401 lines
12 KiB
JSON
401 lines
12 KiB
JSON
{
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"source_file": "trackare-BA121804-23016863_BA121804_23016863.pdf",
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"document_type": "trackare",
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"sejour": {
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"sexe": "M",
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"age": 76,
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"date_entree": "28/02/2023",
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"date_sortie": "03/03/2023",
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"duree_sejour": 3,
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"imc": 27.636,
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"poids": 78.0,
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"taille": 168.0
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},
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"diagnostic_principal": {
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"texte": "Ventilationventilation",
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"cim10_suggestion": "R06.4",
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"sources_rag": [
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{
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"document": "cim10",
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"page": 970,
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"code": "Z99.1",
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"extrait": "Z99.1 Dépendance envers un respirateur\nDépendance envers un ventilateur\nZ99.1+0 Dépendance envers un respirateur : ventilation par trachéostomie\nZ99.1+1 Dépendance envers un respirateur : ventilation "
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},
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{
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"document": "cim10",
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"page": 450,
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"code": "J67.7",
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"extrait": "J67.7 Maladie pulmonaire due aux systèmes de conditionnement et d'humidification de\nl'air\nAlvéolite allergique due à des actinomycètes thermophiles, moisissures et autres microorganismes se\ndéveloppan"
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},
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{
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"document": "cim10",
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"page": 800,
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"code": "T27.3",
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"extrait": "T27.3 Brulure des voies respiratoires, partie non précisée"
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},
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{
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"document": "cim10",
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"page": 293,
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"code": "F45.33",
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"extrait": "F45.33 Dysfonctionnement neurovégétatif d’expression respiratoire\nFormes psychogènes de :\n•hyperventilation\n•toux"
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},
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{
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"document": "cim10",
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"page": 800,
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"code": "T27.2",
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"extrait": "T27.2 Brulure d'autres parties des voies respiratoires\nCavité thoracique"
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},
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{
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"document": "cim10",
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"page": 74,
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"code": "T27",
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"extrait": "T27 Brulure et corrosion des voies respiratoires"
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},
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{
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"document": "ccam",
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"code": "GLLD007",
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"extrait": "GLLD007 Ventilation mécanique à poumons séparés, par 24 heures\nRegroupement: ATM\nTarif S1: 0.0€"
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},
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{
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"document": "ccam",
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"code": "GLLD004",
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"extrait": "GLLD004 Ventilation mécanique intratrachéale avec pression expiratoire positive [PEP] supérieure à 6 et/ou FiO2 supérieure à 60%, avec technique de décubitus ventral alterné par 24 heures\nRegroupement"
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},
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{
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"document": "ccam",
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"code": "GLLD003",
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"extrait": "GLLD003 Ventilation spontanée au masque facial, par canule nasale ou par sonde nasopharyngée, sans aide inspiratoire, avec pression expiratoire positive [VS-PEP] [Continuous positive airway pressure] "
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},
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{
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"document": "ccam",
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"code": "GLLD013",
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"extrait": "GLLD013 Ventilation spontanée sur trachéotomie au cours du sevrage d'une ventilation mécanique, par 24 heures\nRegroupement: ATM\nTarif S1: 0.0€"
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}
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],
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"niveau_severite": "non_evalue",
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"source": "edsnlp"
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},
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"diagnostics_associes": [
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{
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"texte": "Hypertension artérielle",
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"cim10_suggestion": "I10",
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"sources_rag": [
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{
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"document": "cim10",
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"page": 927,
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"code": "Z01.3",
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"extrait": "Z01.3 Mesure de la tension artérielle"
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},
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{
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"document": "cim10",
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"page": 401,
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"code": "I15.0",
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"extrait": "I15.0 Hypertension vasculorénale"
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},
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{
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"document": "cim10",
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"page": 62,
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"code": "O13",
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"extrait": "O13 Hypertension gestationnelle [liée à la grossesse]"
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},
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{
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"document": "cim10",
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"page": 493,
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"code": "K76.6",
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"extrait": "K76.6 Hypertension portale"
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},
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{
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"document": "cim10",
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"page": 401,
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"code": "I15.2",
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"extrait": "I15.2 Hypertension secondaire à des atteintes endocriniennes"
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},
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{
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"document": "cim10_alpha",
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"page": 998,
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"code": "I10",
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"extrait": "145 Hypertension essentielle (primitive) → I10"
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},
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{
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"document": "cim10",
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"page": 428,
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"code": "I95.8",
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"extrait": "I95.8 Autres hypotensions\nHypotension chronique"
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},
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{
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"document": "cim10",
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"page": 401,
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"code": "I13.9",
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"extrait": "I13.9 Cardionéphropathie hypertensive, sans précision"
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},
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{
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"document": "cim10",
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"page": 353,
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"code": "G93.2",
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"extrait": "G93.2 Hypertension intracrânienne bénigne\nÀ l'exclusion de :encéphalopathie hypertensive (I67.4)"
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},
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{
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"document": "cim10",
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"page": 399,
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"code": "I10",
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"extrait": "I10 Hypertension essentielle (primitive)\nComprend : Hypertension (artérielle) (bénigne) (essentielle) (maligne) (primitive)\n(systémique)\nTension artérielle élevée\nÀ l'exclusion de :avec :\n•maladies cé"
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}
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],
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"niveau_severite": "non_evalue",
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"source": "regex"
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},
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{
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"texte": "Fibrillation auriculaire",
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"cim10_suggestion": "I48.9",
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"sources_rag": [
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{
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"document": "cim10",
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"page": 413,
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"code": "I48.0",
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"extrait": "I48.0 Fibrillation auriculaire paroxystique"
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},
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{
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"document": "cim10",
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"page": 50,
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"code": "I48",
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"extrait": "I48 Fibrillation et flutter auriculaires"
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},
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{
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"document": "cim10",
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"page": 413,
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"code": "I49.0",
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"extrait": "I49.0 Fibrillation et flutter ventriculaires"
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},
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{
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"document": "cim10",
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"page": 413,
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"code": "I48.1",
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"extrait": "I48.1 Fibrillation auriculaire persistante"
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},
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{
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"document": "cim10",
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"page": 413,
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"code": "I48.9",
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"extrait": "I48.9 Fibrillation et flutter auriculaires, sans précision"
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},
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{
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"document": "cim10",
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"page": 413,
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"code": "I48.2",
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"extrait": "I48.2 Fibrillation auriculaire chronique [permanente]"
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},
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{
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"document": "cim10",
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"page": 715,
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"code": "R00.2",
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"extrait": "R00.2 Palpitations\nPerception des battements cardiaques"
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},
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{
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"document": "cim10",
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"page": 413,
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"code": "I47.2",
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"extrait": "I47.2 Tachycardie ventriculaire"
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},
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{
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"document": "cim10",
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"page": 715,
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"code": "R00.0",
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"extrait": "R00.0 Tachycardie, sans précision\nRythme cardiaque rapide\nTachycardie :\n•sinoauriculaire SAI\n•sinusale SAI"
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},
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{
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"document": "cim10",
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"page": 413,
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"code": "I49.1",
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"extrait": "I49.1 Dépolarisation auriculaire prématurée\nExtrasystoles auriculaires"
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}
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],
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"est_cma": true,
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"niveau_severite": "non_evalue",
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"source": "regex"
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},
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{
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"texte": "Hyperkaliémie",
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"cim10_suggestion": "E87.5",
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"sources_rag": [
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{
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"document": "cim10",
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"page": 257,
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"code": "E87.5",
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"extrait": "E87.5 Hyperkaliémie\nExcès de potassium [K]\nSurcharge en potassium [K]"
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},
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{
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"document": "cim10",
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"page": 463,
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"code": "K03.4",
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"extrait": "K03.4 Hypercémentose\nHyperplasie cémentaire"
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},
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{
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"document": "cim10",
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"page": 257,
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"code": "E87.58",
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"extrait": "E87.58 Hyperkaliémies, autres et sans précision"
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},
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{
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"document": "cim10",
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"page": 614,
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"code": "O14",
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"extrait": "O14 Prééclampsie\nÀ l'exclusion de :prééclampsie surajoutée (O11)\nO14.0 Prééclampsie légère à modérée\nO14.1 Prééclampsie sévère\nO14.2 HELLP syndrome\nAssociation d'une hémolyse, d'une cytolyse hépatique"
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},
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{
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"document": "cim10",
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"page": 206,
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"code": "D47.5",
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"extrait": "D47.5 Leucémie chronique à éosinophiles [syndrome hyperéosinophilique]"
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},
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{
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"document": "cim10",
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"page": 468,
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"code": "K11.5",
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"extrait": "K11.5 Sialolithiase\nCalcul\ndes glandes salivaires ou d'un canal excréteur\nLithiase"
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},
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{
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"document": "cim10",
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"page": 494,
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"code": "K80.8",
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"extrait": "K80.8 Autres cholélithiases"
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},
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{
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"document": "cim10",
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"page": 495,
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"code": "K82.8",
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"extrait": "K82.8 Autres maladies précisées de la vésicule biliaire\nAdhérences\nAtrophie\nDyskinésie\nExclusion du canal cystique ou de la vésicule biliaire\nHypertrophie\nKyste\nUlcère"
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},
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{
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"document": "cim10",
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"page": 250,
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"code": "E72.3",
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"extrait": "E72.3 Anomalies du métabolisme de la lysine et de l'hydroxylysine\nAcidurie glutarique\nHydroxylysinémie\nHyperlysinémie\nÀ l'exclusion de :maladie de Refsum (G60.1)\nsyndrome de Zellweger (Q87.8)"
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},
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{
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"document": "cim10",
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"page": 495,
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"code": "K82.1",
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"extrait": "K82.1 Hydrocholécyste\nMucocèle de la vésicule biliaire"
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}
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],
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"est_cma": true,
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"niveau_severite": "non_evalue",
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"source": "edsnlp"
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},
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{
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"texte": "Hydrocéphalie",
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"cim10_suggestion": "G91",
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"sources_rag": [
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{
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"document": "cim10",
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"page": 352,
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"code": "G91.2",
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"extrait": "G91.2 Hydrocéphalie à pression normale"
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},
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{
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"document": "cim10",
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"page": 671,
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"code": "Q03.8",
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"extrait": "Q03.8 Autres hydrocéphalies congénitales"
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},
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{
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"document": "cim10",
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"page": 671,
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"code": "Q03.9",
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"extrait": "Q03.9 Hydrocéphalie congénitale, sans précision"
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},
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{
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"document": "cim10",
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"page": 353,
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"code": "G91.9",
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"extrait": "G91.9 Hydrocéphalie, sans précision"
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},
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{
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"document": "cim10",
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"page": 672,
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"code": "Q05.3",
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"extrait": "Q05.3 Spina bifida sacré, avec hydrocéphalie"
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},
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{
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"document": "cim10",
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"page": 672,
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"code": "Q05.0",
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"extrait": "Q05.0 Spina bifida cervical, avec hydrocéphalie"
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},
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{
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"document": "cim10",
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"page": 672,
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"code": "Q05.4",
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"extrait": "Q05.4 Spina bifida, avec hydrocéphalie, sans précision"
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},
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{
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"document": "cim10",
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"page": 672,
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"code": "Q05.8",
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"extrait": "Q05.8 Spina bifida sacré, sans hydrocéphalie"
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},
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{
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"document": "cim10",
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"page": 672,
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"code": "Q05.5",
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"extrait": "Q05.5 Spina bifida cervical, sans hydrocéphalie"
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},
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{
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"document": "cim10_alpha",
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"page": 994,
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"code": "Q05",
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"extrait": "4-036 Hydrocéphalie congénitale et spina bifi- Q03, → Q05"
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}
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],
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"niveau_severite": "non_evalue",
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"source": "edsnlp"
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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": "Hémoglobine",
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"valeur": "13,0",
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"anomalie": false
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},
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{
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"test": "Plaquettes",
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"valeur": "158",
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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": "173",
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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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"alertes_codage": [
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"2 CMA probables détectées — impact potentiel sur le niveau de sévérité GHM",
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"CMA probable : 'Fibrillation auriculaire' (I48.9) — sévérité non_evalue",
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"CMA probable : 'Hyperkaliémie' (E87.5) — sévérité non_evalue"
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],
|
||
"source_files": [],
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||
"ghm_estimation": {
|
||
"cmd": "23",
|
||
"cmd_libelle": "Facteurs influençant l'état de santé (symptômes)",
|
||
"type_ghm": "M",
|
||
"severite": 2,
|
||
"ghm_approx": "23M??2",
|
||
"cma_count": 2,
|
||
"cms_count": 0,
|
||
"alertes": [
|
||
"DP symptomatique (R06.4) — risque de CMD 23, impact tarif"
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||
]
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||
},
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||
"controles_cpam": [],
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||
"processing_time_s": 4.18
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||
} |