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        v: Date Type Problème Sévérité Statut du problème Statut clinique du patient Certitude Commentaire Document référencé 11/01/2024 interprétation diagnostique Thyroïdite auto-immune (CIM-10 : E06.3) modéré Actif fonction corporelle générale : normale Confirmé (texte libre) 05/07/2023 interprétation diagnostique Diabète insulino-dépendant (CISP2 : T89) modéré Actif fonction corporelle générale : normale Confirmé (texte libre) 21/05/2023 interprétation diagnostique Epilepsie (DRC : 114) modéré Actif fonction corporelle générale : normale Confirmé (texte libre) 11/02/2022 interprétation diagnostique Angiœdème bradykinique (OrphaCode : 658) léger à modéré Actif asymptomatique Confirmé (texte libre) 11/02/2022 symptôme rapporté par le patient ou le répondant Autre problème (texte libre) léger Récurrent fonction corporelle générale : normale Non confirmé (texte libre)
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        v: Date Type Problème Sévérité Statut du problème Statut clinique du patient Certitude Commentaire Document référencé 11/02/2022 au 11/03/2022 interprétation diagnostique Accident Ischémique Cérébral Transitoire (CIM-10 : G45.9) modéré Résolu fonction corporelle générale : normale Confirmé (Texte libre) 14/01/2018 au 25/01/2018 interprétation diagnostique Pyélonéphrite aiguë (CIM-10 : N10) modéré Résolu fonction corporelle générale : normale Confirmé (Texte libre)
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        v: Date Acte Voie d’abord Localisation anatomique Motif Commentaire 14/01/2018 Dilatation intraluminale de 2 vaisseaux coronaires avec pose d'endoprothèse, par voie artérielle transcutanée Voie intraartérielle artère coronaire Infarctus inférieur transmural (texte libre) 08/12/2016 Autre acte (texte libre) - - - (texte libre)
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        v: Date Type Agent responsable Statut Criticité Certitude Réaction(s) Sévérité réaction(s) Commentaire 04/12/2021 Allergie médicamenteuse Paracétamol Actif Bas Confirmé Bronchospasme d'origine médicamenteuse Troubles allergiques ou d'hypersensibilité de la peau ou des muqueuses modéré léger (texte libre)
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        v: Date Type Agent responsable Substance(s) incriminée(s) Posologie Voie d’administration Réaction(s) Imputabilité Gravité Evolution Commentaire 04/12/2021 interaction médicamenteuse AMOXICILLINE EG 1G BUV SACH 6 AMOXICILLINE TRIHYDRATÉE 1 g / 2 fois par jour voie orale nausées probable Non grave Guérison sans séquelle (texte libre)
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        v: Traitements au long cours : Date de début Date de fin Médicament Fréquence Dose prescrite Rythme Voie d'administration Motif Commentaire 11/01/2024 - LEVOTHYROX 75 microgrammes, comprimé sécable 1 cp 1 fois/j - Voie orale Thyroïdite auto-immune (texte libre)
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        v: Date début Date fin Type de DM ID du DM Commentaire 11/08/2019 STIMULATEUR CARDIAQUE IMPLANTABLE TRIPLE CHAMBRE inconnu (texte libre) 11/08/2013 Autre DM : (texte libre) inconnu (texte libre)
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        v: Date Type Observation Commentaire 14/01/2018 Score de performance ECOG Capable d’une activité identique à celle précédant la maladie sans aucune restriction (LOINC : LA9622-7) (texte libre) 14/01/2018 Marcher Restriction modérée de la performance de marche sur de courtes distances (CIF : d4500.3) (texte libre) 14/01/2018 Autre statut fonctionnel : (texte libre) (texte libre) (texte libre)
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        v: Signe vital Valeur Date de la mesure Commentaire Poids 58 kg 02/04/2024 (texte libre) Taille 1,60 m 02/04/2024 (texte libre)
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        v: Date Type Observation Commentaire non renseignée Statut tabagique Fumeur quotidien (Texte libre) non renseignée Consommation tabagique 25 PA (Texte libre) non renseignée Consommation d'alcool 5 verres / jour (Texte libre) non renseignée Consommation de drogue Cannabis (Texte libre)
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        v: (texte libre)
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        v: Lien de parenté Antécédent Commentaire Mère Anémie à hématies falciformes sans crises (CIM-10 : D57.1) (texte libre)
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        v: Date Maladie(s) prévenue(s) Vaccin Lot n° Type / Rang Voie Région d'administration Réaction observée Vaccinateur Commentaire 28/09/2009 Diphtérie-poliomyélite-tétanos REVAXIS, suspension injectable en seringue préremplie. Vaccin diphtérique, tétanique et poliomyélitique (inactivé), adsorbé, à teneur réduite en antigènes 4456672 1ère série vaccinante / 2 Voie intramusculaire Deltoïde gauche Fièvre due à des médicaments Dr Charles MULLER Prise récente et ponctuelle de solupred (60mg) en une prise pendant 2 jours 25/08/2009 Diphtérie-poliomyélite-tétanos REVAXIS, suspension injectable en seringue préremplie. Vaccin diphtérique, tétanique et poliomyélitique (inactivé), adsorbé, à teneur réduite en antigènes 4456668 1ère série vaccinante / 1 Voie intramusculaire Deltoïde gauche Fièvre due à des médicaments Dr Charles MULLER -
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        v: Observation Précision Statut de grossesse patiente actuellement enceinte Date prévisionnelle d'accouchement 03/09/2024 Nb d'enfants vivants 1 Nombre d'interruptions de grossesse 1
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        v: Traitements médicamenteux : Médicament Commentaire ROSUVASTATINE EG 5 mg, comprimé pelliculé (texte libre) Autre traitement : (texte libre) (texte libre) Demandes d'examens ou de suivis : Date envisagée Demande Commentaire 01/12/2024 Cholestérol LDL (Texte libre) 01/12/2024 Autre examen (texte libre) (Texte libre) Actes : Date envisagée Priorité Acte Commentaire 01/12/2024 Bénéfique pour le patient mais pas essentiel pour sa survie Pose d'une prothèse auditive implantable dans l'oreille moyenne (Texte libre) 01/12/2024 Aussi vite que possible Autre acte (texte libre) (Texte libre) Rencontres : Date envisagée Type de rencontre Personne Lieu Commentaire 01/12/2024 Ambulatoire PR Jacques PETITJEAN (Médecin - Oncologie, opt Onco-hématologie (SM)) Hôpital Lariboisière (Service hématologie) (Texte libre) Vaccins recommandés : Période de vaccination souhaitable Vaccin Commentaire entre le 01/12/2024 et le 31/12/2024 Vaccin antituberculeux (Texte libre) entre le 01/12/2024 et le 31/12/2024 Autre vaccin (texte libre) (Texte libre)
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        v: Directives anticipées structurées : Directive Précision Date de la directive Commentaire Maintient artificiel en vie Non autorisé 01/01/2018 (Texte libre) Assistance respiratoire Non autorisé 01/01/2018 (Texte libre) Alimentation et hydratation artificielles Non autorisé 01/01/2018 (Texte libre) Dialyse rénale Autorisé 01/01/2018 (Texte libre) Réanimation cardiaque et respiratoire Non autorisé 01/01/2018 (Texte libre) Intervention chirurgicale Autorisé 01/01/2018 (Texte libre) Sédation profonde et continue associée à un traitement de la douleur Autorisé 01/01/2018 (Texte libre) Directives anticipées non structurées : Directives anticipées non structurées (pdf récupérées du DMP 01/04/2024) Commentaire : (Texte libre)

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v: NA

v: #plan-med-02-commentaire
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l: plan-acte-02-commentaire

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    telecom:
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prefix:
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given:
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family:
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suffix:
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xml text:
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v: NAV

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v: #plan-rencontre-01-commentaire
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v: NA

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l: plan-vaccin-02-commentaire

v: 2.16.840.1.113883.10.20.1.1

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v: 1.2.250.1.213.1.1.2.157

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v: LOINC

v: Directives anticipées

v: Directives anticipées

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template id:
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text:
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v: #directive-05-commentaire
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