Foaia de Observatie Stomatologie Estetica
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foaie de observatie estetica
Transcript of Foaia de Observatie Stomatologie Estetica
Judetul Nr
Judetul Nr. Inregistrare
Localitatea........................ Student: ..Cadru didactic: ..........................................
FOAIE DE OBSERVATIE
NUMELE................................................PRENUMELE................................Sexul M/FVARSTA DATA NASTERII : ziua luna anul Mediul U / R PROFESIA......................................................................................
Statut asigurat: C.N.A.S. Asigurare voluntara Neasigurat C.N.P. ..
MOTIVUL PREZENTARII:
Istoricul bolii: ..........................................................................................................................
.................................................................................................................................................. ....................................................................................................................................................................................................................................................................................................Antecedente HC generale:
Antecedente HC
Stomatologice:
Antecedente personale
generale:Antecedente personale
Stomatologice:
Obiceiuri vicioase (daca exista)..................................................................................................
I. EXAMENUL EXOBOCAL1. General
Dezvoltare generala: Hiposom Normosom Hipersom
Tip constitutional: Entomorf Mezomorf EctomorfSistem nervos: Tare Slab ; Echilibrat Neechilibrat
2. Examenul extremitatii cefalice
INSPECTIEForma figurii : 1-muscular 2-respirator 3-cerebral 4-digestiv Forma fetei: dreptunghiulara |_| triunghiulara |_| ovala |_| trapez cu baza sus |_|
(norma frontala) trapez cu baza jos |_| rotunda |_| alte forme |_| Forma fetei drept |_| convex sup |_| convex inf |_| convex asociat|_|
(norma laterala) concav sup |_| concav inf |_| concav asociat |_|Alte aspecte patologice...........................................................................................................
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PALPARE
Textura teg.: elastica (normala) |_| indurate |_| flasca |_| cu anestezie |_| arii anestezice |_|
Contururi osoase.............................................................................................................................................
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..................................................................................................................................................Puncte de emergenta trigeminale: ........................................................................................................................................................................................................................................
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..................................................................................................................................................Grup ganglionar: ...................................................................................................................
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..................................................................................................................................................Formatiuni tumorale: ..............................................................................................................................................................................................................................................................
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Examenul A.T.M.....................................................................................................................................................................................................................................................................
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II. EXAMENUL ENDOBUCALExaenul oncologic preventive
inspectia:..................................................................................................................................
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palpare:..................................................................................................................................... ....................................................................................................................................................................................................................................................................................................
formatiuni si coloratii deosebite:..............................................................................................
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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
.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 OCLUZIEII. In statica
1. In plan SAGITAL:
2. In plan TRANSVERSAL:
3. In plan VERTICAL:
II. In dinamica
1. Ghidaj anterior
2. Ghidaj lateral
Forma arcadelor: superioara :.................................................................................... inferioara:......................................................................................Aprecierea curburilor dentare:- curba lui SPEE ......................................................................................................................
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- curba lui WILSON.................................................................................................................
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- curba incizala (vestibulara)....................................................................................................
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Bolta palatina..........................................................................................................................
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Planseul bucal.........................................................................................................................
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Alte exemene complementare:
Radiografii Fotografii
DIAGNOSTIC
1.Diagnosticul de urgenta ........................................................................................................................................................................................................................................................
2.Diagnosticul odontal .............................................................................................................................................................................................................................................................
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.............................................................................................................................................................................................................................................................
12.Diagnosticul afectiunilor generale..........................................................................................................................................................................................................................................................................................................................................................................................DIAGNOSTICUL COMPLET............................................................................................................................................................................................................................................
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........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................PLAN DE TRATAMENT....................................................................................................................................................................................................................................................
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EVOLUTIE
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