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...........................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
PALPARE
Textura teg.: elastica (normala) |_| indurate |_| flasca |_| cu anestezie |_| arii anestezice |_|
Contururi osoase.............................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................Puncte de emergenta trigeminale: ........................................................................................................................................................................................................................................
.................................................................................................................................................
..................................................................................................................................................Grup ganglionar: ...................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................Formatiuni tumorale: ..............................................................................................................................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
Examenul A.T.M.....................................................................................................................................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
II. EXAMENUL ENDOBUCALExaenul 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
.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 ......................................................................................................................
....................................................................................................................................................................................................................................................................................................
- curba lui WILSON.................................................................................................................
....................................................................................................................................................................................................................................................................................................
- curba incizala (vestibulara)....................................................................................................
..................................................................................................................................................
Bolta palatina..........................................................................................................................
..................................................................................................................................................
Planseul bucal.........................................................................................................................
..................................................................................................................................................
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............................................................................................................................................................................................................................................
.................................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................PLAN DE TRATAMENT....................................................................................................................................................................................................................................................
.................................................................................................................................................
..................................................................................................................................................................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
EVOLUTIE
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
SEMNATURA :________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PAGE 1