From 94fa4e5f3b9ce65692e4e36886be3f8c38ddeeb1 Mon Sep 17 00:00:00 2001 From: dom Date: Tue, 17 Feb 2026 21:47:27 +0100 Subject: [PATCH] =?UTF-8?q?feat:=20r=C3=A9sum=C3=A9=20clinique=20enrichi?= =?UTF-8?q?=20+=20preuves=20cliniques=20+=20validation=20QC=20batch?= MIME-Version: 1.0 Content-Type: text/plain; charset=UTF-8 Content-Transfer-Encoding: 8bit Améliore la qualité du codage CIM-10 sur 3 axes : - Contexte clinique enrichi (interprétations bio, traitements indicatifs, marqueurs sévérité) - Preuves cliniques structurées par diagnostic (evidence linking dans le prompt LLM) - Validation batch post-codage (1 appel LLM/dossier, ajustement confiance, alertes QC) Co-Authored-By: Claude Opus 4.6 --- src/config.py | 7 + src/medical/cim10_extractor.py | 111 +++++++++++ src/medical/clinical_context.py | 315 +++++++++++++++++++++++++++++++ src/medical/rag_search.py | 39 ++-- src/viewer/templates/detail.html | 23 ++- tests/test_clinical_context.py | 264 ++++++++++++++++++++++++++ tests/test_justification.py | 245 ++++++++++++++++++++++++ 7 files changed, 988 insertions(+), 16 deletions(-) create mode 100644 src/medical/clinical_context.py create mode 100644 tests/test_clinical_context.py create mode 100644 tests/test_justification.py diff --git a/src/config.py b/src/config.py index 0209586..d650eab 100644 --- a/src/config.py +++ b/src/config.py @@ -92,6 +92,12 @@ class Sejour(BaseModel): taille: Optional[float] = None +class PreuveClinique(BaseModel): + type: str # "biologie" | "imagerie" | "traitement" | "acte" | "clinique" + element: str # "CRP 180 mg/L" + interpretation: str # "syndrome inflammatoire majeur" + + class Diagnostic(BaseModel): texte: str cim10_suggestion: Optional[str] = None @@ -99,6 +105,7 @@ class Diagnostic(BaseModel): justification: Optional[str] = None raisonnement: Optional[str] = None sources_rag: list[RAGSource] = Field(default_factory=list) + preuves_cliniques: list[PreuveClinique] = Field(default_factory=list) est_cma: Optional[bool] = None est_cms: Optional[bool] = None niveau_severite: Optional[str] = None # "leger" | "modere" | "severe" | "non_evalue" diff --git a/src/medical/cim10_extractor.py b/src/medical/cim10_extractor.py index 9facca8..6cc5a27 100644 --- a/src/medical/cim10_extractor.py +++ b/src/medical/cim10_extractor.py @@ -150,6 +150,10 @@ def extract_medical_info( # Post-processing : retirer DAS dont le code est identique au DP _remove_das_equal_dp(dossier) + # Post-processing : validation justifications (QC batch) + if use_rag: + _validate_justifications(dossier) + # Post-processing : traçabilité source (page + extrait) if page_tracker: _apply_source_tracking(dossier, page_tracker, search_text) @@ -1019,3 +1023,110 @@ def _apply_source_tracking(dossier: DossierMedical, page_tracker, search_text: s if tracked: logger.info(" Traçabilité source : %d/%d diagnostics localisés", tracked, len(all_diags)) + + +def _validate_justifications(dossier: DossierMedical) -> None: + """Validation croisée de tous les diagnostics via un appel LLM unique. + + Vérifie la cohérence, les preuves cliniques et la spécificité des codes. + Ajuste la confiance si la justification est faible et ajoute des alertes QC. + """ + try: + from .ollama_client import call_ollama + from .clinical_context import build_enriched_context, format_enriched_context + except ImportError: + logger.warning("Module clinical_context non disponible pour la validation QC") + return + + all_diags: list[tuple[str, Diagnostic]] = [] + if dossier.diagnostic_principal: + all_diags.append(("DP", dossier.diagnostic_principal)) + for das in dossier.diagnostics_associes: + all_diags.append(("DAS", das)) + + if not all_diags: + return + + # Construire le résumé des codes à valider + codes_section = "" + for i, (type_diag, diag) in enumerate(all_diags, 1): + code = diag.cim10_suggestion or "?" + justif = (diag.justification or "")[:150] + preuves = ", ".join(p.element for p in diag.preuves_cliniques[:3]) or "aucune" + codes_section += f"{i}. [{type_diag}] {code} — {diag.texte}\n" + codes_section += f" Justification: {justif}\n" + codes_section += f" Preuves: {preuves}\n\n" + + ctx = build_enriched_context(dossier) + ctx_str = format_enriched_context(ctx) + + prompt = f"""Tu es un médecin DIM contrôleur qualité PMSI. +Vérifie la cohérence et la justification de ce codage complet. + +DOSSIER CLINIQUE : +{ctx_str} + +CODAGE À VALIDER : +{codes_section} + +Pour CHAQUE code, vérifie : +1. Existe-t-il une preuve clinique concrète dans le dossier ? +2. Le code est-il le plus spécifique possible ? +3. Y a-t-il des conflits ou redondances avec d'autres codes ? + +Réponds avec un JSON : +{{ + "validations": [ + {{ + "numero": 1, + "code": "X99.9", + "verdict": "maintenir|reclasser|supprimer", + "confidence_recommandee": "high|medium|low", + "commentaire": "explication courte" + }} + ], + "alertes_globales": ["..."] +}}""" + + try: + result = call_ollama(prompt, temperature=0.1, max_tokens=2500) + except Exception: + logger.warning("Erreur lors de l'appel Ollama pour validation QC", exc_info=True) + return + + if result is None: + return + + # Appliquer les ajustements + validations = result.get("validations", []) + for v in validations: + if not isinstance(v, dict): + continue + num = v.get("numero") + if not isinstance(num, int) or num < 1 or num > len(all_diags): + continue + type_diag, diag = all_diags[num - 1] + conf = v.get("confidence_recommandee") + verdict = v.get("verdict") + commentaire = v.get("commentaire", "") + + if conf in ("high", "medium", "low") and conf != diag.cim10_confidence: + old = diag.cim10_confidence + diag.cim10_confidence = conf + if old and conf != old: + dossier.alertes_codage.append( + f"QC: {type_diag} {diag.cim10_suggestion} confiance {old}\u2192{conf} \u2014 {commentaire}" + ) + + if verdict == "supprimer" and type_diag == "DAS": + dossier.alertes_codage.append( + f"QC: DAS {diag.cim10_suggestion} ({diag.texte}) à reconsidérer \u2014 {commentaire}" + ) + + alertes_globales = result.get("alertes_globales", []) + for a in alertes_globales: + if isinstance(a, str) and a.strip(): + dossier.alertes_codage.append(f"QC: {a}") + + logger.info(" QC batch : %d validations, %d alertes globales", + len(validations), len(alertes_globales)) diff --git a/src/medical/clinical_context.py b/src/medical/clinical_context.py new file mode 100644 index 0000000..5758cfa --- /dev/null +++ b/src/medical/clinical_context.py @@ -0,0 +1,315 @@ +"""Enrichissement du contexte clinique pour les prompts LLM. + +Interprète les données brutes (biologie, traitements, séjour) en informations +cliniques structurées pour améliorer la qualité du codage CIM-10. +""" + +from __future__ import annotations + +from ..config import DossierMedical +from .cim10_extractor import BIO_NORMALS + +# Seuils d'interprétation biologique (test → liste de (seuil, direction, interprétation)) +# Ordre décroissant : le premier seuil franchi donne l'interprétation +BIO_INTERPRETATIONS: dict[str, list[tuple[float, str, str]]] = { + "CRP": [ + (100, "high", "syndrome inflammatoire majeur"), + (20, "high", "syndrome inflammatoire modéré"), + (5, "high", "syndrome inflammatoire mineur"), + ], + "Lipasémie": [ + (180, "high", "pancréatite biologique (>3N)"), + (60, "high", "élévation modérée de la lipase"), + ], + "ASAT": [ + (200, "high", "cytolyse hépatique majeure (>5N)"), + (80, "high", "cytolyse hépatique modérée (>2N)"), + ], + "ALAT": [ + (200, "high", "cytolyse hépatique majeure (>5N)"), + (80, "high", "cytolyse hépatique modérée (>2N)"), + ], + "Bilirubine totale": [ + (50, "high", "ictère franc"), + (17, "high", "hyperbilirubinémie modérée"), + ], + "Hémoglobine": [ + (7, "low", "anémie sévère (transfusion probable)"), + (10, "low", "anémie modérée"), + ], + "Créatinine": [ + (300, "high", "insuffisance rénale sévère"), + (150, "high", "insuffisance rénale modérée"), + ], + "Plaquettes": [ + (50, "low", "thrombopénie sévère"), + (100, "low", "thrombopénie modérée"), + ], + "Leucocytes": [ + (20, "high", "hyperleucocytose majeure (infection, inflammation)"), + (2, "low", "leucopénie sévère (aplasie, immunodépression)"), + ], +} + +# Médicaments → condition implicite (clé en lowercase) +TREATMENT_INDICATORS: dict[str, str] = { + "insuline": "diabète insulino-traité", + "metformine": "diabète type 2", + "héparine": "anticoagulation (risque thromboembolique)", + "enoxaparine": "anticoagulation (HBPM)", + "lovenox": "anticoagulation (HBPM)", + "warfarine": "anticoagulation au long cours (AVK)", + "fluindione": "anticoagulation au long cours (AVK)", + "amoxicilline": "antibiothérapie", + "ceftriaxone": "antibiothérapie IV", + "tazocilline": "antibiothérapie large spectre IV", + "morphine": "analgésie palier 3 (douleur sévère)", + "oxycodone": "analgésie palier 3 (douleur sévère)", + "oxygène": "oxygénothérapie (insuffisance respiratoire)", + "furosémide": "insuffisance cardiaque / rétention hydrique", + "lasilix": "insuffisance cardiaque / rétention hydrique", +} + + +def interpret_bio_value(test: str, value_str: str, is_abnormal: bool | None) -> str | None: + """Retourne l'interprétation clinique d'une valeur bio, ou None si normale.""" + if test not in BIO_INTERPRETATIONS: + return None + + try: + val = float(value_str.replace(",", ".").replace(" ", "")) + except (ValueError, AttributeError): + return None + + # Si la valeur est normale (pas anormale), pas d'interprétation + if is_abnormal is False: + return None + + thresholds = BIO_INTERPRETATIONS[test] + for seuil, direction, interpretation in thresholds: + if direction == "high" and val >= seuil: + return interpretation + if direction == "low" and val <= seuil: + return interpretation + + return None + + +def detect_treatment_indicators(traitements: list) -> list[dict]: + """Retourne les conditions implicites détectées via les traitements. + + Args: + traitements: Liste d'objets Traitement ou de dicts avec clé 'medicament'. + + Returns: + Liste de dicts {medicament, condition}. + """ + results = [] + seen_conditions: set[str] = set() + + for t in traitements: + med = t.medicament if hasattr(t, "medicament") else t.get("medicament", "") + med_lower = med.lower().strip() + + for keyword, condition in TREATMENT_INDICATORS.items(): + if keyword in med_lower and condition not in seen_conditions: + results.append({"medicament": med, "condition": condition}) + seen_conditions.add(condition) + break + + return results + + +def detect_severity_markers(dossier: DossierMedical) -> list[str]: + """Détecte les marqueurs de sévérité globaux.""" + markers = [] + + duree = dossier.sejour.duree_sejour + if duree is not None: + if duree > 14: + markers.append(f"séjour prolongé ({duree} jours)") + elif duree > 7: + markers.append(f"séjour >7 jours ({duree} jours)") + + age = dossier.sejour.age + if age is not None: + if age >= 80: + markers.append(f"patient très âgé ({age} ans)") + elif age >= 70: + markers.append(f"patient âgé ({age} ans)") + + imc = dossier.sejour.imc + if imc is not None: + if imc >= 40: + markers.append(f"obésité morbide (IMC {imc})") + elif imc >= 30: + markers.append(f"obésité (IMC {imc})") + + if dossier.complications: + markers.append(f"{len(dossier.complications)} complication(s)") + + return markers + + +def build_enriched_context(dossier: DossierMedical) -> dict: + """Construit le contexte clinique enrichi (appel unique par dossier). + + Returns: + Dict avec les clés : patient, duree_sejour, antecedents, + biologie (avec interprétations), imagerie, complications, + dp_texte, das_codes_existants, interpretations_bio, + conditions_traitements, marqueurs_severite. + """ + # Données de base (compatibles avec l'ancien format) + ctx: dict = { + "sexe": dossier.sejour.sexe, + "age": dossier.sejour.age, + "duree_sejour": dossier.sejour.duree_sejour, + "imc": dossier.sejour.imc, + "antecedents": dossier.antecedents[:5], + "biologie_cle": [(b.test, b.valeur, b.anomalie) for b in dossier.biologie_cle], + "imagerie": [(i.type, (i.conclusion or "")[:200]) for i in dossier.imagerie], + "complications": dossier.complications, + } + + # Interprétations biologiques + interpretations = [] + for b in dossier.biologie_cle: + interp = interpret_bio_value(b.test, b.valeur or "", b.anomalie) + if interp: + # Ajouter l'unité si connue + unit = "" + if b.test in ("CRP",): + unit = " mg/L" + elif b.test in ("Lipasémie", "ASAT", "ALAT", "GGT", "PAL"): + unit = " UI/L" + elif b.test in ("Bilirubine totale", "Créatinine"): + unit = " µmol/L" + elif b.test in ("Hémoglobine",): + unit = " g/dL" + elif b.test in ("Plaquettes", "Leucocytes"): + unit = " G/L" + interpretations.append({ + "test": b.test, + "valeur": f"{b.valeur}{unit}", + "interpretation": interp, + }) + ctx["interpretations_bio"] = interpretations + + # Conditions implicites via traitements + ctx["conditions_traitements"] = detect_treatment_indicators(dossier.traitements_sortie) + + # Marqueurs de sévérité + ctx["marqueurs_severite"] = detect_severity_markers(dossier) + + return ctx + + +def format_enriched_context(context: dict) -> str: + """Formate le contexte enrichi en texte structuré pour le prompt. + + Inclut les mêmes sections que l'ancien _format_contexte() PLUS : + interprétations bio, conditions implicites traitements, marqueurs sévérité. + """ + lines = [] + + # Patient + sexe = context.get("sexe") + age = context.get("age") + imc = context.get("imc") + patient_parts = [] + if sexe: + patient_parts.append(sexe) + if age: + patient_parts.append(f"{age} ans") + if imc: + patient_parts.append(f"IMC {imc}") + if patient_parts: + lines.append(f"- Patient : {', '.join(str(p) for p in patient_parts)}") + + # Durée de séjour + duree = context.get("duree_sejour") + if duree: + lines.append(f"- Durée séjour : {duree} jours") + + # Antécédents + antecedents = context.get("antecedents") + if antecedents: + lines.append(f"- Antécédents : {', '.join(antecedents[:5])}") + + # Biologie (avec normes) + biologie = context.get("biologie_cle") + if biologie: + bio_parts = [] + for b in biologie: + test, valeur, anomalie = ( + b if isinstance(b, (list, tuple)) + else (b.get("test"), b.get("valeur"), b.get("anomalie")) + ) + norme_str = "" + if test in BIO_NORMALS: + lo, hi = BIO_NORMALS[test] + lo_s = int(lo) if lo == int(lo) else lo + hi_s = int(hi) if hi == int(hi) else hi + norme_str = f" [N: {lo_s}-{hi_s}]" + marker = " (\u2191)" if anomalie else "" + bio_parts.append(f"{test} {valeur}{norme_str}{marker}") + lines.append(f"- Biologie : {', '.join(bio_parts)}") + + # Imagerie + imagerie = context.get("imagerie") + if imagerie: + for img in imagerie: + img_type, conclusion = ( + img if isinstance(img, (list, tuple)) + else (img.get("type"), img.get("conclusion")) + ) + if conclusion: + lines.append(f"- Imagerie : {img_type} — {conclusion[:200]}") + + # Complications + complications = context.get("complications") + if complications: + lines.append(f"- Complications : {', '.join(complications)}") + + # DP du séjour + dp_texte = context.get("dp_texte") + if dp_texte: + lines.append(f"- DP du séjour : {dp_texte}") + + # DAS déjà codés + das_codes = context.get("das_codes_existants") + if das_codes: + lines.append(f"- DAS déjà codés : {', '.join(das_codes)}") + + # --- Sections enrichies --- + + # Interprétations biologiques + interpretations = context.get("interpretations_bio", []) + if interpretations: + interp_parts = [ + f"{i['test']} {i['valeur']} \u2192 {i['interpretation']}" + for i in interpretations + ] + lines.append(f"\nINTERPRÉTATION CLINIQUE :") + lines.append(f"- Biologie : {' ; '.join(interp_parts)}") + + # Conditions implicites via traitements + conditions = context.get("conditions_traitements", []) + if conditions: + cond_parts = [ + f"{c['medicament']} \u2192 {c['condition']}" + for c in conditions + ] + if not interpretations: + lines.append(f"\nINTERPRÉTATION CLINIQUE :") + lines.append(f"- Traitements indicatifs : {' ; '.join(cond_parts)}") + + # Marqueurs de sévérité + marqueurs = context.get("marqueurs_severite", []) + if marqueurs: + if not interpretations and not conditions: + lines.append(f"\nINTERPRÉTATION CLINIQUE :") + lines.append(f"- Marqueurs de sévérité : {', '.join(marqueurs)}") + + return "\n".join(lines) if lines else "Non précisé" diff --git a/src/medical/rag_search.py b/src/medical/rag_search.py index ff9cc61..2c405c9 100644 --- a/src/medical/rag_search.py +++ b/src/medical/rag_search.py @@ -6,12 +6,13 @@ import logging from concurrent.futures import ThreadPoolExecutor, as_completed from ..config import ( - ActeCCAM, Diagnostic, DossierMedical, RAGSource, + ActeCCAM, Diagnostic, DossierMedical, PreuveClinique, RAGSource, OLLAMA_CACHE_PATH, OLLAMA_MAX_PARALLEL, OLLAMA_MODEL, EMBEDDING_MODEL, RERANKER_MODEL, ) from .cim10_dict import normalize_code, validate_code as cim10_validate, fallback_parent_code from .cim10_extractor import BIO_NORMALS +from .clinical_context import build_enriched_context, format_enriched_context from .ccam_dict import validate_code as ccam_validate from .ollama_client import call_ollama, parse_json_response from .ollama_cache import OllamaCache @@ -347,7 +348,7 @@ def _build_prompt(texte: str, sources: list[dict], contexte: dict, est_dp: bool sources_text += (src.get("extrait", "")[:800]) + "\n\n" type_diag = "DP (diagnostic principal)" if est_dp else "DAS (diagnostic associé significatif)" - ctx_str = _format_contexte(contexte) + ctx_str = format_enriched_context(contexte) return f"""Tu es un médecin DIM (Département d'Information Médicale) expert en codage PMSI. Tu dois coder le diagnostic suivant en respectant STRICTEMENT les règles de l'ATIH. @@ -377,7 +378,10 @@ Réponds UNIQUEMENT avec un objet JSON au format suivant, sans aucun texte avant "regle_pmsi": "conformité aux règles PMSI pour un {type_diag} (guide méthodologique)", "code": "X99.9", "confidence": "high ou medium ou low", - "justification": "explication courte en français" + "justification": "explication courte en français", + "preuves_cliniques": [ + {{"type": "biologie|imagerie|traitement|acte|clinique", "element": "élément concret du dossier", "interpretation": "signification clinique justifiant le code"}} + ] }}""" @@ -398,7 +402,7 @@ def _build_prompt_ccam(texte: str, sources: list[dict], contexte: dict) -> str: sources_text += f"--- Source {i}: {doc_name}{code_info}{page_info} ---\n" sources_text += (src.get("extrait", "")[:800]) + "\n\n" - ctx_str = _format_contexte(contexte) + ctx_str = format_enriched_context(contexte) return f"""Tu es un médecin DIM (Département d'Information Médicale) expert en codage CCAM PMSI. Tu dois coder l'acte chirurgical/médical suivant en respectant STRICTEMENT la nomenclature CCAM. @@ -498,6 +502,20 @@ def _apply_llm_result_diagnostic(diagnostic: Diagnostic, llm_result: dict) -> No if raisonnement: diagnostic.raisonnement = raisonnement + # Stocker les preuves cliniques + preuves = llm_result.get("preuves_cliniques", []) + if preuves and isinstance(preuves, list): + for p in preuves: + if isinstance(p, dict) and p.get("element"): + try: + diagnostic.preuves_cliniques.append(PreuveClinique( + type=p.get("type", "clinique"), + element=p["element"], + interpretation=p.get("interpretation", ""), + )) + except Exception: + pass + def enrich_diagnostic( diagnostic: Diagnostic, @@ -621,7 +639,7 @@ def enrich_acte(acte: ActeCCAM, contexte: dict, cache: OllamaCache | None = None def _build_prompt_das_extraction(text: str, contexte: dict, existing_das: list[str], dp_texte: str) -> str: """Construit le prompt pour l'extraction LLM de DAS supplémentaires.""" - ctx_str = _format_contexte(contexte) + ctx_str = format_enriched_context(contexte) existing_str = "\n".join(f"- {d}" for d in existing_das) if existing_das else "Aucun" return f"""Tu es un médecin DIM (Département d'Information Médicale) expert en codage PMSI. @@ -723,16 +741,7 @@ def enrich_dossier(dossier: DossierMedical) -> None: """ cache = OllamaCache(OLLAMA_CACHE_PATH, OLLAMA_MODEL) - contexte = { - "sexe": dossier.sejour.sexe, - "age": dossier.sejour.age, - "duree_sejour": dossier.sejour.duree_sejour, - "imc": dossier.sejour.imc, - "antecedents": dossier.antecedents[:5], - "biologie_cle": [(b.test, b.valeur, b.anomalie) for b in dossier.biologie_cle], - "imagerie": [(i.type, (i.conclusion or "")[:200]) for i in dossier.imagerie], - "complications": dossier.complications, - } + contexte = build_enriched_context(dossier) # Phase 1 : DP seul (le contexte DAS en dépend) if dossier.diagnostic_principal: diff --git a/src/viewer/templates/detail.html b/src/viewer/templates/detail.html index 713846d..cbbff14 100644 --- a/src/viewer/templates/detail.html +++ b/src/viewer/templates/detail.html @@ -223,6 +223,16 @@ {% if dp.justification %}
{{ dp.justification }}
{% endif %} + {% if dp.preuves_cliniques %} +
+ Preuves cliniques ({{ dp.preuves_cliniques|length }}) +
    + {% for p in dp.preuves_cliniques %} +
  • {{ p.type }} {{ p.element }} → {{ p.interpretation }}
    • + {% endfor %} +
+
+ {% endif %} {% if dp.raisonnement %}
Raisonnement LLM @@ -275,7 +285,18 @@
{% endif %} - {{ das.justification or '' }} + + {{ das.justification or '' }} + {% if das.preuves_cliniques %} +
preuves ({{ das.preuves_cliniques|length }}) +
    + {% for p in das.preuves_cliniques %} +
  • [{{ p.type }}] {{ p.element }} → {{ p.interpretation }}
    • + {% endfor %} +
+
+ {% endif %} + {% if das.raisonnement %} diff --git a/tests/test_clinical_context.py b/tests/test_clinical_context.py new file mode 100644 index 0000000..734282a --- /dev/null +++ b/tests/test_clinical_context.py @@ -0,0 +1,264 @@ +"""Tests pour le module d'enrichissement du contexte clinique.""" + +import pytest + +from src.medical.clinical_context import ( + BIO_INTERPRETATIONS, + TREATMENT_INDICATORS, + interpret_bio_value, + detect_treatment_indicators, + detect_severity_markers, + build_enriched_context, + format_enriched_context, +) +from src.config import ( + BiologieCle, + Diagnostic, + DossierMedical, + Imagerie, + Sejour, + Traitement, +) + + +# --- interpret_bio_value --- + +class TestInterpretBioValue: + def test_crp_major(self): + assert interpret_bio_value("CRP", "180", True) == "syndrome inflammatoire majeur" + + def test_crp_moderate(self): + assert interpret_bio_value("CRP", "45", True) == "syndrome inflammatoire modéré" + + def test_crp_minor(self): + assert interpret_bio_value("CRP", "8", True) == "syndrome inflammatoire mineur" + + def test_crp_normal(self): + assert interpret_bio_value("CRP", "3", False) is None + + def test_lipase_pancreatite(self): + assert interpret_bio_value("Lipasémie", "450", True) == "pancréatite biologique (>3N)" + + def test_lipase_moderee(self): + assert interpret_bio_value("Lipasémie", "90", True) == "élévation modérée de la lipase" + + def test_hemoglobine_severe(self): + assert interpret_bio_value("Hémoglobine", "6.5", True) == "anémie sévère (transfusion probable)" + + def test_hemoglobine_moderee(self): + assert interpret_bio_value("Hémoglobine", "9", True) == "anémie modérée" + + def test_plaquettes_severe(self): + assert interpret_bio_value("Plaquettes", "30", True) == "thrombopénie sévère" + + def test_leucocytes_high(self): + assert interpret_bio_value("Leucocytes", "25", True) == "hyperleucocytose majeure (infection, inflammation)" + + def test_leucocytes_low(self): + assert interpret_bio_value("Leucocytes", "1.5", True) == "leucopénie sévère (aplasie, immunodépression)" + + def test_creatinine_severe(self): + assert interpret_bio_value("Créatinine", "350", True) == "insuffisance rénale sévère" + + def test_unknown_test(self): + assert interpret_bio_value("Glycémie", "2.5", True) is None + + def test_invalid_value(self): + assert interpret_bio_value("CRP", "positive", True) is None + + def test_comma_separator(self): + assert interpret_bio_value("Hémoglobine", "6,5", True) == "anémie sévère (transfusion probable)" + + def test_bilirubine_ictere(self): + assert interpret_bio_value("Bilirubine totale", "55", True) == "ictère franc" + + def test_asat_cytolyse_majeure(self): + assert interpret_bio_value("ASAT", "250", True) == "cytolyse hépatique majeure (>5N)" + + def test_asat_cytolyse_moderee(self): + assert interpret_bio_value("ASAT", "100", True) == "cytolyse hépatique modérée (>2N)" + + +# --- detect_treatment_indicators --- + +class TestDetectTreatmentIndicators: + def test_insuline(self): + traitements = [Traitement(medicament="INSULINE LANTUS 20UI")] + result = detect_treatment_indicators(traitements) + assert len(result) == 1 + assert result[0]["condition"] == "diabète insulino-traité" + + def test_antibiotique_iv(self): + traitements = [Traitement(medicament="CEFTRIAXONE 1g IV")] + result = detect_treatment_indicators(traitements) + assert len(result) == 1 + assert result[0]["condition"] == "antibiothérapie IV" + + def test_multiple(self): + traitements = [ + Traitement(medicament="Metformine 1000mg"), + Traitement(medicament="Enoxaparine 4000UI"), + Traitement(medicament="Paracétamol 1g"), + ] + result = detect_treatment_indicators(traitements) + assert len(result) == 2 + conditions = {r["condition"] for r in result} + assert "diabète type 2" in conditions + assert "anticoagulation (HBPM)" in conditions + + def test_no_match(self): + traitements = [Traitement(medicament="Paracétamol 1g")] + result = detect_treatment_indicators(traitements) + assert result == [] + + def test_dedup_conditions(self): + traitements = [ + Traitement(medicament="Enoxaparine 4000UI"), + Traitement(medicament="Lovenox 4000UI"), + ] + result = detect_treatment_indicators(traitements) + # Les deux sont HBPM, mais une seule condition + assert len(result) == 1 + + def test_dict_input(self): + traitements = [{"medicament": "morphine 10mg"}] + result = detect_treatment_indicators(traitements) + assert len(result) == 1 + assert result[0]["condition"] == "analgésie palier 3 (douleur sévère)" + + +# --- detect_severity_markers --- + +class TestDetectSeverityMarkers: + def test_sejour_prolonge(self): + dossier = DossierMedical(sejour=Sejour(duree_sejour=20)) + markers = detect_severity_markers(dossier) + assert any("séjour prolongé" in m for m in markers) + + def test_sejour_gt7(self): + dossier = DossierMedical(sejour=Sejour(duree_sejour=10)) + markers = detect_severity_markers(dossier) + assert any("séjour >7 jours" in m for m in markers) + + def test_patient_tres_age(self): + dossier = DossierMedical(sejour=Sejour(age=85)) + markers = detect_severity_markers(dossier) + assert any("très âgé" in m for m in markers) + + def test_patient_age(self): + dossier = DossierMedical(sejour=Sejour(age=72)) + markers = detect_severity_markers(dossier) + assert any("patient âgé" in m for m in markers) + + def test_obesite_morbide(self): + dossier = DossierMedical(sejour=Sejour(imc=42.0)) + markers = detect_severity_markers(dossier) + assert any("obésité morbide" in m for m in markers) + + def test_complications(self): + dossier = DossierMedical(complications=["Fièvre", "Hématome"]) + markers = detect_severity_markers(dossier) + assert any("2 complication(s)" in m for m in markers) + + def test_no_markers(self): + dossier = DossierMedical(sejour=Sejour(age=45, duree_sejour=3)) + markers = detect_severity_markers(dossier) + assert markers == [] + + +# --- build_enriched_context --- + +class TestBuildEnrichedContext: + def test_basic_context(self): + dossier = DossierMedical( + sejour=Sejour(sexe="M", age=65, duree_sejour=5), + biologie_cle=[ + BiologieCle(test="CRP", valeur="150", anomalie=True), + ], + traitements_sortie=[ + Traitement(medicament="Ceftriaxone 1g"), + ], + ) + ctx = build_enriched_context(dossier) + + assert ctx["sexe"] == "M" + assert ctx["age"] == 65 + assert len(ctx["interpretations_bio"]) == 1 + assert ctx["interpretations_bio"][0]["interpretation"] == "syndrome inflammatoire majeur" + assert len(ctx["conditions_traitements"]) == 1 + assert ctx["conditions_traitements"][0]["condition"] == "antibiothérapie IV" + + def test_no_abnormal_bio(self): + dossier = DossierMedical( + biologie_cle=[ + BiologieCle(test="CRP", valeur="3", anomalie=False), + ], + ) + ctx = build_enriched_context(dossier) + assert ctx["interpretations_bio"] == [] + + +# --- format_enriched_context --- + +class TestFormatEnrichedContext: + def test_with_interpretations(self): + ctx = { + "sexe": "F", + "age": 70, + "imc": None, + "duree_sejour": 10, + "antecedents": ["HTA", "Diabète"], + "biologie_cle": [("CRP", "180", True)], + "imagerie": [], + "complications": [], + "dp_texte": None, + "das_codes_existants": None, + "interpretations_bio": [ + {"test": "CRP", "valeur": "180 mg/L", "interpretation": "syndrome inflammatoire majeur"}, + ], + "conditions_traitements": [ + {"medicament": "Insuline", "condition": "diabète insulino-traité"}, + ], + "marqueurs_severite": ["séjour >7 jours (10 jours)"], + } + result = format_enriched_context(ctx) + assert "Patient : F, 70 ans" in result + assert "Durée séjour : 10 jours" in result + assert "HTA" in result + assert "CRP 180" in result + assert "INTERPRÉTATION CLINIQUE" in result + assert "syndrome inflammatoire majeur" in result + assert "diabète insulino-traité" in result + assert "séjour >7 jours" in result + + def test_empty_context(self): + ctx = { + "sexe": None, "age": None, "imc": None, + "duree_sejour": None, "antecedents": [], + "biologie_cle": [], "imagerie": [], + "complications": [], "dp_texte": None, + "das_codes_existants": None, + "interpretations_bio": [], + "conditions_traitements": [], + "marqueurs_severite": [], + } + result = format_enriched_context(ctx) + assert result == "Non précisé" + + def test_backward_compat_bio_format(self): + """Le format bio tuple (test, valeur, anomalie) doit rester compatible.""" + ctx = { + "sexe": None, "age": None, "imc": None, + "duree_sejour": None, "antecedents": [], + "biologie_cle": [("CRP", "180", True)], + "imagerie": [], + "complications": [], + "dp_texte": None, + "das_codes_existants": None, + "interpretations_bio": [], + "conditions_traitements": [], + "marqueurs_severite": [], + } + result = format_enriched_context(ctx) + assert "CRP 180" in result + assert "(\u2191)" in result diff --git a/tests/test_justification.py b/tests/test_justification.py new file mode 100644 index 0000000..05e61cf --- /dev/null +++ b/tests/test_justification.py @@ -0,0 +1,245 @@ +"""Tests pour la validation batch des justifications (QC post-codage).""" + +from unittest.mock import patch, MagicMock + +import pytest + +from src.config import ( + Diagnostic, + DossierMedical, + PreuveClinique, + Sejour, + BiologieCle, +) + + +class TestPreuveClinique: + def test_create(self): + p = PreuveClinique(type="biologie", element="CRP 180 mg/L", interpretation="syndrome inflammatoire majeur") + assert p.type == "biologie" + assert p.element == "CRP 180 mg/L" + assert p.interpretation == "syndrome inflammatoire majeur" + + def test_diagnostic_with_preuves(self): + d = Diagnostic( + texte="Pancréatite aiguë", + cim10_suggestion="K85.9", + preuves_cliniques=[ + PreuveClinique(type="biologie", element="Lipasémie 450 UI/L", interpretation="pancréatite biologique"), + PreuveClinique(type="imagerie", element="TDM: pancréatite stade D", interpretation="confirmation"), + ], + ) + assert len(d.preuves_cliniques) == 2 + assert d.preuves_cliniques[0].type == "biologie" + + def test_diagnostic_default_empty_preuves(self): + d = Diagnostic(texte="Test") + assert d.preuves_cliniques == [] + + def test_serialization_round_trip(self): + d = Diagnostic( + texte="Test", + preuves_cliniques=[ + PreuveClinique(type="clinique", element="fièvre 39°C", interpretation="syndrome infectieux"), + ], + ) + data = d.model_dump() + assert data["preuves_cliniques"][0]["type"] == "clinique" + d2 = Diagnostic(**data) + assert d2.preuves_cliniques[0].element == "fièvre 39°C" + + +class TestApplyLlmResultPreuves: + """Teste le stockage des preuves cliniques dans _apply_llm_result_diagnostic.""" + + def test_preuves_stored(self): + from src.medical.rag_search import _apply_llm_result_diagnostic + + diag = Diagnostic(texte="Pneumopathie") + llm_result = { + "code": "J18.9", + "confidence": "high", + "justification": "Pneumopathie confirmée", + "preuves_cliniques": [ + {"type": "biologie", "element": "CRP 120 mg/L", "interpretation": "syndrome inflammatoire"}, + {"type": "imagerie", "element": "Radio thorax: opacité", "interpretation": "foyer pulmonaire"}, + ], + } + _apply_llm_result_diagnostic(diag, llm_result) + assert len(diag.preuves_cliniques) == 2 + assert diag.preuves_cliniques[0].type == "biologie" + assert diag.preuves_cliniques[1].element == "Radio thorax: opacité" + + def test_preuves_empty_list(self): + from src.medical.rag_search import _apply_llm_result_diagnostic + + diag = Diagnostic(texte="Test") + llm_result = {"code": "K85.9", "confidence": "medium", "preuves_cliniques": []} + _apply_llm_result_diagnostic(diag, llm_result) + assert diag.preuves_cliniques == [] + + def test_preuves_missing(self): + from src.medical.rag_search import _apply_llm_result_diagnostic + + diag = Diagnostic(texte="Test") + llm_result = {"code": "K85.9", "confidence": "medium"} + _apply_llm_result_diagnostic(diag, llm_result) + assert diag.preuves_cliniques == [] + + def test_preuves_malformed_skipped(self): + from src.medical.rag_search import _apply_llm_result_diagnostic + + diag = Diagnostic(texte="Test") + llm_result = { + "code": "K85.9", + "confidence": "high", + "preuves_cliniques": [ + {"type": "bio"}, # manque 'element' → ignoré + {"type": "imagerie", "element": "TDM ok", "interpretation": "normal"}, + "not a dict", # ignoré + ], + } + _apply_llm_result_diagnostic(diag, llm_result) + assert len(diag.preuves_cliniques) == 1 + assert diag.preuves_cliniques[0].element == "TDM ok" + + +class TestValidateJustifications: + """Teste la fonction _validate_justifications.""" + + @patch("src.medical.ollama_client.call_ollama") + def test_confidence_adjusted(self, mock_ollama): + from src.medical.cim10_extractor import _validate_justifications + + mock_ollama.return_value = { + "validations": [ + { + "numero": 1, + "code": "K85.9", + "verdict": "maintenir", + "confidence_recommandee": "high", + "commentaire": "bien justifié", + }, + { + "numero": 2, + "code": "I10", + "verdict": "maintenir", + "confidence_recommandee": "low", + "commentaire": "pas de preuve tensionnelle", + }, + ], + "alertes_globales": [], + } + + dossier = DossierMedical( + sejour=Sejour(sexe="M", age=60), + diagnostic_principal=Diagnostic( + texte="Pancréatite aiguë", + cim10_suggestion="K85.9", + cim10_confidence="medium", + ), + diagnostics_associes=[ + Diagnostic( + texte="HTA", + cim10_suggestion="I10", + cim10_confidence="high", + ), + ], + ) + + _validate_justifications(dossier) + + # DP: medium → high + assert dossier.diagnostic_principal.cim10_confidence == "high" + # DAS: high → low + assert dossier.diagnostics_associes[0].cim10_confidence == "low" + # Alertes de confiance + assert any("QC:" in a and "I10" in a for a in dossier.alertes_codage) + + @patch("src.medical.ollama_client.call_ollama") + def test_das_supprimer_alerte(self, mock_ollama): + from src.medical.cim10_extractor import _validate_justifications + + mock_ollama.return_value = { + "validations": [ + { + "numero": 1, + "code": "K85.9", + "verdict": "maintenir", + "confidence_recommandee": "high", + "commentaire": "ok", + }, + { + "numero": 2, + "code": "R10.4", + "verdict": "supprimer", + "confidence_recommandee": "low", + "commentaire": "symptôme couvert par le DP", + }, + ], + "alertes_globales": ["Vérifier la spécificité du DP"], + } + + dossier = DossierMedical( + diagnostic_principal=Diagnostic( + texte="Pancréatite aiguë", + cim10_suggestion="K85.9", + cim10_confidence="high", + ), + diagnostics_associes=[ + Diagnostic( + texte="Douleur abdominale", + cim10_suggestion="R10.4", + cim10_confidence="medium", + ), + ], + ) + + _validate_justifications(dossier) + + # Le DAS n'est pas supprimé automatiquement, mais une alerte est ajoutée + assert any("à reconsidérer" in a for a in dossier.alertes_codage) + assert any("Vérifier la spécificité" in a for a in dossier.alertes_codage) + + @patch("src.medical.ollama_client.call_ollama") + def test_ollama_returns_none(self, mock_ollama): + from src.medical.cim10_extractor import _validate_justifications + + mock_ollama.return_value = None + dossier = DossierMedical( + diagnostic_principal=Diagnostic( + texte="Test", + cim10_suggestion="K85.9", + cim10_confidence="high", + ), + ) + _validate_justifications(dossier) + assert dossier.alertes_codage == [] + + def test_no_diags(self): + from src.medical.cim10_extractor import _validate_justifications + + dossier = DossierMedical() + _validate_justifications(dossier) + assert dossier.alertes_codage == [] + + @patch("src.medical.ollama_client.call_ollama") + def test_invalid_validation_nums_skipped(self, mock_ollama): + from src.medical.cim10_extractor import _validate_justifications + + mock_ollama.return_value = { + "validations": [ + {"numero": 0, "code": "X", "verdict": "supprimer", "confidence_recommandee": "low", "commentaire": "oob"}, + {"numero": 99, "code": "Y", "verdict": "supprimer", "confidence_recommandee": "low", "commentaire": "oob"}, + {"numero": "abc", "code": "Z", "verdict": "supprimer", "confidence_recommandee": "low", "commentaire": "type"}, + ], + "alertes_globales": [], + } + + dossier = DossierMedical( + diagnostic_principal=Diagnostic(texte="T", cim10_suggestion="A00", cim10_confidence="high"), + ) + _validate_justifications(dossier) + # Aucune modification, tous les numéros sont invalides + assert dossier.diagnostic_principal.cim10_confidence == "high" + assert dossier.alertes_codage == []