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fix: Corrections qualité Phase 1 — 261 fuites en moins, 0 régression

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Audit sur 30 fichiers aléatoires (OGC 12-690) révélant un overfitting
sur les 59 premiers OGC. Corrections appliquées avec test de non-régression
à chaque étape :

- NDA pieds de page Trackare : regex Episode N. (227→0 fuites)
- ONDANSETRON : word boundary \b sur RE_NUMERO_DOSSIER (32→0)
- RPPS isolés : détection 11 chiffres dans docs Trackare (3→0)
- Stop words : retrait noms réels (ute, dogue, cambo, bains), ajout
  termes médicaux (AINS, ponction, hanche, burkitt, ORL, GDS, OAP...)
- Pattern DR. Prénom NOM : capture prénoms médecins (Ute ×19, Tam...)
- force_names : contextes structurés (DR., Signé, Note d'évolution)
  bypassent les stop words pour masquer les vrais noms de soignants
- Phase 2b : PiiHit trackare (EPISODE, RPPS) appliqués au texte .txt
- Framework de non-régression (regression_tests/) + batch audit 30 fichiers

Résultat : 322→61 fuites détectées, 113→109 faux positifs, 0 régression.

Co-Authored-By: Claude Opus 4.6 <noreply@anthropic.com>
This commit is contained in:
Domi31tls
2026-03-06 17:32:28 +01:00
parent f9532d5543
commit bc2fe667a0
63 changed files with 30187 additions and 24 deletions
Download Patch File Download Diff File Expand all files Collapse all files

121
anonymizer_core_refactored_onnx.py
View File

@@ -391,7 +391,7 @@ _MEDICAL_STOP_WORDS_SET = {
"digestif", "digestive", "digestives", "nutritive", "digestif", "digestive", "digestives", "nutritive",
# Abréviations soins trackare détectées comme NOM (batch 20 OGC) # Abréviations soins trackare détectées comme NOM (batch 20 OGC)
"soins", "lit", "jeun", "lever", "pose", "surv", "ggt", "vvp", "soins", "lit", "jeun", "lever", "pose", "surv", "ggt", "vvp",
"verif", "crop", "evs", "maco", "pan", "cet", "trou", "nit", "ute", "nfs", "verif", "crop", "evs", "maco", "pan", "cet", "trou", "nit", "nfs",
# Mots narratifs CRH capturés par fusion sidebar 2-colonnes # Mots narratifs CRH capturés par fusion sidebar 2-colonnes
"evolution", "évolution", "explorations", "fermeture", "allergie", "allergies", "evolution", "évolution", "explorations", "fermeture", "allergie", "allergies",
"lotissement", "cholangiographie", "cholecystectomie", "cholécystectomie", "lotissement", "cholangiographie", "cholecystectomie", "cholécystectomie",
@@ -403,7 +403,7 @@ _MEDICAL_STOP_WORDS_SET = {
"responsable", "autre", "autres", "autonome", "autonomes", "responsable", "autre", "autres", "autonome", "autonomes",
"préparations", "preparations", "prévenir", "prevenir", "préparations", "preparations", "prévenir", "prevenir",
"acétylsalicylique", "acetylsalicylique", "angio", "acétylsalicylique", "acetylsalicylique", "angio",
"desc", "diu", "cambo", "bains", "dogue", "barreau", "desc", "diu", "barreau",
"haitz", "alde", "haitz", "alde",
# FP audit OGC 21 — termes médicaux/courants flagués NOM_GLOBAL # FP audit OGC 21 — termes médicaux/courants flagués NOM_GLOBAL
"alimentation", "augmentation", "amelioration", "amélioration", "alimentation", "augmentation", "amelioration", "amélioration",
@@ -486,12 +486,17 @@ _MEDICAL_STOP_WORDS_SET = {
"résistant", "réévaluation", "situation", "temporaire", "urgence", "urgences", "résistant", "réévaluation", "situation", "temporaire", "urgence", "urgences",
"urgent", "validation", "urgent", "validation",
# Mots courants / contextuels # Mots courants / contextuels
"angle", "bille", "boisson", "bureau", "campagne", "cases", "circuit", "angle", "bille", "boisson", "bureau", "cases", "circuit",
"clause", "concubin", "confortable", "demain", "densité", "dernière", "concubin", "confortable", "demain", "densité", "dernière",
"distant", "domaine", "elle", "fils", "frère", "grand", "horizon", "distant", "domaine", "elle", "fils", "frère", "grand", "horizon",
"hui", "identifiant", "minuit", "murent", "neuf", "original", "pages", "hui", "identifiant", "minuit", "murent", "neuf", "original", "pages",
"personne", "premier", "quartier", "retraite", "route", "rés", "personne", "premier", "quartier", "retraite", "route", "rés",
"tam", "terrasses", "trouve", "verrouillé", "villa", "étage", "trouve", "verrouillé", "villa", "étage",
# Termes médicaux courants faussement détectés comme NOM (Phase 2 audit mars 2026)
"ains", "ponction", "hanche", "burkitt", "orl", "gds", "oap", "tvp", "epp",
"bronchite", "accueil", "cadre", "transfert", "relecture", "examens",
"traitements", "traitement", "infectiologie", "cancérologie", "cancerologie",
"maternité", "orale", "sachet", "absence",
} }
# Enrichissement automatique avec les ~4000 noms de médicaments d'edsnlp # Enrichissement automatique avec les ~4000 noms de médicaments d'edsnlp
_MEDICAL_STOP_WORDS_SET.update(_load_edsnlp_drug_names()) _MEDICAL_STOP_WORDS_SET.update(_load_edsnlp_drug_names())
@@ -655,13 +660,15 @@ RE_SERVICE = re.compile(
r"[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇa-zéèàùâêîôûäëïöüç\-']+)*)", r"[A-ZÉÈÀÙÂÊÎÔÛÄËÏÖÜÇa-zéèàùâêîôûäëïöüç\-']+)*)",
) )
RE_NUMERO_DOSSIER = re.compile( RE_NUMERO_DOSSIER = re.compile(
r"(?:dossier|n°\s*dossier|NDA)\s*[:\-n°]+\s*([A-Za-z0-9\-/]{4,})" r"(?:\bdossier|\bn°\s*dossier|\bNDA)\s*[:\-n°]+\s*([A-Za-z0-9\-/]{4,})"
r"|" r"|"
r"(?:référence|réf\.)\s*[:\-n°]+\s*([A-Za-z0-9\-/]{4,})", r"(?:\bréférence|\bréf\.)\s*[:\-n°]+\s*([A-Za-z0-9\-/]{4,})",
re.IGNORECASE, re.IGNORECASE,
) )
RE_EPISODE = re.compile( RE_EPISODE = re.compile(
r"N°\s*[ÉéEe]pisode\s*[:\-]?\s*([A-Za-z0-9\-]{4,})", r"N°\s*[ÉéEe]pisode\s*[:\-]?\s*([A-Za-z0-9\-]{4,})"
r"|"
r"[ÉéEe]pisode\s*N[o°.]?\s*\.?\s*:?\s*(\d{5,})",
re.IGNORECASE, re.IGNORECASE,
) )
@@ -923,10 +930,13 @@ def _mask_line_by_regex(line: str, audit: List[PiiHit], page_idx: int, cfg: Dict
return PLACEHOLDERS["DOSSIER"] return PLACEHOLDERS["DOSSIER"]
line = RE_NUMERO_DOSSIER.sub(_repl_dossier, line) line = RE_NUMERO_DOSSIER.sub(_repl_dossier, line)
# N° EPISODE # N° EPISODE / Episode N. (pieds de page Trackare)
def _repl_episode(m: re.Match) -> str: def _repl_episode(m: re.Match) -> str:
audit.append(PiiHit(page_idx, "EPISODE", m.group(0), PLACEHOLDERS["EPISODE"])) val = m.group(1) or m.group(2) or m.group(0)
return PLACEHOLDERS["EPISODE"] audit.append(PiiHit(page_idx, "EPISODE", val, PLACEHOLDERS["EPISODE"]))
# Reconstruire le remplacement en gardant le préfixe et masquant la valeur
full = m.group(0)
return full[:full.find(val)] + PLACEHOLDERS["EPISODE"]
line = RE_EPISODE.sub(_repl_episode, line) line = RE_EPISODE.sub(_repl_episode, line)
# Établissements de santé (EHPAD Bayonne, SSR La Concha, Hôpital de Bayonne, etc.) # Établissements de santé (EHPAD Bayonne, SSR La Concha, Hôpital de Bayonne, etc.)
@@ -1060,12 +1070,34 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
names: set = set() names: set = set()
hits: List[PiiHit] = [] hits: List[PiiHit] = []
force_names: set = set() # noms issus de contextes structurés (DR., Signé, etc.) → bypass stop words
def _add_name(s: str): def _add_name(s: str):
for tok in s.split(): for tok in s.split():
tok = tok.strip(" .-'(),") tok = tok.strip(" .-'(),")
if len(tok) >= 2 and tok[0].isupper(): if len(tok) >= 2 and tok[0].isupper():
names.add(tok) names.add(tok)
# Termes non-noms fréquents dans les contextes Signé/DR./Note d'évolution
_FORCE_EXCLUDE = _MEDICATION_WHITELIST | {
"elimination", "élimination", "forte", "intraveineuse", "lavage",
"sonde", "normal", "réalisé", "realise", "germes", "bbm", "arw",
"orale", "sachet", "injectable", "comprime", "comprimé", "gelule",
"gélule", "seringue", "poche", "flacon", "ampoule", "preremplie",
"préremplie",
}
def _add_name_force(tok: str):
"""Ajoute un nom depuis un contexte structuré fiable (DR., Signé direct, Note d'évolution).
Bypass les stop words généraux mais filtre médicaments et termes de soins courants."""
tok = tok.strip(" .-'(),")
if len(tok) < 3 or not tok[0].isupper():
return
if tok.lower() in _FORCE_EXCLUDE:
return
names.add(tok)
force_names.add(tok)
# --- Identité patient --- # --- Identité patient ---
# Nom de naissance: DIEGO (peut apparaître 2x : en-tête + récap tabulaire) # Nom de naissance: DIEGO (peut apparaître 2x : en-tête + récap tabulaire)
for m in re.finditer(r"Nom\s+de\s+naissance\s*:\s*(.+?)(?:\s+IPP\b|\s*$)", full_text, re.MULTILINE): for m in re.finditer(r"Nom\s+de\s+naissance\s*:\s*(.+?)(?:\s+IPP\b|\s*$)", full_text, re.MULTILINE):
@@ -1102,6 +1134,10 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
for m in re.finditer(r"Episode\s*N[o°.]?\s*\.?\s*:\s*(\d{5,})", full_text): for m in re.finditer(r"Episode\s*N[o°.]?\s*\.?\s*:\s*(\d{5,})", full_text):
hits.append(PiiHit(-1, "EPISODE", m.group(1), PLACEHOLDERS.get("NDA", "[NDA]"))) hits.append(PiiHit(-1, "EPISODE", m.group(1), PLACEHOLDERS.get("NDA", "[NDA]")))
# RPPS isolés (11 chiffres commençant par 1 ou 2, seul sur une ligne ou en fin de ligne)
for m in re.finditer(r"^\s*([12]\d{10})\s*$", full_text, re.MULTILINE):
hits.append(PiiHit(-1, "RPPS", m.group(1), PLACEHOLDERS["RPPS"]))
# Adresse patient (toutes les occurrences) # Adresse patient (toutes les occurrences)
for m in re.finditer(r"Adresse\s*:\s*(.+?)(?:\s+Ville\s+de\s+r[ée]sidence|\s*$)", full_text, re.MULTILINE): for m in re.finditer(r"Adresse\s*:\s*(.+?)(?:\s+Ville\s+de\s+r[ée]sidence|\s*$)", full_text, re.MULTILINE):
val = m.group(1).strip() val = m.group(1).strip()
@@ -1192,8 +1228,8 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
for g in (m.group(1), m.group(2)): for g in (m.group(1), m.group(2)):
if g: if g:
tok = g.rstrip('-') tok = g.rstrip('-')
if len(tok) >= 3 and tok.lower() not in _MEDICAL_STOP_WORDS_SET: if len(tok) >= 3:
_add_name(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-") ---
for m in re.finditer( for m in re.finditer(
@@ -1204,8 +1240,8 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
for g in (m.group(1), m.group(2)): for g in (m.group(1), m.group(2)):
if g: if g:
tok = g.rstrip('-') tok = g.rstrip('-')
if len(tok) >= 3 and tok.lower() not in _MEDICAL_STOP_WORDS_SET: if len(tok) >= 3:
_add_name(tok) _add_name_force(tok)
# --- "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(
@@ -1230,9 +1266,21 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
if len(tok) >= 3 and tok.lower() not in _MEDICAL_STOP_WORDS_SET: if len(tok) >= 3 and tok.lower() not in _MEDICAL_STOP_WORDS_SET:
_add_name(tok) _add_name(tok)
# --- "DR." / "DR" suivi d'un prénom seul (ex: "DR. Ute", "DR. Tam") dans les prescriptions ---
for m in re.finditer(
r"DR\.?\s+([A-ZÉÈÀÙÂÊÎÔÛ][a-zéèàùâêîôûäëïöüç]{2,})"
r"(?:\s+([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛa-zéèàùâêîôûäëïöüç\-]+))?",
full_text
):
for g in (m.group(1), m.group(2)):
if g:
tok = g.strip()
if len(tok) >= 3:
_add_name_force(tok)
# --- Noms soignants après timestamps dans activités de soins (ex: "07:00 ETCHEBARNE") --- # --- Noms soignants après timestamps dans activités de soins (ex: "07:00 ETCHEBARNE") ---
# 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 pour éviter FP (termes médicaux mixtes) # 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}\s*:\s*\d{2}\s+"
r"([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛ\-]{3,})" r"([A-ZÉÈÀÙÂÊÎÔÛ][A-ZÉÈÀÙÂÊÎÔÛ\-]{3,})"
@@ -1245,11 +1293,12 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
if len(tok) >= 4 and tok.lower() not in _MEDICAL_STOP_WORDS_SET: if len(tok) >= 4 and tok.lower() not in _MEDICAL_STOP_WORDS_SET:
_add_name(tok) _add_name(tok)
# Filtrer les tokens trop courts ou stop words (sauf noms de villes extraits explicitement) # Filtrer les tokens trop courts ou stop words
# Exceptions : force_names (contextes structurés) et city_tokens (villes extraites)
city_tokens = {h.original for h in hits if h.kind == "VILLE"} city_tokens = {h.original for h in hits if h.kind == "VILLE"}
filtered = set() filtered = set()
for tok in names: for tok in names:
if tok in city_tokens: if tok in city_tokens or tok in force_names:
filtered.add(tok) filtered.add(tok)
continue continue
if len(tok) < 3: if len(tok) < 3:
@@ -1258,7 +1307,7 @@ def _extract_trackare_identity(full_text: str) -> Tuple[set, List[PiiHit]]:
continue continue
filtered.add(tok) filtered.add(tok)
return filtered, hits 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]) -> set:
@@ -1358,11 +1407,11 @@ def _extract_document_names(full_text: str, cfg: Dict[str, Any]) -> set:
return names return names
def _apply_extracted_names(text: str, names: set, audit: List[PiiHit]) -> str: def _apply_extracted_names(text: str, names: set, audit: List[PiiHit], force_names: set = None) -> str:
"""Remplace globalement chaque nom extrait dans le texte.""" """Remplace globalement chaque nom extrait dans le texte."""
placeholder = PLACEHOLDERS["NOM"] placeholder = PLACEHOLDERS["NOM"]
# Filtrer les stop words et tokens trop courts en dernière ligne de défense _force = force_names or set()
safe_names = {n for n in names if len(n) >= 3 and 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)}
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 = []
@@ -1393,6 +1442,24 @@ def _apply_extracted_names(text: str, names: set, audit: List[PiiHit]) -> str:
return text return text
def _apply_trackare_hits_to_text(text: str, audit: List[PiiHit]) -> str:
"""Applique les PiiHit non-NOM dans le texte (NDA footers, EPISODE, RPPS, etc.).
Ces hits sont détectés par _extract_trackare_identity mais n'étaient appliqués
qu'au PDF raster, pas au fichier .pseudonymise.txt."""
_APPLY_KINDS = {"EPISODE", "RPPS"}
# Collecter les valeurs à remplacer, groupées par placeholder
replacements: Dict[str, str] = {} # original → placeholder
for h in audit:
if h.kind in _APPLY_KINDS and h.original and len(h.original.strip()) >= 4:
replacements[h.original.strip()] = h.placeholder
# Remplacer les plus longs d'abord (éviter les remplacements partiels)
for original in sorted(replacements, key=len, reverse=True):
placeholder = replacements[original]
# Word boundary pour ne pas casser les mots (ex: ONDANSETRON)
text = re.sub(rf"\b{re.escape(original)}\b", placeholder, text)
return text
# ----------------- Anonymisation (regex) ----------------- # ----------------- Anonymisation (regex) -----------------
def anonymise_document_regex(pages_text: List[str], tables_lines: List[List[str]], cfg: Dict[str, Any]) -> AnonResult: def anonymise_document_regex(pages_text: List[str], tables_lines: List[List[str]], cfg: Dict[str, Any]) -> AnonResult:
@@ -1406,8 +1473,9 @@ def anonymise_document_regex(pages_text: List[str], tables_lines: List[List[str]
# 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)
trackare_force_names: set = set()
if is_trackare: if is_trackare:
trackare_names, trackare_hits = _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)
@@ -1436,7 +1504,12 @@ 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) text_out = _apply_extracted_names(text_out, extracted_names, audit, force_names=trackare_force_names)
# Phase 2b : application globale des PiiHit trackare (NDA footers, EPISODE, etc.)
# Ces hits sont détectés par _extract_trackare_identity mais pas encore remplacés dans le texte
if is_trackare:
text_out = _apply_trackare_hits_to_text(text_out, audit)
return AnonResult(text_out=text_out, tables_block=tables_block, audit=audit, is_trackare=is_trackare) return AnonResult(text_out=text_out, tables_block=tables_block, audit=audit, is_trackare=is_trackare)

48
regression_tests/baseline/79_23187785 Dossier.audit.jsonl Normal file
View File

@@ -0,0 +1,48 @@
{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "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 Ville de résidence", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Unité Médecine Ambulatoire HDJ Médecin 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": "NOM", "original": "José ZULAICA", "placeholder": "[NOM]", "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": "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": "CODE_POSTAL", "original": "64250 CAMBO LES", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Date de naissance: 06/06/1967", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 1, "kind": "ETAB", "original": "SSR Annie ENia", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Mathilde", "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": "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}
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{"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}
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{"page": 1, "kind": "ETAB", "original": "SSR Annie ENia\nIctère", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
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{"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}
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274
regression_tests/baseline/79_23187785 Dossier.pseudonymise.txt Normal file
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@@ -0,0 +1,274 @@
[[VILLE]]
*640N0° F0in0ess162*
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
640000162
POLE MEDECINE INTERNE - [MASK] : [NOM] IPP : [IPP]
Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE]
Sexe : Masculin Lieu de naissance: [VILLE]
Nationalité : ALGERIE [CODE_POSTAL]
Adresse : [ADRESSE]: [NOM]
Détails épisode
Episode No : [NDA]
Localisation : [[VILLE]]: 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] RUE DES BASQUES [CODE_POSTAL] [TEL]
Liste des contacts
Tél.
Type de contact Relation Nom Prénom Adresse Tél. domicile Mobile
professionel
Personne à prévenir
Epouse [NOM] [NOM] [TEL]
(Trakcare)
[ADRESSE]
Personne à prévenir
Epouse [NOM] [NOM] [CODE_POSTAL] [TEL] [TEL]
(Clinicom)
BAINS FRANCE
Alertes
Date
Catégorie Alerte Date début Message
expiration
Staphylocoque
Mettre en place les précautions complémentaires
BMR doré résistant à la 03/04/2023
contact"C"depistage réalisé le 30/03/2023
méticilline (SARM)
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 02/11/2023 02/11/2023 19/10/2023 19/10/2023 19/10/2023 19/10/2023 12/10/2023 12/10/2023
surveillance 12 : 00 09:51 14:57 14:30 14:14 10:07 12:14 09:47
Glycémie
1,22 1,82 3 2,52 1,10
capillaire
Température 36,60 36,70 36,50 36,50
Pouls 90 81 84 81
PA
133 139 129 141
Systolique
PA
67 64 68 63
Diastolique
Saturation
100 99 100 99
O²
Ventilation Ventilation Ventilation Ventilation
spontanée spontanée spontanée spontanée
Ventilation
Air Air Air Air
ambiant ambiant ambiant ambiant
Poids/Taille
Item de 02/11/2023 19/10/2023 12/10/2023 12/10/2023
surveillance 09 : 43 14:24 13:48 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 34,65 30,54 33,55
corporelle
Surface
2,07 1,96 2,04
corporelle
Surv. Isolement et Contention
Item de 02/11/2023 19/10/2023 19/10/2023 [DATE_NAISSANCE]
surveillance 09 : 51 14:57 10:07 09:47
Température 36,60 36,70 36,50 36,50
Pouls 90 81 84 81
PA
[NIR]
Systolique
PA
[TEL]
Diastolique
Saturation
100 99 100 99
O²
Surv. Contention
Item de 02/11/2023 02/11/2023 19/10/2023 19/10/2023 19/10/2023 19/10/2023 [DATE_NAISSANCE] [DATE_NAISSANCE]
surveillance 12 : 00 09:51 14:57 14:30 14:14 10:07 12:14 09:47
Glycémie
1,22 1,82 3 2,52 1,10
capillaire
Température 36,60 36,70 36,50 36,50
Pouls 90 81 84 81
PA
[NIR]
Systolique
PA
[TEL]
Diastolique
Saturation
100 99 100 99
O²
Observations médicales
Type d'observation Nom Date Commentaires
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]
DR. [NOM] 02/11/2023
Note d'évolution [NOM] conjonctival, pas d'encéphalopathie, cohérent, abomen tendu mais dépressible
[NOM] 10 : 54
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
DR. Tam [NOM] 19/10/2023
Note d'évolution ce jour orienté, non encephalopathe
[NOM] 10 : 08
ponction d'ascite
Pas d'argument clinique pour une gale.
Pas de sillon, pas de sarcopte en dermosocpie.
DR. [NOM] [DATE_NAISSANCE]
Note d'évolution [NOM] imputable à l'ictere, pas de bilan complémentaire pour le moment.
[NOM] 15 : 01
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
DR. [NOM] [DATE_NAISSANCE] Vient pour une nouvelle PLA évacuatrice dans le cadre de la prise en charge de sa cirrhose
Note d'évolution
[NOM] 11 : 17 associée à un CHC en soins palliatifs à [VILLE]
Suspicion de galle : avis dermato demandé
Surveillance Psychiatrie
Item de 02/11/2023 19/10/2023 19/10/2023 [DATE_NAISSANCE]
surveillance 09 : 51 14:57 10:07 09:47
Température 36,60 36,70 36,50 36,50
Pouls 90 81 84 81
PA
[NIR]
Systolique
PA
[TEL]
Diastolique
Saturation
100 99 100 99
O²
Notes paramédicales
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : [IPP] ( 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
02/11/2023
Note IDE [NOM] [NOM] tolérance,
14 : 31
CS IDE [NOM],
RDV dans 10 jours donné.
IDE éduc diabéto : Glycémies au dessus de l'objectif pendant une dizaine de jours mais à
[NOM] 02/11/2023
Note IDE l'objectif depuis 3 jours (TIR 38% sur 7 jours). Je ne modifie donc pas le protocole pour le
[NOM] 10 : 40
moment. A réévaluer lors d'une prochaine HDJ.
hdj gastro
vient pour ponction ascite
vu par dr [NOM] [NOM]
19/10/2023
Note IDE [NOM] [NOM] évacuation de 3l700 d'ascite : pas de compensation
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.
19/10/2023
Note IDE [NOM] [NOM] Sur sons FSL2 depuis le changement de protocole les glycémies sont en amélioration avec une
11 : 45
cible à 72 % et pas d'hypos.
Je préconise de baisser la lente à 14 car encore un peu limite par moment la nuit .
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
12/10/2023 compensation albumine faite suivant protocole
Note IDE [NOM] [NOM]
14 : 38 surv cstes
surv poids
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
Date de dernière
Prescription Dose Fréquence Date de début Note Docteur
administration
Voie d`administration : INTRAVEINEUSE
Statut des prescriptions : Réalisé
Le débit a été
VIALEBEX 200MG/
- 1 seule fois 1 seule modifié. Le débit DR. [NOM]
ML SOL INJ 100ML [1] 1 Flacon(s) 12/10/2023 10 : 56 12/10/2023 14:33
fois en cours est : 200 [NOM]
Flacon(s)
par .
Le débit a été
modifié. Le débit
VIALEBEX 200MG/ en cours est : 400
DR. [NOM]
ML SOL INJ 100ML [1] 2 FLACON - URGENT Urgent 02/11/2023 10 : 54 02/11/2023 14:27 par . Notes du
[NOM]
Flacon(s) professionel de
santé : à partir de
5L
Prescriptions de soins
Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur
[NOM] - 1 seule fois 1 seule 19/10/2023 [NOM]
Signé
IDENTIFICATION fois 10 : 07 DOGUE
DESINFECTION
- 1 seule fois 1 seule 12/10/2023 [NOM]
ENVIRONNEMENT Signé
fois 09 : 48 [NOM]
PATIENT
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23187785 ( 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
- 1 seule fois 1 seule 19/10/2023 [NOM]
ENVIRONNEMENT Signé
fois 10 : 07 DOGUE
PATIENT
- 1 seule fois 1 seule 19/10/2023 [NOM]
REPAS : AUTONOME Signé
fois 10 : 07 DOGUE
BRACELET - 1 seule fois 1 seule 12/10/2023 [NOM]
Réalisé
IDENTIFICATION fois 09 : 48 [NOM]
BRACELET - 1 seule fois 1 seule 02/11/2023 [NOM]
Réalisé
IDENTIFICATION fois 09 : 43 [NOM]
DESINFECTION
- 1 seule fois 1 seule 02/11/2023 [NOM]
ENVIRONNEMENT Réalisé
fois 09 : 43 [NOM]
PATIENT
INSTALLATION DU - 1 seule fois 1 seule 12/10/2023 [NOM]
Réalisé
PATIENT (arrivée) fois 09 : 48 [NOM]
INSTALLATION DU - 1 seule fois 1 seule 19/10/2023 [NOM]
Réalisé
PATIENT (arrivée) fois 10 : 07 DOGUE
INSTALLATION DU - 1 seule fois 1 seule 02/11/2023 [NOM]
Réalisé
PATIENT (arrivée) fois 09 : 43 [NOM]
- 1 seule fois 1 seule 12/10/2023 [NOM]
REPAS : AUTONOME Réalisé
fois 09 : 48 [NOM]
- 1 seule fois 1 seule 02/11/2023 [NOM]
REPAS : AUTONOME Réalisé
fois 09 : 43 [NOM]
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : [IPP] ( POLE MEDECINE INTERNE - [MASK] ) - Taille: 168 cm - Poids: 97.8 kg - IMC: 34.651
Le 04/12/2023 16 : 38 Page 4 de 4

81
regression_tests/baseline/CRH 23066188.audit.jsonl Normal file
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{"page": 1, "kind": "IPP", "original": "17001141", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 1, "kind": "EPISODE", "original": "N° Episode 23066188", "placeholder": "[EPISODE]", "bbox_hint": null}

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N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
[MASK]
Chef de Pôle : Bayonne, le 05/04/2023
Dr [NOM]
C eth Pe éf dd ie a tS re ier v Gic ée n - é rU ar leg e en t c Ne és oP né ad ti oa lt or giq ieu : es DR [NOM]
Dr [NOM] – Urgences [ADRESSE]
D Dr [NOM] Ha ét lh èner ei n Le A D NI GD LA OIL ISL E MR E - U P Ré Id Nia Ntr Eie - [CODE_POSTAL]
[NOM]
Pédiatrie de Maternité : Mon cher confrère,
Dr [NOM]
Consultation d’Endocrino-Diabétologie : Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 02/04/2023 au 05/04/2023 pour le motif
Dr [NOM]
Dr [NOM] [NOM] suivant :
Consultation [NOM] :
Dr [NOM] - Méningite à Entérovirus
Consultation d’Hémato-Cancérologie :
Dr [NOM]
Dr [NOM] [NOM] Antécédents personnels :
Consultation de Rhumatologie : Migraine frontale, environ 2 épisodes par mois cédant à la prise de paracétamol et [NOM]
Dr [NOM]
Consultation de Médecine de l'Adolescent : Antécédents familiaux :
Dr [NOM] migraineux chez le père et la mère. Traitement de fond auparavant chez la mère arrêté, prend [NOM] et triptans en
Urgences Pédiatriques cas de crise. [NOM] simple chez le père
Dr [NOM]
Dr [NOM]
Dr [NOM] [NOM] Allergies : non.
D Dr r V Ki ao il ee tt Ete C S HU EC VERRIA-ARRUTY Vaccination : rappel des 6 ans à faire.
[NOM], Réanimation Néonatale :
Dr [NOM] [NOM] [NOM] habituels :
D Dr r H Gé al ëè ln Me ALA ZEN IG RL AO SIS [NOM] - Paracétamol et [NOM] si céphalées.
Dr [NOM]
D Dr [NOM] Ch amlo ié l lL e A OP GE EY RRE [NOM] reçus en hospitalisation :
Dr [NOM] - Réhydratation parentérale IV par Bionolyte G5 pendant 48h.
Dr [NOM]
- Traitement antalgique par paracétamol, Nubain et Advil.
C Do r n Cs au thlt ea rt ii no en D d Ie D N Aé Ip Lh Lr Eo Rpédiatrie : - Traitement par 1 injection de Caféine dans le cadre d'un syndrome post-PL d'évolution favorable.
Dr [NOM] - Une antibiothérapie a été mise en place par Cefotaxime par voie iv pendant 48 heures, interrompue après réception des
Dr [NOM] résultats de la [NOM] lombaire.
Consultation de Neuropédiatrie :
Dr [NOM]
Dr [NOM] [NOM] [NOM] complémentaires pertinents :
D Dr [NOM] [NOM] nr aie [NOM] [NOM] Rse I OPI TC TA EMILH Biologie du 02/04 : leucocytes 8.7 G/L, CRP 53 mg/l, ionogramme normal.
Hémoculture sur VVP du 02/04 : negative à H48
Consultation de Pneumopédiatrie :
Dr [NOM]
[NOM] lombaire : Glycorachie 0.67 g/L, protéinorachie 0.33 g/L, 14 éléments, culture négative à 48h.
Consultation de Cardiopédiatrie :
Dr [NOM] [NOM] Analyse du LCR :
A Dt rt Cac hh rié ss tel [NOM] - Dermatologie
*
*
P PC CR
R
H ES nV
té
r : on vé ig ra ut siv :e
positive
Dr [NOM] - Maternité
D et r D S ro Jp uh li ie e nN VA AU ND -I GO IN LS, D - r G M éna ér ti in qe u L eEGENDRE Synthèse du séjour : méningite à Entérovirus d'évolution favorable après antalgie par paracétamol, Nubain et
Dr [NOM] - [NOM].
Rhumato-immunologie
Dr [NOM] - Gynécopédiatrie/Maternité
D Cr
a
dS rté ep Ih na fn ire
m
D iE erB SE uL pL éE rI ieX
u
-
r
P dn ue Pum ôlo el : ogie Décision d’un retour à domicile. Poids de sortie : 19.4 Kgs.
Mme [NOM]
Cadres Infirmiers : Traitement de sortie : Doliprane et advil si besoin.
Mr K. GLADELPédiatrie Générale
Mme C. [NOM] Urgences UHCD et HDJ
Mme J. [NOM] - [NOM] A Prévoir : contrôle clinique par le médecin traitant.
Psychomotricienne :
M
O
Mrm mthe
e o
A Mp.
h -
A
Lo
.nS MiP sE
t
AeC Ts : T H- IC EL UAIREFOND P Da or ce un mts ei nn tf o rerm mé iss ed ne mla
a
d iné sm pa rr oc ph re
e
d
s
i aa ug xn o ps at ri eq nu te
s
e let t jh oé ur ra p de eu lt ai q su oe rt.
ie.
Mme M. [NOM]
Psychologues : Evènements indésirables :
Mme E. [NOM]
Mme C. [NOM] - Transfusions : non
M
N
Mem mue
er
oL Np.
.s
P GyI
c
UE hR YolA AoG UguN XeO s : LO -
-
P Br Mod Ru i /t s
B
d Hé Rri ev é
/
s
L
d Hu
R
s a
:
n ng
o
n : non
Mme M.[NOM] - Découverte de BMR / BHRe / BHR : non
Assistantes Sociales : - Pose DMI : non
Mme Z. [NOM]
Mme M. [NOM]
Mme J. [NOM]
Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (PEDIATRIE GENERALE)
V1 - Imprimé le 08/04/2025 à 10 : 21 par Page(s): 1 sur 2 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
[MASK]
Chef de Pôle :
Dr [NOM]
Chef de Service - Urgences Pédiatriques Les consignes d'usage ont été remises.
et Pédiatrie Générale et [NOM] :
Dr [NOM] – Urgences
Dr [NOM] - Pédiatrie
Dr [NOM] -
[NOM]
Bien confraternellement,
Pédiatrie de Maternité :
Dr [NOM]
Consultation d’Endocrino-Diabétologie :
Dr [NOM]
Dr [NOM] Docteur [NOM] [NOM]
Consultation [NOM] : *[TEL]*
Dr [NOM]
Consultation d’Hémato-Cancérologie :
D Dr r E Mli as re ie B DA UD BO RU ER L [TEL]
Consultation de Rhumatologie :
Dr [NOM]
Consultation de Médecine de l'Adolescent :
Dr [NOM] [NOM] Liste des destinataires :
Urgences Pédiatriques
Dr [NOM]. [NOM] [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]
Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (PEDIATRIE GENERALE)
V1 - Imprimé le 08/04/2025 à 10 : 21 par Page(s): 2 sur 2

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{"page": 0, "kind": "ETAB", "original": "Pôle Femme - Mère - Enfant", "placeholder": "[MASK]", "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": "NOM", "original": "Aurélie VALADE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "12 PLACE GRAMONT", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Céline BELLEAU", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64000 PAU", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Claudine EMBAREK", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "né le 18/01/2008", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Mathilde LE GALL", "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": "Fanny HENAFF", "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": "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": "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": "Pierre-Marie DUBOUE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Sabrina DUBOIS-ZUAZO", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Agnès PUEL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "IPP", "original": "23009267", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 0, "kind": "EPISODE", "original": "N° Episode 23079402", "placeholder": "[EPISODE]", "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": "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": "NOM", "original": "Aurélie VALADE", "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 Parents", "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": "Marie DUBREL", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "Fanny HENAFF", "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": "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": "PICAMILH Marie-Elise", "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": "PORTET Guillaume", "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": "TOULOUZET JOSH", "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": "IPP", "original": "23009267", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 1, "kind": "EPISODE", "original": "N° Episode 23079402", "placeholder": "[EPISODE]", "bbox_hint": null}

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N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
[MASK]
Chef de Pôle : Bayonne, le 25/04/2023
Dr [NOM]
C eth Pe éf dd ie a tS re ier v Gic ée n - é rU ar leg e en t c Ne és oP né ad ti oa lt or giq ieu : es M [NOM] [NOM]
Dr [NOM] – Urgences [ADRESSE]
D Dr r C Ha ét lh èner ei n Le A D NI GD LA OIL ISL E MR E - U P Ré Id Nia Ntr Eie - [CODE_POSTAL]
Néonatologie
Pédiatrie de [NOM] : Mon cher confrère,
Dr [NOM]
Consultation d’Endocrino-Diabétologie : Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 22/04/2023 au 25/04/2023 pour le motif
Dr [NOM]
Dr [NOM] [NOM] suivant :
Consultation [NOM] :
Dr [NOM] - Découverte de syndrome néphrotique impur.
Consultation d’Hémato-Cancérologie :
Dr [NOM]
Dr [NOM] [NOM] Antécédents personnels : aucun
Consultation de Rhumatologie : Antécédents familiaux : aucun
Dr [NOM] [NOM] Allergies : non.
Consultation de Médecine de l'Adolescent : Vaccination : à jour
Dr [NOM] [NOM] [NOM] habituels : aucun
Urgences Pédiatriques
D Dr r C Leé il rin e e E B TE CL HL AE NA DU Y Histoire de la maladie : Adolescent de 15.5 ans sans antécédent, adressé aux urgences le 22/04 pour syndrome œdémateux
Dr [NOM] d'évolution aigue. Début la semaine précédente par œdèmes des paupières, puis, œdèmes des MI et abdominal depuis le
D Dr r V Ki ao il ee tt Ete C S HU EC VERRIA-ARRUTY 17/04.
AEG depuis 5 jours avec dyspnée modérée à l'effort.
Néonatologie, Réanimation Néonatale :
Dr [NOM] Pas de notion d'hyperthermie, ni vaccination. [NOM] il y a 10 jours sous ttt symptomatique.
Dr [NOM]
Dr [NOM]
Dr [NOM] [NOM] A l'examen clinique aux urgences le 22/04 :
D Dr r C Ch amlo ié l lL e A OP GE EY RRE Poids habituel : 64kg; poids à l'arrivée aux urgences le 22/04 : 82.5 kg (+ 18.5 kg)
Dr [NOM] apyrétique, pas de syndrome infectieux
Dr [NOM]
syndrome œdémateux avec œdèmes déclives prenant le godet remontant jusqu'aux genoux et œdèmes des lombes
C Do r n Cs au thlt ea rt ii no en D d Ie D N Aé Ip Lh Lr Eo Rpédiatrie : auscultation CP : pas de crépitants, pas de diminution du MV
Dr [NOM] BDC réguliers, pas de souffle
Dr [NOM] pas de signe d'[NOM], pas de signe de [NOM]
Consultation de Neuropédiatrie : pas de douleur lombaire, pas d'hématurie macro
Dr [NOM]
Dr [NOM]
D Dr r M Léa nr aie [NOM] Ali Rse I OPI TC TA EMILH Examens complémentaires pertinents :
* Biologie :
C Do r n Cs hu al rt la ot ti to en P d Ee T P Rn IAeu Tmopédiatrie : Na 134mmol/l, K 3.9 mmol/L
créatininémie à 88 µmol/L
Consultation de Cardiopédiatrie :
Dr [NOM] albumine 23.7 g/L
A Dt rt Cac hh rié ss tel [NOM] - Dermatologie
p Nr Fo Sté : i n Gu 1r 0ie ./ 3c r Ge /a Lt i Hni bn u 15ri ge /:
d
L60
,
0
p
l :
a
qp uro ett té en 3iu 4r 5i e
G
s /Lur échantillon 11.5 g/L
Dr [NOM] - [NOM] bilan hépatique normal, proBNP 455 ng/L
D et r D S ro Jp uh li ie e nN VA AU ND -I GO IN LS, D - r G M éna ér ti in qe u L eEGENDRE hypertriglycéridémie à 2.69 g/L.
Dr [NOM] [NOM] - Critères d'anticoagulation préventive : DDimères > 1000, fibrinogène > 6 g/L , AT3 77%
Rhumato-immunologie
Dr [NOM] - Gynécopédiatrie/[NOM]
D
C
Mr
a m
dS ert é
e
Vp
I
ah
n
la éfn
rir
ie
em
D TiE
e
ErB
R
SE RuL
Ip
EL
é
RE rI ieX
u
-
r
P dn ue Pum ôlo el : ogie *
-
R Ea cd hi oo -l do og piq pu le e :
r des reins : N° d'examen : RAD[TEL]
Cadres Infirmiers : Les reins sont mesurés à 11 cm à droite, 11,8 cm à gauche. Leurs contours sont réguliers. La différenciation
M Mr m K e . C G . L PA ISD AE RL SP Ké Id i Uat rr gi ee n G ceé sn é Ura Hle CD et HDJ corticomédullaire est visualisée de façon bilatérale, atténuée. Absence d'anomalie parenchymateuse focale. Absence de
Mme J. [NOM] - Néonatologie modification du volume des systèmes excréteurs. L'enregistrement doppler met en évidence un spectre artériel de type
Psychomotricienne : basse résistance tant en intrarénal qu'au niveau du hile. L'enregistrement veineux est correct tant en intrarénal qu'au
M
O
Mrm mthe
e o
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A
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t
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c
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e
C nto pn lf ei urm raa
l
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t
n
péritonéal significatif.
Mme M. [NOM] CONCLUSION : Absence d'argument en faveur d'une thrombose veineuse rénale
Psychologues :
Mme E. [NOM]
Mme C. [NOM] [NOM] reçus en hospitalisation :
M
N
Mem mue
er
oL Np.
.s
P GyI
c
UE hR YolA AoG UguN XeO s : LO D
-
Céb ou rtt
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o
:
tection gastrique par INEXIUM 20 mg.
Mme M.[NOM] - Mise en place d'antihypertenseur devant l'HTA par RAMIPRIL 2.5 mg .
Assistantes Sociales : - Anticoagulation préventive par LOVENOX SC 0.4 mL/j
M Mm me e Z M. .B JA UP ZT AI NSTON - FUROSEMIDE 40 mg IVD administrer une fois relancer la diurèse.
Mme J. [NOM] - Régime hypo-sodé/ hypo-sucré et restriction hydrique à 500 mL /jour.
Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (Pédia Surv continue (hors Nné))
V1 - Imprimé le 11/04/2025 à 09 : 19 par Page(s): 1 sur 2 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
[MASK]
Chef de Pôle : - Antalgie par Doliprane.
Dr [NOM]
Chef de Service - Urgences Pédiatriques Synthèse du séjour : Syndrome néphrotique impur avec HTA et hématurie microcospique.
e Dt r P Cé éd li ia nt er Bie E G Lé Ln Eé Ara Ule – e Ut N rgé eo nn ca et sologie : Début de la corticothérapie le 23/04
Dr [NOM] - Pédiatrie
Dr [NOM] -
Néonatologie 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.
Pédiatrie de [NOM] :
Dr [NOM] informés de la démarche diagnostique et thérapeutique.
Consultation d’Endocrino-Diabétologie : Document remis en mains propres aux [NOM] le jour de la sortie.
Dr [NOM]
Dr [NOM]
Consultation [NOM] : Evènements indésirables :
Dr [NOM] [NOM] - Transfusions : non
Consultation d’Hémato-Cancérologie : - Produits dérivés du sang : non
Dr [NOM] [NOM] - BMR / BHRe / LHR : non
Dr [NOM]
- Découverte de BMR / BHRe / BHR : non
C Do r n Ls eu irl eta Eti To Cn Hd Ae NR Dhu Ymatologie : - Pose DMI : non
Consultation de Médecine de l'Adolescent :
Dr [NOM]
U Dr r g Ce én lc ine es BPé Ed Li Lat Er Aiq Uues Les consignes d'usage ont été remises.
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
N Dé r o Pn ha ilt io pl po eg i Je O, UR Véa En Nim Ca Et Lion Néonatale : Bien confraternellement,
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM] Docteur [NOM]
Dr [NOM]
*[TEL]*
Consultation de Néphropédiatrie :
Dr [NOM]
Dr [NOM]
Dr [NOM] [TEL]
Consultation de Neuropédiatrie :
Dr [NOM]
Dr [NOM]
Dr [NOM]
Dr [NOM]
[NOM] par [NOM]
Consultation de Pneumopédiatrie :
Dr [NOM]
Consultation de Cardiopédiatrie :
Dr [NOM]
[NOM]
Liste des destinataires :
Dr [NOM] - Dermatologie
Dr [NOM] - [NOM] Monsieur [NOM]
Dr [NOM], Dr [NOM]
et Dr [NOM] - Génétique
Dr [NOM] -
Rhumato-immunologie
Dr [NOM] - Gynécopédiatrie/[NOM]
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] - Néonatologie
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]
Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (Pédia Surv continue (hors Nné))
V1 - Imprimé le 11/04/2025 à 09 : 19 par Page(s): 2 sur 2

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{"page": 1, "kind": "NOM", "original": "PELLERIN-GUIGNARD Aude", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "audemar@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "BOUBE Anthibiothérapie", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 1, "kind": "NOM", "original": "BRUGEL ATB", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 1, "kind": "EMAIL", "original": "brugel@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
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{"page": 1, "kind": "EMAIL", "original": "fgoutorbe@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "PUJOS", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 1, "kind": "EMAIL", "original": "boui@ch-cotebasque.fr", "placeholder": "[EMAIL]", "bbox_hint": null}
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{"page": 1, "kind": "NOM", "original": "PUJOS Marion", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 2, "kind": "NOM", "original": "Thomas Grellety", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "AUDEMAR Franck", "placeholder": "[NOM]", "bbox_hint": null}
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N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
ICANCE - Institut de Cancérologie Bayonne, le 04/07/2023
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération Mon cher confrère,
Chef de [MASK]. [NOM] Votre patient [NOM] [NOM] né le [DATE_NAISSANCE] a été hospitalisé dans le service du 01/07/2023 au 04/07/2023 pour le motif suivant :
A. Interne Hôpitaux Strasbourg
A D. E C Sh Ce Of C ncli on li oq gu ie e – D A igs es s. t iH vô epitaux - MH : douleur anale
Hépato-gastro-entérologue
Oncologue Digestif ATCD : non
[EMAIL]
P raticiens Hospitaliers TTT : non
Dr M. [NOM]
A. In. Hôpitaux [ETABLISSEMENT]
A. Chef de clinique - Ass Hôpitaux Allergie : NC
Hépato-gastro-entérologue
[EMAIL] HdM : A consulté il y a 2 jours sur douleur anale avec dysurie.
Dr M. [NOM] Douleur brutale anale après séance de sport mercredi dans la journée
A A. . I An ste s.r n He ô H piô tap uit xa u Rx e R ime sims HSH - dernier rapport datant d'il y a 7 jours, pas d'insertion de CE
DESC Cancérologie Nous avions conclu à une prostatite et débuté la Levofloxacine et une antalgie palier 1 et 3.
Hépato-gastro-entérologue
O mn bc ruo glo eg l@ue c d hi -g ce os tt ei bf [EMAIL] Depuis majoration des symptômes, fébrile à 39, anorexie.
Dr C. [NOM]
A. Interne Hôpitaux [ETABLISSEMENT] Examen clinique :
A. Chef Clinique – Ass. Hôpitaux Douleur EN 9/
Hépato-gastro-entérologue Febrile 39°C, TA 13/8 mmHg, FC 120bpm, SpO2 98% en AA
Proctologue
Explorations Fonct. Digestives Bdc regulier pas de souffle
[EMAIL] MV+/+ pas de bruit surajouté
Dr F. [NOM] Abdomen souple dépressible, non dl. [NOM] de transit depuis 3j.
A. In. Hôpitaux [ETABLISSEMENT] SFU brulures.
A D. E C Sh Ce Of d ne c oc ll oin gi iq eu De i- g A ess ts iv H [ETABLISSEMENT] PAs découlement urteral
Proctologue
[EMAIL] Examen complémentaires :
Dr A.[NOM] Biologie :
A.Interne Hôpitaux Bordeaux Majoration SIB, GB 15G/L, CRP 168
DESC Oncologie Digestive
Hépato-gastro-entérologue Bilan hépatique subnormal
Oncologue Digestif Fonction rénale normale
[EMAIL] Ionogramme sgx normal
Dr T. [NOM]
A A. . I Cn h. eH f ô Cp li it na iu qx u eC –le Arm sso .n Ht F ôper itr aa un xd Bladder : 600cc
Hépato-gastro-entérologue
Proctologue BU : leuco neg
Explorations Fonct. Digestives
[EMAIL]
ECBU : en cours
Dr D. [NOM]
A. Interne Hôpitaux Bordeaux - Ass.
Hôpitaux Hémocultures : en cours
Hépato-gastro-entérologue
[EMAIL]
SCANNER ABDOMINO-PELVIEN :
D Ar
.
IB nt. eO rnU
e
I
Hôpitaux Bordeaux
A. Chef Clinique - Ass. Hôpitaux Indication :
Hépato-gastro-entérologue Suspicion d'abcès prostatique.
b [EMAIL] Protocole :
Dr F. [NOM] Examen réalisé avec injection de produit de contraste.
RPPS : [RPPS]
Hépato-gastro-entérologue et assistante
nutritive RESULTATS :
[EMAIL] Mise en évidence d'une collection péri rectale mesurée à 3cm associée à une infiltration ?démateuse périrectale.
Unité d’Hospitalisation Prostate de volume préservée. Pas de collection visible prostatique.
T Fe al
x
[TEL]
5
Cadre Infirmier Le foie est homogène et non dysmorphique.
Mme S. [NOM] Il n'y a pas d'anomalie significative de la vésicule biliaire. Les voies biliaires intra et extra hépatiques sont fines.
Secrétariat et R.V. Pas d'anomalie du système porte.
Tel [TEL] Pas d'anomalie du pancréas, de la rate, des reins et des surrénales.
Fax [TEL] Pas d'adénopathie rétropéritonéale ou coelio-mésentérique de taille significative.
Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (MEDECINE GASTRO B2 HC)
V1 - Imprimé le 17/04/2025 à 08 : 31 par Page(s): 1 sur 3 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
ICANCE - Institut de Cancérologie Pas d'épanchement péritonéal.
Navarre Côte Basque Pas d'anomalie des structures pelviennes.
Mme [NOM], cadre de
f Dé rd é Tr ha oti mon
as [NOM], coordonnateur CONCLUSION :
médical de fédération Aspect TDM en faveur d'une collection abcédée péri rectale.
Chef de [MASK]. [NOM]
A. Interne Hôpitaux Strasbourg Dr [NOM]
A. Chef Clinique – Ass. Hôpitaux
DESC Oncologie Digestive
Hépato-gastro-entérologue
Oncologue Digestif Prise en charge évolution :
f [EMAIL] Hydratation Nacl
Praticiens Hospitaliers Antalgie : paracetamol + Morphine
Dr M. [NOM] par Ceftriaxone + Flagyl débuté pour abcès péri rectal
A. In. Hôpitaux Clermont Ferrand SU ?
A. Chef de clinique - Ass Hôpitaux
Hépato-gastro-entérologue
[EMAIL] AU TOTAL : Abcès peri rectal
Dr M. [NOM] C3G Flagyl
A. Interne Hôpitaux [ETABLISSEMENT] Suite de la prise en charge en infectiologie. Faute de place hébergé par la Gastroentérologie
A. Ass. Hôpitaux [ETABLISSEMENT]
DESC Cancérologie
Hépato-gastro-entérologue
Oncologue digestif
m [EMAIL] Evolution :
Dr C. [NOM]
A. Interne Hôpitaux [ETABLISSEMENT] Bloc ce jour :
A. Chef Clinique – Ass. Hôpitaux Volumineux abcès en fer à cheval péri-anal, développé au dépens d'une fistule avec le canal anal située à 6h
Hépato-gastro-entérologue Prélèvement bactério réalisé
Proctologue
Explorations Fonct. Digestives Evacuation de pus en quantité importante
[EMAIL] Elastique dans le trajet fistuleux afin de l'abaisser
Dr F. [NOM]
A. In. Hôpitaux Clermont Ferrand - Sur le plan urologique : reprise mictionnelle sans difficultés, retrait du KT sus-pubien le 04/07 sans complication.
A. Chef de clinique - Ass Hôpitaux
DESC Oncologie Digestive
Proctologue - Sur le plan digestif : abdomen souple, dépressible et indolore. Difficultés à l'exonération, mise en place de laxatifs.
[EMAIL] Réévaluation en consultation dans 2 semaines par le Dr [NOM].
Dr A.[NOM]
A.Interne Hôpitaux Bordeaux - Sur le plan infectieux : analyse du pus en cours, hémocultures toujours en cours à la sortie. Relai de l'antibiothérapie par
DESC Oncologie Digestive
Hépato-gastro-entérologue Rocéphine + Flagyl débutée le 01/07 par Augmentin pour 7 jours au total (fin le 08/07/2023).
Oncologue Digestif Décroissance de la CRP à 174 mg/L lors de la sortie (vs 291 à l'entrée).
[EMAIL] Surveillance biologique hebdomadaire pour surveiller décroissance CRP.
Dr T. [NOM]
A A. . I Cn h. eH f ô Cp li it na iu qx u eC –le Arm sso .n Ht F ôper itr aa un xd Sortie le 04/07 du service avec les consignes devant amener à faire reconsulter en urgence : fièvre, douleurs abdominales
Hépato-gastro-entérologue intenses, écoulements, rétention aigue d'urine.
Proctologue
Explorations Fonct. Digestives
[EMAIL]
Dr D. [NOM]
A. Interne Hôpitaux Bordeaux - Ass.
Hôpitaux Votre patient(e) quitte le service avec :
Hépato-gastro-entérologue
[EMAIL] - Pharmacie :
PARACETAMOL ARW 500MG GELULE [12] Gelule(s) 2 GELULE (ORALE) toutes les 6 heures jusqu'au 14/07/2023 à
Dr B. OUI
A. Interne Hôpitaux Bordeaux 6h04
A. Chef Clinique - Ass. Hôpitaux TRAMADOL - TOPALGIC 50MG GELULE 50MG gelule 1 GELULE (ORALE) toutes les 6 heures jusqu'au 11/07/2023
Hépato-gastro-entérologue à 6h04
[EMAIL]
AMOX/AC CLAV SDZ 1G/125MG AD SACH [12] Sachet(s) 1 G (ORALE) matin midi soir
Dr F. [NOM]
RPPS : [RPPS] MACROGOL - TRANSIPEG 5,9G PDR [NOM] 5,9G poudre 2 SACHET(S) (ORALE) matin [8h]
Hépato-gastro-entérologue et assistante
nutritive
[EMAIL] Conclusion :
U Ten l i 0té 5 .d 5’ 9H .4o 4s .p 3i 7ta .2li 3sation - Draînage d'un abcès péri-rectal avec fistule anale, suites simples.
Fax [TEL] Sera revu en consultation par le Dr [NOM] le 20 Juillet 2023 à 15h30 avec un bilan biologique à réaliser au
Cadre Infirmier
Mme S. [NOM] préalable.
Poursuite de l'antibiothérapie jusqu'au 08/07/2023 pour 7 jours au total.
Secrétariat et R.V.
Tel [TEL]
Fax [TEL]
Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (MEDECINE GASTRO B2 HC)
V1 - Imprimé le 17/04/2025 à 08 : 31 par Page(s): 2 sur 3 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
ICANCE - Institut de Cancérologie Les consignes d'usage ont été remises.
Navarre Côte Basque
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK],
Dr F. [NOM]
A. Interne Hôpitaux Strasbourg
A. Chef Clinique – Ass. Hôpitaux
D HE épS aC to O -gn ac so trlo og -eie n tD éri og le os gti uv ee Docteur [NOM]
Oncologue Digestif *[TEL]*
[EMAIL]
Praticiens Hospitaliers
Dr M. [NOM] [TEL]
A. In. Hôpitaux [VILLE]
A. Chef de clinique - Ass Hôpitaux
Hépato-gastro-entérologue
[EMAIL]
Dr M. [NOM] par [NOM] [NOM]
A. Interne Hôpitaux Reims
A. Ass. Hôpitaux Reims
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 [VILLE]
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 [VILLE]
A. Chef Clinique – Ass. Hôpitaux
Hépato-gastro-entérologue
Proctologue
Explorations Fonct. Digestives
[EMAIL]
Dr D. [NOM]
A. Interne Hôpitaux Bordeaux - Ass.
Hôpitaux
Hépato-gastro-entérologue
[EMAIL]
Dr B. OUI
A. Interne Hôpitaux Bordeaux
A. Chef Clinique - Ass. Hôpitaux
Hépato-gastro-entérologue
[EMAIL]
Dr F. [NOM]
RPPS : [RPPS]
Hépato-gastro-entérologue et assistante
nutritive
[EMAIL]
Unité d’Hospitalisation
Tel [TEL]
Fax [TEL]
Cadre Infirmier
Mme S. [NOM]
Secrétariat et R.V.
Tel [TEL]
Fax [TEL]
Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (MEDECINE GASTRO B2 HC)
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{"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": "PERNAUT Chrystelle", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 5, "kind": "NOM", "original": "Léa LOPEZ DR", "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": "IPP", "original": "07009798", "placeholder": "[IPP]", "bbox_hint": null}
{"page": 5, "kind": "EPISODE", "original": "N° Episode 23132490", "placeholder": "[EPISODE]", "bbox_hint": null}

539
regression_tests/baseline/CRH 23132490.pseudonymise.txt Normal file
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N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
PÔLE MÉDECINE INTERNE
SERVICE RHUMATOLOGIE - MEDECINE INTERNE
ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE
RHUMATOLOGIE Bayonne, le 31/07/2023
Dr [NOM]
Chef de [MASK] [NOM]
Ancien Chef de [ETABLISSEMENT]
de Paris [ADRESSE]
P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 0ta 8l 1ie 7r 005 [CODE_POSTAL]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux Mon cher confrère,
Praticien Hospitalier
RPPS : [RPPS]
Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 24/07/2023 au 27/07/2023 pour le motif
Dr [NOM] [NOM] suivant :
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 1ta 8l 5ie 6r 135 - Médecin traitant : Dr [NOM]
Dr [NOM] [NOM] Hématologue : Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
d Pe ra B tio cir ed ne a hu ox spitalier Motif d'entrée : Cimentoplastie
RPPS : [RPPS]
Dr [NOM] [NOM] Antécédents :
A Prn ac tii ce in e nA hss oi ss pta itn at l id ee rs c H onô tp rait ca tu ux e lde Lyon Lithiase rénale sur hypercalciurie suivi par Dr [NOM]
RPPS : [RPPS] Pic monoclonal IgG Kappa 8.5 g/L suivi par Dr [NOM] en cours de bilan
Secrétariat : [TEL] Fracture T5
MEDECINE INTERNE ET
IMMUNOLOGIE CLINIQUE Chirurgicaux : Lithotritie per cutanée
Dr [NOM]
Ancien Chef de [ETABLISSEMENT] : Œdème de Quincke a l’amoxicilline
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS] Mode de vie :
Vit avec sa femme, patient autonome
Dr [NOM]
Ancien Assistant des Hôpitaux de [VILLE] 5/6 cig par jour. OH occasionnel
Bordeaux et Bayonne
P Nr °a t Ric Pi Pen S H 10o 1sp 0i 1t 4al 8i 0er 506 Traitements :
ALLOPURINOL 100mg 1.0.0
Dr [NOM] NEBIVOLOL 5mg 1/2.0.0
Ancien Chef de [ETABLISSEMENT]
de Lille KARDEGIC 75mg 1.0.0
P Nr °a t Ric Pi Pen S h 1o 0s 0p 0i 4ta 6l 0ie 6r 595 HYDROCHLOROTHIAZIDE 25mg 1.0.1
ZYMAD 10000UI 2gt tous les jours
Dr [NOM] MECIR LP 0.4mg 0.1.1
Assistant spécialiste
RPPS : [RPPS] CITRATE de K 1g 1.1.1
Secrétariat : [TEL] Histoire de la maladie :
DERMATOLOGIE Patient suivi pour une MGUS IgG Kappa à 8.5 g/dL par le Dr [NOM] en surveillance sans traitement pour le
Dr [NOM] moment.
Ancien Chef de [ETABLISSEMENT] mai le patient se plaint de douleur dorsal sans notion de chute ni de traumatisme.
d Pe ra T tio cu ielo nu hs oe spitalier Une radio et un scanner puis une IRM sont réalisées au cours du moi de mai :
RPPS : [RPPS] - Le scanner du 16/05/23 retrouve : Fracture compression d’allure non strictement consolidée étagée du plateau vertébral
Dr [NOM]
supérieur de la pièce du corps vertébrale T5 sans recul du mur postérieur.
Ancien Assistant des Hôpitaux de - L'IRM du Rachis réalisé le 31/05/23 : Fracture T5 sur os non pathologique.
Toulouse
Praticien Hospitalier contractuel
RPPS : [RPPS] Patient douloureux mais non hyperalgique, ne prend pas d’antalgique.
Dr [NOM]
Pas de sciatalgie ni d'argument pour un syndrome de la queue de cheval.
Praticien Hospitalier contractuel
RPPS : [RPPS] Dans le contexte son hématologue souhaite réaliser une biopsie afin d’éliminer définitivement l’origine myélomateuse de la
Dr [NOM] lésion, une cimentoplastie est organisé dans le même temps a but antalgique.
Praticien Hospitalier contractuel
Hospitalisé en rhumatologie pour cimentoplastie + bilan ostéopathie fragilisante.
Secrétariat : [TEL]
CENTRE DE COMPETENCES
D ETE S A M [NOM] OL -A IND FIE LS A A MU MT AO T I OM IRM EU [NOM] Examen clinique :
SYSTEMIQUES RARES : Apyrétique, pas de défaillance hémodynamique.
Médecin coordonnateur : BDC régulier, pas de souffle perçu, pas d'omi, pas de douleur thoracique.
D Ser c I rr éè tn ae ri aM t : A 0C 5.H 33E .L 78A .8R 1T .89 MV +/+ pas de bruit surajouté, pas de toux.
[EMAIL] 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] / [EPISODE] (RHUMATOLOGIE)
V1 - Imprimé le 17/04/2025 à 11 : 24 par Page(s): 1 sur 3 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
PÔLE MÉDECINE INTERNE
SERVICE RHUMATOLOGIE - MEDECINE INTERNE
ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE
RHUMATOLOGIE Douleur élective a la palpation de T5 et des muscle paravertebraux. Pas de déficit sensitivo-moteur ou de paresthésies. Pas
Dr [NOM] d'irradiation de la douleur.
Chef de [MASK], pas de raideur méningée.
A [NOM] is Chef de [ETABLISSEMENT] de trouble vésico-sphinctérien.
Praticien hospitalier
N D°
r
R SP tP éS
p
h10 a1 n0 e0 8 M17 A00 R5
CE
Examens complémentaires :
Ancien Chef de [ETABLISSEMENT]
de Bordeaux Biologie :
Praticien Hospitalier Hb 14.5 g/dL, plaquettes 206 G/L, PNN 4.17 G/L
RPPS : [RPPS]
Ionogramme normal en dehors d'une discrète hyponatrémie à 134 mmol/L, calcémie nomrale à 2.25 mmol/L,
Dr [NOM] hypomagnésémie à 0.67 mmol/L, phosphore normal à 1.12 mmol/L
A den Bci oe rn d C eah ue xf de [ETABLISSEMENT] D normale à 44 ng/mL
Praticien hospitalier PTH normale
N
D
A°
nr
c
R
I
ieP
t
nsP
a
CS
s
h1
o
e0 fO1 d0
D
e1 8 CR5 lI6 inO1 i3 qZ5
ueO dL esA
Hôpitaux
C Cr Ré Pat 1in min gém /Lie 49 umol/L avec DFG 103 ml/min
de Bordeaux Bilan hépatique normal
P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 TP 94 %, TCA ratio 0.94
Dr [NOM] [NOM] [NOM] : pic monoclonal connu et stable à 8.1 g/L
Ancien Assistant des Hôpitaux de Lyon
Praticien hospitalier contractuel Evolution dans le service :
RPPS : [RPPS]
Secrétariat : [TEL]
Patient hospitalisé dans le service pour biopsie et cimentoplastie de T5 suite à une fracture vertébrale de T5 dans un
MEDECINE INTERNE ET contexte de gammapathie monoclonale (MGUS IgG kappa) actuellement sous surveillance.
IMMUNOLOGIE CLINIQUE
Dr [NOM] [NOM] [NOM] des images IRM : en faveur d'une origine ostéoporotique de la lésion.
Ancien Chef de [ETABLISSEMENT]
de Bordeaux Par ailleurs, dans ce contexte de gammapathie monoclonale : pas d'anémie, fonction rénale normale et pas d'hypercalcémie.
Praticien Hospitalier
RPPS : [RPPS]
Vertébroplastie de T5 et biopsie réalisée le 25/07/23 sans complication par le Dr [NOM].
Dr [NOM] Bien soulagé par vertébroplastie.
A Bon rc die en au A xs es ti s Bta an yt o d ne ns e Hôpitaux de Réalisation d'un bilan d'ostéopathie fragilisante : pas de carence en vitamine D, bilan phosphocalcique sans particularité,
Praticien Hospitalier gammapathie monoclonale connue, TSH normale.
RPPS : [RPPS] Facteur de risque ostéopathie fragilisante: tabagisme, gammapathie monoclonale, hypercalciurie primitive, pas d'ATCD de
Dr [NOM] corticothérapie au long cours, pas dATCD personnel ou familiaux de fracture.
Ancien Chef de [ETABLISSEMENT] à l'initiation d'un traitement anti-ostréoporotique et réalisation d'un perfusion d'ACLASTA le 26/07.
de Lille
Praticien hospitalier
RPPS : [RPPS] La patient sera revu en consultation dans un mois par le Dr [NOM] avec les résultats de la biopsie osseuse.
Dr [NOM]
Assistant spécialiste Conclusion :
RPPS : [RPPS] Réalisation d'une cimentoplastie et biopsie de T5.
Secrétariat : [TEL] Lésion d'allure ostéoporotique.
Bilan d'ostéopathie fragilisante normal.
DERMATOLOGIE
Réalisation d'une première perfusion d'Aclasta 5 mg IV.
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Toulouse Suite et devenir :
Praticien hospitalier DMO à réaliser en externe
RPPS : [RPPS]
Injection d'ACLASTA une fois par an pendant les deux prochaines années puis nouvelle DMO.
Dr [NOM] Consultation Dr [NOM] avec les résultats de la biopsie osseuse dans un mois.
Ancien Assistant des Hôpitaux de
Toulouse
Praticien Hospitalier contractuel Traitement de sortie :
RPPS : [RPPS]
inchangé
Dr [NOM]
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM] Les consignes d'usage ont été remises.
Praticien Hospitalier contractuel
Secrétariat : [TEL]
CENTRE DE COMPETENCES
DES MALADIES AUTO IMMUNES Bien confraternellement,
ET AUTO-INFLAMMATOIRES
SYSTEMIQUES RARES :
Médecin coordonnateur :
Dr [NOM]
Secrétariat : [TEL]
[EMAIL] Docteur [NOM]
Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (RHUMATOLOGIE)
V1 - Imprimé le 17/04/2025 à 11 : 24 par Page(s): 2 sur 3 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
PÔLE MÉDECINE INTERNE
SERVICE RHUMATOLOGIE - MEDECINE INTERNE
ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE
RHUMATOLOGIE *[TEL]*
Dr [NOM]
Chef de [MASK] [ETABLISSEMENT] [TEL]
de Paris
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux Liste des destinataires :
Praticien Hospitalier
N ° RPPS : [RPPS] DR. [NOM]
Dr [NOM]. [NOM] [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]
Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (RHUMATOLOGIE)
V1 - Imprimé le 17/04/2025 à 11 : 24 par Page(s): 3 sur 3 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
PÔLE MÉDECINE INTERNE
SERVICE RHUMATOLOGIE - MEDECINE INTERNE
ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE
RHUMATOLOGIE Bayonne, le 31/07/2023
Dr [NOM]
Chef de [MASK] [NOM]
Ancien Chef de [ETABLISSEMENT]
de Paris SERVICE D'HEMATOLOGIE
P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 0ta 8l 1ie 7r 005 [CODE_POSTAL]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux Mon cher confrère,
Praticien Hospitalier
RPPS : [RPPS]
Votre patient [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisé dans le service du 24/07/2023 au 27/07/2023 pour le motif
Dr [NOM] [NOM] suivant :
Ancien Chef de [ETABLISSEMENT]
de Bordeaux
P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 1ta 8l 5ie 6r 135 - Médecin traitant : Dr [NOM]
Dr [NOM] [NOM] Hématologue : Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
d Pe ra B tio cir ed ne a hu ox spitalier Motif d'entrée : Cimentoplastie
RPPS : [RPPS]
Dr [NOM] [NOM] Antécédents :
A Prn ac tii ce in e nA hss oi ss pta itn at l id ee rs c H onô tp rait ca tu ux e lde Lyon Lithiase rénale sur hypercalciurie suivi par Dr [NOM]
RPPS : [RPPS] Pic monoclonal IgG Kappa 8.5 g/L suivi par Dr [NOM] en cours de bilan
Secrétariat : [TEL] Fracture T5
MEDECINE INTERNE ET
IMMUNOLOGIE CLINIQUE Chirurgicaux : Lithotritie per cutanée
Dr [NOM]
Ancien Chef de [ETABLISSEMENT] : Œdème de Quincke a l’amoxicilline
de Bordeaux
Praticien Hospitalier
RPPS : [RPPS] Mode de vie :
Vit avec sa femme, patient autonome
Dr [NOM]
Ancien Assistant des Hôpitaux de [VILLE] 5/6 cig par jour. OH occasionnel
Bordeaux et Bayonne
P Nr °a t Ric Pi Pen S H 10o 1sp 0i 1t 4al 8i 0er 506 Traitements :
ALLOPURINOL 100mg 1.0.0
Dr [NOM] NEBIVOLOL 5mg 1/2.0.0
Ancien Chef de [ETABLISSEMENT]
de Lille KARDEGIC 75mg 1.0.0
P Nr °a t Ric Pi Pen S h 1o 0s 0p 0i 4ta 6l 0ie 6r 595 HYDROCHLOROTHIAZIDE 25mg 1.0.1
ZYMAD 10000UI 2gt tous les jours
Dr [NOM] MECIR LP 0.4mg 0.1.1
Assistant spécialiste
RPPS : [RPPS] CITRATE de K 1g 1.1.1
Secrétariat : [TEL] Histoire de la maladie :
DERMATOLOGIE Patient suivi pour une MGUS IgG Kappa à 8.5 g/dL par le Dr [NOM] en surveillance sans traitement pour le
Dr [NOM] moment.
Ancien Chef de [ETABLISSEMENT] mai le patient se plaint de douleur dorsal sans notion de chute ni de traumatisme.
d Pe ra T tio cu ielo nu hs oe spitalier Une radio et un scanner puis une IRM sont réalisées au cours du moi de mai :
RPPS : [RPPS] - Le scanner du 16/05/23 retrouve : Fracture compression d’allure non strictement consolidée étagée du plateau vertébral
Dr [NOM]
supérieur de la pièce du corps vertébrale T5 sans recul du mur postérieur.
Ancien Assistant des Hôpitaux de - L'IRM du Rachis réalisé le 31/05/23 : Fracture T5 sur os non pathologique.
Toulouse
Praticien Hospitalier contractuel
RPPS : [RPPS] Patient douloureux mais non hyperalgique, ne prend pas d’antalgique.
Dr [NOM]
Pas de sciatalgie ni d'argument pour un syndrome de la queue de cheval.
Praticien Hospitalier contractuel
RPPS : [RPPS] Dans le contexte son hématologue souhaite réaliser une biopsie afin d’éliminer définitivement l’origine myélomateuse de la
Dr [NOM] lésion, une cimentoplastie est organisé dans le même temps a but antalgique.
Praticien Hospitalier contractuel
Hospitalisé en rhumatologie pour cimentoplastie + bilan ostéopathie fragilisante.
Secrétariat : [TEL]
CENTRE DE COMPETENCES
D ETE S A M [NOM] OL -A IND FIE LS A A MU MT AO T I OM IRM EU [NOM] Examen clinique :
SYSTEMIQUES RARES : Apyrétique, pas de défaillance hémodynamique.
Médecin coordonnateur : BDC régulier, pas de souffle perçu, pas d'omi, pas de douleur thoracique.
D Ser c I rr éè tn ae ri aM t : A 0C 5.H 33E .L 78A .8R 1T .89 MV +/+ pas de bruit surajouté, pas de toux.
[EMAIL] 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] / [EPISODE] (RHUMATOLOGIE)
V1 - Imprimé le 17/04/2025 à 11 : 24 par Page(s): 1 sur 3 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
PÔLE MÉDECINE INTERNE
SERVICE RHUMATOLOGIE - MEDECINE INTERNE
ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE
RHUMATOLOGIE Douleur élective a la palpation de T5 et des muscle paravertebraux. Pas de déficit sensitivo-moteur ou de paresthésies. Pas
Dr [NOM] d'irradiation de la douleur.
Chef de [MASK], pas de raideur méningée.
A [NOM] is Chef de [ETABLISSEMENT] de trouble vésico-sphinctérien.
Praticien hospitalier
N D°
r
R SP tP éS
p
h10 a1 n0 e0 8 M17 A00 R5
CE
Examens complémentaires :
Ancien Chef de [ETABLISSEMENT]
de Bordeaux Biologie :
Praticien Hospitalier Hb 14.5 g/dL, plaquettes 206 G/L, PNN 4.17 G/L
RPPS : [RPPS]
Ionogramme normal en dehors d'une discrète hyponatrémie à 134 mmol/L, calcémie nomrale à 2.25 mmol/L,
Dr [NOM] hypomagnésémie à 0.67 mmol/L, phosphore normal à 1.12 mmol/L
A den Bci oe rn d C eah ue xf de [ETABLISSEMENT] D normale à 44 ng/mL
Praticien hospitalier PTH normale
N
D
A°
nr
c
R
I
ieP
t
nsP
a
CS
s
h1
o
e0 fO1 d0
D
e1 8 CR5 lI6 inO1 i3 qZ5
ueO dL esA
Hôpitaux
C Cr Ré Pat 1in min gém /Lie 49 umol/L avec DFG 103 ml/min
de Bordeaux Bilan hépatique normal
P Nr °a t Ric Pi Pen S h 1o 0s 1p 0i 2ta 2l 7ie 2r 209 TP 94 %, TCA ratio 0.94
Dr [NOM] [NOM] [NOM] : pic monoclonal connu et stable à 8.1 g/L
Ancien Assistant des Hôpitaux de Lyon
Praticien hospitalier contractuel Evolution dans le service :
RPPS : [RPPS]
Secrétariat : [TEL]
Patient hospitalisé dans le service pour biopsie et cimentoplastie de T5 suite à une fracture vertébrale de T5 dans un
MEDECINE INTERNE ET contexte de gammapathie monoclonale (MGUS IgG kappa) actuellement sous surveillance.
IMMUNOLOGIE CLINIQUE
Dr [NOM] [NOM] [NOM] des images IRM : en faveur d'une origine ostéoporotique de la lésion.
Ancien Chef de [ETABLISSEMENT]
de Bordeaux Par ailleurs, dans ce contexte de gammapathie monoclonale : pas d'anémie, fonction rénale normale et pas d'hypercalcémie.
Praticien Hospitalier
RPPS : [RPPS]
Vertébroplastie de T5 et biopsie réalisée le 25/07/23 sans complication par le Dr [NOM].
Dr [NOM] Bien soulagé par vertébroplastie.
A Bon rc die en au A xs es ti s Bta an yt o d ne ns e Hôpitaux de Réalisation d'un bilan d'ostéopathie fragilisante : pas de carence en vitamine D, bilan phosphocalcique sans particularité,
Praticien Hospitalier gammapathie monoclonale connue, TSH normale.
RPPS : [RPPS] Facteur de risque ostéopathie fragilisante: tabagisme, gammapathie monoclonale, hypercalciurie primitive, pas d'ATCD de
Dr [NOM] corticothérapie au long cours, pas dATCD personnel ou familiaux de fracture.
Ancien Chef de [ETABLISSEMENT] à l'initiation d'un traitement anti-ostréoporotique et réalisation d'un perfusion d'ACLASTA le 26/07.
de Lille
Praticien hospitalier
RPPS : [RPPS] La patient sera revu en consultation dans un mois par le Dr [NOM] avec les résultats de la biopsie osseuse.
Dr [NOM]
Assistant spécialiste Conclusion :
RPPS : [RPPS] Réalisation d'une cimentoplastie et biopsie de T5.
Secrétariat : [TEL] Lésion d'allure ostéoporotique.
Bilan d'ostéopathie fragilisante normal.
DERMATOLOGIE
Réalisation d'une première perfusion d'Aclasta 5 mg IV.
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Toulouse Suite et devenir :
Praticien hospitalier DMO à réaliser en externe
RPPS : [RPPS]
Injection d'ACLASTA une fois par an pendant les deux prochaines années puis nouvelle DMO.
Dr [NOM] Consultation Dr [NOM] avec les résultats de la biopsie osseuse dans un mois.
Ancien Assistant des Hôpitaux de
Toulouse
Praticien Hospitalier contractuel Traitement de sortie :
RPPS : [RPPS]
inchangé
Dr [NOM]
Praticien Hospitalier contractuel
RPPS : [RPPS]
Dr [NOM] Les consignes d'usage ont été remises.
Praticien Hospitalier contractuel
Secrétariat : [TEL]
CENTRE DE COMPETENCES
DES MALADIES AUTO IMMUNES Bien confraternellement,
ET AUTO-INFLAMMATOIRES
SYSTEMIQUES RARES :
Médecin coordonnateur :
Dr [NOM]
Secrétariat : [TEL]
[EMAIL] Docteur [NOM]
Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (RHUMATOLOGIE)
V1 - Imprimé le 17/04/2025 à 11 : 24 par Page(s): 2 sur 3 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
PÔLE MÉDECINE INTERNE
SERVICE RHUMATOLOGIE - MEDECINE INTERNE
ET IMMUNOLOGIE CLINIQUE - DERMATOLOGIE
RHUMATOLOGIE *[TEL]*
Dr [NOM]
Chef de [MASK] [ETABLISSEMENT] [TEL]
de Paris
Praticien hospitalier
RPPS : [RPPS]
Dr [NOM]
Ancien Chef de [ETABLISSEMENT]
de Bordeaux Liste des destinataires :
Praticien Hospitalier
N ° RPPS : [RPPS] DR. [NOM]
Dr [NOM]. [NOM] [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]
Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (RHUMATOLOGIE)
V1 - Imprimé le 17/04/2025 à 11 : 24 par Page(s): 3 sur 3

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N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
ICANCE - Institut de Bayonne, le 17/09/2023
Cancérologie Navarre Côte
B Ma msq eu Ce
[NOM] [NOM], [NOM] de
DR [NOM]
fédération [ADRESSE]
Dr [NOM], [CODE_POSTAL]
coordonnateur médical de
fédération
Mon cher confrère,
Praticiens Hospitaliers :
Dr T. [NOM] Votre patiente [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisée dans le service du 13/09/2023 au 17/09/2023 pour le motif
Oncologie médicale suivant :
Chef de [MASK]. [NOM] - Motif d'hospitalisation :
Oncologie médicale C3 d’IVADO (sans vincristine) en néoadjuvant d’un rabdomyosarcome de la gencive maxillaire gauche.
Dr G. [NOM] Antécédents :
Oncologie médicale Médicaux : Tumeur du péroné gauche traitée par chirurgie et ZOMETA en 2006.
Dr F. [NOM]
[NOM] habituels :
Oncologie médicale
SERESTA 10 mg
Dr F. DA [NOM] PARACETAMOL 1g : si besoin
Oncologie médicale OXYCONTIN LP 10 mg : 1-0-1
OXYNORMORO 5mg : si besoin
Dr A. [NOM]
Soins de support oncologiques Allergies :
Soins palliatifs
Aucune
Dr T. [NOM]
Oncologie Mode de vie :
Tel : [TEL] (secrétariat) 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
Oncogénétique :
Dr S. [NOM] Histoire de la maladie :
Médecin généticien 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.
Mme A. [NOM]
Août 2023 : réévaluation par IRM après 2 cures : début d’ébauche thérapeutique. Neuropathie de grade 2. Poursuite pour
Conseillère en génétique
deux cures supplémentaires avant geste chirurgical prévu le 23/10/2023.
[NOM] de Service : Par la suite, 5 cures d’IVA seront réalisées (idéalement début 2-3 semaines après l’exérèse chirurgicale).
Mme F. [NOM]
Tel : [TEL] Intercure :
Neuropathie de grade 2 : arrêt de la vincristine au J8 et J15.
Hospitalisation conventionnelle : Nausées grade 1 les 3 jours suivant la chimiothérapie.
Renseignements familles
Mucite grade 2 d’évolution favorable sous fungizone.
Tel : [TEL]
Douleurs gingivales prédominant la nuit, avec 2 interdoses la nuit.
Secrétariat Oncologie : Consultation avec le Dr [NOM] (cf histoire de la maladie).
[NOM] et RDV - Consultations
Tel : [TEL] Examen clinique :
[EMAIL] Patiente OMS 1, poids relativement stable à 49.8kg
Tachycardie régulière
Secrétariat Oncogénétique :
Pas de signe de décompensation cardiaque
Tel : [TEL]
[EMAIL] Tumeur bourgeonante de la gencive gauche
Reste de l’examen sans particularité
[ETABLISSEMENT] :
Acceuil et Programmation Examens complémentaires :
Tel : [TEL] Bilan biologique du 11/09/2023 :
[EMAIL] 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] / [EPISODE] (ONCOLOGIE HC)
V1 - Imprimé le 22/04/2025 à 10 : 53 par Page(s): 1 sur 2 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
ICANCE - Institut de Prévention primaire de la neutropénie fébrile par une injection de PELMEG à J5.
Cancérologie Navarre Côte
Basque Tachycarde à 120 en fin d'hospitalisation sans signe clinique associé. ECG : tachycardie sinusale.
Mme [NOM] [NOM], [NOM] de BS de contrôle 17/09 Hb 8.9 gdl-1 : 1 CGR le 17/09
fédération
Dr [NOM],
[NOM] de sortie :
coordonnateur médical de
fédération Inchangé sauf :
-Majoration OXYCONTIN LP à 15mg le soir, maintien 10mg le matin.
Praticiens Hospitaliers : -Bains de bouche bicarbonate de sodium avec SOLUPRED 60mg dans la bouteille
Dr T. [NOM]
Oncologie médicale Conclusion :
Chef de service C3 d’IVADO (sans vincristine) en néoadjuvant d’un rabdomyosarcome de la gencive maxillaire gauche.
Bonne tolérance immédiate.
Dr L. [NOM] Transfusion d'un 1 CGR le 17/09
Oncologie médicale
Prochaine venue dans 3 semaines pour le C4.
Dr G. [NOM]
Oncologie médicale Prochains rendez-vous :
C4 le 04/10.
Dr F. [NOM] Chirurgie le 23/10.
Oncologie médicale Prévoir reprise chimiothérapie par IVA 2-3 semaines maximum après la chirurgie.
Dr F. DA [NOM]
Oncologie médicale
Dr A. [NOM]
Soins de support oncologiques
Soins palliatifs
Dr T. [NOM] Les consignes d'usage ont été remises.
Oncologie
Tel : [TEL] (secrétariat)
Oncogénétique :
Dr S. [NOM] Bien confraternellement,
Médecin généticien
Mme A. [NOM]
Conseillère en génétique
Docteur [NOM]
[NOM] de Service : *[TEL]*
Mme F. [NOM]
Tel : [TEL]
[TEL]
Hospitalisation conventionnelle :
Renseignements familles
Tel : [TEL]
Secrétariat Oncologie : Rédigé par [NOM]
[NOM] et RDV - Consultations
Tel : [TEL]
[EMAIL]
Secrétariat Oncogénétique : Liste des destinataires:
Tel : [TEL]
DR. [NOM]
[EMAIL]
[ETABLISSEMENT] :
Acceuil et Programmation
Tel : [TEL]
[EMAIL]
Patient(e) : [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (ONCOLOGIE HC)
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{"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": "IPP", "original": "23026373", "placeholder": "[IPP]", "bbox_hint": null}
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714
regression_tests/baseline/CRH 23194278.pseudonymise.txt Normal file
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@@ -0,0 +1,714 @@
N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
ICANCE - Institut de Cancérologie Bayonne, le 12/10/2023
Navarre Côte Basque
Mme [NOM], cadre de
fédération MME [NOM]
Dr [NOM], coordonnateur [ADRESSE]
médical de fédération [CODE_POSTAL]
Chef de [MASK] [NOM] Mon cher confrère,
[NOM]
[EMAIL]
Votre patiente [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisée dans le service du 09/10/2023 au 10/10/2023 pour le motif
Cadre de [MASK] [NOM]
suivant :
Chef de Service - [NOM]
Dr [NOM]
Pneumologue - Motif d'hospitalisation : exacerbation de BPCO
DESC Cancérologie
[EMAIL]
Correspondants :
P Dr ra Dtic ai nen ies
l
H Bo Osp Nit Nal Eie Trs Médecin traitant : Dr [NOM] (Vaires sur Marne)
Pneumologue Pneumologue : Dr [NOM] (Chesse)
DESC [NOM]
[EMAIL] Antécédents :
Dr [NOM] - BPCO
Pneumologue - Dyslipidémie
DESC Cancérologie - Dépression
[EMAIL] - fractures orteils à droite
Dr [NOM]
Pneumologue Allergies :
DESC Cancérologie
[EMAIL] Aucunes connues
Dr [NOM]
Pneumologue [NOM] habituels :
Médecin du Sport - [NOM] [TEL]
[EMAIL] - Lamictal 50 1-0-1
Dr [NOM] - Sertraline 50 1-1-0
Pneumologue - Allergologue - Theralene 5 2-0-0
DESC Réanimation Médicale - simvastatine 10 0-0-1
[EMAIL] - tedralan LP 200 1-0-1
Dr [NOM] - oxazepam 10 0-0-1
Pneumologue - [TEL]
[EMAIL]
Dr [NOM]
- ventoline 2/j
Pneumologue
DESC Cancérologie Mode de vie :
[EMAIL] A la retraite , travaillait à la bourse américaine
Dr [NOM] en vacances au [NOM], était sur le trajet pour rentrer chez elle en région parisienne
Pneumologue Vit avec son marie , sédentarité importante depuis 6/7 mois dans un contexte d'asthénie : c'est son mari qui s'occupe des
DESC Cancérologie courses de la cuisine et du ménage
[EMAIL] A des enfants
Cadre de Santé :
Mme [NOM] [NOM] Toxiques :
Tel : [TEL] Tabac sevré depuis janvier 2023 , commencé à 17 ans : 30 PA
Secrétariat Médical Pas de canabis
Tel : [TEL]
Tel : [TEL] Histoire de la maladie :
[EMAIL] Se sent asthénique depuis 6 mois associée à une anorexie sans perte de poids
Hospitalisation Etait en vacances au [NOM] avec son mari
Chambres 3760 à 3772 Présente une dyspnée progressive depuis plusieurs jours sans notion de fièvre mais avec une toux et des crachats
Tel : [TEL] qui deviennent plus abondants et colorés
Chambres 3773 à 3783
Tel : [TEL]
Cliniquement aux urgences :
Explorations Endoscopies
Tel : [TEL] A l arrivée FR 32 signes de luttes respi pas de sueurs
finit ses phrases
Centre de Lutte Anti Tuberculeuse
C.L.A.T.
expiration à lèvres pincées
Tel : [TEL] abdo souple indolore
sibilants bilatéraux+++ pas de crépitants
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par Page(s): 1 sur 4 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
ICANCE - Institut de Cancérologie
Navarre Côte Basque PEC initiale aux urgences
Mme [NOM], cadre de --> série de 3 aérosols + Augmentin + solumedrol
fédération
Dr [NOM], coordonnateur
médical de fédération [NOM] complémentaires aux urgences :
Chef de [MASK] :
Dr [NOM] [NOM] Hb 13.4 : plaquettes 290 ; leuco 10.2 dont PNN 8.33
[NOM] Pas de troubles ioniques
[EMAIL]
CRP 149
C
M
a mdr ee Cd he rP iô stle
elle [NOM]
P AC ST
A
T0 . 50 89
: ALAT 32
Chef de [MASK] 253 : PAL 130
Dr [NOM] [NOM] tropo 44 : T pro BNP 273
Pneumologue
DESC Cancérologie
[EMAIL] [NOM] sous 2L : pH 7.4 ; pO2 102 pCO2 43 bicar 26.5
Praticiens Hospitaliers
Dr [NOM] [NOM] [NOM] :
Pneumologue PCR covid grippe et VRS négative
DESC [NOM]
[EMAIL] Radio de thorax :
Dr [NOM] ne met pas en évidence de foyer infectieux parenchymateux.
Pneumologue Pas de signe d'épanchement pleural.
DESC Cancérologie Aspect normal de la silhouette cardio-médiastinale. Lésion nodulaire d'allure spiculée en projection de la base droite :
[EMAIL]
Dr [NOM]
lésion parenchymateuse versus mammaire à confronter à distance un scanner dédiée. De la base droite
Pneumologue
DESC Cancérologie ECG : RRS qrs fins pas de trouble de repolarisation pas de s1q3
[EMAIL]
Dr [NOM] [NOM] en pneumologie pour la suite de la prise en charge
Pneumologue
Médecin du Sport
[EMAIL]
Dr [NOM] [NOM] Evolution :
Pneumologue - Allergologue Interrogatoire :
DESC Réanimation Médicale
[EMAIL] M'explique qu'une dyspnée avec majoration de la quantité et la purulence des crachats depuis quelques jours mais n'y a pas
Dr [NOM]
trop prête attention car elle était en vacances
Pneumologue Consulte aux urgences devant la dyspnée qui est devenue trop importante
[EMAIL]
Dr [NOM] Elle m'explique aussi qu'elle présente depuis 6/7 mois une asthénie importante l'empêchant de réaliser seule les AVQ
Pneumologue En parallèle : anorexie sans perte de poids objectivée
DESC Cancérologie
[EMAIL] Cliniquement à l'arrivée en pneumologie :
Dr [NOM] 100% sous 1 L aux lunettes
Pneumologue Non dyspnéique au repos
DESC Cancérologie Dyspnée au moindre effort dans un contexte de probable déconditionnement cardio respi
[EMAIL]
C Ma mdr ee Mde
a
S ria ln yt né :
[NOM]
P [NOM]
u
xd e
e
ts i cg rn ace hs ad te
s
d saé lt ere ssse respiratoire, non polypnéique , pas de tirage
Tel : [TEL]
Pas d'hémoptysie
Secrétariat Médical Auscultation : sibilants avec frein expiratoire
Tel : [TEL]
Tel : [TEL]
[EMAIL] Pas de douleurs thoraciques
Légers OMI prenant le godet
Hospitalisation
Chambres 3760 à 3772
Mollets souples et non douloureux
Tel : [TEL]
Chambres 3773 à 3783 Pas de plaintes abdominales ni urinaires
Tel : [TEL]
Explorations Endoscopies CAT :
Tel : [TEL] Tentative de diminution de l'O2 pour sevrage rapide
Centre de Lutte Anti Tuberculeuse Poursuite aérosol, Augmentin 1g x 3 et Solupred 40 mg
C.L.A.T. Intérêt à consulter son pneumologue dans le mois qui arrive avec un scanner thoracique
Tel : [TEL]
93% en AA, apyrétique
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par Page(s): 2 sur 4 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [[TEL]] - Fax : [[TEL]]
[[TEL]]
[MASK]
[MASK]
ICANCE - Institut de Cancérologie Expectoration sale, encombrement prédominant aux bases, non spastique, pas de signes de luttes
Navarre Côte Basque Autonome dans les AVQ sans désaturation
Mme [NOM], cadre de transit et appétit conservé
fédération
Dr [NOM], coordonnateur
médical de fédération Pas de plaintes
Chef de [MASK] (ordo imprimés dans le dossier)
Dr [NOM]
[NOM] Poursuite AUGMENTIN/ CTC/ Aerosol
[EMAIL]
[NOM] drainage
C
M
a mdr ee Cd he rP iô stle
elle [NOM]
T vaD cM
cin
t h go rir pa px
e
et consult pneumo
Chef de Service 11/10/23 CNE
Dr [NOM] exacerbation de BPCO aujourd'hui pas encore bien contrôlée
Pneumologue apyrétique, [NOM] correcte
DESC Cancérologie
[EMAIL] poursuite de la même prise en charge
le mari de la patiente souhaite un rapatriement => doit contacter son assurance pour qu'ils nous appellent
Praticiens Hospitaliers
Dr [NOM] [DATE_NAISSANCE] CNE
Pneumologue lettre Dr [NOM] : emphysème sur le scanner avec syndrome obstructif (VEMS à 48% soit 660 ml), distension vraie
DESC [NOM] associée (CPT : 130%, VR : 230%)
[EMAIL] ttt par trimbow nexthaler : 2bX2/j
Dr [NOM]
Pneumologue ce jour la patiente va bien
DESC Cancérologie auscultation : RAS
[EMAIL]
Dr [NOM]
retour à domicile avec rapatriement demain
Pneumologue
DESC Cancérologie
[EMAIL]
Dr [NOM]
Votre patient(e) quitte le service avec :
Pneumologue - Pharmacie :
Médecin du Sport LACTEOL 340MG PDR [NOM] [10] Sachet(s) 1 SACHET (ORALE) matin midi soir
j Dpm
r
[EMAIL] L AO MX OE XN
/A
L CP C50 LM [NOM] SG DE ZL U 1GL /E
1
2[6 50 M] GG e Alu Dle S(s A) C1 HG E [1L 2U
]
SL aE
c
h(O etR (sA
)
L
1
E G) (m Oa Rti An Lso Ei )r m(8 ah
t
i-
n
1 m9h id)
i soir
Pneumologue - Allergologue LAMICTAL 25MG CPR DISP [30] COMPRIME(S) 2 COMPRIME (ORALE) matin soir (8h - 19h)
DESC Réanimation Médicale
[EMAIL] LOSARTAN EG 50MG CPR [90] COMPRIME(S) 1 COMPRIME (ORALE) matin [8h]
Dr [NOM]
SERESTA 10MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) nuit [21h]
Pneumologue SIMVASTATINE AHL 20MG CPR [28] COMPRIME(S) .5 COMPRIME (ORALE) soir [19h]
[EMAIL] THERALENE 5MG CPR [50] COMPRIME(S) 2 COMPRIME (ORALE) matin [8h]
Dr [NOM] [NOM] 5/7.2MCG INH 120 D [120] REC. UNIDOSE(s) 2 UNIDOSE (INHALEE) en direct matin soir
Pneumologue (8h - 19h)
DESC Cancérologie
[EMAIL]
Dr [NOM] [NOM] Conclusion :
Pneumologue - Exacerbation aigue d'une BPCO post tabagique chez une [AGE] sur probable surinfection bronchique
DESC Cancérologie
[EMAIL] sans documentation microbiologique d'évolution favorable.
Cadre de Santé :
Mme [NOM]
Traitement de sortie :
Tel : [[TEL]] -AUGMENTIN 1g/8h jusqu’au 16/10 inclus
-PARACETAMOL 1g/6h si douleurs
Secrétariat Médical
Tel : [[TEL]]
-SOLUPRED 40mg le matin jusqu’au 13/10
Tel : [[TEL]]
[EMAIL] Ventoline 5mg/2mL solution inhalée 1 aérosol 3 fois par jour si besoin
Hospitalisation Atrovent 0.5mg/1mL solution inhalée 1 aérosol 3 fois par jour si besoin
Chambres 3760 à 3772 Location d’appareil pour aérosol pneumatique
Tel : [[TEL]]
Chambres 3773 à 3783 Poursuit du traitement habituel par ailleurs
Tel : [[TEL]]
Explorations Endoscopies Suite de prise en charge :
Tel : [TEL] Kinésithérapie drainage
Centre de Lutte Anti Tuberculeuse Vaccination anti grippale
C.L.A.T. TDM thoracique non injecté low dose
Tel : [[TEL]] Consultation pneumologue
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par Page(s): 3 sur 4 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [[TEL]] - Fax : [[TEL]]
[[TEL]]
[MASK]
[MASK]
ICANCE - Institut de Cancérologie
Navarre Côte Basque
Mme [NOM], cadre de
fédération Les consignes d'usage ont été remises.
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK] [NOM] Bien confraternellement,
[NOM]
[EMAIL]
Cadre de [MASK] [NOM]
Docteur [NOM]
Chef de [MASK] [NOM] *[[TEL]]*
Pneumologue
DESC Cancérologie
[EMAIL] [[TEL]]
Praticiens Hospitaliers
Dr [NOM]
Pneumologue
DESC [NOM]
[EMAIL] Liste des destinataires :
Dr [NOM] Madame [NOM] [NOM]
Pneumologue Dr [NOM]
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]]
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par Page(s): 4 sur 4 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
ICANCE - Institut de Cancérologie Bayonne, le 12/10/2023
Navarre Côte Basque
Mme [NOM], cadre de
fédération DR [NOM]
Dr [NOM], coordonnateur [ADRESSE]
médical de fédération [CODE_POSTAL]
DR [NOM]
Chef de [MASK] [NOM]
[ADRESSE]
[NOM] [CODE_POSTAL]
[EMAIL]
C Ma mdr ee Cd he rP iô stle
elle [NOM]
Mon cher confrère,
Chef de [MASK] [NOM] [NOM] [DATE_NAISSANCE] a été hospitalisée dans le service du 09/10/2023 au 10/10/2023 pour le motif
Dr [NOM] [NOM] suivant :
Pneumologue
DESC Cancérologie - Dyspnée
[EMAIL]
P Dr ra Dtic ai nen ies
l
H Bo Osp Nit Nal Eie Trs - Motif d'hospitalisation : exacerbation de BPCO
Pneumologue
DESC [NOM] Correspondants :
[EMAIL] Médecin traitant : Dr [NOM] (Vaires sur Marne)
Dr [NOM] [NOM] Pneumologue : Dr [NOM] (Chesse)
Pneumologue
DESC Cancérologie Antécédents :
[EMAIL] - BPCO
Dr [NOM] - Dyslipidémie
Pneumologue - Dépression
DESC Cancérologie
[EMAIL] - fractures orteils à droite
Dr [NOM]
Pneumologue Allergies :
Médecin du Sport Aucunes connues
[EMAIL]
Dr [NOM] [NOM] [NOM] habituels :
Pneumologue - Allergologue - [NOM] [TEL]
DESC Réanimation Médicale - Lamictal 50 1-0-1
[EMAIL] - Sertraline 50 1-1-0
Dr [NOM] - Theralene [TEL]
Pneumologue - simvastatine 10 0-0-1
[EMAIL]
Dr [NOM]
-
-
t oe xd ar za ela pn
a
mL P
[TEL]
-
[TEL]
Pneumologue
DESC Cancérologie - cozaar 50 1-0-0
[EMAIL] - ventoline 2/j
Dr [NOM]
Pneumologue Mode de vie :
DESC Cancérologie A la retraite , travaillait à la bourse américaine
[EMAIL] [NOM] en vacances au [NOM], était sur le trajet pour rentrer chez elle en région parisienne
Cadre de Santé : Vit avec son marie , sédentarité importante depuis 6/7 mois dans un contexte d'asthénie : c'est son mari qui s'occupe des
Mme [NOM] courses de la cuisine et du ménage
Tel : [TEL] A des enfants
Secrétariat Médical
Tel : [TEL] Toxiques :
Tel : [TEL] Tabac sevré depuis janvier 2023 , commencé à 17 ans : 30 PA
[EMAIL] Pas de canabis
Hospitalisation
Chambres 3760 à 3772 Histoire de la maladie :
Tel : [TEL] Se sent asthénique depuis 6 mois associée à une anorexie sans perte de poids
Chambres 3773 à 3783
Tel : [TEL] Etait en vacances au [NOM] avec son mari
Présente une dyspnée progressive depuis plusieurs jours sans notion de fièvre mais avec une toux et des crachats
Explorations Endoscopies
Tel : [TEL] qui deviennent plus abondants et colorés
Centre de Lutte Anti Tuberculeuse
C.L.A.T.
Cliniquement aux urgences :
Tel : [TEL] 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] / [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par Page(s): 1 sur 4 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
ICANCE - Institut de Cancérologie expiration à lèvres pincées
Navarre Côte Basque abdo souple indolore
Mme [NOM], cadre de sibilants bilatéraux+++ pas de crépitants
fédération
Dr [NOM], coordonnateur
médical de fédération PEC initiale aux urgences
--> série de 3 aérosols + Augmentin + solumedrol
Chef de [MASK] [NOM] [NOM] [NOM] complémentaires aux urgences :
[NOM]
[EMAIL]
Bio :
C
M
a mdr ee Cd he rP iô stle
elle [NOM]
H Pab
s
1 d3 e. 4
tr
o : up bla leq su e iott ne is
q
2 u9 es0 : leuco 10.2 dont PNN 8.33
Chef de [MASK] 149
Dr [NOM] 0.09
Pneumologue ASAT 58 : ALAT 32
DESC Cancérologie
[EMAIL] Cholestase avec GGT 253 : PAL 130
tropo 44 : T pro BNP 273
Praticiens Hospitaliers
Dr [NOM]
Pneumologue [NOM] sous 2L : pH 7.4 ; pO2 102 pCO2 43 bicar 26.5
DESC [NOM]
[EMAIL] [NOM] :
Dr [NOM] PCR covid grippe et VRS négative
Pneumologue
DESC Cancérologie Radio de thorax :
[EMAIL]
Dr [NOM]
O Pan
s
n de
e
m sie gt
n
p ea ds
'
ée pn
a
é nv ci hd ee mnc ee
n
td pe
l
efo uy rae lr
.
infectieux parenchymateux.
Pneumologue
DESC Cancérologie Aspect normal de la silhouette cardio-médiastinale. Lésion nodulaire d'allure spiculée en projection de la base droite :
[EMAIL] lésion parenchymateuse versus mammaire à confronter à distance un scanner dédiée. De la base droite
Dr [NOM]
Pneumologue ECG : RRS qrs fins pas de trouble de repolarisation pas de s1q3
Médecin du Sport
[EMAIL] [NOM] en pneumologie pour la suite de la prise en charge
Dr [NOM]
Pneumologue - Allergologue
DESC Réanimation Médicale
c Dn ro c [NOM] [EMAIL] Evolution :
Pneumologue Interrogatoire :
[EMAIL] M'explique qu'une dyspnée avec majoration de la quantité et la purulence des crachats depuis quelques jours mais n'y a pas
Dr [NOM] trop prête attention car elle était en vacances
Pneumologue Consulte aux urgences devant la dyspnée qui est devenue trop importante
DESC Cancérologie
[EMAIL] Elle m'explique aussi qu'elle présente depuis 6/7 mois une asthénie importante l'empêchant de réaliser seule les AVQ
Dr [NOM] [NOM] En parallèle : anorexie sans perte de poids objectivée
Pneumologue
DESC Cancérologie Cliniquement à l'arrivée en pneumologie :
[EMAIL]
[NOM] 100% sous 1 L aux lunettes
C Ma mdr ee Mde
a
S ria ln yt né :
[NOM]
N [NOM] sn
p
d ny és ep an ué i mqu oe
in
a du
r
er e ep fo fos
rt dans un contexte de probable déconditionnement cardio respi
Tel : [TEL]
Secrétariat Médical Pas de signes de détresse respiratoire, non polypnéique , pas de tirage
Tel : [TEL] Toux et crachats sales
Tel : [TEL]
[EMAIL] Pas d'hémoptysie
Auscultation : sibilants avec frein expiratoire
Hospitalisation
Chambres 3760 à 3772
Tel : [TEL] Pas de douleurs thoraciques
Chambres 3773 à 3783 Légers OMI prenant le godet
Tel : [TEL] Mollets souples et non douloureux
Explorations Endoscopies
Tel : Poste [TEL] Pas de plaintes abdominales ni urinaires
Centre de Lutte Anti Tuberculeuse
C.L.A.T. CAT :
Tel : [TEL] 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] / [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par Page(s): 2 sur 4 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [[TEL]] - Fax : [[TEL]]
[[TEL]]
[MASK]
[MASK]
ICANCE - Institut de Cancérologie Intérêt à consulter son pneumologue dans le mois qui arrive avec un scanner thoracique
Navarre Côte Basque
Mme [NOM], cadre de 93% en AA, apyrétique
fédération Expectoration sale, encombrement prédominant aux bases, non spastique, pas de signes de luttes
Dr [NOM], coordonnateur
médical de fédération Autonome dans les AVQ sans désaturation
transit et appétit conservé
Chef de [MASK] [NOM] Pas de plaintes
[NOM]
[EMAIL]
RAD Paris demain si évolution favorable (ordo imprimés dans le dossier)
Cadre de Pôle
M me [NOM] [NOM] Poursuite AUGMENTIN/ CTC/ Aerosol
Chef de [MASK] [NOM] TDM thorax et consult pneumo
Pneumologue vaccin grippe
DESC Cancérologie
[EMAIL] 11/10/23 CNE
exacerbation de BPCO aujourd'hui pas encore bien contrôlée
Praticiens Hospitaliers
Dr [NOM] apyrétique, [NOM] correcte
Pneumologue poursuite de la même prise en charge
DESC [NOM] le mari de la patiente souhaite un rapatriement => doit contacter son assurance pour qu'ils nous appellent
[EMAIL] 12/10/23 CNE
Dr [NOM] [NOM] lettre Dr [NOM] : emphysème sur le scanner avec syndrome obstructif (VEMS à 48% soit 660 ml), distension vraie
Pneumologue associée (CPT : 130%, VR : 230%)
DESC Cancérologie ttt par trimbow nexthaler : 2bX2/j
[EMAIL]
Dr [NOM] ce jour la patiente va bien
Pneumologue
DESC Cancérologie auscultation : RAS
[EMAIL] retour à domicile avec rapatriement demain
Dr [NOM]
Pneumologue
Médecin du Sport
[EMAIL] Votre patient(e) quitte le service avec :
Dr [NOM] [NOM] - Pharmacie :
Pneumologue - Allergologue LACTEOL 340MG PDR [NOM] [10] Sachet(s) 1 SACHET (ORALE) matin midi soir
DESC Réanimation Médicale
[EMAIL] LOXEN LP 50MG GELULE [60] Gelule(s) 1 GELULE (ORALE) matin soir (8h - 19h)
Dr [NOM]
AMOX/AC CLAV SDZ 1G/125MG AD SACH [12] Sachet(s) 1 G (ORALE) matin midi soir
Pneumologue LAMICTAL 25MG CPR DISP [30] COMPRIME(S) 2 COMPRIME (ORALE) matin soir (8h - 19h)
[EMAIL] LOSARTAN EG 50MG CPR [90] COMPRIME(S) 1 COMPRIME (ORALE) matin [8h]
Dr [NOM] SERESTA 10MG CPR [30] COMPRIME(S) 1 COMPRIME (ORALE) nuit [21h]
Pneumologue SIMVASTATINE AHL 20MG CPR [28] COMPRIME(S) .5 COMPRIME (ORALE) soir [19h]
DESC Cancérologie THERALENE 5MG CPR [50] COMPRIME(S) 2 COMPRIME (ORALE) matin [8h]
[EMAIL] [NOM] [NOM] 5/7.2MCG INH 120 D [120] REC. UNIDOSE(s) 2 UNIDOSE (INHALEE) en direct matin soir
Dr [NOM] (8h - 19h)
Pneumologue
DESC Cancérologie
s [EMAIL] Conclusion :
Cadre de Santé :
Mme [NOM]
- Exacerbation aigue d'une BPCO post tabagique chez une [AGE] sur probable surinfection bronchique
Tel : [[TEL]] sans documentation microbiologique d'évolution favorable.
Secrétariat Médical
Tel : [[TEL]]
Traitement de sortie :
Tel : [[TEL]] -AUGMENTIN 1g/8h jusqu’au 16/10 inclus
[EMAIL] -PARACETAMOL 1g/6h si douleurs
Hospitalisation -SOLUPRED 40mg le matin jusqu’au 13/10
Chambres 3760 à 3772
Tel : [[TEL]] Ventoline 5mg/2mL solution inhalée 1 aérosol 3 fois par jour si besoin
Chambres 3773 à 3783 Atrovent 0.5mg/1mL solution inhalée 1 aérosol 3 fois par jour si besoin
Tel : [[TEL]] Location d’appareil pour aérosol pneumatique
Explorations Endoscopies
Tel : [TEL] Poursuit du traitement habituel par ailleurs
Centre de Lutte Anti Tuberculeuse
C.L.A.T. Suite de prise en charge :
Tel : [[TEL]] Kinésithérapie drainage
Vaccination anti grippale
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par Page(s): 3 sur 4 N° Finess [MASK]
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
☎ [TEL] - Fax : [TEL]
[TEL]
[MASK]
[MASK]
ICANCE - Institut de Cancérologie TDM thoracique non injecté low dose
Navarre Côte Basque Consultation pneumologue
Mme [NOM], cadre de
fédération
Dr [NOM], coordonnateur
médical de fédération
Chef de [MASK].
Dr [NOM]
[NOM]
[EMAIL]
Cadre de [MASK] [NOM]
Bien confraternellement,
Chef de [MASK] [NOM]
Pneumologue
DESC Cancérologie Docteur [NOM]
[EMAIL] *[TEL]*
Praticiens Hospitaliers
Dr [NOM]
Pneumologue [TEL]
DESC [NOM]
[EMAIL]
Dr [NOM]
Pneumologue
DESC Cancérologie Liste des destinataires :
[EMAIL]
Dr [NOM]
M [NOM] kd aa bm be
a
nK [NOM] [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]
Patient(e) : [NOM] [NOM] [NOM] [NOM] [NOM] Né(e) le [DATE_NAISSANCE]
IPP : [IPP] / [EPISODE] (PNEUMOLOGIE PHTISIOLOGIE HC)
V1 - Imprimé le 23/04/2025 à 14 : 29 par Page(s): 4 sur 4

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{"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": "Anne BANOS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Clinique des Hôpitaux de Bordeaux Docteur Pierre COUDANNE", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64240 URT", "placeholder": "[CODE_POSTAL]", "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": "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": 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": "Julie GAY Lumbago", "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": 1, "kind": "DATE_NAISSANCE", "original": "né le 20/02/1981", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 1, "kind": "NOM", "original": "COUDANNE Pierre", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "DATE_NAISSANCE", "original": "né le 20/02/1981", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "COUDANNE Pierre", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 2, "kind": "NOM", "original": "Sophie BERNARD", "placeholder": "[NOM]", "bbox_hint": null}

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C E N T R E H O S P I T A L I E R D E L A C ÔT E B A S Q U E
 [ADRESSE]’Interne [ETABLISSEMENT] - B.P. 8 – [CODE_POSTAL]
[MASK]
[TEL]
*[TEL]* [MASK]
 Secrétariat : [TEL]/34 - Télécopie : [TEL]
 Secteur Conventionnel- [TEL] -  Secteur protégé : [TEL].
 [ETABLISSEMENT] : Secrétariat [TEL] Télécopie [TEL]
Médecin Chef de [MASK] : SB/LL
Dr [NOM] Bayonne, le [DATE_NAISSANCE]
Ancien Interne des Hôpitaux de Lille
Ancien Chef de [ETABLISSEMENT]
AVENUE [NOM]
[CODE_POSTAL]
Praticiens Hospitaliers
Dr [NOM]
Cher Confrère,
Dr [NOM]
Monsieur [NOM], [DATE_NAISSANCE], a été hospitalisé dans le service
d'hématologie du 27 mars au [DATE_NAISSANCE] pour 1ère cure de R-CYVE pour un lymphome de
Dr [NOM]
[NOM].
Dr [NOM] ANTECEDENTS
Dr [NOM] [NOM] [NOM] :
Maladie d’Hashimoto non traitée
Dr [NOM] il y a 5ans
Dr [NOM] [NOM] Allergies : NC
Dr [NOM] [NOM] [NOM] habituels :
BACTRIM FORTE : 1cp/j Lun Me Ve
LEDERFOLINE 25 : 1/sem
VALACICLOVIR 500 : 2/jour
SYMBICORT.
Cadres de santé
Mme [NOM] Bilan pré-thérapeutique
Cadre de [MASK] 19 : Vaccination à jour dont covid x 3 et infection en juillet 2022
VIH – VHB – VHC : négatives le 10/02/23.
Mme [NOM]
Cadre Infirmier ETT : FEVG 63%, sans anomalie retrouvé
Secteur Conventionnel
MODE DE VIE
Mr [NOM] Médecin généraliste à [VILLE]
Cadre Infirmier
Hospitalisation de Jour 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
Secrétariat Médical
Loisirs : tennis
Consultations :
 : [TEL] HISTOIRE DE LA MALADIE
Fax : [TEL] Notion de soins dentaires le 18/01 (détartrage, carie).
[EMAIL] Apparition le 21/01 de douleurs lombaires de type sciatalgie tronquée bilatérale d’horaire
inflammatoire, non soulagées par AINS.
Secr.Hospitalisation Hématologie : Douleur dentaire gauche automédiquée par AUGMENTIN depuis le 26/01. Mise sous
 : [TEL] antalgiques pallier 3.
Fax : [TEL] Le 28/01 au soir, sensation de sueurs avec frissons, subfébrile à 38°C.
[EMAIL] Majoration des douleurs osseuses.
Accueil / Programmation Le patient consulte aux urgences pour suspicion de spondylodiscite. Aux urgences :
[ETABLISSEMENT] :
- sur le plan biologique : LDH 1100UI/l, CRP 120mg/l, myélémie à 6%, CMF B sans
 : [TEL]
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 [NOM] (28/03/23 - Dr [NOM]) : Lésion de 9-10 mm centrée sur la commissure
intermaxillaire gauche bien limitée sans infiltration des structures adjacentes, non évolutive
comparativement aux imageries antérieures dont la caractérisation est difficile mais paraissant
atypique pour de l'atteinte lymphomateuse au vu de l'évolutivité. L'hypothèse d'une tumeur
nerveuse reste possible (schwannome). À confronter à l'évolution
INTERCURE
Fièvre vespérale du 22 au 25/03/23 - associée à des diarrhées
Introduction d'Augmentin le 25/03/23 en HDJ
Prélèvement microbio négatifs.
Se sent beaucoup mieux depuis hier. Monsieur [NOM], [DATE_NAISSANCE] – 3
BILAN BIOLOGIQUE
27/03/23
Hb = 9.6 - plqt = 418 - GB = 10.4
LDH normales - BHC normal - Préalb = 0.17 - Alb = 39
Créat = 67
EXAMEN PHYSIQUE
PS = 0
Pas de syndrome tumoral palpable
Examen neurologique normal
Auscultation cardiopulmonaire normale.
EVOLUTION HOSPITALISATION
Sur le plan hématologique :
J1C1 R-CYVE le 28/03/23
Rituximab 375 mg/m2 soit 750 mg DT J1
Cytarabine 100mg/12h J1 à J5
Cytarabine HD 2000 mg/m2 soit 4000 mg DT J2 à J5
Etoposide 200mg/m2 soit 400 mg J2 à J5
PL triple (rattrapage COP) le 29/03/23 : 1 élément.
Bonne tolérance de la chimiothérapie.
Sur le plan infectieux
Pas de récidive fébrile en hospitalisation.
TRAITEMENT DE SORTIE
BACTRIM FORTE : 1cp/j Lun Me Ve
LEDERFOLINE 25 : 1/sel
VALACICLOVIR 500 : 2/jour
LANSOPRAZOLE 15 : 1/jour
Duphalac et Paracetamol si besoin
SYMBICORT
CONCLUSION : 1ère cure de R-CYVE pour un lymphome de Burkitt traité dans le
groupe C3 du LMB02.
PROCHAIN RDV :
RAD
HDJ transfusionnels demandés avec fiche de consigne transfusionnelle.
R-CYVE n2 en hospitalisation le 24/04/2023
TEP + IRM post R-CYVE n2 demandés.
Patient informé de la prise en charge thérapeutique et ou sa personne de confiance.
Bien confraternellement.
Docteur [NOM]
Courrier lu et validé par le médecin

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

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CROp [NOM] - [NOM], [NOM] [NOM]
____________________________________________________________________________________________________________________________________________
Compte rendu opératoire
>>>1 CRO type chirurgie viscérale 06/05/23 10 : 32 (mod. le 12/05/23 12:23 par [NOM] An
LE/ AA
Bayonne, le 11 mai 2023
Docteur [NOM]
[ADRESSE]
[CODE_POSTAL]
Madame [NOM]
[DATE_NAISSANCE]
CHOLECYSTECTOMIE SOUS COELIOSCOPIE
DIAGNOSTIC : Cholécystite aiguë. Patiente admise aux urgences sur des douleurs fébriles de 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

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

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CROp Epi - [NOM], [NOM]
____________________________________________________________________________________________________________________________________________
Compte rendu opératoire
>>>1 CRO type chirurgie viscérale 06/06/23 15 : 58 (mod. le 06/06/23 16:03 par [NOM] [NOM] , statut : Rés
LM / EP
Docteur [NOM]
[ADRESSE]
[CODE_POSTAL]
Monsieur [NOM]
[DATE_NAISSANCE]
RTV
Histoire Clinique :
- Patient initialement pris en charge par le Docteur [NOM] pour des hématuries macroscopiques.
- Une échographie fait état d'une lésion polypoïde vésicale.
- Du fait d'une récidive de ses hématuries macroscopiques, on décide d'avancer le geste d'intervention pour e
exploration plus ou moins résection.
Compte-rendu opératoire du 6 juin 2023 :
Opérateur : Docteur [NOM]
Anesthésiste : Docteur [NOM]
Aide(s) [NOM] [NOM], Interne
- Sous anesthésie générale, en position gynécologique, après antibiothérapie péri-opératoire.
- Introduction du résecteur qui réalise une cystoscopie complète et retrouve des méats urétéraux normaux, av
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

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{"page": 0, "kind": "NOM", "original": "Anne SEVILLA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64500 CIBOURE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Valerico SANCHEZ", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "10, avenue Layats", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "ETAB", "original": "Polyclinique Côte Basque Sud", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64500 ST JEAN DE LUZ", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Jean-Daniel BADIOLA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "2 Avenue Pierre Larramendy", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64500 ST JEAN DE LUZ", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Andon LAZAROV", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Né le 27/11/1958", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Alessandro FALCHETTI", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Estelle QUEANT", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Alessandro FALCHETTI", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Estelle QUEANT", "placeholder": "[NOM]", "bbox_hint": null}

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CROp Epi - [NOM], ANDON
____________________________________________________________________________________________________________________________________________
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 Epi - LAZAROV, [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

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{"page": 0, "kind": "NOM", "original": "Anthony MURET", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "2, ALLÉE DE PLAISANCE", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64600 ANGLET", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARIE BARETS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "10 AVENUE MARECHAL SOULT", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64100 BAYONNE", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARIE BARETS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARIE BARETS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Romain BILLON-GRAND", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "DATE_NAISSANCE", "original": "Date de naissance : 08/12/1952", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "2, ALLÉE DE PLAISANCE\n", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "ADRESSE", "original": "10 AVENUE MARECHAL SOULT\n", "placeholder": "[ADRESSE]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64600 ANGLET\nMme MARIE BARETS\nRES LE PARADOR", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "CODE_POSTAL", "original": "64100 BAYONNE\nPatient", "placeholder": "[CODE_POSTAL]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Anthony MURET RÉSIDENCE", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARIE BARETS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "MARIE BARETS", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Romain BILLON-GRAND", "placeholder": "[NOM]", "bbox_hint": null}

36
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Courrier Epi - [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

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{"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}

274
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[MASK]
Anesthésiste : Dr [NOM]
DOSSIER DE CONSULTATION
(modifié le 23/02/2023)
Date :
17/02/23
Nom :
M. [NOM]
N°Ipp :
[TEL]
Né(e) le :
[DATE_NAISSANCE]
79 ans
Adresse :
MAISON [NOM]
[CODE_POSTAL]
N? Csult : [IPP] /
23025988
N° Tél : [TEL]
Poids : 65 kg
Taille : 170 cm
B.M.I. : 22.5
Profession :
Nom naiss. :
Spécialiste :
Médecin traitant :
Date d'Intervention : 23/02/2023
Opérateur : Dr [NOM]
Motif d'admission : HOLEP
à
11 : 55
CHIR.UROLOGIE C2
Hospitalisé(e) le :
à :
Service :
__ : __
__/__/__
Ambulatoire
Urgence
Entrée le jour de l'intervention
Hospit. < 30 jours
Anesthésiste en salle d'opération :
Dr [NOM]
Prévenir :
Mémo :
Obstétrique
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] 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
Décisions / 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
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]
N°Ipp :
[TEL]
Né(e) le :
[DATE_NAISSANCE]
79 ans
Adresse :
MAISON [NOM]
[CODE_POSTAL]
N? Csult : [IPP] /
23025988
N° Tél : [TEL]
Poids : 65 kg
Taille : 170 cm
B.M.I. : 22.5
Profession :
Nom naiss. :
Intubation :
. Mallampati 2
. Distance Interincisive : >35mm
. Distance thyromentonière : >65mm
. Mobilité cervicale : normale
Synthèse pré-opératoire :
Programmation opératoire : maintenue
Allergie : pyostacine
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]
Date :
17/02/2023 09 : 31
Patient : [NOM] [NOM] [NOM] né(e) le :
[DATE_NAISSANCE]
I.P.P. : [TEL]
N? Interv : [IPP]
Né(e) le : [DATE_NAISSANCE]
79 ans
Consigne(s) IDE
A jeun le 23/02/2023 à 00 : 00
PCR COVID a recuperer
Paracetamol 1gr per os en pre-medication
PREPARATIONS
- PER-Opératoires : BIS, Baby-Noradrenaline
Adaptation du traitement personnel
Nom du médicament, dosage, posologie
Soir J-1
Arrêt
Matin J 0
Prescription selon ordonnance du médecin traitant
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

19
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{"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": "DATE_NAISSANCE", "original": "né le 13/12/1943", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10002828365", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "TEL", "original": "05 59 44 40 84", "placeholder": "[TEL]", "bbox_hint": null}
{"page": 0, "kind": "RPPS", "original": "10107546912", "placeholder": "[RPPS]", "bbox_hint": null}
{"page": 0, "kind": "NOM", "original": "Colette BRANA", "placeholder": "[NOM]", "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": "AGE", "original": "Patient de 79 ans", "placeholder": "[AGE]", "bbox_hint": null}
{"page": 0, "kind": "TEL", "original": "05 59 44 35 17", "placeholder": "[TEL]", "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}

85
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C E N T R E H O S P I T A L I E R D E L A C ÔT E B A S Q U E
B.P.8 - [CODE_POSTAL] - Tél [TEL]
[TEL] PÔLE DE CHIRURGIE – ANESTHÉSIE – BLOC OPÉRATOIRE
*[TEL]*
CHIRURGIE ORTHOPÉDI QUE – TRAUMATOLOGIE
____________________________________________________________________________________________________________________________
FINESS juridique : [IPP] FINESS géographique : [IPP]
Bayonne, le 26/08/2023
Dr M. [NOM]
[NOM]
[NOM] Réf_CRO : AD
RPPS : [RPPS] COMPTE RENDU OPERATOIRE
Secrétariat : [TEL]
Dr P. [NOM] M [NOM] [NOM] [DATE_NAISSANCE]
[NOM]
[NOM]
RPPS : [RPPS]
Secrétariat : [TEL] [ADRESSE]
INTERVENTION : [NOM] [NOM] [NOM] (PIH)
Dr P. [NOM]
[NOM]
[NOM] [NOM] [NOM] : Docteur A. [NOM]
RPPS : [RPPS]
Médecin Traitant : DR. [NOM]
Secrétariat : [TEL] Aide : l'interne J. [NOM]
Anesthésiste : Docteur B. [NOM]
Dr A. [NOM]
[NOM] /CHEVILLE
[NOM] [NOM] RÉSUME CLINIQUE :
RPPS : [RPPS] [AGE], ayant présenté une fracture déplacée Garden IV du col fémoral droit/gauche
Secrétariat : [TEL] pour laquelle il est retenu une indication arthroplastie intermédiaire de [NOM].
DISPOSITIF MÉDICAL IMPLANTÉ (DMI) :
Dr S. [NOM]
CHIRURGIE [NOM] [NOM] fémorale : HYPE taille 5 non cimentée, société SERF
PEDIATRIQUE Cupule mobile : CHIBF diamètre 49/28 mm, société SERF
RPPS : [RPPS] Tête : Inox diamètre 28 mm, col moyen 0 mm, cône 12/14
Secrétariat : [TEL]
PRÉPARATION :
Installation : Décubitus latéral
Dr C. [NOM]
[NOM] Anesthésie : Anesthésie générale
[NOM] Vérification des points d’appui
RPPS : [RPPS] Préparation, désinfection et champage stérile selon protocole du CLIN
Antibioprophylaxie par Céfazoline 2g
Check list HAS avant incision
Dr C. [NOM]
MÉDECIN [NOM]
RPPS : [RPPS] TECHNIQUE OPÉRATOIRE :
Voie d’abord postérieure de Moore
[EMAIL] Ouverture du fascia lata
Discision du muscle gluteus maximus.
Passage derrière le gluteus medius
Rens. familles : [TEL] / 35 46
Désinsertion trochantérienne des pelvi trochantériens avec respect total du piriforme et partiel du
Prise de RDV : [TEL]
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 [NOM] définitive 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 [NOM], 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 [NOM] 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
[NOM] opérée)
Docteur A. [NOM]

111
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1829
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regression_tests/baseline/trackare-07019278-23219173_07019278_23219173.audit.jsonl Normal file
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regression_tests/baseline/trackare-07026002-23061319_07026002_23061319.audit.jsonl Normal file
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1430
regression_tests/baseline/trackare-07026002-23061319_07026002_23061319.pseudonymise.txt Normal file
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98
regression_tests/baseline/trackare-15021750-23135549_15021750_23135549.audit.jsonl Normal file
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1770
regression_tests/baseline/trackare-15021750-23135549_15021750_23135549.pseudonymise.txt Normal file
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regression_tests/baseline/trackare-18009635-23098754_18009635_23098754.audit.jsonl Normal file
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{"page": 4, "kind": "TEL", "original": "05 59 29 77 31", "placeholder": "[TEL]", "bbox_hint": null}
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{"page": 5, "kind": "NOM", "original": "Thomas MOULIN", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 5, "kind": "NOM", "original": "Thomas MOULIN", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 5, "kind": "NOM", "original": "Thomas MOULIN", "placeholder": "[NOM]", "bbox_hint": null}
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1013
regression_tests/baseline/trackare-21041742-23220878_21041742_23220878.pseudonymise.txt Normal file
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regression_tests/baseline/trackare-22028007-23158603_22028007_23158603.audit.jsonl Normal file
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@@ -0,0 +1,93 @@
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{"page": 8, "kind": "NOM", "original": "Emilie LAROSA", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 8, "kind": "NOM", "original": "Guillaume GOLDZAK", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 8, "kind": "NOM", "original": "Emilie LAROSA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 8, "kind": "NOM", "original": "Emilie LAROSA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 8, "kind": "NOM", "original": "Emilie LAROSA", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 13, "kind": "DATE_NAISSANCE", "original": "Date de naissance : 21/10/1957", "placeholder": "[DATE_NAISSANCE]", "bbox_hint": null}
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{"page": 13, "kind": "VILLE", "original": "99999", "placeholder": "[VILLE]", "bbox_hint": null}
{"page": 13, "kind": "NOM", "original": "LAROSA Emilie", "placeholder": "[NOM]", "bbox_hint": null}
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971
regression_tests/baseline/trackare-22028007-23158603_22028007_23158603.pseudonymise.txt Normal file
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@@ -0,0 +1,971 @@
[MASK]
*640N0° F0in0ess162*
✉ [ADRESSE]. [ADRESSE], [CODE_POSTAL]
640000162
ONCOLOGIE - ONCOLOGIE HC
Dossier Patient
Détails des patients
Nom de naissance : [NOM] IPP : [IPP]
Nom et Prénom : [NOM] [NOM] [DATE_NAISSANCE]
Sexe : Masculin Lieu de naissance: [VILLE]
Nationalité : FRANCE [CODE_POSTAL]
Adresse : [ADRESSE]: BAYONNE
Détails épisode
Episode No : [NDA]
Localisation : ONCOLOGIE HC Médecin courant: DR. [NOM]
Date d'admission : 18/08/2023 Heure d'admission: 17:58
Date de sortie : 21/08/2023 Heure de sortie: 14:15
Liste des contacts
Tél.
Type de contact Relation Nom Prénom Adresse Tél. domicile Mobile
professionel
Personne à prévenir [TEL]
Epouse [NOM] [NOM]
(Trakcare) [ADRESSE]18/08/2023
Episode - Heure 17 : 58
Mode de transport à l'arrivée Véhicule personnel
Médicalisation du transport Aucune médicalisation
Mode d'entrée Autres admissions urgentes
Date d'orientation 18/08/2023
Heure d'orientation 18 : 05
IAO [NOM] [NOM]
Priorité Priorité 3
Sous-type épisode URG - Circuit court
Motif de prise en charge Faiblesse de membre / déficit / symptômes pouvant évoquer un AVC
déficit MSG depuis le 4/08
MAO au courant
Observ. IDE Urg COVID le 30/07
bi ok
HTA
Médecin de la prise en charge médicale [NOM] [NOM]
Date de prise en charge médicale 18/08/2023
Heure de prise en charge médicale 17 : 58
Médecin de la décision médicale [NOM] [NOM]
Date de décision médicale 19/08/2023
Heure de décision médicale 00 : 03
Décision médicale Hospitalisation MCO
Orientation du patient hospitalisation dans une [MASK], SI, REA
Date de sortie des urgences 19/08/2023
Heure de sortie des Urgences 00 : 14
US de destination US ONCOLOGIE
UF de destination ONCOLOGIE HC
Diagnostic aux urgences
Type Etat Code Date
Principal actif C71.1 Tumeur maligne du lobe frontal [CMA2] 19/08/2023 00 : 02
Antécédents (texte libre)
Type de note Nom Date Heure Note
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : [NDA] ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 1 de 16 Aucune donnée
renseignée
Antécédents habitus (texte libre)
Type de note Nom Date Heure Note
Aucune donnée
renseignée
Signes vitaux
Item de [DATE_NAISSANCE] 20/08/2023 20/08/2023 [DATE_NAISSANCE] [DATE_NAISSANCE] [DATE_NAISSANCE] [DATE_NAISSANCE] [DATE_NAISSANCE] 18/08/2023 18/08/2023
surveillance 08 : 24 20:02 08:16 18:16 16:13 08:27 01:24 00:03 21:59 18:30
Température 37,40 37,60 36,90 37,10 37,40 37,30 37,30 37,50
Pouls 82 94 84 101 94 87 99 99 99
PA
155 140 159 154 173 187 183 119 182 189
Systolique
PA
95 84 101 91 102 108 103 74 108 103
Diastolique
Saturation
99 98 99 97 99 97 99 98 97
O²
Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation Ventilation
spontanée spontanée spontanée spontanée spontanée spontanée spontanée spontanée
Ventilation
Air Air Air Air Air Air Air Air
ambiant ambiant ambiant ambiant ambiant ambiant ambiant ambiant
Echelle
EN EN EN EN EN EN EN
douleur
Score au
0 0 0 0 0 0 0
repos
Glycémie
0,99 1,04 1,52
capillaire
Transit Absence Normal Absence
PA
Gauche
Latéralité
Débit O²
0
[L/mn]
Poids/Taille
Item de [DATE_NAISSANCE]
surveillance 11 : 29
Poids [kg] 61
Surv. Isolement et Contention
Item de [DATE_NAISSANCE] 20/08/2023 20/08/2023 [DATE_NAISSANCE] [DATE_NAISSANCE] [DATE_NAISSANCE] [DATE_NAISSANCE] [DATE_NAISSANCE] 18/08/2023 18/08/2023
surveillance 08 : 24 20:02 08:16 18:16 16:13 08:27 01:24 00:03 21:59 18:30
Température 37,40 37,60 36,90 37,10 37,40 37,30 37,30 37,50
Pouls 82 94 84 101 94 87 99 99 99
PA
155 140 159 154 173 187 183 119 182 189
Systolique
PA
95 84 101 91 102 108 103 74 108 103
Diastolique
Saturation
99 98 99 97 99 97 99 98 97
O²
Transit Absence Normal Absence
Surv. Contention
Item de [DATE_NAISSANCE] 20/08/2023 20/08/2023 [DATE_NAISSANCE] [DATE_NAISSANCE] [DATE_NAISSANCE] [DATE_NAISSANCE] [DATE_NAISSANCE] 18/08/2023 18/08/2023
surveillance 08 : 24 20:02 08:16 18:16 16:13 08:27 01:24 00:03 21:59 18:30
Température 37,40 37,60 36,90 37,10 37,40 37,30 37,30 37,50
Pouls 82 94 84 101 94 87 99 99 99
PA
155 140 159 154 173 187 183 119 182 189
Systolique
PA
95 84 101 91 102 108 103 74 108 103
Diastolique
Saturation
99 98 99 97 99 97 99 98 97
O²
Glycémie
0,99 1,04 1,52
capillaire
Transit Absence Normal Absence
Observations médicales
Type d'observation Nom Date Commentaires
Histoire de la DR. [NOM] [DATE_NAISSANCE]
Motif d'hospitalisation :
maladie [NOM] 12 : 43
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le [DATE_NAISSANCE] 15 : 11 Page 2 de 16 Prise en charge initiale d'une hémiparésie gauche d'installation insidieuse révélant une image
suspecte d'une métastase d'un cancer frontale droite unique, dont les caractéristiques imageries
pourraient orienter vers une tumeur d'origine mélanique.
Mode de vie :
Habite Bayonne, marié, 4 enfants ( 1 fille dans la région)
Retraité, ancien officier de la marine marchande ( dont il reste réserviste)
Passion : Couse à pied, rando, sport, ski
Traitement en cours :
Ramipril 5 mg
Antécédents médicaux :
HTA
Antécédents chirurgicaux :
Appendicectomie
Antécédents familiaux de cancer :
Cancer du sein chez sa mère
Tabac : non fumeur
Consommation d'alcool occasionnelle
Pas d'allergie connue
Latéralité : Gaucher, mais écrit de la main droite
Taille 177 Poids 62 kg ( poids de forme)
Histoire de la maladie :
4 Aout 2023 : remarque une discrète faiblesse du membre supérieur gauche des difficultés de
préhension de sa main dominante (gauche)
08 Aout 2023 : Consultation auprès du Dr [NOM], son médecin traitant qui prescrit une IRM
cérébrale (prévue initialement fin aout)
18 Aout 2023 : Devant une aggravation des symptômes, consulte aux urgences
IRM cérébrale N° d'examen : RAD001191393 : Prise de contraste nodulaire de 13 x 11 mm
isolée du lobe frontal droit en région précentrale évocatrice d'une lésion secondaire compte tenu
des caractéristiques morphologiques. À noter l'hypersignal T1 spontané pouvant faire évoquer
une localisation secondaire de type mélanome.
Un scanner [NOM] réalisé en suivant à la recherche d'un primitif également
le 18/08 ne retrouvant pas de lésion suspecte d'être tumorale N° d'examen : RAD[TEL]
Examen Clinique :
PS0 Poids 62 kg
TA 18/9 ( mais contexte de stress lié à l'annonce) FC 110
Hémiparesie 4/5 membre supérieur gauche, en amélioration sous cortisone
Aucun élément évocateur dans l'anamèse évoquant une crise d'épilepsie partielle ou généralisée
Pas d'autre déficit.
Examen cutané non spécialisé sans anomalie évidente.
Biologie
Pas d'anomalie cliniquement signioficative
Imageries :
IRM cérébrale N° d'examen : RAD001191393 : Prise de contraste nodulaire de 13 x 11 mm
isolée du lobe frontal droit en région précentrale évocatrice d'une lésion secondaire compte tenu
des caractéristiques morphologiques. À noter l'hypersignal T1 spontané pouvant faire évoquer
une localisation secondaire de type mélanome.
Un scanner [NOM] réalisé en suivant à la recherche d'un primitif également
le 18/08 ne retrouvant pas de lésion suspecte d'être tumorale N° d'examen : RAD[TEL]
NB : ETT octobre 2022 dans le cadre du bilan sportif FEVG 75% pas d'anomalie significative
Evolution :
Au total : [AGE] en excellent état général, de phototype clair, présentant une
lésion cérébrale légèrement supra centimetrique, frontale droite, sans autre lésion cérébrale
ou extracérébrale visible, dont les caractéristiques sont compatibles avec une lésion d'allure
secondaire, potentiellement mélanique.
[NOM] du patient de la suspicion diagnostique mais de l'absence de certitude sur le caractère
cancéreux et encore moins le primitif.
Proposition diagnostique :
Demande de TEP scanner corps entier
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 3 de 16 Demande Examen dermatologique spécialisé à l'hopital
Avis neurochirurgical (Dr [NOM]) : lésion profonde, à 3cm du cortex, dans une zone
fonctionnelle, et de petite taille. Possibilité de biopsie si nécessaire au diagnostic, mais chirurgie
d'exérèse à ne proposer qu'en deuxième intention ( on préfèrera une radiothérapie stéréotaxique si
le diagnostic est confirmé). Nous validerons ceci en RCP neuro oncologique le 24/08.
Anticipation CS d'anesth car étant donné TAP normal et dicussion avec le Dr [NOM] il est
hautement probable que l'on retienne la biopsie stéréotaxique.
Evolution dans le [MASK], amélioration partielle sous corticoïdes avec déficit uniquement de tout
le MSD à 4+/5. Disparition du déficit du MID.
=> poursuite corticothérapie aux mêmes doses pour la sortie
Sur le plan oncologique, patient au clair sur la suspicion diagnostique.
=> avis dermatologique Dr [NOM] : pas de primitif retrouvé
=> courriers remis pour consultation ORL + ophtalmologique
=> date du TEP TDM le 31/08
=> cs Dr [NOM] demandée après TEP TDM pour anticiper biopsie cérébrale probable (si
pas de lésion accessible retrouvé en TEP TDM)
Conclusion
Découverte d'une lésion cérébrale symptomatique unique d'allure tumorale, avec doute sur
caractère mélanique, sans primitif cutané retrouvé. Scanner TAP normal.
Complément de bilan par cs ORL + ophtalmologique + TEP scanner, avant de discuter une
biopsie cérébrale.
Traitement de sortie
PREDNISONE 20mg : 4cp matin
RAMIPRIL 5mg matin
LANSOPRAZOLE 30mg : 1cp matin
Prochains rendez-vous
TEP TDM le 31/08 à 14h45
Cs Dr [NOM] le
Sur le plan neurologique, amélioration partielle sous corticoïdes avec déficit uniquement de tout
le MSD à 4+/5. Disparition du déficit du MID.
=> poursuite corticothérapie aux mêmes doses pour la sortie
DR. [NOM] 21/08/2023 Sur le plan oncologique, patient au clair sur la suspicion diagnostique.
Note d'évolution
[NOM] 10 : 43 => avis dermatologique Dr [NOM] : pas de primitif retrouvé
=> courriers remis pour consultation ORL + ophtalmologique
=> date du TEP TDM le 31/08
=> cs Dr [NOM] demandée après TEP TDM pour anticiper biopsie cérébrale probable (si
pas de lésion accessible retrouvé en TEP TDM)
Avis dermato :
Avis demandé pour découverte de lésion cérébrale d'allure secondaire, recherche de primitif
cutané.
Photoexposition professionnelle + loisirs.
Pas d'antécédent personnel ni familial de carcinome cutané ni de mélanome.
Examen : rares naevi, un cuisse droite monochrome bien régulier, non suspect en dermoscopie.
DR. [NOM] 21/08/2023
Note d'évolution Pas de lésion cutanée suspecte sur l'ensemble du tégument à l'examen clinique et dermoscopique
[NOM] 10 : 36
corps entier. Pas de nodule sous-cutané palpé.
Au total :
Pas de lésion cutanée suspecte de mélanome à l'examen corps entier.
Compléter le bilan par cs ophtalmo + ORL + TEP TDM.
DR. [NOM] [DATE_NAISSANCE]
Note d'évolution [NOM] sur la Contre indication conduite automobile
[NOM] 10 : 30
Vu et informé en présence de son gendre
DR. [NOM] [DATE_NAISSANCE] Permission
Note d'évolution
[NOM] 10 : 25 Bio pré thérapeutique demandé demain matin
Evolution :
Au total : [AGE] en excellent état général, de phototype clair, présentant une
lésion cérébrale légèrement supra centimetrique, frontale droite, sans autre lésion cérébrale
ou extracérébrale visible, dont les caractéristiques sont compatibles avec une lésion d'allure
DR. [NOM] [DATE_NAISSANCE]
Note d'évolution secondaire, potentiellement mélanique.
[NOM] 09 : 12
[NOM] du patient de la suspicion diagnostique mais de l'absence de certitude sur le caractère
cancéreux et encore moins le primitif.
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 4 de 16 Proposition diagnostique :
Demande de TEP scanner corps entier
Demande Examen dermatologique spécialisé à l'hopital
Avis neurochirurgical (Dr [NOM]) : lésion profonde, à 3cm du cortex, dans une
zone fonctionnelle, et de petite taille. Possibilité de biopsie si nécessaire au diagnostic,
mais chirurgie d'exérèse à ne proposer qu'en deuxième intention ( on préfèrera une
radiothérapie stéréotaxique si le diagnostic est confirmé). Nous validerons ceci en RCP
neuro oncologique le 24/08.
Anticipation CS d'anesth car étant donné TAP normal et dicussion avec le Dr [NOM] il est
hautement probable que l'on retienne la biopsie stéréotaxique.
Motif d'hospitalisation :
Prise en charge initiale d'une hémiparésie gauche d'installation insidieuse révélant une image
suspecte d'une métastase d'un cancer frontale droite unique, dont les caractéristiques imageries
pourraient orienter vers une tumeur d'origine mélanique.
Mode de vie :
Habite Bayonne, marié, 4 enfants ( 1 fille dans la région)
Retraité, ancien officier de la marine marchande ( dont il reste réserviste)
Passion : Couse à pied, rando, sport, ski
Traitement en cours :
Ramipril 5 mg
Antécédents médicaux :
HTA
Antécédents chirurgicaux :
Appendicectomie
Antécédents familiaux de cancer :
Cancer du sein chez sa mère
Tabac : non fumeur
Consommation d'alcool occasionnelle
Pas d'allergie connue
Latéralité : Gaucher, mais écrit de la main droite
Taille 177 Poids 62 kg ( poids de forme)
Histoire de la maladie :
Histoire de la DR. [NOM] 19/08/2023 4 Aout 2023 : remarque une discrète faiblesse du membre supérieur gauche des difficultés de
maladie [NOM] 10 : 59 préhension de sa main dominante (gauche)
08 Aout 2023 : Consultation auprès du Dr [NOM], son médecin traitant qui prescrit une IRM
cérébrale (prévue initialement fin aout)
18 Aout 2023 : Devant une aggravation des symptômes, consulte aux urgences
IRM cérébrale N° d'examen : RAD001191393 : Prise de contraste nodulaire de 13 x 11 mm
isolée du lobe frontal droit en région précentrale évocatrice d'une lésion secondaire compte tenu
des caractéristiques morphologiques. À noter l'hypersignal T1 spontané pouvant faire évoquer
une localisation secondaire de type mélanome.
Un scanner [NOM] réalisé en suivant à la recherche d'un primitif également
le 18/08 ne retrouvant pas de lésion suspecte d'être tumorale N° d'examen : RAD[TEL]
Examen Clinique :
PS0 Poids 62 kg
TA 18/9 ( mais contexte de stress lié à l'annonce) FC 110
Hémiparesie 4/5 membre supérieur gauche, en amélioration sous cortisone
Aucun élément évocateur dans l'anamèse évoquant une crise d'épilepsie partielle ou généralisée
Pas d'autre déficit.
Examen cutané non spécialisé sans anomalie évidente.
Biologie
Pas d'anomalie cliniquement signioficative
Imageries :
IRM cérébrale N° d'examen : RAD001191393 : Prise de contraste nodulaire de 13 x 11 mm
isolée du lobe frontal droit en région précentrale évocatrice d'une lésion secondaire compte tenu
des caractéristiques morphologiques. À noter l'hypersignal T1 spontané pouvant faire évoquer
une localisation secondaire de type mélanome.
Un scanner [NOM] réalisé en suivant à la recherche d'un primitif également
le 18/08 ne retrouvant pas de lésion suspecte d'être tumorale N° d'examen : RAD[TEL]
NB : ETT octobre 2022 dans le cadre du bilan sportif FEVG 75% pas d'anomalie significative
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 5 de 16 Evolution :
Au total : [AGE] en excellent état général, de phototype clair, présentant une
lésion cérébrale légèrement supra centimetrique, frontale droite, sans autre lésion cérébrale
ou extracérébrale visible, dont les caractéristiques sont compatibles avec une lésion d'allure
secondaire, potentiellement mélanique.
[NOM] du patient de la suspicion diagnostique mais de l'absence de certitude sur le caractère
cancéreux et encore moins le primitif.
Proposition diagnostique :
Demande de TEP scanner corps entier
Demande Examen dermatologique spécialisé à l'hopital
Avis neurochirurgical (Dr [NOM]) : lésion profonde, à 3cm du cortex, dans une
zone fonctionnelle, et de petite taille. Possibilité de biopsie si nécessaire au diagnostic,
mais chirurgie d'exérèse à ne proposer qu'en deuxième intention ( on préfèrera une
radiothérapie stéréotaxique si le diagnostic est confirmé). Nous validerons ceci en RCP
neuro oncologique le 24/08.
Anticipation CS d'anesth car étant donné TAP normal et dicussion avec le Dr [NOM] il est
hautement probable que l'on retienne la biopsie stéréotaxique.
Discussion avec oncologue d'astreinte :
- 1mg solumedrol IV
- Hospit en oncologie
19/08/2023
Note d'évolution DR. [NOM]
00 : 05
Patient et son épouse informés de la présence d'une lésion suspecte très probablement cancéreuse
et de l'absence d'autre retrouvées au scanner. Informés de la nécessité de rencontre avec
oncologue et d'autres examens complémentaires.
Beau fils informé Dr [NOM]
SCANNER [NOM]
Indication :
Recherche de lésion évolutive.
Protocole :
Examen réalisé avec injection de produit de contraste.
RESULTATS :
A l'étage thoracique :
Absence de foyer parenchymateux systématisé.
Absence de nodule pulmonaire suspect.
Absence d'adénomégalie médiastino-hilaire ou axillaire.
Absence d'épanchement pleuro péricardique.
18/08/2023
Note d'évolution DR. [NOM]
23 : 52
A l'étage sous diaphragmatique :
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. Athéromatose calcifiée
de l'aorte abdominale sans dilatation anévrismale. Pas d'adénopathie rétropéritonéale ou coelio-
mésentérique de taille significative.
Pas d'épanchement péritonéal.
Pas d'anomalie des structures pelviennes.
CONCLUSION :
Absence de lésion tumorale décelée à l'étage sous-diaphragmatique.
IRM [NOM]
Indication :
Hémiparésie gauche d'apparition progressive dpeuis le 04/08/2023 chez une patient aux
DR. [NOM] 18/08/2023 ATCD d'hta traité
Note d'évolution
[NOM] 21 : 41 Recherche : Syndrome de masse? autre?
Protocole :
Séquence 3D T1 SE, 3D FLAIR et 3D T1 SE après injection de Gadolinium.
Séquences axiales diffusion, T2* et de perfusion.
RESULTATS :
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 6 de 16 Mise en évidence d'une prise de contraste nodulaire en cocarde mesurée à 13 x 11 mm du
lobe frontal droit en région précentrale. Il s'y associé à un volumineux ?dème périlésionnel sans
effet de masse significatif. La lésion apparaît en hypersignal T1 spontané et hyposignal T2*
(localisation secondaire de mélanome ?).
Pas d'autre prise de contraste décelée
Pas de déviation des structures médianes, pas d'engagement. Hypersignaux punctiformes de la
substance blanche profonde en faveur de lésions de microangiopathie (face et cassent I).
Sur la séquence de perfusion, augmentation du CBV en regard de la lésion nodulaire
précentrale droite évoquant une néoangiogenèse.
CONCLUSION :
Prise de contraste nodulaire de 13 x 11 mm isolée du lobe frontal droit en région précentrale
évocatrice d'une lésion secondaire compte tenu des caractéristiques morphologiques. À noter
l'hypersignal T1 spontané pouvant faire évoquer une localisation secondaire de type mélanome.
Un scanner [NOM] réalisé en suivant à la recherche d'un primitif.
[NOM] [NOM], interne
MA : hémiparésie gauche
ATCD : HTA
Allergie : 0
TTT en cours : Ramipril 5mg 1cp le matin
Mode de vie : retraité pilote maritime, autonome à domicile
HDM :
Infection COVID le 30/07/2023.
Asthénie +++ au décours.
Sensation de faiblesse membre sup gauche débutant la 04 août 2023 associée à une faiblesse
membre inf gauche depuis quelques jours.
Pas de céphalée.
Pas d'AEG.
Histoire de la DR. [NOM] [DATE_NAISSANCE]
Pas de notion de traumatisme.
maladie [NOM] 18 : 25
FDR CV : HTA traitée
Cliniquement :
TA189/103, FC 99/min, sat à 97% aa
Apyrexie
G15, pupilles sir, hémiparésie gauche prédominance brachiale à 4/5, pas de déficit sensitif
associé, pas de synd pyramidal, pas de PF, pas de trouble visuel, pas de céphalée/vomissement
Bdc reg, pas de souffle/frottement, pouls+/+, pas de signes de décomp cardiaque
MV+/+, pas de bsa
Abdomen souple, dépressible et indolore
CAT
Bio/ECG/IRM cérébral (radiologue ok)
Surveillance Psychiatrie
Item de 21/08/2023 20/08/2023 20/08/2023 19/08/2023 19/08/2023 19/08/2023 19/08/2023 19/08/2023 [DATE_NAISSANCE] [DATE_NAISSANCE]
surveillance 08 : 24 20:02 08:16 18:16 16:13 08:27 01:24 00:03 21:59 18:30
Température 37,40 37,60 36,90 37,10 37,40 37,30 37,30 37,50
Pouls 82 94 84 101 94 87 99 99 99
PA
155 140 159 154 173 187 183 119 182 189
Systolique
PA
95 84 101 91 102 108 103 74 108 103
Diastolique
Saturation
99 98 99 97 99 97 99 98 97
O²
Transit Absence Normal Absence
Notes paramédicales
Type de note Nom Date Note
Neuro :
Amélioration des hémiparésies sous CTC
Suivi onco :
21/08/2023
Note IDE [NOM] [NOM] A eu consult dermato ce matin
12 : 45
aura consult ORL
TEP scan prévu le 31/08
Devenir :
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 7 de 16 RAD ce jour
20/08/2023
Note IDE [NOM] [NOM] Neuro : stabilité neurologique
23 : 20
[NOM] 20/08/2023
Note IDE RAS en perm toute la journée
[NOM] 18 : 59
neuro :
Hémiparésie stable
20/08/2023 Risque d'hyperglycémie :
Note IDE [NOM] [NOM]
10 : 51 Hgt à 1.04 ce matin
Permission :
Patient partit en permission pour la journée, VVP retirée à la demande du patient
19/08/2023
Note IDE [NOM] [NOM] Neuro : hémiparésie G en régression
23 : 43
[NOM] 19/08/2023 Hémodynamique :
Note IDE
[NOM] 20 : 23 > Patient hypertendu en début d'AM, non ressenti = > contrôle TA par la suite, mieux
Neuro :
Diminution de l'hémiparésie G ce matin
Suivi onco :
TEP scan ddé
19/08/2023
Note IDE [NOM] [NOM] Avis neuro chir ddé
11 : 03
Consult dermato ddé
Hypertension :
HTA à 18 persistante, bien tolérée --> médecin prévenu , à surveiller
Patient entrant pour hémiparésie G d'abord au niveau du MSG débutée le
04/08/23 évoluant par la suite au MIG.
ATCD d'HTA.
Neuro : a passé un IRMc qui a montré une lésion suspecte
19/08/2023
Note IDE [NOM] [NOM] > éveillé, cohérent, orienté dans le T/E
01 : 42
> hémiparésie G
> chute L de l'hémicorps G avec main creuse et perte de force
> CTCthérapie débutée
PEC : a passé un scanTAP qui n'a pas retrouvé de primitif au premier abord
> patient au courant du diagnostic probablement cancéreuse
19/08/2023 Prise de constanteInventaire ok
Note [NOM] [NOM]
[TEL]
A eu IRM.
[NOM] en faveur de lésions suspectes au niveau cérébral, annonce faite par le médecin au
18/08/2023 patient ainsi qu'à son épouse.
Note IDE [NOM] [NOM]
20 : 55 Corticoïdes IV débutés selon PM.
[NOM] :
Hospitalisation en oncologie pour suite prise en charge, transmissions IDE faites.
18/08/2023 ecg fait et montré
Note [NOM] [NOM]
18 : 35 F [NOM] AS
entre pour déficit MSG depuis le 4/8 progressif au MIG
18/08/2023
Note IDE [NOM] [NOM] COVID le 30/07BS+KTOECGIRM en attente pré médic donné en per os
18 : 29
Traitements médicamenteux
Date de dernière
Prescription Dose Fréquence Date de début Note Docteur
administration
Voie d`administration : INTRAVEINEUSE
Statut des prescriptions : Réalisé
Le débit a été
METHYLPREDNISOLONE modifié. Le débit
- 1 seule fois 1 seule DR. [NOM]
MYL 120MG PDR INJ [10] 80 mg 18/08/2023 23 : 50 19/08/2023 00:08 en cours est :
fois [NOM]
Flacon(s) 1.3333333333333332
par .
Voie d`administration : ORALE
Statut des prescriptions : Signé
RAMIPRIL ACT 10MG CPR DR. [NOM]
0,5 CPR - 1xJour [8h] Normal 18/08/2023 21 : 05 21/08/2023 08:17
[30] COMPRIME(S) [NOM]
SOLUPRED 20MG
DR. [NOM]
CPR ORODISP [20] 4 CPR - Matin [8h] Normal 19/08/2023 08 : 58 21/08/2023 08:15
[NOM]
COMPRIME(S)
Statut des prescriptions : Réalisé
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 8 de 16 SERESTA 10MG CPR [30] - 1 seule fois 1 seule DR. [NOM]
1 CPR 18/08/2023 18 : 17 18/08/2023 18:31
COMPRIME(S) fois [NOM]
Prescriptions de radiologie
Heure Date Heure
Date début Prescription Statut Docteur [NOM]
début exécution exécution
IRM Cérébrale +AngioIRM
18/08/2023 19 : 57 18/08/2023 20:14 Réalisé DR. [NOM]
des Troncs Supra-Aortiques
Scanner Thoraco Abdomino
18/08/2023 20 : 39 18/08/2023 20:48 Réalisé DR. [NOM]
Pelvien
31/08/2023 15 : 30 TEP au [ETABLISSEMENT] RDV pris DR. [NOM]
Prescriptions de laboratoire
Date de
Date Heure Prescription Docteur [NOM]
collection
18/08/2023
18/08/2023 18 : 15 Ionogramme ( Na, K, CL ) DR. [NOM]
18 : 31
Prescriptions de soins
Prescription Dose Statut Fréquence Date de début Quantité administrée Note Docteur
[NOM]
18/08/2023 [NOM] [NOM]
ENVIRONNEMENT Réalisé - Matin [8h] Normal
11 : 08 [NOM]
PATIENT
LIT : REFECTION 18/08/2023 [NOM] [NOM]
Réalisé - Matin [8h] Normal
COMPLETE 11 : 08 [NOM]
- Matin midi goûter 18/08/2023 [NOM] [NOM]
REPAS : AUTONOME Réalisé
soir Normal 11 : 08 [NOM]
- 3x/Nuit (22h 2h 6h) 21/08/2023 [NOM]
SOMMEIL : SURV. Réalisé
Normal 00 : 06 [NOM]
18/08/2023 [NOM] [NOM]
TOILETTE : AUTONOME Réalisé - Matin [8h] Normal
11 : 08 [NOM]
Notes du
professionel
- 1 seule fois 1 seule 18/08/2023 DR. [NOM]
ECG (FAIRE RELEVÉ) Réalisé de santé :
fois 18 : 15 [NOM]
ECG 12
dérivations
- 1 seule fois 1 seule 18/08/2023 DR. [NOM]
VVP : BOUCHON Réalisé
fois 18 : 15 [NOM]
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 9 de 16 Plan de soins Jour J du 21/08/2023 07h00 au 22/08/2023 07h00
Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
[NOM] [NOM]
Signé — RAMIPRIL [NOM] 10MG CPR - 10MG Début le 18/08/2023 à
comprime - Dose 0,5 CPR - ORALE - 1xJour [8h] 21 : 05 08:17 * 0.5
- 1ère dose : 19/08/2023 @ 08:00 Fin le 25/08/2023 à CPR
08 : 00
Admin le 21/08/2023 à
08 : 17
[NOM] [NOM]
Signé — SOLUPRED 20MG CPR ORODISP - Début le 19/08/2023 à
20MG comprime - Dose 4 CPR - ORALE - Matin 08 : 58 08:15 * 4
[8h] - 1ère dose : 20/08/2023 @ 08:00 Fin le 18/09/2023 à CPR
08 : 00
Admin le 21/08/2023 à
08 : 15
[NOM] [NOM]
Réalisé — DESINFECTION [NOM]
ENVIRONNEMENT PATIENT - Matin [8h] - Début le 18/08/2023 à
pendant 7 Jour(s)- Date Début : 18/08/2023 @ 11:08 08:00 * 1
11 : 08 Fin le 25/08/2023 à
08 : 00
Admin le 21/08/2023 à
08 : 00
[NOM] [NOM]
[NOM]
Réalisé — LIT : REFECTION COMPLETE Début le 18/08/2023 à
- Matin [8h] - pendant 7 Jour(s)- Date Début : 11:08
18/08/2023 @ 11 : 08 Fin le 25/08/2023 à 08:00 * 1
08 : 00
Admin le 21/08/2023 à
08 : 00
[NOM] [NOM]
[NOM]
Réalisé — REPAS : AUTONOME - Matin midi Début le 18/08/2023 à
goûter soir - pendant 7 Jour(s)- Date Début : 11:08
18/08/2023 @ 11 : 08 Fin le 25/08/2023 à 16:00 * 1
08 : 00
Admin le 21/08/2023 à
12 : 00
[NOM] [NOM]
[NOM]
Réalisé — REPAS : AUTONOME - Matin midi Début le 18/08/2023 à
goûter soir - pendant 7 Jour(s)- Date Début : 11:08
18/08/2023 @ 11 : 08 Fin le 25/08/2023 à 19:00 * 1
08 : 00
Admin le 21/08/2023 à
12 : 00
[NOM] [NOM]
[NOM]
Réalisé — REPAS : AUTONOME - Matin midi Début le 18/08/2023 à
goûter soir - pendant 7 Jour(s)- Date Début : 11:08
18/08/2023 @ 11 : 08 Fin le 25/08/2023 à 08:56 * 1
08 : 00
Admin le 21/08/2023 à
12 : 00
[NOM] [NOM]
[NOM]
Réalisé — REPAS : AUTONOME - Matin midi Début le 18/08/2023 à
goûter soir - pendant 7 Jour(s)- Date Début : 11:08
18/08/2023 @ 11 : 08 Fin le 25/08/2023 à 12:00 * 1
08 : 00
Admin le 21/08/2023 à
12 : 00
[NOM] [NOM]
Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 21/08/2023 à
6h) - pendant 7 Jour(s)- Date Début : 21/08/2023 00:06
@ 00 : 06 Fin le 27/08/2023 à 22:00 * 1
22 : 00
Admin le 21/08/2023 à
06 : 41
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 10 de 16 [NOM] [NOM]
Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 21/08/2023 à
6h) - pendant 7 Jour(s)- Date Début : 21/08/2023 00:06
@ 00 : 06 Fin le 27/08/2023 à 02:00 * 1
22 : 00
Admin le 21/08/2023 à
06 : 41
[NOM] [NOM]
Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 21/08/2023 à
6h) - pendant 7 Jour(s)- Date Début : 21/08/2023 00:06
@ 00 : 06 Fin le 27/08/2023 à 06:00 * 1
22 : 00
Admin le 21/08/2023 à
06 : 41
[NOM] [NOM]
[NOM]
Réalisé — TOILETTE : AUTONOME - Matin Début le 18/08/2023 à
[8h] - pendant 7 Jour(s)- Date Début : 18/08/2023 11:08
@ 11 : 08 Fin le 25/08/2023 à 11:48 * 1
08 : 00
Admin le 21/08/2023 à
11 : 48
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 11 de 16 Plan de soins Jour J + 1 du 22/08/2023 07h00 au 23/08/2023 07h00
Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
[NOM] [NOM]
Signé — RAMIPRIL [NOM] 10MG CPR - 10MG Début le 18/08/2023 à
comprime - Dose 0,5 CPR - ORALE - 1xJour [8h] 21 : 05 08:00 * 0.5
- 1ère dose : 19/08/2023 @ 08:00 Fin le 25/08/2023 à CPR
08 : 00
Admin le 21/08/2023 à
08 : 17
[NOM] [NOM]
Signé — SOLUPRED 20MG CPR ORODISP - Début le 19/08/2023 à
20MG comprime - Dose 4 CPR - ORALE - Matin 08 : 58 08:00 * 4
[8h] - 1ère dose : 20/08/2023 @ 08:00 Fin le 18/09/2023 à CPR
08 : 00
Admin le 21/08/2023 à
08 : 15
[NOM] [NOM]
Réalisé — DESINFECTION [NOM]
ENVIRONNEMENT PATIENT - Matin [8h] - Début le 18/08/2023 à
pendant 7 Jour(s)- Date Début : 18/08/2023 @ 11:08 08:00 * 1
11 : 08 Fin le 25/08/2023 à
08 : 00
Admin le 21/08/2023 à
08 : 00
[NOM] [NOM]
[NOM]
Réalisé — LIT : REFECTION COMPLETE Début le 18/08/2023 à
- Matin [8h] - pendant 7 Jour(s)- Date Début : 11:08
18/08/2023 @ 11 : 08 Fin le 25/08/2023 à 08:00 * 1
08 : 00
Admin le 21/08/2023 à
08 : 00
[NOM] [NOM]
[NOM]
Réalisé — REPAS : AUTONOME - Matin midi Début le 18/08/2023 à
goûter soir - pendant 7 Jour(s)- Date Début : 11:08
18/08/2023 @ 11 : 08 Fin le 25/08/2023 à 08:00 * 1
08 : 00
Admin le 21/08/2023 à
12 : 00
[NOM] [NOM]
[NOM]
Réalisé — REPAS : AUTONOME - Matin midi Début le 18/08/2023 à
goûter soir - pendant 7 Jour(s)- Date Début : 11:08
18/08/2023 @ 11 : 08 Fin le 25/08/2023 à 12:00 * 1
08 : 00
Admin le 21/08/2023 à
12 : 00
[NOM] [NOM]
[NOM]
Réalisé — REPAS : AUTONOME - Matin midi Début le 18/08/2023 à
goûter soir - pendant 7 Jour(s)- Date Début : 11:08
18/08/2023 @ 11 : 08 Fin le 25/08/2023 à 16:00 * 1
08 : 00
Admin le 21/08/2023 à
12 : 00
[NOM] [NOM]
[NOM]
Réalisé — REPAS : AUTONOME - Matin midi Début le 18/08/2023 à
goûter soir - pendant 7 Jour(s)- Date Début : 11:08
18/08/2023 @ 11 : 08 Fin le 25/08/2023 à 19:00 * 1
08 : 00
Admin le 21/08/2023 à
12 : 00
[NOM] [NOM]
Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 21/08/2023 à
6h) - pendant 7 Jour(s)- Date Début : 21/08/2023 00:06
@ 00 : 06 Fin le 27/08/2023 à 22:00 * 1
22 : 00
Admin le 21/08/2023 à
06 : 41
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 12 de 16 [NOM] [NOM]
Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 21/08/2023 à
6h) - pendant 7 Jour(s)- Date Début : 21/08/2023 00:06
@ 00 : 06 Fin le 27/08/2023 à 02:00 * 1
22 : 00
Admin le 21/08/2023 à
06 : 41
[NOM] [NOM]
Réalisé — SOMMEIL : SURV. - 3x/Nuit (22h 2h Début le 21/08/2023 à
6h) - pendant 7 Jour(s)- Date Début : 21/08/2023 00:06
@ 00 : 06 Fin le 27/08/2023 à 06:00 * 1
22 : 00
Admin le 21/08/2023 à
06 : 41
[NOM] [NOM]
[NOM]
Réalisé — TOILETTE : AUTONOME - Matin Début le 18/08/2023 à
[8h] - pendant 7 Jour(s)- Date Début : 18/08/2023 11:08
@ 11 : 08 Fin le 25/08/2023 à 08:00 * 1
08 : 00
Admin le 21/08/2023 à
11 : 48
Résultats de radiologie
Prescription Date Résultat
Compte rendu au format texte
Bayonne, le 18/08/2023
Docteur [NOM]
Nom de naissance : [NOM]
Nom utilisé : [NOM]
Prénom de naissance : [NOM]
Prénom utilisé : [NOM]
Date de naissance : [DATE_NAISSANCE]
Lieu de naissance : [VILLE]
Sexe : M
Matricule INS :
Examen du : 18/08/2023
Compte-rendu validé électroniquement par [NOM] [NOM] le 18/08/2023
IRM [NOM]
Indication :
Hémiparésie gauche d'apparition progressive dpeuis le 04/08/2023 chez une patient aux ATCD d'hta traité
Recherche : Syndrome de masse? autre?
Protocole :
Séquence 3D T1 SE, 3D FLAIR et 3D T1 SE après injection de Gadolinium.
Séquences axiales diffusion, T2* et de perfusion.
18/08/2023
CR IRM RESULTATS :
19 : 57
Mise en évidence d'une prise de contraste nodulaire en cocarde mesurée à 13 x 11 mm du lobe frontal droit en région précentrale. Il
s'y associé à un volumineux ?dème périlésionnel sans effet de masse significatif. La lésion apparaît en hypersignal T1 spontané et
hyposignal T2* (localisation secondaire de mélanome ?).
Pas d'autre prise de contraste décelée
Pas de déviation des structures médianes, pas d'engagement. Hypersignaux punctiformes de la substance blanche profonde en
faveur de lésions de microangiopathie (face et cassent I).
Sur la séquence de perfusion, augmentation du CBV en regard de la lésion nodulaire précentrale droite évoquant une
néoangiogenèse.
CONCLUSION :
Prise de contraste nodulaire de 13 x 11 mm isolée du lobe frontal droit en région précentrale évocatrice d'une lésion secondaire
compte tenu des caractéristiques morphologiques. À noter l'hypersignal T1 spontané pouvant faire évoquer une localisation
secondaire de type mélanome.
Un scanner [NOM] réalisé en suivant à la recherche d'un primitif.
[NOM] [NOM], interne
Technique :
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 13 de 16 Cet examen rendu anonyme est accessible sur le site WEB de l'établissement pour une durée de 10 mois : www.ch-cote-basque.fr
« accès examens d'imagerie »
N° d'examen : RAD[TEL]
Date de naissance : [DATE_NAISSANCE]
Compte rendu au format texte
Bayonne, le 18/08/2023
Docteur [NOM]
Nom de naissance : [NOM]
Nom utilisé : [NOM]
Prénom de naissance : [NOM]
Prénom utilisé : [NOM]
Date de naissance : [DATE_NAISSANCE]
Lieu de naissance : [VILLE]
Sexe : M
Matricule INS :
Examen du : 18/08/2023
Compte-rendu validé électroniquement par [NOM] [NOM] le 18/08/2023
SCANNER [NOM]
Indication :
Recherche de lésion évolutive.
Protocole :
Examen réalisé avec injection de produit de contraste.
RESULTATS :
A l'étage thoracique :
Absence de foyer parenchymateux systématisé.
Absence de nodule pulmonaire suspect.
Absence d'adénomégalie médiastino-hilaire ou axillaire.
Absence d'épanchement pleuro péricardique.
18/08/2023
CR Scanner
20 : 39 A l'étage sous diaphragmatique :
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. Athéromatose calcifiée de l'aorte abdominale sans dilatation
anévrismale. Pas d'adénopathie rétropéritonéale ou coelio-mésentérique de taille significative.
Pas d'épanchement péritonéal.
Pas d'anomalie des structures pelviennes.
CONCLUSION :
Absence de lésion tumorale décelée à l'étage sous-diaphragmatique.
[NOM] [NOM], interne
Technique :
PDL : 421.72 mGy.cm CTDI : 5.42 mGy
Protocole d'acquisition : 5.7 TAP Portal
XENETIX 350 200mL 23wf017d01 95.00 ml
Cet examen rendu anonyme est accessible sur le site WEB de l'établissement pour une durée de 10 mois : www.ch-cote-basque.fr
« accès examens d'imagerie »
N° d'examen : RAD[TEL]
Date de naissance : [DATE_NAISSANCE]
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : [IPP] ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 14 de 16 Résultats de laboratoire
18/08/2023 18 : 31
Résultat de labo
(6030672)
Non-applicable en cas
d'insuffisance rénale
aigue. Estimation du
DFG non validée dans
les situations suivantes :
- patients âgés &gt : 75
ans - poids extrêmes
Commentaire CKD-EPI
et variations de la
masse musculaire -
alimentation pauvre
en protéines animales
et patients dénutris -
patients d'origine non
caucasienne
Calcium 2,34 mmol/l
Estimation du DFG (CKD-
97 ml/mn/1.73 m2
EPI)
Chlore 105 mmol/l
Créatinine 66 µmol/l
CRP 1 mg/l
Compte-rendu laboratoire Labo230819001606-1.pdf
Polynucléaires neutrophiles
76,1 %
(%)
Polynucléaires neutrophiles
7,50 10.9/l
(#)
Polynucléaires éosinophiles
0,0 %
(%)
Polynucléaires éosinophiles
0,00 10.9/l
(#)
Polynucléaires basophiles (%) 0,2 %
Polynucléaires basophiles (#) 0,02 10.9/l
Lymphocytes (%) 13,8 %
Lymphocytes (#) 1,36 10.9/l
Monocytes (%) 9,9 %
Monocytes (#) 0,98 10.9/l
Glucose 5,6 mmol/l
réalisée sur automate
Formule sanguine
XN (Sysmex)
Hématocrite (%) 42,5 %
Indice de distribution des
13,3 %
hématies
Absence de traitement
Traitement anticoagulant
anticoagulant
Potassium 3,6 mmol/l
Leucocytes 9,86 10.9/l
Hématies 4,92 10.12/l (t/l)
Hémoglobine 14,7 g/dl
VGM 86,4 fl
TCMH 29,9 pg
CCMH 34,6 g/dl
Sodium 141 mmol/l
Osmolarité sang 288 mOSM/l
Plaquettes 229 10.9/l
Protéines 78 g/l
Réserve alcaline 25 mmol/l
Validation et diffusion sous la Dr. [NOM]
responsabilité du biologiste [NOM]
Trou anionique 15
TCA 26,3 secondes
TCA ratio 0,87
TP 85 %
Temps de Quick 12,7 secondes
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 15 de 16 Volume plaquettaire moyen 11,5 fl
Patient : [NOM] [NOM] [NOM] - [DATE_NAISSANCE] ([IPP] )
Episode N. : 23158603 ( ONCOLOGIE - ONCOLOGIE HC ) - Poids: 61 kg
Le 21/08/2023 15 : 11 Page 16 de 16

204
regression_tests/baseline/trackare-23005591-23126805_23005591_23126805.audit.jsonl Normal file
View File

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{"page": 9, "kind": "NOM", "original": "Delphine", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 10, "kind": "NOM", "original": "Prune", "placeholder": "[NOM]", "bbox_hint": null}
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{"page": 10, "kind": "NOM", "original": "Delphine", "placeholder": "[NOM]", "bbox_hint": null}
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2186
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2214
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1366
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regression_tests/baseline/trackare-99252128-23177582_99252128_23177582.audit.jsonl Normal file
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1422
regression_tests/baseline/trackare-99252128-23177582_99252128_23177582.pseudonymise.txt Normal file
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regression_tests/baseline/trackare-BA054633-23116794_BA054633_23116794.audit.jsonl Normal file
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{"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": 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}

2508
regression_tests/baseline/trackare-BA054633-23116794_BA054633_23116794.pseudonymise.txt Normal file
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regression_tests/baseline/trackare-BA102259-23141032_BA102259_23141032.audit.jsonl Normal file
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{"page": 0, "kind": "force_term", "original": "CENTRE HOSPITALIER COTE BASQUE", "placeholder": "[MASK]", "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": "NOM", "original": "Gilles DELMAS", "placeholder": "[NOM]", "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": 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": "ETAB", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 3, "kind": "ETAB", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "bbox_hint": null}
{"page": 3, "kind": "NOM", "original": "Marie", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 3, "kind": "ETAB", "original": "SSR", "placeholder": "[ETABLISSEMENT]", "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": "Laclau", "placeholder": "[NOM]", "bbox_hint": null}
{"page": 3, "kind": "AGE", "original": "Patiente de 68ans", "placeholder": "[AGE]", "bbox_hint": null}
{"page": 3, "kind": "NOM", "original": "Julie LARRIEU", "placeholder": "[NOM]", "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": "DOSSIER", "original": "NDANSETRON", "placeholder": "[DOSSIER]", "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": "DATE_NAISSANCE", "original": "Date de naissance: 23/09/1954", "placeholder": "[DATE_NAISSANCE]", "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": "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": "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": 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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#!/usr/bin/env python3
"""Test de non-régression : compare baseline vs nouvelle sortie.
Usage:
python regression_tests/check_regression.py [--rerun]
Sans --rerun : compare baseline/ vs current output (anonymise_audit_30/)
Avec --rerun : relance l'anonymisation puis compare
"""
import json
import re
import sys
from collections import Counter
from pathlib import Path
BASELINE_DIR = Path(__file__).parent / "baseline"
OUTPUT_DIR = Path("/home/dom/Téléchargements/II-1 Ctrl_T2A_2025_CHCB_DocJustificatifs (1)/anonymise_audit_30")
# === Patterns de fuites connues ===
LEAK_CHECKS = {
"NDA_footer": re.compile(r"Episode\s+N[o°.]?\s*\.?\s*:\s*(\d{5,})"),
"ONDANSETRON_broken": re.compile(r"O\[DOSSIER\]"),
"RPPS_raw": re.compile(r"\b[12]\d{10}\b"), # 11 chiffres commençant par 1 ou 2
"bracket_double": re.compile(r"\[\["),
"www_hospital": re.compile(r"www\.ch-cote-basque"),
"FINESS_raw": re.compile(r"\b640000162\b"),
}
# === Termes médicaux qui NE doivent PAS être masqués ===
FALSE_POSITIVE_CHECKS = {
"AINS_masked": re.compile(r"\[NOM\].*(?:céphalée|paracétamol)|paracétamol.*\[NOM\]", re.I),
"ponction_masked": re.compile(r"\[NOM\]\s+lombaire", re.I),
"hanche_masked": re.compile(r"(?:de\s+la|de)\s+\[NOM\].*(?:profil|opérée|fémorale)", re.I),
"ORL_masked": re.compile(r"IRM\s+\[NOM\]", re.I),
"burkitt_masked": re.compile(r"\[NOM\]\s*\.\s*(?:stade|type|lymphome)?", re.I),
}
PLACEHOLDER_RE = re.compile(r"\[(NOM|TEL|EMAIL|NIR|IPP|DOSSIER|NDA|EPISODE|RPPS|DATE_NAISSANCE|ADRESSE|CODE_POSTAL|VILLE|MASK|FINESS|OGC|AGE|ETABLISSEMENT|IBAN)\]")
def analyze_file(txt_path: Path) -> dict:
"""Analyse un fichier pseudonymisé et retourne les métriques."""
text = txt_path.read_text(encoding="utf-8", errors="replace")
lines = text.splitlines()
result = {
"file": txt_path.name,
"lines": len(lines),
"chars": len(text),
"empty": len(text.strip()) == 0,
}
# Comptage des placeholders
ph_counts = Counter()
for m in PLACEHOLDER_RE.finditer(text):
ph_counts[m.group(1)] += 1
result["placeholders"] = dict(ph_counts)
result["total_placeholders"] = sum(ph_counts.values())
# Détection de fuites
leaks = {}
for name, pattern in LEAK_CHECKS.items():
matches = pattern.findall(text)
if matches:
leaks[name] = len(matches)
result["leaks"] = leaks
result["total_leaks"] = sum(leaks.values())
# Détection de faux positifs
fps = {}
for name, pattern in FALSE_POSITIVE_CHECKS.items():
matches = pattern.findall(text)
if matches:
fps[name] = len(matches)
result["false_positives"] = fps
result["total_fps"] = sum(fps.values())
return result
def compare_reports(baseline_report: dict, new_report: dict) -> dict:
"""Compare deux rapports et identifie régressions/améliorations."""
changes = {
"improved_leaks": [],
"regressed_leaks": [],
"improved_fps": [],
"regressed_fps": [],
"placeholder_delta": {},
}
# Comparer les fuites
all_leak_keys = set(baseline_report["leaks"].keys()) | set(new_report["leaks"].keys())
for k in all_leak_keys:
old = baseline_report["leaks"].get(k, 0)
new = new_report["leaks"].get(k, 0)
if new < old:
changes["improved_leaks"].append((k, old, new))
elif new > old:
changes["regressed_leaks"].append((k, old, new))
# Comparer les FP
all_fp_keys = set(baseline_report["false_positives"].keys()) | set(new_report["false_positives"].keys())
for k in all_fp_keys:
old = baseline_report["false_positives"].get(k, 0)
new = new_report["false_positives"].get(k, 0)
if new < old:
changes["improved_fps"].append((k, old, new))
elif new > old:
changes["regressed_fps"].append((k, old, new))
# Comparer les placeholders
all_ph = set(baseline_report["placeholders"].keys()) | set(new_report["placeholders"].keys())
for k in all_ph:
old = baseline_report["placeholders"].get(k, 0)
new = new_report["placeholders"].get(k, 0)
if old != new:
changes["placeholder_delta"][k] = new - old
return changes
def main():
rerun = "--rerun" in sys.argv
if rerun:
print("=== Relance de l'anonymisation des 30 fichiers ===\n")
import subprocess
result = subprocess.run(
[sys.executable, "run_batch_30_audit.py"],
cwd=str(Path(__file__).parent.parent),
capture_output=False,
)
if result.returncode != 0:
print("ERREUR: batch échoué")
sys.exit(1)
print()
# Analyser la baseline
baseline_files = sorted(BASELINE_DIR.glob("*.pseudonymise.txt"))
new_files = sorted(OUTPUT_DIR.glob("*.pseudonymise.txt"))
if not baseline_files:
print("ERREUR: pas de fichiers baseline trouvés")
sys.exit(1)
print(f"=== RAPPORT DE NON-RÉGRESSION ===")
print(f"Baseline: {len(baseline_files)} fichiers")
print(f"Nouveau: {len(new_files)} fichiers\n")
# Rapport par fichier
baseline_reports = {}
new_reports = {}
for f in baseline_files:
baseline_reports[f.name] = analyze_file(f)
for f in new_files:
new_reports[f.name] = analyze_file(f)
# === Métriques globales baseline ===
total_leaks_baseline = sum(r["total_leaks"] for r in baseline_reports.values())
total_fps_baseline = sum(r["total_fps"] for r in baseline_reports.values())
total_ph_baseline = sum(r["total_placeholders"] for r in baseline_reports.values())
empty_baseline = sum(1 for r in baseline_reports.values() if r["empty"])
total_leaks_new = sum(r["total_leaks"] for r in new_reports.values())
total_fps_new = sum(r["total_fps"] for r in new_reports.values())
total_ph_new = sum(r["total_placeholders"] for r in new_reports.values())
empty_new = sum(1 for r in new_reports.values() if r["empty"])
print("--- MÉTRIQUES GLOBALES ---")
print(f"{'Métrique':<30} {'Baseline':>10} {'Nouveau':>10} {'Delta':>10}")
print("-" * 62)
def delta_str(old, new):
d = new - old
if d > 0:
return f"+{d}"
return str(d)
print(f"{'Fuites détectées':<30} {total_leaks_baseline:>10} {total_leaks_new:>10} {delta_str(total_leaks_baseline, total_leaks_new):>10}")
print(f"{'Faux positifs détectés':<30} {total_fps_baseline:>10} {total_fps_new:>10} {delta_str(total_fps_baseline, total_fps_new):>10}")
print(f"{'Total placeholders':<30} {total_ph_baseline:>10} {total_ph_new:>10} {delta_str(total_ph_baseline, total_ph_new):>10}")
print(f"{'Fichiers vides':<30} {empty_baseline:>10} {empty_new:>10} {delta_str(empty_baseline, empty_new):>10}")
# Détail des fuites par type
all_leak_types = set()
for r in list(baseline_reports.values()) + list(new_reports.values()):
all_leak_types.update(r["leaks"].keys())
if all_leak_types:
print("\n--- FUITES PAR TYPE ---")
print(f"{'Type':<30} {'Baseline':>10} {'Nouveau':>10} {'Delta':>10}")
print("-" * 62)
for lt in sorted(all_leak_types):
old = sum(r["leaks"].get(lt, 0) for r in baseline_reports.values())
new = sum(r["leaks"].get(lt, 0) for r in new_reports.values())
marker = " ✓" if new < old else (" ✗" if new > old else "")
print(f"{lt:<30} {old:>10} {new:>10} {delta_str(old, new):>10}{marker}")
# Détail des FP par type
all_fp_types = set()
for r in list(baseline_reports.values()) + list(new_reports.values()):
all_fp_types.update(r["false_positives"].keys())
if all_fp_types:
print("\n--- FAUX POSITIFS PAR TYPE ---")
print(f"{'Type':<30} {'Baseline':>10} {'Nouveau':>10} {'Delta':>10}")
print("-" * 62)
for ft in sorted(all_fp_types):
old = sum(r["false_positives"].get(ft, 0) for r in baseline_reports.values())
new = sum(r["false_positives"].get(ft, 0) for r in new_reports.values())
marker = " ✓" if new < old else (" ✗" if new > old else "")
print(f"{ft:<30} {old:>10} {new:>10} {delta_str(old, new):>10}{marker}")
# Fichiers avec régressions
regressions = []
improvements = []
for fname in sorted(set(baseline_reports.keys()) & set(new_reports.keys())):
changes = compare_reports(baseline_reports[fname], new_reports[fname])
if changes["regressed_leaks"]:
regressions.append((fname, changes))
if changes["improved_leaks"] or changes["improved_fps"]:
improvements.append((fname, changes))
if regressions:
print(f"\n⚠ RÉGRESSIONS ({len(regressions)} fichiers):")
for fname, changes in regressions:
for k, old, new in changes["regressed_leaks"]:
print(f" {fname}: {k} {old}→{new} (+{new-old})")
if improvements:
print(f"\n✓ AMÉLIORATIONS ({len(improvements)} fichiers):")
for fname, changes in improvements:
for k, old, new in changes["improved_leaks"]:
print(f" {fname}: {k} {old}→{new} (-{old-new})")
for k, old, new in changes["improved_fps"]:
print(f" {fname}: FP {k} {old}→{new} (-{old-new})")
# Verdict final
print("\n" + "=" * 62)
if total_leaks_new > total_leaks_baseline:
print("❌ RÉGRESSION : plus de fuites qu'avant")
sys.exit(1)
elif total_leaks_new < total_leaks_baseline:
print(f"✅ AMÉLIORATION : {total_leaks_baseline - total_leaks_new} fuites en moins")
else:
print("➡ NEUTRE : même nombre de fuites")
if total_fps_new < total_fps_baseline:
print(f"✅ AMÉLIORATION : {total_fps_baseline - total_fps_new} faux positifs en moins")
elif total_fps_new > total_fps_baseline:
print(f"⚠ ATTENTION : {total_fps_new - total_fps_baseline} faux positifs en plus")
sys.exit(0)
if __name__ == "__main__":
main()

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run_batch_30_audit.py Normal file
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#!/usr/bin/env python3
"""Batch 30 fichiers aléatoires pour contrôle humain."""
import sys
import time
import json
from pathlib import Path
from collections import Counter
sys.path.insert(0, str(Path(__file__).parent))
import anonymizer_core_refactored_onnx as core
from eds_pseudo_manager import EdsPseudoManager
SRC = Path("/home/dom/Téléchargements/II-1 Ctrl_T2A_2025_CHCB_DocJustificatifs (1)")
OUTDIR = SRC / "anonymise_audit_30"
CONFIG = Path("/home/dom/ai/anonymisation/config/dictionnaires.yml")
PDFS = [
SRC / "110_23061319/trackare-07026002-23061319_07026002_23061319.pdf",
SRC / "115_23066188/CRH 23066188.pdf",
SRC / "161_23098838/CRO 23098838.pdf",
SRC / "179_23126805/trackare-23005591-23126805_23005591_23126805.pdf",
SRC / "181_23127286/CRH 23127286.pdf",
SRC / "192_23132490/CRH 23132490.pdf",
SRC / "208_23151988/trackare-23020064-23151988_23020064_23151988.pdf",
SRC / "215_23158603/trackare-22028007-23158603_22028007_23158603.pdf",
SRC / "227_23173599/CRH 23173599.pdf",
SRC / "236_23116794/trackare-BA054633-23116794_BA054633_23116794.pdf",
SRC / "248_23194278/CRH 23194278.pdf",
SRC / "263_23203642/CRO 23203642.pdf",
SRC / "28_23135549/trackare-15021750-23135549_15021750_23135549.pdf",
SRC / "321_23043929/CRH 321_23066387.pdf",
SRC / "379_23098754/trackare-18009635-23098754_18009635_23098754.pdf",
SRC / "39_23167029/trackare-23022121-23167029_23022121_23167029.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 / "556_23220878/trackare-21041742-23220878_21041742_23220878.pdf",
SRC / "602_23070052/trackare-20028293-23070052_20028293_23070052.pdf",
SRC / "604_23070704/trackare-23008170-23070704_23008170_23070704.pdf",
SRC / "655_23163458/trackare-01296746-23163458_01296746_23163458.pdf",
SRC / "684_23207941/CRH 684_23207941.pdf",
SRC / "79_23187785/79_23187785 Dossier.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 / "122_23070126/LETTRE DE SORTIE 23070126.pdf",
SRC / "131_23079402/CRH 23079402.pdf",
SRC / "290_23025988/cr anesth 290_23025988.pdf",
]
def main():
print("Chargement EDS-Pseudo...", flush=True)
ner = EdsPseudoManager()
ner.load()
assert ner.is_loaded(), "EDS-Pseudo non chargé"
print("EDS-Pseudo chargé.\n", flush=True)
# Vérifier existence des fichiers
existing = [p for p in PDFS if p.exists()]
missing = [p for p in PDFS if not p.exists()]
if missing:
print(f"ATTENTION: {len(missing)} fichiers manquants:")
for p in missing:
print(f" - {p.name}")
print()
print(f"Fichiers à traiter: {len(existing)}/30\n")
OUTDIR.mkdir(exist_ok=True)
ok = ko = skip_encrypted = 0
global_counts = Counter()
t0 = time.time()
for i, pdf in enumerate(existing, 1):
ogc = pdf.parent.name.split("_")[0]
print(f"[{i}/{len(existing)}] {pdf.name} (OGC {ogc})...", end=" ", flush=True)
try:
outputs = core.process_pdf(
pdf_path=pdf,
out_dir=OUTDIR,
make_vector_redaction=False,
also_make_raster_burn=True,
config_path=CONFIG,
use_hf=True,
ner_manager=ner,
ner_thresholds=None,
ogc_label=ogc,
)
audit_path = Path(outputs.get("audit", ""))
if audit_path.exists():
for line in audit_path.read_text().splitlines():
try:
h = json.loads(line)
global_counts[h["kind"]] += 1
except Exception:
pass
print("OK", flush=True)
ok += 1
except Exception as e:
err = str(e)
if "encrypted" in err.lower() or "password" in err.lower():
print(f"SKIP (chiffré)", flush=True)
skip_encrypted += 1
else:
print(f"ERREUR: {e}", flush=True)
ko += 1
elapsed = time.time() - t0
print(f"\n{'='*60}")
print(f"Terminé en {elapsed:.0f}s — OK: {ok}, Chiffrés: {skip_encrypted}, Erreurs: {ko}")
print(f"Total PII détectés: {sum(global_counts.values())}")
print(f"\nDétail par type:")
for k, v in sorted(global_counts.items(), key=lambda x: -x[1]):
print(f" {k:30s} {v:6d}")
print(f"\nSortie: {OUTDIR}")
if __name__ == "__main__":
main()