chore: add .gitignore
This commit is contained in:
dom
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{
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"source_file": "trackare-07000323-23111304_07000323_23111304.pdf",
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"document_type": "trackare",
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"sejour": {
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"sexe": "F",
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"age": 75,
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"date_entree": "08/06/2023",
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"date_sortie": "15/06/2023",
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"duree_sejour": 7,
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"mode_entree": "Autres admissions urgentes",
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"imc": 24.0,
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"poids": 60.0,
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"taille": 155.0
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},
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"diagnostic_principal": {
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"texte": "Pancréatite aiguë, sans précision",
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"cim10_suggestion": "K85.9",
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"cim10_confidence": "high",
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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": 2,
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"source": "trackare",
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"source_page": 2,
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"source_excerpt": "...ds: 60 kg - IMC: 24.974\nLe 15/06/2023 14:56 Page 1 de 22\n\nType Etat Code Date\nPrincipal actif K85.9 Pancréatite aiguë, sans précision [CMA2] 08/06/2023 19:07\nAllergies\nCatégorie Allergène Sévérité Date Nature de la réaction Commentai..."
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},
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"diagnostics_associes": [
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{
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"texte": "Lithiase vésiculaire",
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"cim10_suggestion": "K80.2",
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"cim10_confidence": "high",
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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": 2,
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"source": "regex"
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},
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{
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"texte": "Prophylactique",
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"cim10_suggestion": "Z40",
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"cim10_confidence": "high",
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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": "edsnlp",
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"source_page": 4,
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"source_excerpt": "...ue de contrôle\nPatiente vue ce soir :\nExplications données sur :\n- l'indication de cholécystectomie prophylactique afin de la mettre à l'abri d'une récidive de\nmigration lithiasique ainsi que des autres complicatio..."
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},
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{
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"texte": "Goute",
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"cim10_suggestion": "M10",
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"cim10_confidence": "high",
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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": "edsnlp",
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"source_page": 7,
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"source_excerpt": "...Apyrétique cet am\nNote IDE Laida MATEO\n16:13 gazs cet am\nScan de contrôle demain\nAlimentation : ne goute pas, fais attention à la reprise alimentaire\nEXAMEN: n'aura pas d'echo abdo mais TDM TAP prevu dema..."
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},
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{
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"texte": "Hernie ombilicale",
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"cim10_suggestion": "K42",
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"cim10_confidence": "high",
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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": "edsnlp",
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"source_page": 18,
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"source_excerpt": "...iculose colique, sans signe de complication. Pas d'épaississement\npariétal digestif suspect. Petite hernie ombilicale de contenu colique, sans signe de complication. Augmentation de taille de\nl'éventration de la ligne..."
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},
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{
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"texte": "Lithiase vésiculaire SAI",
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"cim10_suggestion": "K80.1",
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"cim10_confidence": "high",
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"justification": "Le diagnostic principal est une pancréatite aiguë, et la lithiase vésiculaire est un facteur étiologique connu. Il s'agit d'un DAS car il a mobilisé des ressources supplémentaires (imagerie, biologie).",
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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": 2,
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"source": "llm_das"
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}
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],
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"actes_ccam": [
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{
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"texte": "Cholécystectomie",
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"code_ccam_suggestion": "HMFC004",
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"sources_rag": [],
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"validite": "valide",
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"alertes": []
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},
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{
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"texte": "TDM abdominal",
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"code_ccam_suggestion": "ZCQK002",
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"sources_rag": [],
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"date": "11/06",
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"validite": "valide",
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"alertes": []
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}
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],
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"antecedents": [
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"(texte libre)",
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"Antécédents habitus (texte libre)",
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"Signes vitaux",
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"VentilationVentilationVentilationVentilationVentilation VentilationVentilation VentilationVentilation Ventilation",
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"spontanée spontanée spontanée spontanée spontanée spontanée spontanée spontanée spontanée spontanée",
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"Ventilation",
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"Air Air Air Air Air Air Air Air Air Air",
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"ambiant ambiant ambiant ambiant ambiant ambiant ambiant ambiant ambiant ambiant",
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"Echelle",
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"EN EN EN EVA EN EN EN EN EN EN EN EN",
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"[MEDECIN]",
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"Score au",
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"Glycémie",
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"capillaire",
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"Transit Gaz Absence Absence Normal Gaz Gaz Absence Absence Absence Absence Absence Normal",
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"selles",
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"Débit O²",
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"[L/mn]",
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"Latéralité",
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"respiratoire",
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"Poids/Taille",
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"Poids [kg] 60 58 58 58",
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"Taille [cm] 155 155 155 155",
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"Indice",
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"de masse 24,97 24,14",
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"corporelle",
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"Surface",
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"corporelle",
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"Surv. Isolement et Contention",
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"Transit Gaz Absence Absence Normal",
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"selles",
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"respiratoire",
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"[PATIENT]: [PATIENT_3]: [DATE_NAISS_1] ([IPP_1] )",
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"Episode N.: [EPISODE_1] ( MEDECINE GASTRO ENTERO HC - MEDECINE GASTRO B2 HC ) - Taille: 155 cm - Poids: 60 kg - IMC: 24.974",
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"Le 15/06/2023 14:56 Page 2 de 22",
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"Surv. Contention",
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"Glycémie",
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"capillaire",
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"Transit Gaz Absence Absence Normal",
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"selles",
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"Observations médicales",
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"Type d'observation [MEDECIN] Date Commentaires",
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"Motif d'hospitalisation: Pancréatite aigüe",
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"Antécédents:",
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"néoplasie ovarienne traitée chirurgicalement en 2009",
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"appendicectomie",
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"Traitement habituel:",
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"LIPRUZET",
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"TELMISARTAN /HYDROCHLOROTHIAZIDE"
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],
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"traitements_sortie": [
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{
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"medicament": "LOVENOX 0.4 ml /j",
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"posologie": "pendant 14 jours",
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"code_atc": "B01AB05"
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},
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{
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"medicament": "PARACETAMOL 1 g 3 fois par jour",
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"posologie": "si besoin",
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"code_atc": "N02BE01"
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},
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{
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"medicament": "LIPRUZET"
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},
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{
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"medicament": "TELMISARTAN /HYDROCHLOROTHIAZIDE",
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"code_atc": "C09CA07"
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},
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{
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"medicament": "Cholécystectomie par cœlioscopie ce jour"
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},
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{
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"medicament": "Fils résorbables + colle à la peau"
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},
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{
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"medicament": "Plusieurs micro-débris lithiasiques dans la vésicule"
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},
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{
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"medicament": "14/06/2023"
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},
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{
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"medicament": "Note d'évolution [MEDECIN_4]"
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},
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{
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"medicament": "17:44"
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},
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{
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"medicament": "Réalimentation ce",
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"posologie": "soir"
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},
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{
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"medicament": "Sortie demain si RAS"
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},
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{
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"medicament": "Consultation ans 1 mois Dr [MEDECIN_47] bilan hépatique de contrôle"
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}
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],
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"biologie_cle": [
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{
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"test": "Lipasémie",
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"valeur": "13",
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"anomalie": false
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},
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{
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"test": "CRP",
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"valeur": "56",
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"anomalie": true
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},
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{
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"test": "ASAT",
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"valeur": "142",
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"anomalie": true
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},
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{
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"test": "ALAT",
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"valeur": "126",
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"anomalie": true
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},
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{
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"test": "GGT",
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"valeur": "263",
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"anomalie": true
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},
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{
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"test": "Hémoglobine",
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"valeur": "13,3",
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"anomalie": false
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},
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{
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"test": "Plaquettes",
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"valeur": "260",
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"anomalie": false
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},
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{
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"test": "Leucocytes",
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"valeur": "5",
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"anomalie": false
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}
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],
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"imagerie": [
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{
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"type": "TDM abdominal",
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"conclusion": "une pancréatite aiguë de stade C (CTSI = 2) et une\n[MEDECIN] de contraste de la voie biliaire principale compatible [MEDECIN] une migration\nlithiasique compatible [MEDECIN] une migration lithiasique récente et épaississement pariétal\nvésiculaire, sans distension vésiculaire significative. Mise en évidence également de\nl'[PATIENT_8] taille d'une lésion rehaussée du lobe hépatique gauche pour laquelle une IRM\nest réalisée le 12/06: image nodulaire non suspecte.\net l'[PATIENT_8] taille de l'éventra"
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},
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{
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"type": "Échographie",
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"conclusion": "une pancréatite aiguë de stade C (CTSI = 2) et une\n[MEDECIN] de contraste de la voie biliaire principale compatible [MEDECIN] une migration\nlithiasique compatible [MEDECIN] une migration lithiasique récente et épaississement pariétal\nvésiculaire, sans distension vésiculaire significative. Mise en évidence également de\nl'[PATIENT_8] taille d'une lésion rehaussée du lobe hépatique gauche pour laquelle une IRM\nest réalisée le 12/06: image nodulaire non suspecte.\net l'[PATIENT_8] taille de l'éventra"
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}
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],
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"complications": [
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"Infection"
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],
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"alertes_codage": [
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"DAS 'Nausées ni vomissements' (R11) exclu : symptôme redondant avec le diagnostic précis K85.9",
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"2 CMA probables détectées — impact potentiel sur le niveau de sévérité GHM",
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"CMA niveau 2 : 'Lithiase vésiculaire' (K80.2) — sévérité non_evalue",
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"CMA niveau 2 : 'Lithiase vésiculaire SAI' (K80.1) — sévérité non_evalue",
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"QC: L",
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"QC: e",
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"QC: c",
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"QC: o",
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"QC: d",
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"QC: e",
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"QC: K",
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"QC: 8",
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"QC: 0",
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"QC: .",
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"QC: 1",
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"QC: e",
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"QC: s",
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"QC: t",
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"QC: u",
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"QC: t",
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"QC: i",
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"QC: l",
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"QC: i",
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"QC: s",
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"QC: é",
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"QC: p",
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"QC: o",
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"QC: u",
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"QC: r",
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"QC: l",
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"QC: a",
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"QC: m",
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"QC: i",
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"QC: g",
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"QC: r",
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"QC: a",
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"QC: t",
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"QC: i",
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"QC: o",
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"QC: n",
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"QC: l",
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"QC: i",
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"QC: t",
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"QC: h",
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"QC: i",
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"QC: a",
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"QC: s",
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"QC: i",
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"QC: q",
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"QC: u",
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"QC: e",
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"QC: ,",
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"QC: c",
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"QC: e",
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"QC: q",
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"QC: u",
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"QC: e",
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"QC: s",
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"QC: t",
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"QC: e",
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"QC: x",
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"QC: p",
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"QC: l",
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"QC: i",
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"QC: c",
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"QC: m",
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"QC: c",
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"QC: l",
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"QC: u",
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"QC: d",
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"QC: a",
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"QC: n",
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"QC: s",
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"QC: l",
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"QC: e",
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"QC: c",
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"QC: o",
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"QC: n",
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"QC: t",
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"QC: e",
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"QC: x",
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"QC: t",
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"QC: e",
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"QC: c",
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"QC: l",
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"QC: i",
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"QC: n",
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"QC: i",
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"QC: q",
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"QC: u",
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"QC: e",
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"QC: .",
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"QC: I",
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"QC: l",
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"QC: f",
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"QC: a",
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"QC: u",
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"QC: t",
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"QC: d",
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"QC: o",
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"QC: n",
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"QC: c",
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"QC: o",
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"QC: i",
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"QC: s",
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"QC: i",
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"QC: n",
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"QC: c",
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"QC: o",
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"QC: d",
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"QC: e",
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"QC: ."
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],
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"source_files": [],
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"ghm_estimation": {
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"cmd": "07",
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"cmd_libelle": "Affections hépatobiliaires et pancréatiques",
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"type_ghm": "C",
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"severite": 2,
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"ghm_approx": "07C??2",
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"cma_count": 2,
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"cms_count": 0,
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"alertes": []
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},
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"controles_cpam": [],
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"processing_time_s": 36.72
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}
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Block a user