84 lines
1.9 KiB
JSON
84 lines
1.9 KiB
JSON
{
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"source_file": "trackare-05017783-23056475_05017783_23056475.pdf",
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"document_type": "trackare",
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"sejour": {
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"sexe": "M",
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"age": 42,
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"date_entree": "20/03/2023",
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"imc": 26.08,
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"poids": 91.0,
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"taille": 187.0
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},
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"diagnostics_associes": [
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{
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"texte": "Embolie pulmonaire",
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"cim10_suggestion": "I26.9",
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"sources_rag": [],
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"preuves_cliniques": [],
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"est_cma": true,
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"est_cms": true,
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"niveau_severite": "severe",
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"niveau_cma": 3,
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"source": "regex",
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"source_page": 3,
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"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..."
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}
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],
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"actes_ccam": [
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{
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"texte": "TDM abdominal",
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"code_ccam_suggestion": "ZCQK002",
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"sources_rag": [],
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"validite": "valide",
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"alertes": []
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}
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],
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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": "CRP",
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"valeur": "198",
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"anomalie": true
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},
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{
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"test": "Hémoglobine",
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"valeur": "11.6",
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"anomalie": true
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},
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{
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"test": "Plaquettes",
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"valeur": "674",
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"anomalie": true
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},
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{
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"test": "Leucocytes",
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"valeur": "5",
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"anomalie": false
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},
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{
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"test": "Créatinine",
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"valeur": "78",
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"anomalie": false
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}
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],
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"imagerie": [],
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"complications": [
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"Fièvre"
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],
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"alertes_codage": [
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"CMA niveau 3 : 'Embolie pulmonaire' (I26.9) — sévérité severe, marqueurs : aigu"
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],
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"source_files": [],
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"ghm_estimation": {
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"type_ghm": "K",
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"severite": 3,
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"cma_count": 1,
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"cms_count": 1,
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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": 5.16
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} |