chore: add .gitignore
This commit is contained in:
dom
126
output/structured/103_23056749/103_23056749_fusionne_cim10.json
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126
output/structured/103_23056749/103_23056749_fusionne_cim10.json
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{
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"source_file": "",
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"document_type": "trackare",
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"sejour": {
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"sexe": "F",
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"age": 68,
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"date_entree": "18/03/2023",
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"date_sortie": "21/03/2023",
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"duree_sejour": 3,
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"mode_entree": "Autres admissions urgentes",
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"imc": 16.437,
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"poids": 40.0,
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"taille": 156.0
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},
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"diagnostic_principal": {
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"texte": "Douleur abdominale",
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"cim10_suggestion": "R10.4",
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"sources_rag": [],
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"preuves_cliniques": [],
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"niveau_severite": "non_evalue",
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"niveau_cma": 1,
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"source": "regex",
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"source_page": 6,
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"source_excerpt": "...signes de TVP , pas d’OMI ,\nauscultation pulmonaire libre et symétrique\nAu niveau digestif : pas de douleur abdominale , pas de nausée ni vomissements , abdomen\nsouple dépressible indolore BHA+\nPatient: FUENMAYOR MAYOR..."
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},
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"diagnostics_associes": [
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{
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"texte": "Thrombose veineuse profonde",
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"cim10_suggestion": "I80.2",
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"sources_rag": [],
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"preuves_cliniques": [],
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"est_cma": true,
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"niveau_severite": "non_evalue",
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"niveau_cma": 3,
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"source": "regex"
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},
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{
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"texte": "Insuffisance rénale",
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"cim10_suggestion": "N19",
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"sources_rag": [],
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"preuves_cliniques": [],
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"niveau_severite": "non_evalue",
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"niveau_cma": 1,
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"source": "regex",
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"source_page": 15,
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"source_excerpt": "...tale fractions conjuguée\net non conjugée non\nréalisé.\nNon-applicable en cas Non-applicable en cas\nd'insuffisance rénale d'insuffisance rénale\naigue. Estimation du aigue. Estimation du\nDFG non validée dans DFG non validé..."
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}
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],
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"actes_ccam": [],
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"antecedents": [],
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"traitements_sortie": [],
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"biologie_cle": [
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{
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"test": "CRP",
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"valeur": "1",
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"anomalie": false,
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"source_page": 3,
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"source_excerpt": "...ortir de chez elle.\nAux urgences :\n- Examen clinique normal\n- Biologie normale : ionogramme normal, CRP neg, créat 38µM\n- Neurologiquement : pas de signe de focalisation, pas d’élément confusisonel\n- Avi..."
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},
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{
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"test": "ASAT",
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"valeur": "27",
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"anomalie": false,
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"source_page": 15,
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"source_excerpt": "...t Immuno cliniq. ) - Taille: 156 cm - Poids: 40 kg - IMC: 16.437\nLe 21/03/2023 14:03 Page 14 de 16\n\nASAT 27 U/l\nBilirubine totale <\n21 µmol/L : dosage des\nCommentaire bilirubine totale fractions conjug..."
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},
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{
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"test": "ALAT",
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"valeur": "20",
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"anomalie": false,
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"source_page": 16,
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"source_excerpt": "...3 Page 15 de 16\n\nMonocytes (%) 6,8 % 7,1 %\nMonocytes (#) 0,49 10.9/l 0,60 10.9/l\nGlucose 8,7 mmol/l\nALAT 20 U/l\nAnticorps anti-HBs 0 UI/l\nAntigène HBs Négatif\nAc anti-HBc Négatif\nréalisée sur automate réa..."
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},
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{
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"test": "Hémoglobine",
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"valeur": "11,3",
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"anomalie": true,
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"source_page": 16,
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"source_excerpt": "...mmol/l 3,7 mmol/l\nLeucocytes 7,19 10.9/l 8,46 10.9/l\nHématies 3,64 10.12/l (t/l) 3,63 10.12/l (t/l)\nHémoglobine 11,3 g/dl 11,6 g/dl\nVGM 92,3 fl 95,3 fl\nTCMH 31,0 pg 32,0 pg\nCCMH 33,6 g/dl 33,5 g/dl\nSodium 142 mm..."
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},
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{
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"test": "Plaquettes",
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"valeur": "270",
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"anomalie": false,
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"source_page": 16,
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"source_excerpt": "...H 33,6 g/dl 33,5 g/dl\nSodium 142 mmol/l 141 mmol/l\nOsmolarité sang 291 mOSM/l\nPhosphore 1,04 mmol/l\nPlaquettes 270 10.9/l 262 10.9/l\nProtéines 72 g/l\nRéserve alcaline 28 mmol/l\nValidation et diffusion sous la\nD..."
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},
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{
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"test": "Leucocytes",
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"valeur": "7",
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"anomalie": false,
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"source_page": 16,
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"source_excerpt": "...ion VHC Négatif\nSérologie Hépatite C\nConclusion Hépatite C\nnégative\nPotassium 3,4 mmol/l 3,7 mmol/l\nLeucocytes 7,19 10.9/l 8,46 10.9/l\nHématies 3,64 10.12/l (t/l) 3,63 10.12/l (t/l)\nHémoglobine 11,3 g/dl 11,6 g..."
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},
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{
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"test": "Créatinine",
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"valeur": "34",
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"anomalie": true,
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"source_page": 9,
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"source_excerpt": "...23\n20/03/2023 08:00 Ionogramme ( Na, K, CL ) DR. Alexia HOURDILLE\n08:08\n20/03/2023\n20/03/2023 08:00 Créatinine sang ( dosage ) DR. Alexia HOURDILLE\n08:08\nPatient: FUENMAYOR MAYORCA SEGUIN CARMEN - Date de naiss..."
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}
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],
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"imagerie": [],
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"complications": [],
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"alertes_codage": [
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"FUSION: 2 documents fusionnés",
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"CMA niveau 3 : 'Thrombose veineuse profonde' (I80.2) — sévérité non_evalue"
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],
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"source_files": [
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"CRH 23056749.pdf",
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"trackare-21008244-23056749_21008244_23056749.pdf"
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],
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"ghm_estimation": {
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"cmd": "23",
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"cmd_libelle": "Facteurs influençant l'état de santé (symptômes)",
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"type_ghm": "M",
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"severite": 3,
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"ghm_approx": "23M??3",
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"cma_count": 1,
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"cms_count": 0,
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"alertes": [
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"DP symptomatique (R10.4) — risque de CMD 23, impact tarif"
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]
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},
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"controles_cpam": []
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}
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31
output/structured/103_23056749/CRH_23056749_cim10.json
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31
output/structured/103_23056749/CRH_23056749_cim10.json
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{
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"source_file": "CRH 23056749.pdf",
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"document_type": "crh",
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"sejour": {
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"sexe": "F",
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"age": 68,
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"date_entree": "18/03/2023",
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"date_sortie": "21/03/2023",
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"duree_sejour": 3
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},
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"diagnostics_associes": [],
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"actes_ccam": [],
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"antecedents": [],
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"traitements_sortie": [],
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"biologie_cle": [],
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"imagerie": [],
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"complications": [],
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"alertes_codage": [],
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"source_files": [],
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"ghm_estimation": {
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"type_ghm": "M",
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"severite": 1,
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"cma_count": 0,
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"cms_count": 0,
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"alertes": [
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"DP absent — CMD non déterminable"
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]
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},
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"controles_cpam": [],
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"processing_time_s": 4.85
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}
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@@ -0,0 +1,121 @@
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{
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"source_file": "trackare-21008244-23056749_21008244_23056749.pdf",
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"document_type": "trackare",
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"sejour": {
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"sexe": "F",
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"age": 68,
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"date_entree": "18/03/2023",
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"mode_entree": "Autres admissions urgentes",
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"imc": 16.437,
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"poids": 40.0,
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"taille": 156.0
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},
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"diagnostic_principal": {
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"texte": "Douleur abdominale",
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"cim10_suggestion": "R10.4",
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"sources_rag": [],
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"preuves_cliniques": [],
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"niveau_severite": "non_evalue",
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"niveau_cma": 1,
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"source": "regex",
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"source_page": 6,
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"source_excerpt": "...signes de TVP , pas d’OMI ,\nauscultation pulmonaire libre et symétrique\nAu niveau digestif : pas de douleur abdominale , pas de nausée ni vomissements , abdomen\nsouple dépressible indolore BHA+\nPatient: FUENMAYOR MAYOR..."
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},
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"diagnostics_associes": [
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{
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"texte": "Thrombose veineuse profonde",
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"cim10_suggestion": "I80.2",
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"sources_rag": [],
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"preuves_cliniques": [],
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"est_cma": true,
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"niveau_severite": "non_evalue",
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"niveau_cma": 3,
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"source": "regex"
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},
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{
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"texte": "Insuffisance rénale",
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"cim10_suggestion": "N19",
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"sources_rag": [],
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"preuves_cliniques": [],
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"niveau_severite": "non_evalue",
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"niveau_cma": 1,
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"source": "regex",
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"source_page": 15,
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"source_excerpt": "...tale fractions conjuguée\net non conjugée non\nréalisé.\nNon-applicable en cas Non-applicable en cas\nd'insuffisance rénale d'insuffisance rénale\naigue. Estimation du aigue. Estimation du\nDFG non validée dans DFG non validé..."
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}
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],
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"actes_ccam": [],
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"antecedents": [],
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"traitements_sortie": [],
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"biologie_cle": [
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{
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"test": "CRP",
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"valeur": "1",
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"anomalie": false,
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"source_page": 3,
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"source_excerpt": "...ortir de chez elle.\nAux urgences :\n- Examen clinique normal\n- Biologie normale : ionogramme normal, CRP neg, créat 38µM\n- Neurologiquement : pas de signe de focalisation, pas d’élément confusisonel\n- Avi..."
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},
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{
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"test": "ASAT",
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"valeur": "27",
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"anomalie": false,
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"source_page": 15,
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"source_excerpt": "...t Immuno cliniq. ) - Taille: 156 cm - Poids: 40 kg - IMC: 16.437\nLe 21/03/2023 14:03 Page 14 de 16\n\nASAT 27 U/l\nBilirubine totale <\n21 µmol/L : dosage des\nCommentaire bilirubine totale fractions conjug..."
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},
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{
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"test": "ALAT",
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"valeur": "20",
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"anomalie": false,
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"source_page": 16,
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"source_excerpt": "...3 Page 15 de 16\n\nMonocytes (%) 6,8 % 7,1 %\nMonocytes (#) 0,49 10.9/l 0,60 10.9/l\nGlucose 8,7 mmol/l\nALAT 20 U/l\nAnticorps anti-HBs 0 UI/l\nAntigène HBs Négatif\nAc anti-HBc Négatif\nréalisée sur automate réa..."
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},
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{
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"test": "Hémoglobine",
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"valeur": "11,3",
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"anomalie": true,
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"source_page": 16,
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"source_excerpt": "...mmol/l 3,7 mmol/l\nLeucocytes 7,19 10.9/l 8,46 10.9/l\nHématies 3,64 10.12/l (t/l) 3,63 10.12/l (t/l)\nHémoglobine 11,3 g/dl 11,6 g/dl\nVGM 92,3 fl 95,3 fl\nTCMH 31,0 pg 32,0 pg\nCCMH 33,6 g/dl 33,5 g/dl\nSodium 142 mm..."
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},
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{
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"test": "Plaquettes",
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"valeur": "270",
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"anomalie": false,
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"source_page": 16,
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"source_excerpt": "...H 33,6 g/dl 33,5 g/dl\nSodium 142 mmol/l 141 mmol/l\nOsmolarité sang 291 mOSM/l\nPhosphore 1,04 mmol/l\nPlaquettes 270 10.9/l 262 10.9/l\nProtéines 72 g/l\nRéserve alcaline 28 mmol/l\nValidation et diffusion sous la\nD..."
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},
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{
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"test": "Leucocytes",
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"valeur": "7",
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"anomalie": false,
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"source_page": 16,
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"source_excerpt": "...ion VHC Négatif\nSérologie Hépatite C\nConclusion Hépatite C\nnégative\nPotassium 3,4 mmol/l 3,7 mmol/l\nLeucocytes 7,19 10.9/l 8,46 10.9/l\nHématies 3,64 10.12/l (t/l) 3,63 10.12/l (t/l)\nHémoglobine 11,3 g/dl 11,6 g..."
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},
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{
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"test": "Créatinine",
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"valeur": "34",
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"anomalie": true,
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"source_page": 9,
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"source_excerpt": "...23\n20/03/2023 08:00 Ionogramme ( Na, K, CL ) DR. Alexia HOURDILLE\n08:08\n20/03/2023\n20/03/2023 08:00 Créatinine sang ( dosage ) DR. Alexia HOURDILLE\n08:08\nPatient: FUENMAYOR MAYORCA SEGUIN CARMEN - Date de naiss..."
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}
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],
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"imagerie": [],
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"complications": [],
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"alertes_codage": [
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"CMA niveau 3 : 'Thrombose veineuse profonde' (I80.2) — sévérité non_evalue"
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],
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"source_files": [],
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"ghm_estimation": {
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"cmd": "23",
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"cmd_libelle": "Facteurs influençant l'état de santé (symptômes)",
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"type_ghm": "M",
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"severite": 3,
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"ghm_approx": "23M??3",
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"cma_count": 1,
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"cms_count": 0,
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"alertes": [
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"DP symptomatique (R10.4) — risque de CMD 23, impact tarif"
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]
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},
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"controles_cpam": [],
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"processing_time_s": 4.51
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}
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