{
  "source_file": "CONSULTATION ANESTHESISTE 23057452.pdf",
  "document_type": "trackare",
  "sejour": {},
  "diagnostic_principal": {
    "texte": "Examen général",
    "cim10_suggestion": "Z00.0",
    "cim10_confidence": "high",
    "sources_rag": [],
    "preuves_cliniques": [],
    "niveau_severite": "non_evalue",
    "niveau_cma": 1,
    "source": "edsnlp",
    "source_page": 1,
    "source_excerpt": "...a FMT; FEVG= Hémostase clinique : RAS Anesthésie : AG avec IOT\n60%/Epreuve d'effort normale en 2017 Examen général :\nATCD pulmonaires : RAS Homme, Poids : 79 Kg, Taille : 172 cm,\nATCD médicaux : B.S.A. : 1.9 m², B...."
  },
  "diagnostics_associes": [
    {
      "texte": "Hypertension artérielle",
      "cim10_suggestion": "I10",
      "cim10_confidence": "high",
      "sources_rag": [],
      "preuves_cliniques": [],
      "niveau_severite": "non_evalue",
      "niveau_cma": 1,
      "source": "regex"
    },
    {
      "texte": "Glaucome",
      "cim10_suggestion": "H40",
      "cim10_confidence": "medium",
      "sources_rag": [],
      "preuves_cliniques": [],
      "niveau_severite": "non_evalue",
      "niveau_cma": 1,
      "source": "edsnlp",
      "source_page": 1,
      "source_excerpt": "...e, Poids : 79 Kg, Taille : 172 cm,\nATCD médicaux : B.S.A. : 1.9 m², B.M.I. : 26.7\n. Ophtalmologique/Glaucome Fréquence cardiaque : 110\n. Endocrino-métabolique/Diabète/ Type Pression artérielle : 142 / 83\n2/ E..."
    },
    {
      "texte": "Hydrocéphalie",
      "cim10_suggestion": "G91",
      "cim10_confidence": "medium",
      "sources_rag": [],
      "preuves_cliniques": [],
      "niveau_severite": "non_evalue",
      "niveau_cma": 1,
      "source": "edsnlp",
      "source_page": 1,
      "source_excerpt": "...Pression artérielle : 142 / 83\n2/ Equilibré . Abord(s) veineux : A priori sans\n. Neurologique/Autre Hydrocéphalie problème\navec troubles de la marche découverte à Etat général : 4 vaccins Covid\nla suite d'une chut..."
    },
    {
      "texte": "Troubles de la",
      "cim10_suggestion": "R49",
      "cim10_confidence": "medium",
      "sources_rag": [],
      "preuves_cliniques": [],
      "niveau_severite": "non_evalue",
      "niveau_cma": 1,
      "source": "edsnlp",
      "source_page": 1,
      "source_excerpt": "...83\n2/ Equilibré . Abord(s) veineux : A priori sans\n. Neurologique/Autre Hydrocéphalie problème\navec troubles de la marche découverte à Etat général : 4 vaccins Covid\nla suite d'une chute avec trouble de Etat dentai..."
    },
    {
      "texte": "Cervicale",
      "cim10_suggestion": "M54.2",
      "cim10_confidence": "high",
      "sources_rag": [],
      "preuves_cliniques": [],
      "niveau_severite": "non_evalue",
      "niveau_cma": 1,
      "source": "edsnlp",
      "source_page": 1,
      "source_excerpt": "...ératoire : maintenue\n. Distance Interincisive : >35mm\n. Distance thyromentonière : >65mm\n. Mobilité cervicale : normale\nTraitement(s) : Risques - classe ASA : Prescription biologique :\nAjout/Modification de tr..."
    },
    {
      "texte": "Goutte",
      "cim10_suggestion": "M10",
      "cim10_confidence": "medium",
      "sources_rag": [],
      "preuves_cliniques": [],
      "niveau_severite": "non_evalue",
      "niveau_cma": 1,
      "source": "edsnlp",
      "source_page": 1,
      "source_excerpt": "...nuer le matin . Ventilation : A priori sans difficulté - Plaquettes( N ) [166]\n. Bimatoprost 0,1 % (goutte), Soir (1) - TP TCK( N ) [119/0.89]\n. Bisoprolol 3,75 (CP), Matin (1), A - Créat / DFG( A ) [154/41..."
    }
  ],
  "actes_ccam": [],
  "antecedents": [
    "/ Traitements Examen clinique Décisions / Prescriptions",
    "ATCD chirurgicaux : Examen clinique : Informations données au patient :",
    ". Appendicectomie . Etat général/Altéré . Brochure d'information remise au",
    ". Autres/1 Strabisme/2 Blephroplastie . Capacité d'effort limité par une marche patient",
    "sous AL x 2 difficile . Rapport bénéfice/risque expliqué",
    "ATCD cardio-vasculaires : . Pas de virose récente . Risque dentaire expliqué",
    ". HTA/Bithérapie . Pas de symptome cardio-vasculaire, . Techniques Anesthésiques",
    ". Derniers examens/Echo Dobu Sept auscultation normale Technique d'anesthésie envisagée :",
    "ATCD pulmonaires : RAS Homme, Poids : 79 Kg, Taille : 172 cm,",
    "ATCD médicaux : B.S.A. : 1.9 m², B.M.I. : 26.7",
    ". Ophtalmologique/Glaucome Fréquence cardiaque : 110",
    ". Endocrino-métabolique/Diabète/ Type Pression artérielle : 142 / 83",
    ". Neurologique/Autre Hydrocéphalie problème",
    "avec troubles de la marche découverte à Etat général : 4 vaccins Covid",
    "la suite d'une chute avec trouble de Etat dentaire / Prothèse :",
    "l'équilibre en 2020 Etat dentaire : Dents fragiles",
    "Interrogatoire / Autorisation / Prothèse dentaire (BAS) : partielle,",
    "Latéralité :",
    "amovible",
    ". Vu seul",
    "Etat auditif : Prothèse auditive GAUCHE,",
    ". Patient apte à exprimer sa volonté et",
    "DROITE",
    "participe à la décision",
    ". Consentement éclairé/À récupérer"
  ],
  "traitements_sortie": [],
  "biologie_cle": [],
  "imagerie": [],
  "complications": [],
  "alertes_codage": [
    "QC: L",
    "QC: e",
    "QC: c",
    "QC: o",
    "QC: d",
    "QC: e",
    "QC: Z",
    "QC: 0",
    "QC: 0",
    "QC: .",
    "QC: 0",
    "QC: e",
    "QC: s",
    "QC: t",
    "QC: u",
    "QC: t",
    "QC: i",
    "QC: l",
    "QC: i",
    "QC: s",
    "QC: é",
    "QC: c",
    "QC: o",
    "QC: m",
    "QC: m",
    "QC: e",
    "QC: D",
    "QC: P",
    "QC: ,",
    "QC: c",
    "QC: e",
    "QC: q",
    "QC: u",
    "QC: i",
    "QC: e",
    "QC: s",
    "QC: t",
    "QC: c",
    "QC: o",
    "QC: n",
    "QC: f",
    "QC: o",
    "QC: r",
    "QC: m",
    "QC: e",
    "QC: a",
    "QC: u",
    "QC: x",
    "QC: r",
    "QC: è",
    "QC: g",
    "QC: l",
    "QC: e",
    "QC: s",
    "QC: P",
    "QC: M",
    "QC: S",
    "QC: I",
    "QC: p",
    "QC: o",
    "QC: u",
    "QC: r",
    "QC: u",
    "QC: n",
    "QC: e",
    "QC: x",
    "QC: a",
    "QC: m",
    "QC: e",
    "QC: n",
    "QC: g",
    "QC: é",
    "QC: n",
    "QC: é",
    "QC: r",
    "QC: a",
    "QC: l",
    "QC: .",
    "QC: L",
    "QC: e",
    "QC: s",
    "QC: a",
    "QC: u",
    "QC: t",
    "QC: r",
    "QC: e",
    "QC: s",
    "QC: c",
    "QC: o",
    "QC: d",
    "QC: e",
    "QC: s",
    "QC: s",
    "QC: o",
    "QC: n",
    "QC: t",
    "QC: d",
    "QC: e",
    "QC: s",
    "QC: D",
    "QC: A",
    "QC: S",
    "QC: e",
    "QC: t",
    "QC: s",
    "QC: o",
    "QC: n",
    "QC: t",
    "QC: j",
    "QC: u",
    "QC: s",
    "QC: t",
    "QC: i",
    "QC: f",
    "QC: i",
    "QC: é",
    "QC: s",
    "QC: p",
    "QC: a",
    "QC: r",
    "QC: l",
    "QC: e",
    "QC: c",
    "QC: o",
    "QC: n",
    "QC: t",
    "QC: e",
    "QC: x",
    "QC: t",
    "QC: e",
    "QC: c",
    "QC: l",
    "QC: i",
    "QC: n",
    "QC: i",
    "QC: q",
    "QC: u",
    "QC: e",
    "QC: .",
    "QC: I",
    "QC: l",
    "QC: n",
    "QC: '",
    "QC: y",
    "QC: a",
    "QC: p",
    "QC: a",
    "QC: s",
    "QC: d",
    "QC: e",
    "QC: r",
    "QC: e",
    "QC: d",
    "QC: o",
    "QC: n",
    "QC: d",
    "QC: a",
    "QC: n",
    "QC: c",
    "QC: e",
    "QC: o",
    "QC: u",
    "QC: d",
    "QC: e",
    "QC: c",
    "QC: o",
    "QC: n",
    "QC: f",
    "QC: l",
    "QC: i",
    "QC: t",
    "QC: e",
    "QC: n",
    "QC: t",
    "QC: r",
    "QC: e",
    "QC: l",
    "QC: e",
    "QC: s",
    "QC: c",
    "QC: o",
    "QC: d",
    "QC: e",
    "QC: s",
    "QC: ."
  ],
  "source_files": [],
  "ghm_estimation": {
    "cmd": "23",
    "cmd_libelle": "Facteurs influençant l'état de santé",
    "type_ghm": "M",
    "severite": 1,
    "ghm_approx": "23M??1",
    "cma_count": 0,
    "cms_count": 0,
    "alertes": [
      "DP symptomatique (Z00.0) — risque de CMD 23, impact tarif"
    ]
  },
  "controles_cpam": [],
  "processing_time_s": 16.09
}