{
  "source_file": "",
  "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": "Leucémie monocytaire",
      "cim10_suggestion": "C96.0",
      "cim10_confidence": "high",
      "justification": "Leucémie monocytaire identifiée comme DAS, nécessitant une prise en charge spécifique.",
      "sources_rag": [],
      "preuves_cliniques": [],
      "niveau_severite": "non_evalue",
      "niveau_cma": 1,
      "source": "llm_das"
    },
    {
      "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": 1,
      "source_excerpt": "...ATION\nGHRISSI Rabha _ 15/12/1947\nREPRISE D’ARTHROPLASTIE POUR INSTABILITE RESIDUELLE AVEC NOTION DE SEPSIS NON AVERE DANS\nPATIENTE OPEREE A L’HOPITAL DE LA TRINITE EN MARTINIQUE D’UNE PROTHESE TOTALE DE HAN..."
    },
    {
      "texte": "Infection",
      "cim10_suggestion": "A49.8",
      "cim10_confidence": "high",
      "justification": "Le patient présente une infection, sans précision, qui a nécessité une prise en charge spécifique.",
      "sources_rag": [],
      "preuves_cliniques": [],
      "est_cma": true,
      "niveau_severite": "non_evalue",
      "niveau_cma": 2,
      "source": "llm_das"
    },
    {
      "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": [
    "FUSION: 3 documents fusionnés",
    "2 CMA probables détectées — impact potentiel sur le niveau de sévérité GHM",
    "CMA niveau 3 : 'Sepsis' (A41.9) — sévérité non_evalue",
    "CMA niveau 2 : 'Infection' (A49.8) — sévérité non_evalue",
    "QC: L",
    "QC: e",
    "QC: s",
    "QC: p",
    "QC: i",
    "QC: t",
    "QC: d",
    "QC: é",
    "QC: j",
    "QC: à",
    "QC: c",
    "QC: o",
    "QC: m",
    "QC: D",
    "QC: P",
    "QC: ,",
    "QC: l",
    "QC: n",
    "QC: '",
    "QC: a",
    "QC: r",
    "QC: A",
    "QC: S",
    "QC: .",
    "QC: 4",
    "QC: 9",
    "QC: 8",
    "QC: ê",
    "QC: u",
    "QC: 1",
    "QC: M",
    "QC: 6",
    "QC: I",
    "QC: q"
  ],
  "source_files": [
    "BACTERIO 23018396.pdf",
    "CRH 23018396.pdf",
    "trackare-23000862-23018396_23000862_23018396.pdf"
  ],
  "ghm_estimation": {
    "type_ghm": "M",
    "severite": 3,
    "cma_count": 2,
    "cms_count": 0,
    "alertes": [
      "DP absent — CMD non déterminable"
    ]
  },
  "controles_cpam": []
}