{
  "source_file": "trackare-05017783-23056475_05017783_23056475.pdf",
  "document_type": "trackare",
  "sejour": {
    "sexe": "M",
    "age": 42,
    "date_entree": "20/03/2023",
    "imc": 26.08,
    "poids": 91.0,
    "taille": 187.0
  },
  "diagnostics_associes": [
    {
      "texte": "Embolie pulmonaire",
      "cim10_suggestion": "I26.9",
      "sources_rag": [],
      "preuves_cliniques": [],
      "est_cma": true,
      "est_cms": true,
      "niveau_severite": "severe",
      "niveau_cma": 3,
      "source": "regex",
      "source_page": 3,
      "source_excerpt": "...adénopathie\ndiaphragmatique estimée à 9 mm en jugulo-carotidien inférieur gauche. Apparition d’une\nembolie pulmonaire, postéro-basale droite avec thrombose partielle de la veine rénale gauche.\nPatient: BEGUE BEGUE ERI..."
    }
  ],
  "actes_ccam": [
    {
      "texte": "TDM abdominal",
      "code_ccam_suggestion": "ZCQK002",
      "sources_rag": [],
      "validite": "valide",
      "alertes": []
    }
  ],
  "antecedents": [],
  "traitements_sortie": [],
  "biologie_cle": [
    {
      "test": "CRP",
      "valeur": "198",
      "anomalie": true
    },
    {
      "test": "Hémoglobine",
      "valeur": "11.6",
      "anomalie": true
    },
    {
      "test": "Plaquettes",
      "valeur": "674",
      "anomalie": true
    },
    {
      "test": "Leucocytes",
      "valeur": "5",
      "anomalie": false
    },
    {
      "test": "Créatinine",
      "valeur": "78",
      "anomalie": false
    }
  ],
  "imagerie": [],
  "complications": [
    "Fièvre"
  ],
  "alertes_codage": [
    "CMA niveau 3 : 'Embolie pulmonaire' (I26.9) — sévérité severe, marqueurs : aigu"
  ],
  "source_files": [],
  "ghm_estimation": {
    "type_ghm": "K",
    "severite": 3,
    "cma_count": 1,
    "cms_count": 1,
    "alertes": [
      "DP absent — CMD non déterminable"
    ]
  },
  "controles_cpam": [],
  "processing_time_s": 5.16
}