4e2b4bd946
- Réorganisation data/referentiels/ : pdfs/, dicts/, user/ (structure unifiée) - Fix badges "Source absente" sur page admin référentiels - Ré-indexation COCOA 2025 (555 → 1451 chunks, couverture 94%) - Fix VRAM OOM : embeddings forcés CPU via T2A_EMBED_CPU - Nouveaux modules : document_router, docx_extractor, image_extractor, ocr_engine - Module complétude (quality/completude.py + config YAML) - Template DIM (synthèse dimensionnelle) - Gunicorn config + systemd service t2a-viewer - Suppression t2a_install_rag_cleanup/ (copie obsolète) - Suppression scripts/ et scripts_t2a_v2/ (anciens benchmarks) - Suppression 81 fichiers _doc.txt de test - Cache Ollama : TTL configurable, corrections loader YAML - Dashboard : améliorations templates (base, index, detail, cpam, validation) Co-Authored-By: Claude Opus 4.6 <noreply@anthropic.com>
435 lines
16 KiB
Python
435 lines
16 KiB
Python
"""Extraction des diagnostics (DP, DAS) et actes CCAM depuis le texte médical."""
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from __future__ import annotations
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import logging
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import re
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from typing import Optional
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from .cim10_dict import lookup as dict_lookup, normalize_text, validate_code as cim10_validate
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from .ccam_dict import lookup as ccam_lookup, validate_code as ccam_validate
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from .das_filter import clean_diagnostic_text, is_valid_diagnostic_text, expand_medical_abbreviations
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from ..config import ActeCCAM, Diagnostic, DossierMedical
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try:
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from .edsnlp_pipeline import EdsnlpResult
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except ImportError:
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EdsnlpResult = None # type: ignore[assignment,misc]
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logger = logging.getLogger(__name__)
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# Mapping diagnostics fréquents → codes CIM-10
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CIM10_MAP: dict[str, str] = {
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# Pancréatite
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"pancréatite aiguë biliaire": "K85.1",
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"pancréatite aigue biliaire": "K85.1",
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"pancréatite aiguë lithiasique": "K85.1",
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"pancréatite aigue lithiasique": "K85.1",
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"pancréatite aiguë": "K85.9",
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"pancréatite aigue": "K85.9",
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"pancréatite": "K85.9",
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# Lithiases biliaires
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"lithiase cholédoque": "K80.5",
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"lithiase du cholédoque": "K80.5",
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"calcul des canaux biliaires": "K80.5",
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"lithiase vésiculaire": "K80.2",
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"lithiases vésiculaires": "K80.2",
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"vésicule lithiasique": "K80.2",
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"colique hépatique": "K80.2",
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# Cholécystite
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"cholécystite aiguë": "K81.0",
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"cholecystite aigue": "K81.0",
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"angiocholite": "K83.0",
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# Obésité
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"obésité": "E66.0",
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"obesite": "E66.0",
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"surpoids": "E66.0",
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# Réactions médicamenteuses
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"éruption médicamenteuse": "L27.0",
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"eruption medicamenteuse": "L27.0",
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"éruption cutanée médicamenteuse": "L27.0",
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"toxidermie": "L27.0",
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"réaction au tramadol": "L27.0",
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"allergie médicamenteuse": "T88.7",
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# Douleur
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"douleur abdominale": "R10.4",
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"douleur hypochondre droit": "R10.1",
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# Ictère
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"ictère": "R17",
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"jaunisse": "R17",
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# HTA
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"hypertension artérielle": "I10",
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"hta": "I10",
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# Diabète
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"diabète type 2": "E11.9",
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"diabète de type 2": "E11.9",
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"diabète type 1": "E10.9",
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}
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# Mapping actes → codes CCAM
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CCAM_MAP: dict[str, str] = {
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"cholécystectomie": "HMFC004",
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"cholecystectomie": "HMFC004",
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"cholécystectomie par cœlioscopie": "HMFC004",
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"cholecystectomie par coelioscopie": "HMFC004",
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"cholangiographie": "HHHE002",
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"cholangiographie peropératoire": "HHHE002",
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"cpre": "HHHE002",
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"sphinctérotomie endoscopique": "HHHE003",
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"scanner abdominal": "ZCQK002",
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"tdm abdominal": "ZCQK002",
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"échographie abdominale": "ZCQJ001",
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"echo abdominale": "ZCQJ001",
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"irm abdominale": "ZCQN001",
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}
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# Patterns DAS : (pattern_normalisé, label, code_fallback)
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# Les patterns sont appliqués sur du texte normalisé (sans accents, lowercase)
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_DAS_PATTERNS: list[tuple[str, str, str]] = [
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# Lithiases biliaires
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(r"lithiase\s+(?:du\s+)?(?:bas\s+)?choledoque", "Lithiase du cholédoque", "K80.5"),
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(r"vesicule\s+lithiasique|lithiases?\s+vesiculaire", "Lithiase vésiculaire", "K80.2"),
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# Inflammation biliaire
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(r"cholecystite\s+aigue", "Cholécystite aiguë", "K81.0"),
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(r"angiocholite|cholangite", "Angiocholite", "K83.0"),
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# Réactions médicamenteuses
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(r"eruption\s+cutanee|toxidermie|reaction\s+au\s+tramadol", "Éruption cutanée médicamenteuse", "L27.0"),
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# Cardiovasculaire
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(r"hypertension\s+arterielle|\bhta\b", "Hypertension artérielle", "I10"),
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(r"fibrillation\s+auriculaire|\bfa\b(?:\s+paroxystique)?|\bacfa\b", "Fibrillation auriculaire", "I48.9"),
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(r"embolie\s+pulmonaire", "Embolie pulmonaire", "I26.9"),
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(r"thrombose\s+veineuse\s+profonde|\btvp\b", "Thrombose veineuse profonde", "I80.2"),
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# Métabolique
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(r"diabete\s+(?:sucre\s+)?(?:de\s+)?type\s+2|diabete\s+type\s*2", "Diabète de type 2", "E11.9"),
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(r"diabete\s+(?:sucre\s+)?(?:de\s+)?type\s+1|diabete\s+type\s*1", "Diabète de type 1", "E10.9"),
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(r"dyslipidemie|hypercholesterolemie", "Dyslipidémie", "E78.5"),
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(r"denutrition\s+severe|malnutrition\s+severe|denutrition\s+grade\s+(?:3|iii|III)", "Dénutrition sévère", "E43"),
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(r"denutrition\s+moderee?|malnutrition\s+moderee?|denutrition\s+grade\s+(?:2|ii|II)", "Dénutrition modérée", "E44.0"),
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(r"denutrition|malnutrition|hypoalbuminemie\s+severe", "Dénutrition", "E46"),
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# Infectieux
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(r"pneumopathie|pneumonie", "Pneumopathie", "J18.9"),
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(r"infection\s+urinaire|pyelonephrite", "Infection urinaire", "N39.0"),
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(r"\bsepsis\b|septicemie|choc\s+septique", "Sepsis", "A41.9"),
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# Rénal
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(r"insuffisance\s+renale", "Insuffisance rénale", "N19"),
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# Hématologique
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(r"anemie", "Anémie", "D64.9"),
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# Addictions
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(r"tabagisme|tabac\s+actif", "Tabagisme", "F17.2"),
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(r"ethylisme|alcoolisme|intoxication\s+ethylique", "Éthylisme", "F10.1"),
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]
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def _extract_diagnostics(
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parsed: dict,
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text: str,
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dossier: DossierMedical,
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edsnlp_result: Optional[EdsnlpResult] = None,
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) -> None:
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"""Extrait le diagnostic principal et les diagnostics associés."""
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text_lower = text.lower()
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# Diagnostics codés depuis Trackare (prioritaires)
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for diag in parsed.get("diagnostics", []):
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texte = clean_diagnostic_text(diag.get("libelle", ""))
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texte = expand_medical_abbreviations(texte)
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is_principal = diag.get("type", "").lower() == "principal"
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# Le DP Trackare est toujours accepté (pré-codé avec CIM-10 validé).
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# Seuls les DAS passent le filtre anti-bruit.
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if not is_principal and not is_valid_diagnostic_text(texte):
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continue
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d = Diagnostic(
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texte=texte,
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cim10_suggestion=diag.get("code_cim10"),
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source="trackare",
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)
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if is_principal:
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dossier.diagnostic_principal = d
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else:
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dossier.diagnostics_associes.append(d)
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# Extraction du texte "Au total:" ou conclusion
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conclusion = ""
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m = re.search(
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r"Au total\s*[:：]?\s*(.*?)(?=\n\s*(?:Devenir|TTT|Sortie|$))",
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text,
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re.DOTALL | re.IGNORECASE,
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)
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if m:
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conclusion = m.group(1).strip()
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# Enrichissement via edsnlp (CIM-10)
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edsnlp_codes: dict[str, str] = {}
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if edsnlp_result:
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for ent in edsnlp_result.cim10_entities:
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if not ent.negation and not ent.hypothese:
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edsnlp_codes[ent.code] = ent.texte
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# Si pas de DP depuis le codage, chercher dans le texte
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if not dossier.diagnostic_principal:
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# D'abord essayer le fallback regex (plus précis pour les patterns spécifiques)
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dp = _find_diagnostic_principal(text_lower, conclusion)
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if dp:
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dossier.diagnostic_principal = dp
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elif edsnlp_codes:
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# Utiliser la première entité CIM-10 edsnlp comme DP
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code, texte = next(iter(edsnlp_codes.items()))
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texte_clean = texte.capitalize()
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if is_valid_diagnostic_text(texte_clean):
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dossier.diagnostic_principal = Diagnostic(
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texte=texte_clean, cim10_suggestion=code,
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source="edsnlp",
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)
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# Diagnostics associés depuis le texte (regex)
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das = _find_diagnostics_associes(text_lower, conclusion, dossier)
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das = [d for d in das if is_valid_diagnostic_text(d.texte)]
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dossier.diagnostics_associes.extend(das)
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# Enrichissement DAS depuis edsnlp
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if edsnlp_result:
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existing_codes = set()
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if dossier.diagnostic_principal:
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existing_codes.add(dossier.diagnostic_principal.cim10_suggestion)
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for d in dossier.diagnostics_associes:
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existing_codes.add(d.cim10_suggestion)
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for ent in edsnlp_result.cim10_entities:
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if ent.negation or ent.hypothese:
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continue
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texte = clean_diagnostic_text(ent.texte.capitalize())
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if not is_valid_diagnostic_text(texte):
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continue
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if ent.code not in existing_codes:
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dossier.diagnostics_associes.append(Diagnostic(
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texte=texte,
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cim10_suggestion=ent.code,
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source="edsnlp",
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))
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existing_codes.add(ent.code)
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def _find_diagnostic_principal(text_lower: str, conclusion: str) -> Diagnostic | None:
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"""Trouve le diagnostic principal dans le texte.
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Normalise le texte avant matching pour gérer les variations d'accents/casse.
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"""
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conclusion_norm = normalize_text(conclusion)
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# Chercher dans la conclusion d'abord via CIM10_MAP (domain override)
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for terme, code in CIM10_MAP.items():
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if normalize_text(terme) in conclusion_norm:
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return Diagnostic(texte=terme.capitalize(), cim10_suggestion=code, source="regex")
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text_norm = normalize_text(text_lower)
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# Patterns courants pour le DP (normalisés, sans accents)
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dp_patterns = [
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r"pancreatite\s+aigue\s+(?:d'origine\s+)?lithiasique",
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r"pancreatite\s+aigue\s+biliaire",
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r"pancreatite\s+aigue",
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]
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for pat in dp_patterns:
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m = re.search(pat, text_norm)
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if m:
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matched = m.group(0)
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code = _lookup_cim10(matched)
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return Diagnostic(texte=matched.capitalize(), cim10_suggestion=code, source="regex")
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return None
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def _find_diagnostics_associes(
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text_lower: str, conclusion: str, dossier: DossierMedical
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) -> list[Diagnostic]:
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"""Trouve les diagnostics associés.
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Utilise des patterns normalisés (sans accents) pour une détection robuste.
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"""
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das: list[Diagnostic] = []
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existing_codes = set()
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if dossier.diagnostic_principal:
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existing_codes.add(dossier.diagnostic_principal.cim10_suggestion)
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for d in dossier.diagnostics_associes:
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existing_codes.add(d.cim10_suggestion)
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text_norm = normalize_text(text_lower)
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# Patterns DAS
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for pat, label, code in _DAS_PATTERNS:
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if re.search(pat, text_norm) and code not in existing_codes:
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das.append(Diagnostic(texte=label, cim10_suggestion=code, source="regex"))
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existing_codes.add(code)
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# Obésité (IMC >= 30) — pattern spécial avec extraction de valeur
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m = re.search(r"imc\s*[:=]?\s*(\d{2,3}[.,]\d+)", text_norm)
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if m:
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imc_val = float(m.group(1).replace(",", "."))
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if imc_val >= 30 and "E66.0" not in existing_codes:
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das.append(Diagnostic(texte=f"Obésité (IMC {imc_val})", cim10_suggestion="E66.0", source="regex"))
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existing_codes.add("E66.0")
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return das
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def _detect_nutrition_has2021(dossier: DossierMedical) -> None:
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"""Détecte la dénutrition selon les critères HAS/FFN novembre 2021.
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Logique déterministe basée sur données structurées (IMC + âge + albumine).
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- Critère phénotypique : IMC < seuil (âge-dépendant)
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- Critère de sévérité : albumine < 30 g/L → sévère, 30-35 → modéré
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- Code final : max(sévérité IMC, sévérité albumine) → E43 ou E44.0
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Ref: HAS/FFN nov 2021 « Diagnostic de la dénutrition chez l'enfant,
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l'adulte, et la personne de 70 ans et plus »
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"""
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# 1. Vérifier qu'aucun code E40-E46 n'est déjà codé
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existing_codes: set[str] = set()
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if dossier.diagnostic_principal and dossier.diagnostic_principal.cim10_suggestion:
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existing_codes.add(dossier.diagnostic_principal.cim10_suggestion)
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for d in dossier.diagnostics_associes:
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if d.cim10_suggestion:
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existing_codes.add(d.cim10_suggestion)
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for code in existing_codes:
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if code.startswith(("E4",)) and code[:3] in ("E40", "E41", "E42", "E43", "E44", "E45", "E46"):
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return # Déjà codé
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# 2. Vérifier qu'on a un IMC (critère phénotypique obligatoire)
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imc = dossier.sejour.imc if dossier.sejour else None
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if imc is None:
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return
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age = dossier.sejour.age if dossier.sejour else None
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# 3. Seuils IMC HAS 2021 (âge-dépendants)
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if age is not None and age >= 70:
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# Personne âgée ≥ 70 ans
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if imc >= 22:
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return # Au-dessus du seuil
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imc_severe = imc < 20
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imc_moderate = not imc_severe # 20 ≤ IMC < 22
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else:
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# Adulte 18-69 ans (ou âge inconnu → seuils adulte par défaut)
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if imc >= 18.5:
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return # Au-dessus du seuil
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imc_severe = imc <= 17
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imc_moderate = not imc_severe # 17 < IMC < 18.5
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# 4. Critère de sévérité : albumine
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albumine_val = None
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for bio in dossier.biologie_cle:
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if bio.test == "Albumine" and bio.valeur_num is not None:
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if bio.quality != "discarded":
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albumine_val = bio.valeur_num
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break
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albumine_severe = albumine_val is not None and albumine_val < 30
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albumine_moderate = albumine_val is not None and 30 <= albumine_val < 35
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# 5. Code final : max(sévérité IMC, sévérité albumine)
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is_severe = imc_severe or albumine_severe
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is_moderate = imc_moderate or albumine_moderate
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if is_severe:
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code = "E43"
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label = "Dénutrition sévère"
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elif is_moderate:
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code = "E44.0"
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label = "Dénutrition modérée"
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else:
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return # Ne devrait pas arriver vu les checks précédents
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# 6. Construire l'alerte explicative
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parts = []
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if age is not None and age >= 70:
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parts.append(f"IMC {imc} (seuil ≥70 ans : <22 modéré, <20 sévère)")
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else:
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parts.append(f"IMC {imc} (seuil adulte : <18.5 modéré, ≤17 sévère)")
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if albumine_val is not None:
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parts.append(f"Albumine {albumine_val} g/L (<30 sévère, 30-35 modéré)")
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alerte = f"HAS 2021 — {label} ({code}) : {' ; '.join(parts)}"
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dossier.diagnostics_associes.append(
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Diagnostic(texte=label, cim10_suggestion=code, source="has2021")
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)
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dossier.alertes_codage.append(alerte)
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logger.info("HAS 2021 dénutrition : %s ajouté (%s)", code, alerte)
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def _extract_actes(text: str, dossier: DossierMedical) -> None:
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"""Extrait les actes CCAM."""
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text_lower = text.lower()
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# Cholécystectomie par cœlioscopie
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if re.search(r"chol[ée]cystectomie\s+par\s+c[oœ][ea]lioscopie", text_lower):
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date = _find_act_date(text, r"chol[ée]cystectomie")
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dossier.actes_ccam.append(ActeCCAM(
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texte="Cholécystectomie par cœlioscopie",
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code_ccam_suggestion="HMFC004",
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date=date,
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))
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elif re.search(r"chol[ée]cystectomie|cholecystectomie", text_lower):
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date = _find_act_date(text, r"chol[ée]cystectomie|cholecystectomie")
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dossier.actes_ccam.append(ActeCCAM(
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texte="Cholécystectomie",
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code_ccam_suggestion="HMFC004",
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date=date,
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))
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# Cholangiographie
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if re.search(r"cholangiographie", text_lower):
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date = _find_act_date(text, r"cholangiographie")
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dossier.actes_ccam.append(ActeCCAM(
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texte="Cholangiographie peropératoire",
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code_ccam_suggestion="HHHE002",
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date=date,
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))
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# TDM
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if re.search(r"(?:tdm|scanner|tomodensitométrie)", text_lower):
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date = _find_act_date(text, r"(?:TDM|scanner)")
|
||
dossier.actes_ccam.append(ActeCCAM(
|
||
texte="TDM abdominal",
|
||
code_ccam_suggestion="ZCQK002",
|
||
date=date,
|
||
))
|
||
|
||
# Fallback : tenter le lookup CCAM dict pour les actes sans code
|
||
for acte in dossier.actes_ccam:
|
||
if not acte.code_ccam_suggestion:
|
||
code = ccam_lookup(acte.texte, domain_overrides=CCAM_MAP)
|
||
if code:
|
||
acte.code_ccam_suggestion = code
|
||
|
||
|
||
def _find_act_date(text: str, act_pattern: str) -> str | None:
|
||
"""Trouve la date associée à un acte."""
|
||
# Chercher "acte le DD/MM" ou "acte le DD/MM/YYYY"
|
||
m = re.search(
|
||
rf"{act_pattern}.*?(?:le\s+)?(\d{{2}}/\d{{2}}(?:/\d{{4}})?)",
|
||
text,
|
||
re.IGNORECASE,
|
||
)
|
||
if m:
|
||
return m.group(1)
|
||
|
||
# Chercher dans la ligne d'observation juste avant
|
||
m = re.search(
|
||
rf"(\d{{2}}/\d{{2}}/\d{{4}}).*?{act_pattern}",
|
||
text,
|
||
re.IGNORECASE,
|
||
)
|
||
if m:
|
||
return m.group(1)
|
||
return None
|
||
|
||
|
||
def _lookup_cim10(text: str) -> str | None:
|
||
"""Cherche un code CIM-10 pour un texte donné.
|
||
|
||
Utilise le dictionnaire complet (10 893 codes) avec CIM10_MAP en override prioritaire.
|
||
"""
|
||
return dict_lookup(text, domain_overrides=CIM10_MAP)
|