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t2a/output/structured/145_23057452/CONSULTATION_ANESTHESISTE_23057452_cim10.json
dom d2e0fec97d chore: add .gitignore
2026-03-05 00:37:34 +01:00

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{
"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": [
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],
"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
}
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