{ "source_file": "CRH 23050890.pdf", "document_type": "crh", "sejour": { "sexe": "F" }, "diagnostic_principal": { "texte": "Anémie", "cim10_suggestion": "D64.9", "cim10_confidence": "high", "cim10_final": "D64.9", "sources_rag": [], "preuves_cliniques": [], "est_cma": true, "niveau_severite": "non_evalue", "niveau_cma": 2, "source": "nuke3", "source_page": 1, "source_excerpt": "...le.\nElle bénéficiera d’une rééducation libérale, avec un traitement martial pour compenser un peu l’anémie postopératoire.\nElle bénéficiera d’une rééducation libérale, avec un traitement martial pour compen..." }, "dp_selection": { "chosen_index": 0, "chosen_term": "Anémie", "chosen_code": "D64.9", "verdict": "REVIEW", "evidence": [ "Scores proches : 3.0 vs 2.0" ], "reason": "Écart 1.0 < seuil 3.0, LLM indisponible", "candidates": [ { "index": 0, "term": "Anémie", "code": "D64.9", "source": "regex", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 3, "num_occurrences": 1, "score": 3.0, "score_details": { "section": 3, "confidence": 0 } }, { "index": 3, "term": "Épispadias", "code": "Q64.0", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 2, "score": 2.0, "score_details": { "section": 1, "confidence": 0, "occurrences": 1 } }, { "index": 4, "term": "Extrophie vésicale", "code": "Q64.1", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 2, "score": 2.0, "score_details": { "section": 1, "confidence": 0, "occurrences": 1 } }, { "index": 1, "term": "Dysplasie de hanche congénitale", "code": "Q65.8", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } }, { "index": 2, "term": "Dysraphie antérieure", "code": "Q06.8", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } } ], "debug_scores": { "top1": 3.0, "top2": 2.0, "delta": 1.0 } }, "dp_crh_only": { "chosen_index": 0, "chosen_term": "Anémie", "chosen_code": "D64.9", "verdict": "REVIEW", "evidence": [ "Scores proches : 3.0 vs 2.0" ], "reason": "Écart 1.0 < seuil 3.0, LLM indisponible", "candidates": [ { "index": 0, "term": "Anémie", "code": "D64.9", "source": "regex", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 3, "num_occurrences": 1, "score": 3.0, "score_details": { "section": 3, "confidence": 0 } }, { "index": 3, "term": "Épispadias", "code": "Q64.0", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 2, "score": 2.0, "score_details": { "section": 1, "confidence": 0, "occurrences": 1 } }, { "index": 4, "term": "Extrophie vésicale", "code": "Q64.1", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 2, "score": 2.0, "score_details": { "section": 1, "confidence": 0, "occurrences": 1 } }, { "index": 1, "term": "Dysplasie de hanche congénitale", "code": "Q65.8", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } }, { "index": 2, "term": "Dysraphie antérieure", "code": "Q06.8", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } } ], "debug_scores": { "top1": 3.0, "top2": 2.0, "delta": 1.0 } }, "dp_final": { "chosen_index": 0, "chosen_term": "Anémie", "chosen_code": "D64.9", "verdict": "REVIEW", "evidence": [ "Scores proches : 3.0 vs 2.0" ], "reason": "Écart 1.0 < seuil 3.0, LLM indisponible", "candidates": [ { "index": 0, "term": "Anémie", "code": "D64.9", "source": "regex", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 3, "num_occurrences": 1, "score": 3.0, "score_details": { "section": 3, "confidence": 0 } }, { "index": 3, "term": "Épispadias", "code": "Q64.0", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 2, "score": 2.0, "score_details": { "section": 1, "confidence": 0, "occurrences": 1 } }, { "index": 4, "term": "Extrophie vésicale", "code": "Q64.1", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 2, "score": 2.0, "score_details": { "section": 1, "confidence": 0, "occurrences": 1 } }, { "index": 1, "term": "Dysplasie de hanche congénitale", "code": "Q65.8", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } }, { "index": 2, "term": "Dysraphie antérieure", "code": "Q06.8", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } } ], "debug_scores": { "top1": 3.0, "top2": 2.0, "delta": 1.0 } }, "quality_flags": { "rag_status": "error", "crh_only_mode": true }, "diagnostics_associes": [ { "texte": "Dysplasie de hanche congénitale", "cim10_suggestion": "Q65.8", "cim10_confidence": "medium", "cim10_final": "Q65.8", "justification": "Diagnostic congénital explicitement mentionné comme indication chirurgicale. La dysplasie de hanche a mobilisé des ressources supplémentaires (technique chirurgicale spécifique, matériel adapté) et justifie l'intervention réalisée.", "sources_rag": [], "preuves_cliniques": [], "niveau_severite": "non_evalue", "niveau_cma": 1, "source": "llm_das", "source_page": 1, "source_excerpt": "...TE SUR HANCHE DYSPLASIQUE.\nHistoire de la maladie :\nPatiente âgée de 52 ans.\nPatiente victime d’une dysplasie de hanche congénitale associée à une dysraphie antérieure et un épispadias et à une\nextrophie vésicale.\nEn ce qui concern..." }, { "texte": "Dysraphie antérieure", "cim10_suggestion": "Q06.8", "cim10_confidence": "medium", "cim10_final": "Q06.8", "justification": "Malformation congénitale associée explicitement mentionnée dans le contexte clinique du patient, faisant partie de son tableau clinique global.", "sources_rag": [], "preuves_cliniques": [], "est_cma": true, "niveau_severite": "non_evalue", "niveau_cma": 2, "source": "llm_das", "source_page": 1, "source_excerpt": "...ie :\nPatiente âgée de 52 ans.\nPatiente victime d’une dysplasie de hanche congénitale associée à une dysraphie antérieure et un épispadias et à une\nextrophie vésicale.\nEn ce qui concerne la hanche, il s’agit d’une dysplas..." }, { "texte": "Épispadias", "cim10_suggestion": "Q64.0", "cim10_confidence": "low", "cim10_final": "Q64.0", "justification": "Malformation congénitale urogénitale explicitement mentionnée dans le contexte clinique du patient.", "sources_rag": [], "preuves_cliniques": [], "niveau_severite": "non_evalue", "niveau_cma": 1, "source": "llm_das", "source_page": 1, "source_excerpt": "...s.\nPatiente victime d’une dysplasie de hanche congénitale associée à une dysraphie antérieure et un épispadias et à une\nextrophie vésicale.\nEn ce qui concerne la hanche, il s’agit d’une dysplasie tout à fait ha..." }, { "texte": "Extrophie vésicale", "cim10_suggestion": "Q64.1", "cim10_confidence": "low", "cim10_final": "Q64.1", "justification": "Malformation congénitale urogénitale majeure explicitement mentionnée dans le contexte clinique du patient.", "sources_rag": [], "preuves_cliniques": [], "niveau_severite": "non_evalue", "niveau_cma": 1, "source": "llm_das", "source_page": 1, "source_excerpt": "...d’une dysplasie de hanche congénitale associée à une dysraphie antérieure et un épispadias et à une\nextrophie vésicale.\nEn ce qui concerne la hanche, il s’agit d’une dysplasie tout à fait habituelle, j’ai plus l’opérer..." } ], "actes_ccam": [], "antecedents": [], "traitements_sortie": [], "biologie_cle": [], "biologie_discarded": [], "imagerie": [], "complications": [], "alertes_codage": [ "QUALITE DEGRADEE : erreur RAG — codage sans référentiels", "NUKE-3 REVIEW: DP ambigu — Écart 1.0 < seuil 3.0, LLM indisponible", "2 CMA probables détectées — impact potentiel sur le niveau de sévérité GHM", "CMA niveau 2 : 'Anémie' (D64.9) — sévérité non_evalue", "CMA niveau 2 : 'Dysraphie antérieure' (Q06.8) — sévérité non_evalue", "QC: 🔴 CRITIQUE : Aucune preuve clinique documentée pour AUCUN code. Les justifications sont génériques sans référence au dossier réel.", "QC: 🔴 CRITIQUE : Conflit diagnostique majeur entre Q64.0 (épispadias) et Q64.1 (extrophie vésicale). Ces deux malformations graves coexistent exceptionnellement. Clarifier le diagnostic exact.", "QC: 🟠 GRAVE : D64.9 (anémie) codée sans justification clinique - risque de surcodage.", "QC: 🟠 GRAVE : Tous les codes Q (malformations congénitales) manquent de preuves documentées (examens, imagerie, compte-rendu opératoire).", "QC: 🟡 MOYEN : Codes Q65.8 et Q06.8 manquent de spécificité - utiliser codes plus précis si données disponibles.", "QC: 🟡 MOYEN : Absence de codes relatifs à la prise en charge chirurgicale (actes) - vérifier cohérence avec les interventions réalisées.", "QC: ⚠️ RECOMMANDATION : Demander au clinicien les preuves documentées (CR opératoire, imagerie, examen clinique) avant validation définitive." ], "source_files": [], "ghm_estimation": { "cmd": "16", "cmd_libelle": "Tumeurs bénignes, hémopathies", "type_ghm": "M", "severite": 2, "ghm_approx": "16M??2", "cma_count": 1, "cms_count": 0, "alertes": [] }, "controles_cpam": [], "veto_report": { "verdict": "PASS", "score_contestabilite": 100, "issues": [] }, "completude": { "checks": [ { "code": "D64.9", "libelle": "Anémie", "type_diag": "DP", "items": [ { "categorie": "biologie", "element": "Hémoglobine", "statut": "absent", "importance": "obligatoire", "impact_cpam": "Hémoglobine indispensable pour confirmer et qualifier une anémie" }, { "categorie": "biologie", "element": "Ferritine", "statut": "absent", "importance": "recommande", "impact_cpam": "Permet de typer l'anémie (carentielle vs inflammatoire)" }, { "categorie": "biologie", "element": "VGM", "statut": "absent", "importance": "recommande", "impact_cpam": "Oriente l'étiologie (microcytaire/macrocytaire)" } ], "score": 0, "verdict": "indefendable", "resume": "0/1 obligatoires, 0/2 recommandés" } ], "score_global": 0, "verdict_global": "indefendable", "documents_presents": [ "crh" ], "documents_manquants": [] }, "processing_time_s": 15.18, "metrics": { "das_total": 4, "das_active": 4, "das_excluded": 0, "das_removed": 0, "das_ruled_out": 0, "das_no_code": 0, "actes_total": 0, "actes_with_code": 0, "dp_has_code": true }, "rules_runtime": { "router_version": 1, "mode": "strict", "enabled_packs": [ "decisions_core", "vetos_core" ], "always_on_rules": [], "triggers_fired": [] } }