Foaia de Observatie (Buna) [PDF]

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Judetul ………………… Localiatea........................

Nr. Inregistrare

FOAIE DE OBSERVATIE STOMATOLOGICA NUMELE................................................PRENUMELE................... .............Sexul M/F VARSTA anul

DATA NASTERII :

ziua

luna

Mediul U / R PROFESIA...................................................................................... Statut asigurat: Neasigurat

C.N.A.S.

MOTIVUL PREZENTARII:

Asigurare voluntara

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Istoricul bolii: ..................................................................................................... ..................... ............................................................................................................. ..................................... ....................................................................... ........................................................................... ............................................................................................................. ..................................... Antecedente HC generale:

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Antecedente HC Stomatologice: Antecedente personale ________________________________________ generale:

________________________________________ ________________________________________ Antecedente personale ________________________________________ Stomatologice: ________________________________________ ________________________________________ ________________________________________

Obiceiuri vicioase (daca exista)................................................................................................ I. EXAMENUL EXOBOCAL 1. General Dezvoltare generala: Tip constitutional: Sistem nervos:

Hiposom Entomorf Tare

Slab

Normosom Mezomorf ; Echilibrat

Hipersom Ectomorf Neechilibrat

2. Examenul extremitatii cefalice INSPECTIE Forma figurii : 1-muscular

2-respirator

2

3-cerebral

4-digestiv

Forma fetei: dreptunghiulara |_| triunghiulara |_| ovala |_| trapez cu baza sus | _| (norma frontala) trapez cu baza jos |_| rotunda |_| alte forme |_| Forma fetei _| (norma laterala)

drept |_|

convex sup |_| concav sup |_|

convex inf |_|

concav inf |_|

convex asociat|

concav asociat |_|

Alte aspecte patologice........................................................................................................... ........................................................................................................................................... ....... ........................................................................................................................................... ....... ........................................................................................................................................... ....... ........................................................................................................................................... ....... ........................................................................................................................................... ....... ........................................................................................................................................... .......

PALPARE Textura tegum: elastica (normala) |_|

indurate |_|

flasca |_|

cu anestezie |_|

arii

anestezice |_| Contururi osoase.............................................................................................................................................

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........................................................................................................................................... ....... ........................................................................................................................................... ....... Puncte de E.T. ........................................................................................................................ ........................................................................................................................................... ....... ........................................................................................................................................... ....... ........................................................................................................................................... ....... Grup ganglionar: ................................................................................................................... ........................................................................................................................................... ....... ........................................................................................................................................... ....... ........................................................................................................................................... ....... Formatiuni tumorale: ............................................................................................................ ........................................................................................................................................... ....... ........................................................................................................................................... ....... ........................................................................................................................................... ....... Examenul A.T.M................................................................................................................... ........................................................................................................................................... ....... ........................................................................................................................................... ....... ........................................................................................................................................... ....... 4

II. EXAMENUL ENDOBUCAL Exaenul oncologic preventive inspectia:............................................................................................................................ ...... ........................................................................................................................................... ........................................................................................................................................... .............. palpare:.............................................................................................................................. ....... ................................................................................................................................... ........................................................................................................................................... ...................... formatiuni si coloratii deosebite:.............................................................................................. ........................................................................................................................................... ........................................................................................................................................... .............. ............................................................................................................................ ........................................................................................................................................... ............................. Examenul odontal APELUL DINTILOR

.1.8 .1.7 .1.6 .1.5 .1.4 .1.3 .1.2 .1.1 .2.1 .2.2 .2.3 .2.4 .2.5 .2.6 .2.7 .2.8

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.4.8 .4.7 .4.6 .4.5 .4.4 .4.3 .4.2 .4.1 .3.1. .3.2 .3.3 .3.4 .3.5 .3.6 .3.7 .3.8

EXAMENUL OCLUZIEI I. In statica 1. In plan SAGITAL:

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2. In plan TRANSVERSAL:

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3. In plan VETICAL: 6

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II. In dinamica 1. Ghidaj anterior

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2. Ghidaj lateral

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EXAMENUL MODELELOR DE STUDIU Forma arcadelor: superioara :.................................................................................... inferioara:............................................................................... ....... 7

Aprecierea curburilor dentare: - curba lui SPE ......................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... .............. - curba lui WILSON................................................................................................................. ........................................................................................................................................... ........................................................................................................................................... .............. - curba incizala (vestibulara).................................................................................................... ........................................................................................................................................... ....... ................................................................................................................................... ............... Bolta palatina.......................................................................................................................... ........................................................................................................................................... ....... Planseul bucal......................................................................................................................... ........................................................................................................................................... ....... Alte exemene complementare: Radiografii

Fotografii

DIAGNOSTIC 1.Diagnosticul de urgenta ....................................................................................................... ........................................................................................................................................... ...... 2.Diagnosticul odontal ............................................................................................................ ........................................................................................................................................... ...... 8

3. Diagnosticul parodontal...................................................................................................... ........................................................................................................................................... ...... 4. Diagnosticul de edentatie.................................................................................................... ........................................................................................................................................... ...... 5.Diagnosticul de ocluzie........................................................................................................ ........................................................................................................................................... ...... 6.Diagnosticul ortodontic........................................................................................................ ........................................................................................................................................... ...... 7.Diagnosticul afectiunilor A.T.M. ......................................................................................... ........................................................................................................................................... ...... 8.Diagnosticul afectiunilor mucoasei bucale........................................................................... ........................................................................................................................................... ...... 9.Diagnosticul chirurgical....................................................................................................... ........................................................................................................................................... ...... 10.Diagnosticul oncologic...................................................................................................... ........................................................................................................................................... ...... 11.Diagnostic evolutiv............................................................................................................ ........................................................................................................................................... ...... 11.Diagnosticul afectiunilor generale...................................................................................... ........................................................................................................................................... ...... 9

DIAGNOSTICUL COMPLET........................................................................................... ........................................................................................................................................... ...... ........................................................................................................................................... ...... ........................................................................................................................................... ...... PLAN DE TRATAMENT................................................................................................... ........................................................................................................................................... ...... ........................................................................................................................................... ...... ........................................................................................................................................... ...... TRATAMENT ........................................................................................................................................... ...... ........................................................................................................................................... ...... ........................................................................................................................................... ...... ........................................................................................................................................... ...... ........................................................................................................................................... ...... ........................................................................................................................................... ...... ........................................................................................................................................... ...... ........................................................................................................................................... ...... ........................................................................................................................................... ...... ........................................................................................................................................... ...... 10

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