{
  "source_file": "trackare-23000862-23018396_23000862_23018396.pdf",
  "document_type": "trackare",
  "sejour": {
    "sexe": "F",
    "age": 75,
    "date_entree": "23/05/2023",
    "imc": 23.0,
    "poids": 60.0,
    "taille": 160.0
  },
  "diagnostics_associes": [
    {
      "texte": "Sepsis",
      "cim10_suggestion": "A41.9",
      "cim10_confidence": "high",
      "sources_rag": [],
      "preuves_cliniques": [],
      "est_cma": true,
      "niveau_severite": "non_evalue",
      "niveau_cma": 3,
      "source": "regex",
      "source_page": 2,
      "source_excerpt": "...irine donc reprise plavix à J1\nCOUTRIX 17:30\nDescellment cotyloïdien PTH Gauche\nNotion de doute sur sepsis mais pas de signe macroscopique d'infection\nDR. Pierre 25/05/2023\nNote d'évolution\nBRUNETEAU 11:32..."
    },
    {
      "texte": "Autres ostéomyélites",
      "cim10_suggestion": "M86.8",
      "cim10_confidence": "high",
      "justification": "Le code M86.8 est déjà présent dans les DAS codés, mais il est important de le mentionner pour une analyse complète.",
      "sources_rag": [],
      "preuves_cliniques": [],
      "niveau_severite": "non_evalue",
      "niveau_cma": 1,
      "source": "llm_das"
    }
  ],
  "actes_ccam": [],
  "antecedents": [],
  "traitements_sortie": [],
  "biologie_cle": [
    {
      "test": "CRP",
      "valeur": "21",
      "anomalie": true
    },
    {
      "test": "Hémoglobine",
      "valeur": "10,4",
      "anomalie": true
    },
    {
      "test": "Plaquettes",
      "valeur": "246",
      "anomalie": false
    },
    {
      "test": "Leucocytes",
      "valeur": "7",
      "anomalie": false
    },
    {
      "test": "Créatinine",
      "valeur": "70",
      "anomalie": false
    }
  ],
  "imagerie": [],
  "complications": [
    "Infection"
  ],
  "alertes_codage": [
    "CMA niveau 3 : 'Sepsis' (A41.9) — sévérité non_evalue",
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  ],
  "source_files": [],
  "ghm_estimation": {
    "type_ghm": "M",
    "severite": 3,
    "cma_count": 1,
    "cms_count": 0,
    "alertes": [
      "DP absent — CMD non déterminable"
    ]
  },
  "controles_cpam": [],
  "processing_time_s": 18.02
}