237 lines
4.6 KiB
JSON
237 lines
4.6 KiB
JSON
{
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"source_file": "BACTERIO 23111304.pdf",
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"document_type": "crh",
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"sejour": {},
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"diagnostics_associes": [
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{
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"texte": "Infection urinaire",
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"cim10_suggestion": "N39.0",
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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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"source_page": 1,
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"source_excerpt": "...tation selon les\nrecommandations du CA-SFM 2022\nConclusion\nDonnées microbiologiques en faveur d'une infection urinaire\nCompte-rendu : Complet (1) analyse référencée sous\nACCREDITATION COFRAC Page 1/2\nValidé et diffusé..."
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},
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{
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"texte": "Cystite",
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"cim10_suggestion": "N30",
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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": 2,
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"source_excerpt": "...ramme\n.\nEscherichia coli\nCMI (mg/l)\nAMOXICILLINE Sensible à posologie standard\nAMOX+ AC.CLAVU (pour CYSTITE) Sensible à posologie standard\nAMOXICILLINE + AC.CLAVULANIQUESensible à posologie standard\nTICARCIL..."
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},
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{
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"texte": "Leucémie monocytaire (C93.1 †)",
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"cim10_suggestion": "C93.1",
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"cim10_confidence": "high",
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"justification": "La leucémie monocytaire est une forme de leucémie mononucléaire, qui peut être associée à des complications infectieuses et inflammatoires, comme celles observées chez ce patient. Le terme 'Leucémie monocytaire' est inclus dans la note d'exclusion de la cystite aiguë (N30.8) et est déjà codé comme DP.",
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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": "leger",
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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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"antecedents": [],
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"traitements_sortie": [],
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"biologie_cle": [
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{
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"test": "Leucocytes",
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"valeur": "51",
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"anomalie": true
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}
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],
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"imagerie": [],
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"complications": [
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"Infection"
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],
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"alertes_codage": [
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"2 CMA probables détectées — impact potentiel sur le niveau de sévérité GHM",
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"CMA niveau 2 : 'Infection urinaire' (N39.0) — sévérité non_evalue",
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"CMA niveau 2 : 'Leucémie monocytaire (C93.1 †)' (C93.1) — sévérité leger, marqueurs : chronique",
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],
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"source_files": [],
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"ghm_estimation": {
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"type_ghm": "M",
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"severite": 2,
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"cma_count": 2,
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"cms_count": 0,
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"alertes": [
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"DP absent — CMD non déterminable"
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]
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},
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"controles_cpam": [],
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"processing_time_s": 53.51
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} |