150 lines
3.5 KiB
JSON
150 lines
3.5 KiB
JSON
{
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"source_file": "",
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"document_type": "trackare",
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"sejour": {
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"sexe": "F",
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"age": 75,
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"date_entree": "23/05/2023",
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"imc": 23.0,
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"poids": 60.0,
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"taille": 160.0
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},
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"diagnostics_associes": [
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{
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"texte": "Leucémie monocytaire",
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"cim10_suggestion": "C96.0",
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"cim10_confidence": "high",
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"justification": "Leucémie monocytaire identifiée comme DAS, nécessitant une prise en charge spécifique.",
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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": "llm_das"
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},
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{
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"texte": "Sepsis",
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"cim10_suggestion": "A41.9",
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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": 3,
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"source": "regex",
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"source_page": 1,
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"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..."
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},
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{
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"texte": "Infection",
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"cim10_suggestion": "A49.8",
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"cim10_confidence": "high",
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"justification": "Le patient présente une infection, sans précision, qui a nécessité une prise en charge spécifique.",
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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": "llm_das"
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},
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{
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"texte": "Autres ostéomyélites",
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"cim10_suggestion": "M86.8",
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"cim10_confidence": "high",
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"justification": "Le code M86.8 est déjà présent dans les DAS codés, mais il est important de le mentionner pour une analyse complète.",
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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": "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": "CRP",
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"valeur": "21",
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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": "10,4",
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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": "246",
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"anomalie": false
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},
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{
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"test": "Leucocytes",
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"valeur": "7",
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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": "70",
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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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"Infection"
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],
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"alertes_codage": [
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"FUSION: 3 documents fusionnés",
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"2 CMA probables détectées — impact potentiel sur le niveau de sévérité GHM",
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"CMA niveau 3 : 'Sepsis' (A41.9) — sévérité non_evalue",
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"CMA niveau 2 : 'Infection' (A49.8) — sévérité non_evalue",
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"QC: L",
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"QC: e",
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"QC: s",
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"QC: p",
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"QC: i",
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"QC: t",
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"QC: d",
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"QC: é",
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"QC: j",
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"QC: à",
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"QC: c",
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"QC: o",
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"QC: m",
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"QC: D",
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"QC: P",
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"QC: ,",
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"QC: l",
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"QC: n",
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"QC: '",
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"QC: a",
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"QC: r",
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"QC: A",
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"QC: S",
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"QC: .",
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"QC: 4",
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"QC: 9",
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"QC: 8",
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"QC: ê",
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"QC: u",
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"QC: 1",
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"QC: M",
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"QC: 6",
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"QC: I",
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"QC: q"
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],
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"source_files": [
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"BACTERIO 23018396.pdf",
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"CRH 23018396.pdf",
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"trackare-23000862-23018396_23000862_23018396.pdf"
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],
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"ghm_estimation": {
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"type_ghm": "M",
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"severite": 3,
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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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} |