HANCHE
RPPS : [RPPS]
Secrétariat : [TEL]
Dr P. [NOM]
[NOM]
HANCHE
RPPS : [RPPS]
Réf_CRO : AD
COMPTE RENDU OPERATOIRE
M [NOM] [NOM] [DATE_NAISSANCE]
FRACTURE DU COL FEMORAL DROIT GARDEN IV
INTERVENTION : [NOM] [NOM] HANCHE (PIH)
Secrétariat : [TEL]
Dr P. [NOM]
[NOM]
[NOM] [NOM]
RPPS : [RPPS]
Secrétariat : [TEL]
Dr A. [NOM]
[NOM] /[NOM]
[NOM] [NOM]
RPPS : [RPPS]
Secrétariat : [TEL]
Dr S. [NOM]
CHIRURGIE [NOM]
[NOM] : Docteur A. [NOM]
Médecin [NOM] : DR. [NOM]
Aide : l'interne J. [NOM]
Anesthésiste : Docteur B. [NOM]
[NOM] CLINIQUE :
[AGE], ayant présenté une fracture déplacée Garden IV du col fémoral droit/gauche
pour laquelle il est retenu une indication arthroplastie intermédiaire de hanche.
DISPOSITIF MÉDICAL IMPLANTÉ (DMI) :
Tige fémorale : HYPE taille 5 non cimentée, société SERF
Cupule mobile : CHIBF diamètre 49/28 mm, société SERF
Tête : Inox diamètre 28 mm, col moyen 0 mm, cône 12/14
PRÉPARATION :
Installation : Décubitus latéral
Anesthésie : Anesthésie générale
Vérification des points dappui
Préparation, désinfection et champage stérile selon protocole du CLIN
Antibioprophylaxie par Céfazoline 2g
Check list HAS avant incision
TECHNIQUE OPÉRATOIRE :
Voie dabord postérieure de Moore
Ouverture du fascia lata
Discision du muscle gluteus maximus.
Passage derrière le gluteus medius
Désinsertion trochantérienne des pelvi trochantériens avec respect total du piriforme et partiel du
carré fémoral.
Capsulectomie
Mise en évidence de la fracture et levée de lhématome
Recoupe du col fémoral à 1 cm du calcar
Extraction de la tête fémorale
Préparation du fût fémoral par des râpes de taille croissante
Mise en place de la tige définitive
PEDIATRIQUE
RPPS : [RPPS]
Secrétariat : [TEL]
Dr C. [NOM]
HANCHE
[NOM]
RPPS : [RPPS]
Dr C. [NOM]
MÉDECIN [NOM]
RPPS : [RPPS]
[EMAIL]
Rens. familles : [TEL] / 35 46
Prise de RDV : [TEL] Mise en place de la cupule mobile sur un col court après essai et vérification de la longueur et de
la stabilité
Réduction
Contrôle de la bonne souplesse de hanche, de la stabilité et de labsence dinégalité de longueur
Lavage abondant
Infiltration selon le protocole du [MASK] : fermeture du fascia au Vicryl 2 (résorbable), fermeture sous-cutanée
au Vicryl 0 (résorbable), fermeture cutanée par agrafes
Pansement sec
Durée opératoire : 39 min
CONSIGNES POST-OPÉRATOIRES :
Réfection du pansement : à J2, puis tous les 2 jours
Radiographie post-op : à J0 Bassin de face et hanche opérée de profil
Immobilisation : NON
Appui : COMPLET dès J0
Anticoagulation préventive 35 jours
Rééducation : OUI
-
réhabilitation à la marche et aux transferts,
-
apprentissage des mouvements luxants,
-
ré-autonomisation,
-
lutte contre le syndrome post-chute
Sortie : J2-J3
RDV en consultation : à 6 semaines avec radiographies de contrôle (bassin de face et profil de
hanche opérée)
Docteur A. [NOM]

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{"page": 17, "kind": "DATE_NAISSANCE", "original": "née le 27/11/1947", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 17, "kind": "ETAB", "original": "Service Madame GLAZEWSKI JADWIGA", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 17, "kind": "NOM", "original": "KHUONG HUU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 17, "kind": "NOM", "original": "Renaud GONTIER", "placeholder": "[NOM]", "bbox_hint": null}

View File

@@ -425,7 +425,7 @@ Note d'évolution
08/10/2023 08/10/2023
10 : 52 10 : 52
J4 colostomie sigmoïdienne J4 colostomie sigmoïdienne
Gaz bien repris mais pas encore de selle, [NOM] rosée légèrement œdématiée Gaz bien repris mais pas encore de selle, stomie rosée légèrement œdématiée
Abdomen souple Abdomen souple
RAS par ailleurs RAS par ailleurs
Stimulée à la marche ++ Stimulée à la marche ++
@@ -595,7 +595,7 @@ rdv pour la chimio en hospitalisation donné à la patiente
Douleur : non algique ce matin Douleur : non algique ce matin
Risque infectieux : Apyrétique Risque infectieux : Apyrétique
Plaies colles propres Plaies colles propres
Digestifs : [NOM] rosée, légèrement œdématiée Digestifs : Stomie rosée, légèrement œdématiée
, G+/S+++ molles -> fuite ++, appareillage refait ce matin , G+/S+++ molles -> fuite ++, appareillage refait ce matin
Devenir : RAD ce jour, papiers de sortie ok, ordo ok, rdv ok Devenir : RAD ce jour, papiers de sortie ok, ordo ok, rdv ok
J7 Colostomie de décharge + pose de PAC J7 Colostomie de décharge + pose de PAC
@@ -609,7 +609,7 @@ Risque infectieux :
- apyrétique - apyrétique
- plaies colles propres - plaies colles propres
Digestif : Digestif :
- [NOM] en place, rosée et oedématiée - stomie en place, rosée et oedématiée
1 flacon de gastro donnée -> G+ SL avec matières + vidées 1 flacon de gastro donnée -> G+ SL avec matières + vidées
-> fuite appareillage à 3h -> réfection avec poudre, anneau, pate, socle et poche G+ traces SL -> fuite appareillage à 3h -> réfection avec poudre, anneau, pate, socle et poche G+ traces SL
avec matières => G+ S- avec matières => G+ S-
@@ -617,10 +617,10 @@ Devenir :
- RAD le 10/10 VSL 11h30, frère au courant, message laissé sur répondeur IDEL rappeler le - RAD le 10/10 VSL 11h30, frère au courant, message laissé sur répondeur IDEL rappeler le
10/10 10/10
manque ordo stomathérapeute manque ordo stomathérapeute
[NOM] : œdématiée , rosée productive après lavement, fuite au niveau appareillage socle changé Stomie : œdématiée , rosée productive après lavement, fuite au niveau appareillage socle changé
Devenir : RAD demain papiers ok manque ordo stomathérapeute Devenir : RAD demain papiers ok manque ordo stomathérapeute
Transit : Transit :
-[NOM] en place avec gaz sans selles ce jour -Stomie en place avec gaz sans selles ce jour
=>Vu avec médecin et 1 flacon gastro donné =>Vu avec médecin et 1 flacon gastro donné
==>Début de selles fin de matinée ==>Début de selles fin de matinée
Allo [NOM] ce jour pour début éducation Allo [NOM] ce jour pour début éducation
@@ -640,7 +640,7 @@ Douleur :
- Plainte algique abdominale à 2h20, ATG1 donné - Plainte algique abdominale à 2h20, ATG1 donné
- Toujours algique à 5h, ATS donné -> non prescrit, à prescrire svp - Toujours algique à 5h, ATS donné -> non prescrit, à prescrire svp
Digestif : Digestif :
- [NOM] en place et perméable, légèrement œdématiée - Stomie en place et perméable, légèrement œdématiée
- Transit : G-/S- - Transit : G-/S-
Syndrome infectieux : apyrétique Syndrome infectieux : apyrétique
Douleur : non algique Douleur : non algique
@@ -694,34 +694,34 @@ Note IDE
[NOM] [NOM]
05/10/2023 05/10/2023
00 : 12 00 : 12
[NOM] : vascularisé , des gaz pas de selles appareillage refait cette AM Stomie : vascularisé , des gaz pas de selles appareillage refait cette AM
Douleur : non algique Douleur : non algique
Risque infectieux : Apyrétique Risque infectieux : Apyrétique
VVP en place propre VVP en place propre
Digestif : [NOM] en place, rosée, G+/S- -> gastrographine donné à 8h + duphalac prescrit à 12h Digestif : stomie en place, rosée, G+/S- -> gastrographine donné à 8h + duphalac prescrit à 12h
Alimentation bien toléré Alimentation bien toléré
HGT : 2.10 à 13h post prandial HGT : 2.10 à 13h post prandial
Douleur : Douleur :
- Douleur modérée au niveau abdominal -> ATG1 + ATS donnés à 02h -> non algique ensuite - Douleur modérée au niveau abdominal -> ATG1 + ATS donnés à 02h -> non algique ensuite
Digestif : Digestif :
- [NOM] en place et perméable, légèrement œdématiée - Stomie en place et perméable, légèrement œdématiée
- Transit : G+ et traces de selles liquides - Transit : G+ et traces de selles liquides
Syndrome infectieux : apyrétique Syndrome infectieux : apyrétique
Douleur : non algique Douleur : non algique
Surv dig : alimentation bien toléré Surv dig : alimentation bien toléré
[NOM] : vascularisé , des gaz pas de selles -> traitement débuté ce soir cf PM Stomie : vascularisé , des gaz pas de selles -> traitement débuté ce soir cf PM
Douleur : Algique à 8h -> ATG1 donné Douleur : Algique à 8h -> ATG1 donné
Risque infectieux : apyrétique Risque infectieux : apyrétique
Plaies colles propres Plaies colles propres
Digestif : [NOM] en place, légèrement oedématiée G+/S- liquide séreux -> refait ce jour car fuite Digestif : stomie en place, légèrement oedématiée G+/S- liquide séreux -> refait ce jour car fuite
Absence nausées/vomissement/rots Absence nausées/vomissement/rots
P02 bien toléré P02 bien toléré
Hmd : TA à 10/5 ttt HTA non donné ce matin Hmd : TA à 10/5 ttt HTA non donné ce matin
Devenir : Sera hospitalisé le 25/10 à 15h en gastroenterologie , patiente informé Devenir : Sera hospitalisé le 25/10 à 15h en gastroenterologie , patiente informé
Digestif : Digestif :
- [NOM] en place et perméable, légèrement œdématiée - Stomie en place et perméable, légèrement œdématiée
- Transit : traces selles liquides / liquide séreux - Transit : traces selles liquides / liquide séreux
[NOM]/baguette= G+S- => ablation baguette faite, [NOM] oedématiée = socle+poche changés Stomie/baguette= G+S- => ablation baguette faite, stomie oedématiée = socle+poche changés
Douleur=confortable Douleur=confortable
J3 Colostomie de décharge + pose de PAC J3 Colostomie de décharge + pose de PAC
Douleur : Douleur :
@@ -730,12 +730,12 @@ Risque infectieux :
- plaies colles propres - plaies colles propres
- bn - bn
Digestif : Digestif :
- [NOM] + baguette : environs 10cc séro sanglant et G+ ablation baguette le 6/10 - stomie + baguette : environs 10cc séro sanglant et G+ ablation baguette le 6/10
- pas de nausées, pas de vomissements, pas de rots - pas de nausées, pas de vomissements, pas de rots
Devenir : Devenir :
- vit en maison autonome, allo IDEL dès que sortante - vit en maison autonome, allo IDEL dès que sortante
Transit : Transit :
-[NOM] en place avec baguette : gaz sans selles, traces séreuses -Stomie en place avec baguette : gaz sans selles, traces séreuses
=>Vu avec chir et ablation baguette demain =>Vu avec chir et ablation baguette demain
-Pas de nausées ni rots -Pas de nausées ni rots
-Ventre souple -Ventre souple
@@ -746,7 +746,7 @@ Douleur :
Patiente confortable Patiente confortable
Fatiguée cette après-midi, est beaucoup restée dans le lit Fatiguée cette après-midi, est beaucoup restée dans le lit
RAD envisagée semaine prochaine RAD envisagée semaine prochaine
[NOM]/baguette= G+S- = poche changée Stomie/baguette= G+S- = poche changée
Douleur=confortable av ATG1+ATS en systématique Douleur=confortable av ATG1+ATS en systématique
Alim= CY ce matin , léger ce midi Alim= CY ce matin , léger ce midi
J2 Colostomie de décharge + pose de PAC J2 Colostomie de décharge + pose de PAC
@@ -791,14 +791,14 @@ Traitements médicamenteux
- plaies colles propres - plaies colles propres
- bn - bn
Digestif : Digestif :
- [NOM] + baguette : environs 10cc séro sanglant et G+ - stomie + baguette : environs 10cc séro sanglant et G+
- pas de nausées, pas de vomissements, pas de rots - pas de nausées, pas de vomissements, pas de rots
Endocrino : Endocrino :
- glycémie correcte - glycémie correcte
Devenir : Devenir :
- vit en maison autonome, allo IDEL dès que sortante - vit en maison autonome, allo IDEL dès que sortante
Transit : Transit :
-[NOM] avec baguette en place : présence e gaz sans selles ce jour -Stomie avec baguette en place : présence e gaz sans selles ce jour
Traces séreuses dans la poche Traces séreuses dans la poche
-Pas de nausées ni rots -Pas de nausées ni rots
-Ventre souple -Ventre souple
@@ -815,7 +815,7 @@ Allo de son IDE libérale=>Souhaite RAD post-op et l'appeler quand date de sorti
- Douleur : non algique ce matin, légèrement algique à la mobilisation dans la matinée, ATG + - Douleur : non algique ce matin, légèrement algique à la mobilisation dans la matinée, ATG +
ATS donnés ATS donnés
- Risque infectieux : apyrétique, plaies colles propres - Risque infectieux : apyrétique, plaies colles propres
- Transit : [NOM] sur baguette, traces séreuses - Transit : stomie sur baguette, traces séreuses
- Endocrino : 0.85 à 12h, repas servi - Endocrino : 0.85 à 12h, repas servi
- Alimentation : CY autorisé à midi - Alimentation : CY autorisé à midi
- Mobilisation : autonome - Mobilisation : autonome
@@ -826,7 +826,7 @@ Surveillances post-op :
- Constantes correctes - Constantes correctes
- Apyrétique - Apyrétique
- Plaies colles propres - Plaies colles propres
- [NOM] : baguette en place, traces sérosanglantes environ 20cc - Stomie : baguette en place, traces sérosanglantes environ 20cc
- Absence de rot/nausée/vomissement - Absence de rot/nausée/vomissement
- Miction ok - Miction ok
- Mobilisation autonome - Mobilisation autonome
@@ -836,7 +836,7 @@ Respiration : bonne SAT en AA
Douleur : algique au niveau abdo à son arrivée avec une intensité modérée , ATG 1 administré Douleur : algique au niveau abdo à son arrivée avec une intensité modérée , ATG 1 administré
selon PM à 17h , confortable par la suite selon PM à 17h , confortable par la suite
PLAie colle : propre PLAie colle : propre
[NOM] : vascularisé , baguette en place , fond de poche sero sanglante Stomie : vascularisé , baguette en place , fond de poche sero sanglante
SUrv dig : eau autorisé bien toléré SUrv dig : eau autorisé bien toléré
Elimination : reprise mictionnelle effective urines ++ à 19h45 Elimination : reprise mictionnelle effective urines ++ à 19h45
Mob : 1er lever effectué bien toléré Mob : 1er lever effectué bien toléré
@@ -862,7 +862,7 @@ Date de dernière
administration administration
Note Note
Docteur Docteur
[NOM] d`administration : INTRAVEINEUSE Voie d`administration : INTRAVEINEUSE
Statut des prescriptions : Signé Statut des prescriptions : Signé
ESOMEPRAZOLE [NOM] ESOMEPRAZOLE [NOM]
40MG FL 5ML [10] 40MG FL 5ML [10]
@@ -1039,7 +1039,7 @@ PREREMPLIE(S)
[NOM] [NOM]
Voie d`administration : INHALEE Voie d`administration : INHALEE
Statut des prescriptions : Signé Statut des prescriptions : Signé
Oxygene [NOM] Oxygene Vrac
- Normal - Normal
03/10/2023 15 : 13 03/10/2023 15 : 13
08/10/2023 11 : 53 08/10/2023 11 : 53
@@ -1059,7 +1059,7 @@ Heure
exécution exécution
Statut Statut
Docteur Docteur
[NOM] Note
03/10/2023 03/10/2023
16 : 34 16 : 34
Thorax Thorax
@@ -1073,7 +1073,7 @@ Date
Heure Heure
Prescription Prescription
Docteur Docteur
[NOM] de Date de
collection collection
Note Note
Dihydropyrimidine déshydrogénase Dihydropyrimidine déshydrogénase
@@ -1198,7 +1198,7 @@ Notes du
professionel professionel
de santé : de santé :
Soins de Soins de
[NOM] par stomie par
une IDE à une IDE à
domicile, 2x/ domicile, 2x/
jour, tous les jour, tous les
@@ -1373,7 +1373,7 @@ Normal
07 : 00 07 : 00
[NOM] [NOM]
[NOM] [NOM]
SOINS DE [NOM] SOINS DE STOMIE
Réalisé Réalisé
Prescriptions de sortie Prescriptions de sortie
Prescription Prescription
@@ -1479,7 +1479,7 @@ Matin (07h-12h)
Midi (12h-16h) Midi (12h-16h)
Soir (16h-21h) Soir (16h-21h)
Soir (21h-07h) Soir (21h-07h)
Signé — ESOMEPRAZOLE [NOM] 40MG FL Signé — ESOMEPRAZOLE SUN 40MG FL
5ML - 40MG poudre (5 mL) - Dose 40 mg - sur 5ML - 40MG poudre (5 mL) - Dose 40 mg - sur
15 min - INTRAVEINEUSE Discontinue - Matin 15 min - INTRAVEINEUSE Discontinue - Matin
[8h] - 1ère dose : 04/10/2023 @ 08:00 [8h] - 1ère dose : 04/10/2023 @ 08:00
@@ -1873,22 +1873,22 @@ Réalisé — SIGNES VITAUX (Pls, TA, FR, T°,
Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h Glyc, Miction, Transit) - Ttes les 6h [2h 8h 14h
20h] - 1 Mois (30j)- Date Début : 03/10/2023 @ 20h] - 1 Mois (30j)- Date Début : 03/10/2023 @
15 : 13 15 : 13
Réalisé — SOINS DE [NOM] - Ttes les 4H [0h Réalisé — SOINS DE STOMIE - Ttes les 4H [0h
4h ... 16h 20h] - pendant 7 Jour(s)- Date Début : 4h ... 16h 20h] - pendant 7 Jour(s)- Date Début :
09/10/2023 @ 07 : 00 09/10/2023 @ 07 : 00
Réalisé — SOINS DE [NOM] - Ttes les 4H [0h Réalisé — SOINS DE STOMIE - Ttes les 4H [0h
4h ... 16h 20h] - pendant 7 Jour(s)- Date Début : 4h ... 16h 20h] - pendant 7 Jour(s)- Date Début :
09/10/2023 @ 07 : 00 09/10/2023 @ 07 : 00
Réalisé — SOINS DE [NOM] - Ttes les 4H [0h Réalisé — SOINS DE STOMIE - Ttes les 4H [0h
4h ... 16h 20h] - pendant 7 Jour(s)- Date Début : 4h ... 16h 20h] - pendant 7 Jour(s)- Date Début :
09/10/2023 @ 07 : 00 09/10/2023 @ 07 : 00
Réalisé — SOINS DE [NOM] - Ttes les 4H [0h Réalisé — SOINS DE STOMIE - Ttes les 4H [0h
4h ... 16h 20h] - pendant 7 Jour(s)- Date Début : 4h ... 16h 20h] - pendant 7 Jour(s)- Date Début :
09/10/2023 @ 07 : 00 09/10/2023 @ 07 : 00
Réalisé — SOINS DE [NOM] - Ttes les 4H [0h Réalisé — SOINS DE STOMIE - Ttes les 4H [0h
4h ... 16h 20h] - pendant 7 Jour(s)- Date Début : 4h ... 16h 20h] - pendant 7 Jour(s)- Date Début :
09/10/2023 @ 07 : 00 09/10/2023 @ 07 : 00
Réalisé — SOINS DE [NOM] - Ttes les 4H [0h Réalisé — SOINS DE STOMIE - Ttes les 4H [0h
4h ... 16h 20h] - pendant 7 Jour(s)- Date Début : 4h ... 16h 20h] - pendant 7 Jour(s)- Date Début :
09/10/2023 @ 07 : 00 09/10/2023 @ 07 : 00
Début le 03/10/2023 à Début le 03/10/2023 à
@@ -1962,7 +1962,7 @@ Matin (07h-12h)
Midi (12h-16h) Midi (12h-16h)
Soir (16h-21h) Soir (16h-21h)
Soir (21h-07h) Soir (21h-07h)
Signé — ESOMEPRAZOLE [NOM] 40MG FL Signé — ESOMEPRAZOLE SUN 40MG FL
5ML - 40MG poudre (5 mL) - Dose 40 mg - sur 5ML - 40MG poudre (5 mL) - Dose 40 mg - sur
15 min - INTRAVEINEUSE Discontinue - Matin 15 min - INTRAVEINEUSE Discontinue - Matin
[8h] - 1ère dose : 04/10/2023 @ 08:00 [8h] - 1ère dose : 04/10/2023 @ 08:00
@@ -2355,7 +2355,7 @@ Fin le 16/10/2023 à
04 : 00 04 : 00
Admin le 10/10/2023 à Admin le 10/10/2023 à
12 : 00 12 : 00
Réalisé — SOINS DE [NOM] - Ttes les 4H [0h Réalisé — SOINS DE STOMIE - Ttes les 4H [0h
4h ... 16h 20h] - pendant 7 Jour(s)- Date Début : 4h ... 16h 20h] - pendant 7 Jour(s)- Date Début :
09/10/2023 @ 07 : 00 09/10/2023 @ 07 : 00
08 : 00 * 1 08 : 00 * 1
@@ -2366,7 +2366,7 @@ Fin le 16/10/2023 à
04 : 00 04 : 00
Admin le 10/10/2023 à Admin le 10/10/2023 à
12 : 00 12 : 00
Réalisé — SOINS DE [NOM] - Ttes les 4H [0h Réalisé — SOINS DE STOMIE - Ttes les 4H [0h
4h ... 16h 20h] - pendant 7 Jour(s)- Date Début : 4h ... 16h 20h] - pendant 7 Jour(s)- Date Début :
09/10/2023 @ 07 : 00 09/10/2023 @ 07 : 00
12 : 00 * 1 12 : 00 * 1
@@ -2377,7 +2377,7 @@ Fin le 16/10/2023 à
04 : 00 04 : 00
Admin le 10/10/2023 à Admin le 10/10/2023 à
12 : 00 12 : 00
Réalisé — SOINS DE [NOM] - Ttes les 4H [0h Réalisé — SOINS DE STOMIE - Ttes les 4H [0h
4h ... 16h 20h] - pendant 7 Jour(s)- Date Début : 4h ... 16h 20h] - pendant 7 Jour(s)- Date Début :
09/10/2023 @ 07 : 00 09/10/2023 @ 07 : 00
16 : 00 * 1 16 : 00 * 1
@@ -2388,7 +2388,7 @@ Fin le 16/10/2023 à
04 : 00 04 : 00
Admin le 10/10/2023 à Admin le 10/10/2023 à
12 : 00 12 : 00
Réalisé — SOINS DE [NOM] - Ttes les 4H [0h Réalisé — SOINS DE STOMIE - Ttes les 4H [0h
4h ... 16h 20h] - pendant 7 Jour(s)- Date Début : 4h ... 16h 20h] - pendant 7 Jour(s)- Date Début :
09/10/2023 @ 07 : 00 09/10/2023 @ 07 : 00
20 : 00 * 1 20 : 00 * 1
@@ -2399,7 +2399,7 @@ Fin le 16/10/2023 à
04 : 00 04 : 00
Admin le 10/10/2023 à Admin le 10/10/2023 à
12 : 00 12 : 00
Réalisé — SOINS DE [NOM] - Ttes les 4H [0h Réalisé — SOINS DE STOMIE - Ttes les 4H [0h
4h ... 16h 20h] - pendant 7 Jour(s)- Date Début : 4h ... 16h 20h] - pendant 7 Jour(s)- Date Début :
09/10/2023 @ 07 : 00 09/10/2023 @ 07 : 00
00 : 00 * 1 00 : 00 * 1
@@ -2410,7 +2410,7 @@ Fin le 16/10/2023 à
04 : 00 04 : 00
Admin le 10/10/2023 à Admin le 10/10/2023 à
12 : 00 12 : 00
Réalisé — SOINS DE [NOM] - Ttes les 4H [0h Réalisé — SOINS DE STOMIE - Ttes les 4H [0h
4h ... 16h 20h] - pendant 7 Jour(s)- Date Début : 4h ... 16h 20h] - pendant 7 Jour(s)- Date Début :
09/10/2023 @ 07 : 00 09/10/2023 @ 07 : 00
04 : 00 * 1 04 : 00 * 1
@@ -2434,7 +2434,7 @@ Compte-rendu validé électroniquement par Dr [NOM] le 03/10/2023
CR RX-Echo CR RX-Echo
03/10/2023 03/10/2023
16 : 34 16 : 34
[NOM] THORACIQUE DE FACE RADIOGRAPHIE THORACIQUE DE FACE
Indication : Indication :
Contrôle après pose de PAC. Contrôle après pose de PAC.
RESULTATS : RESULTATS :

View File

@@ -1,70 +0,0 @@
{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "15 RUE BOUROUSSE", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Romain DIDAILLER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Bertrand DELAS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "2 AVENUE PIERRE LARRAMENDY GROUPE ELGAR ", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64500 ST JEAN DE LUZ", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 1, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 2, "kind": "ETAB", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Marie", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 3, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 4, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 5, "kind": "NOM", "original": "Marie", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 5, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Rafael GUIJARRO", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Rafael GUIJARRO", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Romain DIDAILLER", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Marie LACLAU-LACROUTS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "NOM", "original": "Marie LACLAU-LACROUTS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 6, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 7, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 8, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
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{"page": 9, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 9, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 9, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 25, "kind": "NOM", "original": "Rémi SEGUES", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 25, "kind": "NOM", "original": "Marie-Laure CURUTCHET BURTIN", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 25, "kind": "NOM", "original": "Lucie DECOEUR", "placeholder": "[NOM]", "bbox_hint": null}

View File

@@ -10,42 +10,43 @@ sys.path.insert(0, str(Path(__file__).parent))
import anonymizer_core_refactored_onnx as core import anonymizer_core_refactored_onnx as core
from eds_pseudo_manager import EdsPseudoManager from eds_pseudo_manager import EdsPseudoManager
from vlm_manager import VlmManager
SRC = Path("/home/dom/Téléchargements/II-1 Ctrl_T2A_2025_CHCB_DocJustificatifs (1)") SRC = Path("/home/dom/Téléchargements/II-1 Ctrl_T2A_2025_CHCB_DocJustificatifs (1)")
OUTDIR = SRC / "anonymise_audit_30" OUTDIR = SRC / "anonymise_audit_30"
CONFIG = Path("/home/dom/ai/anonymisation/config/dictionnaires.yml") CONFIG = Path("/home/dom/ai/anonymisation/config/dictionnaires.yml")
PDFS = [ PDFS = [
SRC / "110_23061319/trackare-07026002-23061319_07026002_23061319.pdf", SRC / "114_23060661/CONSULTATION ANESTHESISTE 23060661.pdf",
SRC / "115_23066188/CRH 23066188.pdf", SRC / "124_23074376/trackare-05000272-23074376_05000272_23074376.pdf",
SRC / "161_23098838/CRO 23098838.pdf", SRC / "133_23056022/CONSULTATION ANESTHESISTE 23056022.pdf",
SRC / "179_23126805/trackare-23005591-23126805_23005591_23126805.pdf", SRC / "141_23090597/trackare-BA042686-23090597_BA042686_23090597.pdf",
SRC / "181_23127286/CRH 23127286.pdf", SRC / "148_23018396/trackare-23000862-23018396_23000862_23018396.pdf",
SRC / "192_23132490/CRH 23132490.pdf", SRC / "183_23087212/LETTRE DE SORTIE 23087212.pdf",
SRC / "208_23151988/trackare-23020064-23151988_23020064_23151988.pdf", SRC / "216_23159905/CRO 23159905.pdf",
SRC / "215_23158603/trackare-22028007-23158603_22028007_23158603.pdf", SRC / "216_23159905/trackare-99246761-23159905_99246761_23159905.pdf",
SRC / "227_23173599/CRH 23173599.pdf", SRC / "222_23139653/CONSULTATION ANESTHESISTE 23139653.pdf",
SRC / "236_23116794/trackare-BA054633-23116794_BA054633_23116794.pdf", SRC / "225_23160703/CRO 23160703.pdf",
SRC / "248_23194278/CRH 23194278.pdf", SRC / "26_23127395/trackare-BA192486-23127395_BA192486_23127395.pdf",
SRC / "263_23203642/CRO 23203642.pdf", SRC / "269_23232115/BACTERIO 23232115.pdf",
SRC / "28_23135549/trackare-15021750-23135549_15021750_23135549.pdf", SRC / "290_23025988/CR consultation anesth-290-23025988.pdf",
SRC / "321_23043929/CRH 321_23066387.pdf", SRC / "315_23060770/trackare-05012965-23060770_05012965_23060770.pdf",
SRC / "379_23098754/trackare-18009635-23098754_18009635_23098754.pdf", SRC / "385_23102874/trackare-BA065989-23102874_BA065989_23102874.pdf",
SRC / "39_23167029/trackare-23022121-23167029_23022121_23167029.pdf", SRC / "433_23135726/trackare-BA127127-23135726_BA127127_23135726.pdf",
SRC / "444_23141032/trackare-BA102259-23141032_BA102259_23141032.pdf",
SRC / "478_23161697/cro 478_23161697.pdf",
SRC / "50_23219173/trackare-07019278-23219173_07019278_23219173.pdf",
SRC / "520_23177582/trackare-99252128-23177582_99252128_23177582.pdf", SRC / "520_23177582/trackare-99252128-23177582_99252128_23177582.pdf",
SRC / "556_23220878/trackare-21041742-23220878_21041742_23220878.pdf", SRC / "552_23214501/trackare-BA171849-23214501_BA171849_23214501.pdf",
SRC / "602_23070052/trackare-20028293-23070052_20028293_23070052.pdf", SRC / "590_23043950/trackare-17015185-23043950_17015185_23043950.pdf",
SRC / "604_23070704/trackare-23008170-23070704_23008170_23070704.pdf", SRC / "60_23106634/CRH 60_23106634.pdf",
SRC / "655_23163458/trackare-01296746-23163458_01296746_23163458.pdf", SRC / "603_23070213/trackare-00260974-23070213_00260974_23070213.pdf",
SRC / "684_23207941/CRH 684_23207941.pdf", SRC / "609_23076655/trackare-BA067657-23076655_BA067657_23076655.pdf",
SRC / "79_23187785/79_23187785 Dossier.pdf", SRC / "625_23098722/trackare-05012679-23098722_05012679_23098722.pdf",
SRC / "12_23084754/CRO 23084754.pdf" if (SRC / "12_23084754/CRO 23084754.pdf").exists() else SRC / "122_23070126/LETTRE DE SORTIE 23070126.pdf", SRC / "632_23124019/trackare-11004431-23124019_11004431_23124019.pdf",
SRC / "122_23070126/LETTRE DE SORTIE 23070126.pdf", SRC / "639_23135847/trackare-07003136-23135847_07003136_23135847.pdf",
SRC / "131_23079402/CRH 23079402.pdf", SRC / "656_23165708/trackare-13013848-23165708_13013848_23165708.pdf",
SRC / "290_23025988/cr anesth 290_23025988.pdf", SRC / "664_23175616/trackare-03020576-23175616_03020576_23175616.pdf",
SRC / "8_23074520/trackare-BA093659-23074520_BA093659_23074520.pdf",
SRC / "88_23034958/trackare-14025311-23034958_14025311_23034958.pdf",
SRC / "89_23016863/trackare-BA121804-23016863_BA121804_23016863.pdf",
] ]
@@ -54,7 +55,16 @@ def main():
ner = EdsPseudoManager() ner = EdsPseudoManager()
ner.load() ner.load()
assert ner.is_loaded(), "EDS-Pseudo non chargé" assert ner.is_loaded(), "EDS-Pseudo non chargé"
print("EDS-Pseudo chargé.\n", flush=True) print("EDS-Pseudo chargé.", flush=True)
print("Chargement VLM (Ollama qwen2.5vl:7b)...", flush=True)
vlm = VlmManager()
try:
vlm.load()
print(f"VLM chargé.\n", flush=True)
except Exception as e:
print(f"VLM indisponible ({e}), on continue sans.\n", flush=True)
vlm = None
# Vérifier existence des fichiers # Vérifier existence des fichiers
existing = [p for p in PDFS if p.exists()] existing = [p for p in PDFS if p.exists()]
@@ -86,6 +96,7 @@ def main():
ner_manager=ner, ner_manager=ner,
ner_thresholds=None, ner_thresholds=None,
ogc_label=ogc, ogc_label=ogc,
vlm_manager=vlm,
) )
audit_path = Path(outputs.get("audit", "")) audit_path = Path(outputs.get("audit", ""))
if audit_path.exists(): if audit_path.exists():