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:
@@ -191,7 +191,8 @@ RE_EMAIL = re.compile(r"[A-Za-z0-9._%+-]+@[A-Za-z0-9.-]+\.[A-Za-z]{2,}")
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RE_TEL = re.compile(r"(?<!\d)(?:\+33\s?|0)\d(?:[\s.\-]?\d){8}(?!\d)")
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RE_TEL = re.compile(r"(?<!\d)(?:\+33\s?|0)\d(?:[\s.\-]?\d){8}(?!\d)")
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RE_TEL_COMPACT = re.compile(r"(?<!\d)0[1-9]\d{8}(?!\d)")
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RE_TEL_COMPACT = re.compile(r"(?<!\d)0[1-9]\d{8}(?!\d)")
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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")
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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")
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RE_IPP = re.compile(r"\bIPP\s*[:\-]?\s*([A-Za-z0-9]{6,})\b", re.IGNORECASE)
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RE_IPP = re.compile(r"\b(?:I\.?P\.?P\.?|IPP|N°\s*Ipp)\s*[:\-]?\s*([A-Za-z0-9]{6,})\b", re.IGNORECASE)
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RE_CSULT = re.compile(r"\b(?:N°\s*Csult|N°\s*Interv)\s*[:\-]?\s*(\d{6,})\b", re.IGNORECASE)
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RE_FINESS = re.compile(r"\b(?:N°\s*)?FINESS?\s*[:\-]?\s*(\d{9})\b", re.IGNORECASE)
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RE_FINESS = re.compile(r"\b(?:N°\s*)?FINESS?\s*[:\-]?\s*(\d{9})\b", re.IGNORECASE)
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RE_OGC = re.compile(r"\b(?:N°\s*)?OGC\s*[:\-]?\s*([A-Za-z0-9\-]{1,})\b", re.IGNORECASE)
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RE_OGC = re.compile(r"\b(?:N°\s*)?OGC\s*[:\-]?\s*([A-Za-z0-9\-]{1,})\b", re.IGNORECASE)
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RE_RPPS = re.compile(r"\b(?:N°\s*)?RPPS\s*[:\-]?\s*(\d{8,11})\b", re.IGNORECASE)
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RE_RPPS = re.compile(r"\b(?:N°\s*)?RPPS\s*[:\-]?\s*(\d{8,11})\b", re.IGNORECASE)
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@@ -294,8 +295,12 @@ _MEDICAL_STOP_WORDS_SET = {
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"meropenem", "imipenem", "clindamycine", "doxycycline",
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"meropenem", "imipenem", "clindamycine", "doxycycline",
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"azithromycine", "clarithromycine", "cotrimoxazole", "bactrim",
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"azithromycine", "clarithromycine", "cotrimoxazole", "bactrim",
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"polyionique", "propranolol", "apidra", "solostar",
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"polyionique", "propranolol", "apidra", "solostar",
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# Suffixes laboratoires pharmaceutiques
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# Noms et suffixes laboratoires pharmaceutiques
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"arw", "myl", "myp", "arg", "teva", "bga", "agt",
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"arw", "myl", "myp", "arg", "teva", "bga", "agt",
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"mylan", "biogaran", "arrow", "sandoz", "zentiva", "cristers",
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"accord", "viatris", "ranbaxy", "ratiopharm", "almus", "qualimed",
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"evolugen", "alter", "zydus", "medisol", "substipharm",
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"sdz", "bgr", "egt", "rnb",
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# Formes galéniques / voies d'administration
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# Formes galéniques / voies d'administration
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"cpr", "sachet", "orale", "oral", "sol", "buv", "stylo", "flexpen",
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"cpr", "sachet", "orale", "oral", "sol", "buv", "stylo", "flexpen",
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"flestouch", "kwikpen", "inj", "susp", "gelule", "comprime",
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"flestouch", "kwikpen", "inj", "susp", "gelule", "comprime",
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@@ -374,6 +379,9 @@ _MEDICAL_STOP_WORDS_SET = {
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"montelukast", "rosuvastatine",
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"montelukast", "rosuvastatine",
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# Abréviations pharma courtes
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# Abréviations pharma courtes
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"cpr", "sol", "bic", "agt", "poche", "inhal",
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"cpr", "sol", "bic", "agt", "poche", "inhal",
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# Termes chirurgicaux/cliniques FP
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"cure", "endocrine", "operatoire", "opératoire", "realisee", "réalisée",
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"gauche", "droit", "droite", "face", "profil",
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# Faux positifs EDS supplémentaires
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# Faux positifs EDS supplémentaires
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"psy", "inhales", "inhalés", "kwikpen", "lansoprazole", "tiorfan", "smecta",
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"psy", "inhales", "inhalés", "kwikpen", "lansoprazole", "tiorfan", "smecta",
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"axa", "ttt", "anionique", "abdomino", "cod", "omi", "urg", "med",
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"axa", "ttt", "anionique", "abdomino", "cod", "omi", "urg", "med",
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@@ -444,6 +452,20 @@ _MEDICAL_STOP_WORDS_SET = {
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"thermie", "alim", "alimentation", "admin",
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"thermie", "alim", "alimentation", "admin",
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# Médicaments/tests labo capturés par patterns soignants
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# Médicaments/tests labo capturés par patterns soignants
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"biprofenid", "bi-profenid", "phosphatase", "phosphatases",
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"biprofenid", "bi-profenid", "phosphatase", "phosphatases",
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"ecbu", "suppo", "suppositoire", "mucite", "microlax", "normacol",
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"ciprofloxacine", "lavement", "desinfection", "désinfection",
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"avaler", "rachis", "lombaire", "thoraco-lombaire",
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"cérébrale", "cerebrale", "cérébral", "cerebral", "hépatique", "hepatique",
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"thoracique", "abdominale", "abdominal", "pelvienne", "pelvien", "médullaire",
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# Dosages et labos pharma (FP fréquents dans prescriptions Trackare)
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"faible", "fort", "forte",
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"myl", "mylan", "sandoz", "teva", "arrow", "biogaran", "zentiva", "eg",
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"arw", "pan", "mso", "bgn", "ratiopharm", "accord", "vts", "viatris",
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"abdomino-pelvien", "abdomino", "pelvien", "thoraco-abdominal",
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"entree", "entrée", "continu", "continue",
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"morphine", "claforan", "skenan", "actiskenan",
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# Fragments de noms de médicaments (pdfplumber split)
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"sium", "pegic", "fenid", "profenid",
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# Termes structurels trackare
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# Termes structurels trackare
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"transmissions", "transmission", "releve", "relevé",
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"transmissions", "transmission", "releve", "relevé",
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"objectif", "objectifs", "evaluation", "évaluation",
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"objectif", "objectifs", "evaluation", "évaluation",
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@@ -507,11 +529,11 @@ _MEDICAL_STOP_WORDS = (
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# Un token de nom : commence par majuscule, lettres/tirets/apostrophes (PAS d'espace ni de point)
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# Un token de nom : commence par majuscule, lettres/tirets/apostrophes (PAS d'espace ni de point)
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_PERSON_TOKEN = r"[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇa-zéèàùâêîôûäëïöüç\-\']+"
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_PERSON_TOKEN = r"[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇa-zéèàùâêîôûäëïöüç\-\']+"
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RE_PERSON_CONTEXT = re.compile(
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RE_PERSON_CONTEXT = re.compile(
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r"(?:(?:Dr\.?|DR\.?|Docteur|Pr\.?|Professeur|Mme|MME|Madame|M\.|Mr\.?|Monsieur"
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r"(?:(?:\bDr\.?|\bDR\.?|\bDocteur|\bPr\.?|\bProfesseur|\bMme|\bMME|\bMadame|\bM\.|\bMr\.?|\bMonsieur"
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r"|Nom\s*:\s*"
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r"|\bNom[ \t]*:[ \t]*"
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r"|Rédigé\s+par|Validé\s+par|Signé\s+par|Saisi\s+par|Réalisé\s+par"
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r"|\bRédigé[ \t]+par|\bValidé[ \t]+par|\bSigné[ \t]+par|\bSaisi[ \t]+par|\bRéalisé[ \t]+par"
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r")\s+)"
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r")[ \t]+)"
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rf"({_PERSON_TOKEN}(?:\s+{_PERSON_TOKEN}){{0,2}})" # Max 3 mots
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rf"({_PERSON_TOKEN}(?:[ \t]+{_PERSON_TOKEN}){{0,2}})" # Max 3 mots, pas de newline
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)
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)
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# Noms en MAJUSCULES dans des listes virgulées (ex: "le Dr X, Y, LAZARO")
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# Noms en MAJUSCULES dans des listes virgulées (ex: "le Dr X, Y, LAZARO")
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@@ -561,8 +583,8 @@ RE_EXTRACT_CONTACT = re.compile(
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r"(?:\s+([A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇa-zéèàùâêîôûäëïöüç\-\']+))?",
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r"(?:\s+([A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇa-zéèàùâêîôûäëïöüç\-\']+))?",
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)
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)
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RE_EXTRACT_REDIGE = re.compile(
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RE_EXTRACT_REDIGE = re.compile(
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r"(?:Rédigé|Validé|Signé|Saisi)\s+par\s+"
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r"(?:Rédigé|Validé|Signé|Saisi)[ \t]+par[ \t]+"
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rf"((?:{_UC_NAME_TOKEN})(?:\s+(?:{_UC_NAME_TOKEN}))*)",
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rf"((?:{_UC_NAME_TOKEN})(?:[ \t]+(?:{_UC_NAME_TOKEN})){{0,2}})",
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)
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)
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# Token nom composé : JEAN-PIERRE, CAZELLES-BOUDIER, etc.
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# Token nom composé : JEAN-PIERRE, CAZELLES-BOUDIER, etc.
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_UC_COMPOUND = r"[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,}(?:-[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,})*"
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_UC_COMPOUND = r"[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,}(?:-[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,})*"
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@@ -573,22 +595,34 @@ RE_EXTRACT_MME_MR = re.compile(
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)
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)
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_INITIAL_OPT = r"(?:[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]\.\s*(?:-?\s*[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]\.\s*)?)?"
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_INITIAL_OPT = r"(?:[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]\.\s*(?:-?\s*[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]\.\s*)?)?"
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RE_EXTRACT_DR_DEST = re.compile(
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RE_EXTRACT_DR_DEST = re.compile(
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r"(?:DR\.?|Dr\.?|Docteur)\s+"
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r"(?:DR\.?|Dr\.?|Docteur)[ \t]+"
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+ _INITIAL_OPT +
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+ _INITIAL_OPT +
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rf"((?:{_UC_NAME_TOKEN})(?:\s+(?:{_UC_NAME_TOKEN}))*)",
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rf"((?:{_UC_NAME_TOKEN})(?:[ \t]+(?:{_UC_NAME_TOKEN})){{0,2}})",
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)
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)
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# Noms du personnel médical après un rôle : "Aide : Marie-Paule BORDABERRY"
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# Noms du personnel médical après un rôle : "Aide : Marie-Paule BORDABERRY"
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RE_EXTRACT_STAFF_ROLE = re.compile(
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RE_EXTRACT_STAFF_ROLE = re.compile(
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r"(?:Aide|Infirmière?|IDE|IADE|IBODE|ASH?|Cadre\s+Infirmier"
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r"(?:Aide|Infirmière?|IDE|IADE|IBODE|ASH?|Cadre[ \t]+Infirmier"
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r"|Prescripteur|Prescrit\s+par|Exécut[ée]\s+par|Réalisé\s+par)\s*:?\s*"
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r"|Prescripteur|Prescrit[ \t]+par|Exécut[ée][ \t]+par|Réalisé[ \t]+par)[ \t]*:?[ \t]*"
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r"((?:[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][a-zéèàùâêîôûäëïöüç]+(?:\s*-\s*[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][a-zéèàùâêîôûäëïöüç]+)?\s+)?"
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r"((?:[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][a-zéèàùâêîôûäëïöüç]+(?:[ \t]*-[ \t]*[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ][a-zéèàùâêîôûäëïöüç]+)?[ \t]+)?"
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r"(?:[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,}[\-]?)(?:[\s\-]+[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,}){0,2})",
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r"(?:[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,}[\-]?)(?:[ \t\-]+[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇ]{2,}){0,2})",
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)
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)
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# "Pr DUVAL", "Pr. J.-M. DUVAL", "Professeur DUVAL"
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# "Pr DUVAL", "Pr. J.-M. DUVAL", "Professeur DUVAL"
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RE_EXTRACT_PR = re.compile(
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RE_EXTRACT_PR = re.compile(
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r"(?:Pr\.?|Professeur)\s+"
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r"(?:Pr\.?|Professeur)[ \t]+"
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+ _INITIAL_OPT +
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+ _INITIAL_OPT +
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rf"((?:{_UC_NAME_TOKEN})(?:\s+(?:{_UC_NAME_TOKEN}))*)",
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rf"((?:{_UC_NAME_TOKEN})(?:[ \t]+(?:{_UC_NAME_TOKEN})){{0,2}})",
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)
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# "Opérateur : Docteur X. NOM", "Anesthésiste(s) Docteur J. NOM",
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# "Opérateur : Dr J.-M. NOM", "Anesthésiste : NOM"
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RE_EXTRACT_OPERATEUR = re.compile(
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r"(?:Op[ée]rateur|Anesth[ée]siste\(?s?\)?|Chirurgien)[ \t]*:?[ \t]*"
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r"(?:(?:Docteur|Dr\.?|Pr\.?)[ \t]+)?"
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+ _INITIAL_OPT +
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rf"((?:{_UC_COMPOUND})(?:[ \t]+(?:{_UC_COMPOUND})){{0,2}})",
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)
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# Téléphone avec extension slash : 05.59.44.38.32/34
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RE_TEL_SLASH = re.compile(
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r"(?<!\d)(?:\+33\s?|0)\d(?:[\s.\-]?\d){8}(?:/\d{1,4})(?!\d)"
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)
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)
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CID_PATTERN = re.compile(r"\(cid:\d+\)")
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CID_PATTERN = re.compile(r"\(cid:\d+\)")
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@@ -596,7 +630,7 @@ CID_PATTERN = re.compile(r"\(cid:\d+\)")
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# --- Nouvelles regex : dates, adresses, âges, dossiers ---
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# --- Nouvelles regex : dates, adresses, âges, dossiers ---
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_MOIS_FR = r"(?:janvier|février|mars|avril|mai|juin|juillet|août|septembre|octobre|novembre|décembre)"
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_MOIS_FR = r"(?:janvier|février|mars|avril|mai|juin|juillet|août|septembre|octobre|novembre|décembre)"
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RE_DATE_NAISSANCE = re.compile(
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RE_DATE_NAISSANCE = re.compile(
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r"(?:n[ée]+\s+le|date\s+de\s+naissance|DDN)\s*[:\-]?\s*"
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r"(?:\bn[ée]+(?:\(?e?\)?)?\s+le|date\s+de\s+naissance|DDN)\s*[:\-]?\s*"
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r"(\d{1,2}[\s/.\-]\d{1,2}[\s/.\-]\d{2,4}|\d{1,2}\s+" + _MOIS_FR + r"\s+\d{4})",
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r"(\d{1,2}[\s/.\-]\d{1,2}[\s/.\-]\d{2,4}|\d{1,2}\s+" + _MOIS_FR + r"\s+\d{4})",
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re.IGNORECASE,
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re.IGNORECASE,
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)
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)
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@@ -947,6 +981,10 @@ def _mask_admin_label(line: str, audit: List[PiiHit], page_idx: int) -> str:
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if m:
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if m:
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val = m.group(1); audit.append(PiiHit(page_idx, "IPP", val, PLACEHOLDERS["IPP"]))
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val = m.group(1); audit.append(PiiHit(page_idx, "IPP", val, PLACEHOLDERS["IPP"]))
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return RE_IPP.sub(lambda _: f"IPP : {PLACEHOLDERS['IPP']}", line)
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return RE_IPP.sub(lambda _: f"IPP : {PLACEHOLDERS['IPP']}", line)
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m = RE_CSULT.search(line)
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if m:
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val = m.group(1); audit.append(PiiHit(page_idx, "DOSSIER", val, PLACEHOLDERS["DOSSIER"]))
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return RE_CSULT.sub(lambda _: f"N° : {PLACEHOLDERS['DOSSIER']}", line)
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m = RE_RPPS.search(line)
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m = RE_RPPS.search(line)
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if m:
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if m:
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val = m.group(1); audit.append(PiiHit(page_idx, "RPPS", val, PLACEHOLDERS["RPPS"]))
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val = m.group(1); audit.append(PiiHit(page_idx, "RPPS", val, PLACEHOLDERS["RPPS"]))
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@@ -975,6 +1013,7 @@ def _mask_line_by_regex(line: str, audit: List[PiiHit], page_idx: int, cfg: Dict
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def _repl_tel(m: re.Match) -> str:
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def _repl_tel(m: re.Match) -> str:
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audit.append(PiiHit(page_idx, "TEL", m.group(0), PLACEHOLDERS["TEL"]))
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audit.append(PiiHit(page_idx, "TEL", m.group(0), PLACEHOLDERS["TEL"]))
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return PLACEHOLDERS["TEL"]
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return PLACEHOLDERS["TEL"]
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line = RE_TEL_SLASH.sub(_repl_tel, line) # slash d'abord (plus spécifique)
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line = RE_TEL.sub(_repl_tel, line)
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line = RE_TEL.sub(_repl_tel, line)
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line = RE_TEL_COMPACT.sub(_repl_tel, line)
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line = RE_TEL_COMPACT.sub(_repl_tel, line)
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@@ -1140,6 +1179,7 @@ def _mask_critical_in_key(key: str, audit: List[PiiHit], page_idx: int) -> str:
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def _repl_tel(m: re.Match) -> str:
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def _repl_tel(m: re.Match) -> str:
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audit.append(PiiHit(page_idx, "TEL", m.group(0), PLACEHOLDERS["TEL"]))
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audit.append(PiiHit(page_idx, "TEL", m.group(0), PLACEHOLDERS["TEL"]))
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return PLACEHOLDERS["TEL"]
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return PLACEHOLDERS["TEL"]
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key = RE_TEL_SLASH.sub(_repl_tel, key)
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key = RE_TEL.sub(_repl_tel, key)
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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 token.upper() in wl_sections or token in wl_phrases:
|
||||||
|
continue
|
||||||
|
if token.lower() in _MEDICAL_STOP_WORDS_SET:
|
||||||
|
continue
|
||||||
if i == 0:
|
if i == 0:
|
||||||
# Premier token après Dr/Mme : toujours un nom, bypass stop words
|
# Premier token après Dr/Mme : contexte fiable
|
||||||
if token.upper() not in wl_sections:
|
names.add(token)
|
||||||
names.add(token)
|
|
||||||
else:
|
else:
|
||||||
if len(token) < 3:
|
if len(token) < 3:
|
||||||
continue
|
continue
|
||||||
if token.upper() in wl_sections or token in wl_phrases:
|
|
||||||
continue
|
|
||||||
if token.lower() in _MEDICAL_STOP_WORDS_SET:
|
|
||||||
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":
|
||||||
|
|||||||
@@ -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
|
||||||
|
|||||||
@@ -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}
|
|
||||||
@@ -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
|
|
||||||
O²
|
|
||||||
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
|
|
||||||
O²
|
|
||||||
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
|
|
||||||
O²
|
|
||||||
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
|
|
||||||
O²
|
|
||||||
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
|
|
||||||
178
regression_tests/baseline/BACTERIO 23232115.pseudonymise.txt
Normal file
178
regression_tests/baseline/BACTERIO 23232115.pseudonymise.txt
Normal file
@@ -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]
|
||||||
@@ -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
|
||||||
@@ -0,0 +1,383 @@
|
|||||||
|
[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
|
||||||
@@ -0,0 +1,248 @@
|
|||||||
|
[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
|
||||||
@@ -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}
|
|
||||||
@@ -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 d’Endocrino-Diabétologie :
|
|
||||||
Dr [NOM]
|
|
||||||
Dr [NOM]
|
|
||||||
Consultation [NOM] :
|
|
||||||
Dr [NOM]
|
|
||||||
Consultation d’Hémato-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 d’un retour à domicile. Poids de sortie : 19.4 Kgs.
|
|
||||||
Traitement de sortie : Doliprane et advil si besoin.
|
|
||||||
A Prévoir : contrôle clinique par le médecin traitant.
|
|
||||||
Parents informés de la démarche diagnostique et thérapeutique.
|
|
||||||
Document remis en mains propres aux parents le jour de la sortie.
|
|
||||||
Evènements indésirables :
|
|
||||||
- Transfusions : non
|
|
||||||
- Produits dérivés du sang : non
|
|
||||||
- BMR / BHRe / LHR : non
|
|
||||||
- Découverte de BMR / BHRe / BHR : non
|
|
||||||
- Pose DMI : non
|
|
||||||
[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 d’Endocrino-Diabétologie :
|
|
||||||
Dr [NOM]
|
|
||||||
Dr [NOM]
|
|
||||||
Consultation [NOM] :
|
|
||||||
Dr [NOM]
|
|
||||||
Consultation d’Hémato-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
|
|
||||||
@@ -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": "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}
|
|
||||||
{"page": 0, "kind": "ETAB", "original": "Service de Néonatologie - Réanimation Néonatale - Soins Continus Pédiatriques", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "IPP", "original": "23009267", "placeholder": "[IPP]", "bbox_hint": null}
|
|
||||||
{"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}
|
|
||||||
{"page": 1, "kind": "EPISODE", "original": "23079402", "placeholder": "[EPISODE]", "bbox_hint": null}
|
|
||||||
@@ -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 d’Endocrino-Diabétologie :
|
|
||||||
Dr [NOM]
|
|
||||||
Dr [NOM]
|
|
||||||
Consultation [NOM] :
|
|
||||||
Dr [NOM]
|
|
||||||
Consultation d’Hémato-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 d’Endocrino-Diabétologie :
|
|
||||||
Dr [NOM]
|
|
||||||
Dr [NOM]
|
|
||||||
Consultation [NOM] :
|
|
||||||
Dr [NOM]
|
|
||||||
Consultation d’Hémato-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 d’un 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
|
|
||||||
@@ -1,65 +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": "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}
|
|
||||||
{"page": 0, "kind": "EMAIL", "original": "mcboudier@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "EMAIL", "original": "fgoutorbe@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "EMAIL", "original": "aguilngar@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "EMAIL", "original": "tkhuong-huu@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
|
|
||||||
{"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}
|
|
||||||
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|
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||||||
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|
|
||||||
{"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}
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|
||||||
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||||||
{"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}
|
|
||||||
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|
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||||||
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|
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||||||
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||||||
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|
|
||||||
{"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}
|
|
||||||
@@ -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 d’Hospitalisation
|
|
||||||
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 d’Hospitalisation
|
|
||||||
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 d’Hospitalisation
|
|
||||||
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
|
|
||||||
@@ -1,251 +0,0 @@
|
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|
||||||
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|
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|
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|
||||||
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||||||
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|
||||||
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|
||||||
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|
||||||
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|
||||||
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|
||||||
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|
||||||
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|
||||||
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|
||||||
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|
|
||||||
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|
|
||||||
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|
|
||||||
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|
|
||||||
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|
|
||||||
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|
||||||
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|
||||||
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|
|
||||||
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|
||||||
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|
||||||
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|
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|
||||||
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||||||
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|
||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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|
||||||
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||||||
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||||||
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|
|
||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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|
||||||
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|
||||||
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|
||||||
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|
||||||
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|
||||||
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|
||||||
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|
||||||
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||||||
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|
||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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|
||||||
{"page": 3, "kind": "RPPS", "original": "10101480506", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Hilaire CHARLANNE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "RPPS", "original": "10004606595", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Kevin DEVE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "RPPS", "original": "10101639580", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Suzanne DEVAUX", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "RPPS", "original": "10100163277", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Elisabeth GUINARD", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "RPPS", "original": "10101096005", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Alice MARNEFFE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "RPPS", "original": "10110601324", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Anne BARTEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Irène MACHELART", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "EMAIL", "original": "secr.medint@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "DELPHINE MARTINEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "CODE_POSTAL", "original": "64100 BAYONNE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "DATE_NAISSANCE", "original": "né le 14/04/1950", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "PERNAUT", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "MARTINEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "LACRAZ", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "MARTINEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "MARTINEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "IPP", "original": "07009798", "placeholder": "[IPP]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "EPISODE", "original": "23132490", "placeholder": "[EPISODE]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Alexia HOURDILLE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "RPPS", "original": "10100817005", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Stéphane MARCE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "RPPS", "original": "10002815024", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Léa LOPEZ", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "RPPS", "original": "10101856135", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Itsaso ODRIOZOLA", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "RPPS", "original": "10102272209", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Thomas CLAVERIE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "RPPS", "original": "10102268702", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Irène MACHELART", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "RPPS", "original": "10100858090", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Visal KEO", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "RPPS", "original": "10101480506", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Hilaire CHARLANNE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "RPPS", "original": "10004606595", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Kevin DEVE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "RPPS", "original": "10101639580", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Suzanne DEVAUX", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "RPPS", "original": "10100163277", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Elisabeth GUINARD", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "RPPS", "original": "10101096005", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Alice MARNEFFE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "RPPS", "original": "10110601324", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Anne BARTEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Irène MACHELART", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "EMAIL", "original": "secr.medint@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "CASAYUS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "MARTINEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "MARTINEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "LOPEZ Léa", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "IPP", "original": "07009798", "placeholder": "[IPP]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "EPISODE", "original": "23132490", "placeholder": "[EPISODE]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Alexia HOURDILLE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "RPPS", "original": "10100817005", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Stéphane MARCE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "RPPS", "original": "10002815024", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Léa LOPEZ", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "RPPS", "original": "10101856135", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Itsaso ODRIOZOLA", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "RPPS", "original": "10102272209", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Thomas CLAVERIE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "RPPS", "original": "10102268702", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Irène MACHELART", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "RPPS", "original": "10100858090", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Visal KEO", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "RPPS", "original": "10101480506", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Hilaire CHARLANNE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "RPPS", "original": "10004606595", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Kevin DEVE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "RPPS", "original": "10101639580", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Suzanne DEVAUX", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "ETAB", "original": "Clinique des Hôpitaux", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "RPPS", "original": "10100163277", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Elisabeth GUINARD", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "RPPS", "original": "10101096005", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Alice MARNEFFE", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "RPPS", "original": "10110601324", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Anne BARTEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Irène MACHELART", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "EMAIL", "original": "secr.medint@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "PERNAUT Chrystelle", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Delphine MARTINEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "IPP", "original": "07009798", "placeholder": "[IPP]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "EPISODE", "original": "23132490", "placeholder": "[EPISODE]", "bbox_hint": null}
|
|
||||||
@@ -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 l’amoxicilline
|
|
||||||
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 d’allure 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 d’antalgique.
|
|
||||||
Pas de sciatalgie ni d'argument pour un syndrome de la queue de cheval.
|
|
||||||
Dans le contexte son hématologue souhaite réaliser une biopsie afin d’éliminer définitivement l’origine 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 l’amoxicilline
|
|
||||||
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 d’allure 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 d’antalgique.
|
|
||||||
Pas de sciatalgie ni d'argument pour un syndrome de la queue de cheval.
|
|
||||||
Dans le contexte son hématologue souhaite réaliser une biopsie afin d’éliminer définitivement l’origine 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
|
|
||||||
@@ -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}
|
|
||||||
@@ -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 d’IVADO (sans vincristine) en néoadjuvant d’un 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 l’informatique. Vit seul à [VILLE], 1 sœur qui vit à [VILLE]. Pas d’enfant.
|
|
||||||
Activités : Randonnées (dernières semaines seulement quelques balades de 15 minutes devant asthénie), vélo électrique
|
|
||||||
|
|
||||||
Histoire de la maladie :
|
|
||||||
Juillet 2023 : Diagnostic d’un 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 d’ébauche thérapeutique. Neuropathie de grade 2. Poursuite pour
|
|
||||||
deux cures supplémentaires avant geste chirurgical prévu le 23/10/2023.
|
|
||||||
Par la suite, 5 cures d’IVA seront réalisées (idéalement début 2-3 semaines après l’exérèse 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 d’évolution 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 l’examen 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 d’IVADO (sans vincristine) en néoadjuvant d’un 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
|
|
||||||
@@ -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}
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|
||||||
{"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}
|
|
||||||
{"page": 7, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "ETAB", "original": "Pôle Spécialités Médicales", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "ETAB", "original": "Service des Maladies Respiratoires et Allergiques", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "NOCENT Cécilia", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "KRIEGER ANA", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "IPP", "original": "23026373", "placeholder": "[IPP]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "EPISODE", "original": "23194278", "placeholder": "[EPISODE]", "bbox_hint": null}
|
|
||||||
@@ -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 jusqu’au 16/10 inclus
|
|
||||||
-PARACETAMOL 1g/6h si douleurs
|
|
||||||
-SOLUPRED 40mg le matin jusqu’au 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 d’appareil 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 jusqu’au 16/10 inclus
|
|
||||||
-PARACETAMOL 1g/6h si douleurs
|
|
||||||
-SOLUPRED 40mg le matin jusqu’au 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 d’appareil 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
|
|
||||||
Page(s) : 4 sur 4
|
|
||||||
@@ -1,26 +0,0 @@
|
|||||||
{"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}
|
|
||||||
@@ -1,219 +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
|
|
||||||
[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 d’Hashimoto 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 d’intoxication 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 d’horaire
|
|
||||||
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
|
|
||||||
d’allure 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
|
|
||||||
138
regression_tests/baseline/CRH 60_23106634.pseudonymise.txt
Normal file
138
regression_tests/baseline/CRH 60_23106634.pseudonymise.txt
Normal file
@@ -0,0 +1,138 @@
|
|||||||
|
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 d’une altération de l’état général depuis environ 3 semaines.
|
||||||
|
Contexte de décompensation cardio-respiratoire associée et poussée d’insuffisance rénale aigue sur insuffisance
|
||||||
|
rénale chronique.
|
||||||
|
Scanner TAP retrouvant un syndrome de masse développé au niveau de l’utérus 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 d’allergie médicamenteuse connue.
|
||||||
|
|
||||||
|
Mode de vie : vit habituellement au domicile avec son époux, son fils et sa belle fille.
|
||||||
|
Jusqu’à peu de temps, autonome à son domicile mais ne sortait plus à l’extérieur.
|
||||||
|
|
||||||
|
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
|
||||||
@@ -1 +0,0 @@
|
|||||||
|
|
||||||
@@ -1,5 +0,0 @@
|
|||||||
{"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}
|
|
||||||
@@ -1,57 +0,0 @@
|
|||||||
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 l’hypochondre.
|
|
||||||
cholécystite.
|
|
||||||
Compte rendu opératoire du 01/05/2023 :
|
|
||||||
Opérateur : Docteur L. [NOM]
|
|
||||||
Anesthésiste(s) Docteur J. [NOM]
|
|
||||||
Aide(s) : L'interne
|
|
||||||
VOIE D’ADORD : Laparoscopie
|
|
||||||
CONSTATATIONS OPERATOIRES :
|
|
||||||
La vésicule est en réplétion, inflammatoire :
|
|
||||||
Le foie est d’aspect normal,
|
|
||||||
Le canal cystique est court, mais facilement individualisable
|
|
||||||
Cholangiographie per-opératoire : non
|
|
||||||
GESTES EFFECTUES :
|
|
||||||
Création d’un pneumopéritoine par open laparoscopie péri-ombilicale. Introduction d’un trocart de 10 mm sous
|
|
||||||
pour insufflation du pneumopéritoine jusqu’à 12 mm de Hg.
|
|
||||||
Introduction sous contrôle de la vue d’un trocart de 5 mm dans le flanc droit. D’un trocart de 10 mm dans l’hyp
|
|
||||||
d’un 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 l’infundibulum vésiculaire permettant d’individualiser 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
|
|
||||||
@@ -1,13 +0,0 @@
|
|||||||
{"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}
|
|
||||||
@@ -1,33 +0,0 @@
|
|||||||
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
|
|
||||||
d’allure 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
|
|
||||||
71
regression_tests/baseline/CRO 23159905.pseudonymise.txt
Normal file
71
regression_tests/baseline/CRO 23159905.pseudonymise.txt
Normal file
@@ -0,0 +1,71 @@
|
|||||||
|
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 l’expression 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 D’UN SITE D’ACCES 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 d’un site d’accès intrathécal pour des tests à Baclofène.
|
||||||
|
L’intervention s’était 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 l’a
|
||||||
|
Après discussion collégiale avec nos collègues MPR, Dr [NOM] à [NOM], Mr [NOM] a été transféré dan
|
||||||
|
neurochirurgie pour ablation du site d’accès intrathécal, surtout que l’exposition à l’air libre du cathéter intrathé
|
||||||
|
risque important d’infection 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 d’appuis après intubation oro
|
||||||
|
Vérification des points d’appui.
|
||||||
|
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 jusqu’à 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 l’air 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 l’étude bactériologique.
|
||||||
|
Ablation du réservoir avec le cathéter correspondant.
|
||||||
|
Avivement des berges de la cicatrice thoraco-lombaire jusqu’à avoir un retour sanguin suffisant et fermeture d
|
||||||
|
l’aide de fil à peau en Blair Donati.
|
||||||
|
Fermeture de l’incision para-ombilicale droite à l’aide de fil à peau en points séparés Blair Donati.
|
||||||
|
Durée de l’intervention : 15 mn
|
||||||
|
Perte sanguine : négligeable, non compensée
|
||||||
|
Docteur [NOM]
|
||||||
|
Courrier lu et validé par le médecin
|
||||||
|
_______________________________________________________________________________________________________________
|
||||||
|
Information patient
|
||||||
|
Page 2
|
||||||
|
18/04/2025 11 : 54:37
|
||||||
54
regression_tests/baseline/CRO 23160703.pseudonymise.txt
Normal file
54
regression_tests/baseline/CRO 23160703.pseudonymise.txt
Normal file
@@ -0,0 +1,54 @@
|
|||||||
|
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 d’un trocart de 10 mm à l’ombilic par la technique d’open coelioscopie et insufflation du pneumo
|
||||||
|
L’exploration de la cavité abdominale retrouve un globe vésical et des adhérences sur le grand épiploon et le f
|
||||||
|
Mise en place d’un trocart de 5 mm en fosse iliaque gauche, d’un 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.
|
||||||
|
L’exploration 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 d’une incision de Pfannenstiel.
|
||||||
|
Mise en place d’une 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 d’autre 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.
|
||||||
|
_______________________________________________________________________________________________________________
|
||||||
|
Information patient
|
||||||
|
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.
|
||||||
|
_______________________________________________________________________________________________________________
|
||||||
|
Information patient
|
||||||
|
Page 2
|
||||||
|
22/04/2025 10 : 07:08
|
||||||
@@ -1,15 +0,0 @@
|
|||||||
{"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}
|
|
||||||
@@ -1,72 +0,0 @@
|
|||||||
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 s’agit d’un patient qui présente une thrombose d’anévrisme poplité gauche symptomatique avec une ischém
|
|
||||||
inférieur gauche.
|
|
||||||
- On propose la réalisation d’un 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 d’abord un abord poplité.
|
|
||||||
- On met sur LAC l’artère poplitée en dessous de l’articulation.
|
|
||||||
- On prélève la veine saphène qui est un peu grêle en dessous du genou, on remontera donc le prélèvement d
|
|
||||||
jusqu’à la jonction tiers proximal – tiers moyen de cuisse.
|
|
||||||
- On aborde ensuite l’artère fémorale au niveau de son segment II.
|
|
||||||
- Mise sur LAC de cette artère.
|
|
||||||
- Réalisation d’un trajet de tunnélisation entre l’incision poplitée et l’abord de l’artère fémorale superficielle pro
|
|
||||||
- Héparinisation du patient par 3500Ui d’HEPARINE 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 d’abord l’anastomose proximale.
|
|
||||||
- Clampage de l’artère fémorale superficielle.
|
|
||||||
- Artériotomie d’1cm.
|
|
||||||
- Réalisation d’une anastomose termino-latérale entre la veine et l’artère 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 l’artère poplitée d’une artériotomie à ce niveau de 1cm également.
|
|
||||||
- Veinotomie correspondante.
|
|
||||||
- Anastomose termino-latérale entre la veine et l’artère au Prolène 6/0.
|
|
||||||
- Après purge, déclampage.
|
|
||||||
- On réalise une bourse au Prolène 5/0 en amont de l’anastomose proximale sur l’artère fémorale superficielle
|
|
||||||
- A ce niveau, mise en place d’un 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 l’introducteur, fermeture de la bourse.
|
|
||||||
- Vérification de l’hémostase 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.
|
|
||||||
_______________________________________________________________________________________________________________
|
|
||||||
Information patient
|
|
||||||
Page 2
|
|
||||||
24/04/2025 10 : 03:34
|
|
||||||
@@ -1,18 +0,0 @@
|
|||||||
{"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}
|
|
||||||
@@ -1,38 +0,0 @@
|
|||||||
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 D’HOSPITALISATION
|
|
||||||
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 l’a finalement opérée en semi-urgence.
|
|
||||||
Les suites sont extrêmement simples, avec d’emblée une patiente beaucoup plus confortable, bien consciente et sans
|
|
||||||
focal.
|
|
||||||
Elle sort donc avec de simples soins de pansements, et l’ablation des sutures à faire à une semaine de l’intervention, s
|
|
||||||
vers le 15 avril.
|
|
||||||
Je la reverrai dans un mois (le 11/05 à 11h50), munie d’un scanner qui est prescrit (rdv le 10/05 à 10h30).
|
|
||||||
Pas de consigne particulière d’ici-là.
|
|
||||||
Je vous remercie de votre confiance et reste à votre disposition.
|
|
||||||
Mes respects.
|
|
||||||
Docteur [NOM]
|
|
||||||
Courrier lu et validé par le médecin
|
|
||||||
___________________________________________________________________________________________________________________________
|
|
||||||
Information patient
|
|
||||||
Page 1
|
|
||||||
08/04/2025 10 : 29:37
|
|
||||||
@@ -0,0 +1,50 @@
|
|||||||
|
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.
|
||||||
|
J’ai 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. J’ai donc réalisé une urétéroscopie descendante, permettant de de
|
||||||
|
jusqu'en bas de l’uretère 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. J’ai 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, j’ai 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.
|
||||||
|
J’ai 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
|
||||||
|
___________________________________________________________________________________________________________________________
|
||||||
|
Information patient
|
||||||
|
Page 2
|
||||||
|
17/04/2025 09 : 17:42
|
||||||
@@ -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}
|
|
||||||
@@ -1,274 +0,0 @@
|
|||||||
[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
|
|
||||||
@@ -1,18 +0,0 @@
|
|||||||
{"page": 0, "kind": "NOM", "original": "BLANGIS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "RPPS", "original": "10100981090", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "05 59 44 35 12", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "RPPS", "original": "10002828365", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "DATE_NAISSANCE", "original": "né le 13/12/1943", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "RPPS", "original": "10107546912", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "05 59 44 40 59", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "RPPS", "original": "10102402095", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "05 59 44 35 17", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "NOM", "original": "Colette BRANA", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "AGE", "original": "Patient de 79 ans", "placeholder": "[AGE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "RPPS", "original": "10004431168", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "05 59 44 31 35", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "RPPS", "original": "10101988433", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "RPPS", "original": "10101061272", "placeholder": "[RPPS]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "EMAIL", "original": "secr.chirortho@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "05 59 44 35 13", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "05 59 44 35 14", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
@@ -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 d’appui
|
|
||||||
Préparation, désinfection et champage stérile selon protocole du CLIN
|
|
||||||
Antibioprophylaxie par Céfazoline 2g
|
|
||||||
Check list HAS avant incision
|
|
||||||
|
|
||||||
TECHNIQUE OPÉRATOIRE :
|
|
||||||
Voie d’abord 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 l’hématome
|
|
||||||
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 l’absence d’inégalité 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]
|
|
||||||
File diff suppressed because it is too large
Load Diff
@@ -1,143 +0,0 @@
|
|||||||
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|
|
||||||
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|
|
||||||
{"page": 0, "kind": "NOM", "original": "Yann LAMMERTYN", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "NOM", "original": "BERNARD GIMENEZ", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
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|
|
||||||
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|
|
||||||
{"page": 0, "kind": "TEL", "original": "05 59 63 16 91", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "0770316127", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "05.59.31.91.30", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "07.70.31.61.27", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "ETAB", "original": "unité de Chirurgie hors SC", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 13/09/1936", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 1, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 13/09/1936", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 2, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 13/09/1936", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Pascale", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "David MATHIS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Edouard", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Rotarsky", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Edouard", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Edouard", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "ROTARSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 13/09/1936", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 13/09/1936", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 13/09/1936", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 6, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 13/09/1936", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "ETAB", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "ETAB", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 13/09/1936", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "ROTARSKI", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Edouard", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 13/09/1936", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 9, "kind": "NOM", "original": "Pascale", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 9, "kind": "NOM", "original": "Edouard", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 9, "kind": "NOM", "original": "Edouard", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 9, "kind": "NOM", "original": "Edouard", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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@@ -1,123 +0,0 @@
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||||||
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||||||
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||||||
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||||||
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@@ -1,118 +0,0 @@
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||||||
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||||||
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|
||||||
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||||||
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{"page": 1, "kind": "NOM", "original": "Tam KHUONG", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 5, "kind": "NOM", "original": "Claire", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 5, "kind": "NOM", "original": "Claire", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 5, "kind": "NOM", "original": "Claire", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 5, "kind": "NOM", "original": "Claire", "placeholder": "[NOM]", "bbox_hint": null}
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||||||
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||||||
{"page": 7, "kind": "NOM", "original": "Claire", "placeholder": "[NOM]", "bbox_hint": null}
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||||||
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||||||
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||||||
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||||||
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||||||
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|
||||||
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|
||||||
{"page": 16, "kind": "NOM", "original": "LE GUEN Raphael", "placeholder": "[NOM]", "bbox_hint": null}
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||||||
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||||||
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|
||||||
{"page": 17, "kind": "DATE_NAISSANCE", "original": "née le 27/11/1947", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
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|
||||||
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|
||||||
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|
||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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||||||
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|
||||||
{"page": 5, "kind": "NOM", "original": "Claire LEGRAS", "placeholder": "[NOM]", "bbox_hint": null}
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||||||
{"page": 5, "kind": "NOM", "original": "Claire LEGRAS", "placeholder": "[NOM]", "bbox_hint": null}
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||||||
{"page": 5, "kind": "NOM", "original": "Claire LEGRAS", "placeholder": "[NOM]", "bbox_hint": null}
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||||||
{"page": 5, "kind": "NOM", "original": "Claire LEGRAS", "placeholder": "[NOM]", "bbox_hint": null}
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|
||||||
{"page": 5, "kind": "NOM", "original": "Claire LEGRAS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 6, "kind": "NOM", "original": "Tam KHUONG HUU", "placeholder": "[NOM]", "bbox_hint": null}
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|
||||||
{"page": 7, "kind": "NOM", "original": "Claire LEGRAS", "placeholder": "[NOM]", "bbox_hint": null}
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||||||
{"page": 7, "kind": "NOM", "original": "Claire LEGRAS", "placeholder": "[NOM]", "bbox_hint": null}
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|
||||||
{"page": 17, "kind": "DATE_NAISSANCE", "original": "née le 27/11/1947", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
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|
||||||
{"page": 17, "kind": "ETAB", "original": "Service Madame GLAZEWSKI JADWIGA", "placeholder": "[MASK]", "bbox_hint": null}
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|
||||||
{"page": 17, "kind": "NOM", "original": "KHUONG HUU", "placeholder": "[NOM]", "bbox_hint": null}
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|
||||||
{"page": 17, "kind": "NOM", "original": "Renaud GONTIER", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
@@ -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 :
|
||||||
|
|||||||
File diff suppressed because it is too large
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@@ -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}
|
|
||||||
{"page": 9, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 10, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 11, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 12, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 13, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 14, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 15, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 16, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 17, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 18, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 19, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 20, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 21, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 22, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 23, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 24, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 25, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 26, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 27, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 28, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 29, "kind": "NOM", "original": "Lucie DECOEUR", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 29, "kind": "NOM", "original": "Lucie DECOEUR", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 29, "kind": "DATE_NAISSANCE", "original": "née le 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 29, "kind": "ETAB", "original": "Service Madame DUHALDE MICHELLE", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 29, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 30, "kind": "NOM", "original": "Romain DIDAILLER", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 30, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "IPP", "original": "BA054633", "placeholder": "[IPP]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 17/08/1944", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "VILLE", "original": "BOULOGNE BILLANCOURT", "placeholder": "[VILLE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "CODE_POSTAL", "original": "Code Postal: 64500", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "ADRESSE", "original": "15 RUE BOUROUSSE\tVille de résidence", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "NOM", "original": "Romain DIDAILLER", "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": "TEL", "original": "06 71 72 17\n05", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "06 17 98 70\n17", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 2, "kind": "ETAB", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 2, "kind": "NOM", "original": "Marie LACLAU- LACROUTS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "NOM", "original": "Ute DURANTEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "NOM", "original": "Marie LACLAU- LACROUTS", "placeholder": "[NOM]", "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": 29, "kind": "NOM", "original": "Lucie DECOEUR Dr", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
File diff suppressed because it is too large
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Load Diff
File diff suppressed because it is too large
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@@ -1,149 +0,0 @@
|
|||||||
{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "ADRESSE", "original": "3 IMPASSE DU TÉNÉ APT ", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "NOM", "original": "Marie LACLAU-LACROUTS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "NOM", "original": "Gilles DELMAS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "ADRESSE", "original": "12 rue de l'industrie ", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "CODE_POSTAL", "original": "64600 ANGLET", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "0670194026", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "CODE_POSTAL", "original": "64100 BAYONNE FRANCE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "06.68.18.96.02", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "NOM", "original": "Gontier", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "ETAB", "original": "unité de Chirurgie hors SC", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 1, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 2, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Marie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Marie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Julie LARRIEU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Julie LARRIEU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "ETAB", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "ETAB", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "ETAB", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Laclau", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "AGE", "original": "Patiente de 68ans", "placeholder": "[AGE]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "ETAB", "original": "SSR Les Terrasses", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "ETAB", "original": "SSR Les Terrasses", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 5, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 6, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 6, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Julie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Julie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Julie LARRIEU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Julie LARRIEU-NARZABAL", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Ute DURANTEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Ute DURANTEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 9, "kind": "NOM", "original": "Ute DURANTEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 9, "kind": "NOM", "original": "Marie LACLAU-LACROUTS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 9, "kind": "NOM", "original": "Marie LACLAU-LACROUTS", "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": 9, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 9, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 9, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 10, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 11, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 12, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 13, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 14, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 15, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 16, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 17, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 18, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 19, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 20, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 21, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 22, "kind": "NIR", "original": "254094027200584", "placeholder": "[NIR]", "bbox_hint": null}
|
|
||||||
{"page": 22, "kind": "NOM", "original": "BERGOUGNOUX Brice", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 22, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 23, "kind": "NOM", "original": "BERGOUGNOUX Brice", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 23, "kind": "ETAB", "original": "www.ch-cote-basque.fr", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 23, "kind": "NIR", "original": "254094027200584", "placeholder": "[NIR]", "bbox_hint": null}
|
|
||||||
{"page": 23, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 24, "kind": "ETAB", "original": "www.ch-cote-basque.fr", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 24, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 25, "kind": "NOM", "original": "Marie-Laure", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 25, "kind": "NOM", "original": "Rémi SEGUES", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 25, "kind": "NOM", "original": "Lucie DECOEUR", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 25, "kind": "DATE_NAISSANCE", "original": "née le 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 25, "kind": "ETAB", "original": "Service Madame FOIS CLAUDETTE", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 25, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 26, "kind": "NOM", "original": "Marie LACLAU-LACROUTS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 26, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "IPP", "original": "BA102259", "placeholder": "[IPP]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "VILLE", "original": "ST MARTIN DE HINX", "placeholder": "[VILLE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "CODE_POSTAL", "original": "Code Postal: 64100", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "ADRESSE", "original": "3 IMPASSE DU TÉNÉ APT ", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "VILLE", "original": "BAYONNE", "placeholder": "[VILLE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "NOM", "original": "Marie LACLAU-LACROUTS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "ADRESSE", "original": "12 rue de l'industrie ", "placeholder": "[ADRESSE]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "CODE_POSTAL", "original": "64600 ANGLET", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "0670194026", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "TEL", "original": "06.68.18.96.02", "placeholder": "[TEL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "CODE_POSTAL", "original": "64100 BAYONNE FRANCE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "NOM", "original": "Gontier", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 0, "kind": "ETAB", "original": "unité de Chirurgie hors SC", "placeholder": "[MASK]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "ETAB", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "ETAB", "original": "SSR\nBloc", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Marie LACLAU- LACROUTS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Marie LACLAU- LACROUTS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Julie LARRIEU- NARZABAL", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 3, "kind": "NOM", "original": "Laclau", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "ETAB", "original": "SSR Les Terrasses", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 4, "kind": "ETAB", "original": "SSR Les Terrasses", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Julie LARRIEU- NARZABAL", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Julie LARRIEU- NARZABAL", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 7, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Lucie", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Julie LARRIEU- NARZABAL", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Julie LARRIEU-NARZABAL", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Ute DURANTEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 8, "kind": "NOM", "original": "Ute DURANTEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 9, "kind": "NOM", "original": "Ute DURANTEAU", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 9, "kind": "NOM", "original": "Marie LACLAU-LACROUTS", "placeholder": "[NOM]", "bbox_hint": null}
|
|
||||||
{"page": 9, "kind": "NOM", "original": "Marie LACLAU-LACROUTS", "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": 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}
|
|
||||||
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@@ -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():
|
||||||
|
|||||||
Reference in New Issue
Block a user