Status Ortho

  • View
    44

  • Download
    0

Embed Size (px)

DESCRIPTION

Rekam Medis Ortho

Transcript

STATUS PEMERIKSAAN

DAN PERAWATAN ORTHODONTI

NOMOR MODEL :

...

NAMA PASIEN:

OPERATOR : NO.MHS

:

PEMBIMBING:

PROGRAM STUDI KEDOKTERAN GIGI

FAKULTAS KEDOKTERAN

UNIVERSITAS SRIWIJAYA

2011STATUS PEMERIKSAAN

DAN PERAWATAN ORTHODONTIOperator: No.Mhs:

Pembimbing:

No. Kartu:

No. Model: I. IDENTITAS Nama pasien

: Umur

:

Suku

:

Jenis kelamin

:

Status Kawin

:

Alamat

:

Telepon

:

Pekerjaan

:

Rujukan dari

:

Nama Ayah

: Suku

: Umur

:

Nama Ibu

:

Suku

: Umur

:

Pekerjaan orang tua:

Alamat orang tua:II. WAKTU PERAWATANPendaftaran

: Tgl.

Pencetakan

: Tgl.

Pemasangan alat: Tgl.

Retainer

: Tgl.

III. PEMERIKSAAN KLINISA. Pemeriksaan Subjektif ( Anamnesis )

Keluhan Utama : .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Riwayat Kesehatan : Kelahiran : Normal / Komplikasi

Urutan kelahiran : Anak Ke.dari anak

Nutrisi

: ASI .bulan

Penyakit berat yang pernah diderita :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ Kelainan Kongenital :

.................................................................................................................................................................................................................................................................................................................................................................. Lain-lain :..................................................................................................................................................................................................................................................................................................................................................................

Keterangan :..................................................................................................................................................................................................................................................................................................................................................................

Riwayat Pertumbuhan dan Perkembangan gigi geligi :

Gigi Decidui :..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Gigi Bercampur :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Gigi Permanen : ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ Kebiasaan Buruk (berkaitan dengan keluhan pasien): Ada /Tidak ada Jenis kebiasaanDurasi Frekuensi Intensitas Keterangan

..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Riwayat Keluarga (berkaitan dengan keluhan pasien): Ada/Tidak ada Ayah Ibu Saudara laki-laki Saudara perempuanKeterangan : ..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................B. Pemeriksaan Objektif

Umum : Jasmani: Baik Sedang Jelek Ket : ...... Mental: Baik Sedang Jelek Ket : ...... Status gizi :

Tinggi badan (TB) : m

Berat badan (BB) : kg

Indeks masa tubuh (IMT) = BB( kg ) = = TB ( m ) ( )

Kategori status gizi : Kurang Normal Lebih

Lokal :

a. Ekstra Oral : Wajah Depan

Bentuk kepala : Brakisefali Mesosefali Dolikosefali Indeks kepala : Lebar kepala___ X 100 = X 100 = Panjang kepala Bentuk muka : Hipereuriprosop Euriprosop Mesoprosop Leptoprosop Hiperleptoprosop Indeks muka : Jarak N GN __ X 100 = X 100 = Lbr Bizigomatic Simetri : Simetris / Tidak simetris

Proporsi : Normal / Tidak normal

Tonus otot mastikasi : Normal / Tidak normal

Tonus otot bibir : Normal / Tidak normal

Posisi bibir waktu istirahat: Tertutup / Terbuka

Wajah Samping

Profil muka : Lurus Cekung Cembung

b. Intra Oral

Jaringan Lunak

Gingiva: Normal / Tidak normalMukosa: Normal / Tidak normal

Lidah: Normal / Tidak normal

Tonsil: Normal / Tidak normal

Palatum: Tinggi / Normal / Rendah

Frenulum : Fren. Labii Superior : Tinggi / Normal / Rendah

Fren. Labii Inferior : Tinggi / Normal / Rendah

Fren. Labii Lingualis : Tinggi / Normal / Rendah

Hygiene mulut : OHI-S : Baik Sedang Jelek Pemeriksaan Gigi :

V VI III II I I II III IV V

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

V VI III II I I II III IV V

Keterangan : K : Karies

R : Radiks

T : Tambalan

I : Inlay

X : Telah dicabutP : Persistensi

Im : ImpaksiJ : Jaket

O : Belum Erupsi

Ag : AgenesisB : Bridge

En : Prwtn endodontik

Analisa Fungsi

Penelanan

: Normal / Tidak normal

Bicara

: Lidah normal / Lidah terletak di antara gigi

Penutupan mulut: Normal / Tidak normal

Pernapasan

: Mulut tertutup / Mulut terbuka

Senyum

: Gusi terlihat / Normal

Kelainan TMJ:

IV. ANALISA FOTO GRAFI

A. Analisa Foto Wajah

Tampak Depan

Tampak samping

Bentuk wajah: Oval / Bulat / Persegi