126 lines
4.8 KiB
JSON
126 lines
4.8 KiB
JSON
{
|
||
"source_file": "",
|
||
"document_type": "trackare",
|
||
"sejour": {
|
||
"sexe": "F",
|
||
"age": 68,
|
||
"date_entree": "18/03/2023",
|
||
"date_sortie": "21/03/2023",
|
||
"duree_sejour": 3,
|
||
"mode_entree": "Autres admissions urgentes",
|
||
"imc": 16.437,
|
||
"poids": 40.0,
|
||
"taille": 156.0
|
||
},
|
||
"diagnostic_principal": {
|
||
"texte": "Douleur abdominale",
|
||
"cim10_suggestion": "R10.4",
|
||
"sources_rag": [],
|
||
"preuves_cliniques": [],
|
||
"niveau_severite": "non_evalue",
|
||
"niveau_cma": 1,
|
||
"source": "regex",
|
||
"source_page": 6,
|
||
"source_excerpt": "...signes de TVP , pas d’OMI ,\nauscultation pulmonaire libre et symétrique\nAu niveau digestif : pas de douleur abdominale , pas de nausée ni vomissements , abdomen\nsouple dépressible indolore BHA+\nPatient: FUENMAYOR MAYOR..."
|
||
},
|
||
"diagnostics_associes": [
|
||
{
|
||
"texte": "Thrombose veineuse profonde",
|
||
"cim10_suggestion": "I80.2",
|
||
"sources_rag": [],
|
||
"preuves_cliniques": [],
|
||
"est_cma": true,
|
||
"niveau_severite": "non_evalue",
|
||
"niveau_cma": 3,
|
||
"source": "regex"
|
||
},
|
||
{
|
||
"texte": "Insuffisance rénale",
|
||
"cim10_suggestion": "N19",
|
||
"sources_rag": [],
|
||
"preuves_cliniques": [],
|
||
"niveau_severite": "non_evalue",
|
||
"niveau_cma": 1,
|
||
"source": "regex",
|
||
"source_page": 15,
|
||
"source_excerpt": "...tale fractions conjuguée\net non conjugée non\nréalisé.\nNon-applicable en cas Non-applicable en cas\nd'insuffisance rénale d'insuffisance rénale\naigue. Estimation du aigue. Estimation du\nDFG non validée dans DFG non validé..."
|
||
}
|
||
],
|
||
"actes_ccam": [],
|
||
"antecedents": [],
|
||
"traitements_sortie": [],
|
||
"biologie_cle": [
|
||
{
|
||
"test": "CRP",
|
||
"valeur": "1",
|
||
"anomalie": false,
|
||
"source_page": 3,
|
||
"source_excerpt": "...ortir de chez elle.\nAux urgences :\n- Examen clinique normal\n- Biologie normale : ionogramme normal, CRP neg, créat 38µM\n- Neurologiquement : pas de signe de focalisation, pas d’élément confusisonel\n- Avi..."
|
||
},
|
||
{
|
||
"test": "ASAT",
|
||
"valeur": "27",
|
||
"anomalie": false,
|
||
"source_page": 15,
|
||
"source_excerpt": "...t Immuno cliniq. ) - Taille: 156 cm - Poids: 40 kg - IMC: 16.437\nLe 21/03/2023 14:03 Page 14 de 16\n\nASAT 27 U/l\nBilirubine totale <\n21 µmol/L : dosage des\nCommentaire bilirubine totale fractions conjug..."
|
||
},
|
||
{
|
||
"test": "ALAT",
|
||
"valeur": "20",
|
||
"anomalie": false,
|
||
"source_page": 16,
|
||
"source_excerpt": "...3 Page 15 de 16\n\nMonocytes (%) 6,8 % 7,1 %\nMonocytes (#) 0,49 10.9/l 0,60 10.9/l\nGlucose 8,7 mmol/l\nALAT 20 U/l\nAnticorps anti-HBs 0 UI/l\nAntigène HBs Négatif\nAc anti-HBc Négatif\nréalisée sur automate réa..."
|
||
},
|
||
{
|
||
"test": "Hémoglobine",
|
||
"valeur": "11,3",
|
||
"anomalie": true,
|
||
"source_page": 16,
|
||
"source_excerpt": "...mmol/l 3,7 mmol/l\nLeucocytes 7,19 10.9/l 8,46 10.9/l\nHématies 3,64 10.12/l (t/l) 3,63 10.12/l (t/l)\nHémoglobine 11,3 g/dl 11,6 g/dl\nVGM 92,3 fl 95,3 fl\nTCMH 31,0 pg 32,0 pg\nCCMH 33,6 g/dl 33,5 g/dl\nSodium 142 mm..."
|
||
},
|
||
{
|
||
"test": "Plaquettes",
|
||
"valeur": "270",
|
||
"anomalie": false,
|
||
"source_page": 16,
|
||
"source_excerpt": "...H 33,6 g/dl 33,5 g/dl\nSodium 142 mmol/l 141 mmol/l\nOsmolarité sang 291 mOSM/l\nPhosphore 1,04 mmol/l\nPlaquettes 270 10.9/l 262 10.9/l\nProtéines 72 g/l\nRéserve alcaline 28 mmol/l\nValidation et diffusion sous la\nD..."
|
||
},
|
||
{
|
||
"test": "Leucocytes",
|
||
"valeur": "7",
|
||
"anomalie": false,
|
||
"source_page": 16,
|
||
"source_excerpt": "...ion VHC Négatif\nSérologie Hépatite C\nConclusion Hépatite C\nnégative\nPotassium 3,4 mmol/l 3,7 mmol/l\nLeucocytes 7,19 10.9/l 8,46 10.9/l\nHématies 3,64 10.12/l (t/l) 3,63 10.12/l (t/l)\nHémoglobine 11,3 g/dl 11,6 g..."
|
||
},
|
||
{
|
||
"test": "Créatinine",
|
||
"valeur": "34",
|
||
"anomalie": true,
|
||
"source_page": 9,
|
||
"source_excerpt": "...23\n20/03/2023 08:00 Ionogramme ( Na, K, CL ) DR. Alexia HOURDILLE\n08:08\n20/03/2023\n20/03/2023 08:00 Créatinine sang ( dosage ) DR. Alexia HOURDILLE\n08:08\nPatient: FUENMAYOR MAYORCA SEGUIN CARMEN - Date de naiss..."
|
||
}
|
||
],
|
||
"imagerie": [],
|
||
"complications": [],
|
||
"alertes_codage": [
|
||
"FUSION: 2 documents fusionnés",
|
||
"CMA niveau 3 : 'Thrombose veineuse profonde' (I80.2) — sévérité non_evalue"
|
||
],
|
||
"source_files": [
|
||
"CRH 23056749.pdf",
|
||
"trackare-21008244-23056749_21008244_23056749.pdf"
|
||
],
|
||
"ghm_estimation": {
|
||
"cmd": "23",
|
||
"cmd_libelle": "Facteurs influençant l'état de santé (symptômes)",
|
||
"type_ghm": "M",
|
||
"severite": 3,
|
||
"ghm_approx": "23M??3",
|
||
"cma_count": 1,
|
||
"cms_count": 0,
|
||
"alertes": [
|
||
"DP symptomatique (R10.4) — risque de CMD 23, impact tarif"
|
||
]
|
||
},
|
||
"controles_cpam": []
|
||
} |