a. Kelainan Darah e.

Kelainan Saraf

b. Kelainan Endokrin f. Alergi

c. Diabetes Mellitus g. Keganasan / Kanker

FAKULTAS KEDOKTERAN GIGI d. Kelainan Jantung h. Lain-lain ......................................................................
INSTITUT ILMU KESEHATAN BHAKTI WIYATA KEDIRI
BAGIAN ILMU PENYAKIT MULUT
III. PEMERIKSAAN KLINIS
STATUS DAN RENCANA PERAWATAN ILMU PENYAKIT MULUT
1. EKSTRA ORAL *
No. Rekam Medik :. ……………
a. Muka : ................................................................................................................
Tanggal : ….... - ........ - …......
b. Pipi kanan : ................................................................................................................

kiri : ................................................................................................................
I. DATA PRIBADI
c. Bibir atas (1) : ................................................................................................................

bawah (2) : ................................................................................................................

Nama : .......................................... Suku Bangsa : ........................................
d. Sudut mulut : ................................................................................................................
Alamat : .......................................... Telepon : ..........................................
e. Kelenjar Limfe
Usia :........................................... Berat Badan : ......................................kg
- Submandibularis kanan : ................................................................................................................
Jenis Kelamin : .......................................... Tinggi Badan : .....................................cm
kiri : ................................................................................................................
Pekerjaan : ......................................... Konsul dari :....................................................
- Submentalis : ................................................................................................................
Status : Belum menikah / Menikah Dengan suspek : ....................................................
- Leher : ................................................................................................................
II. RIWAYAT KASUS

1. Keluhan Utama : ...........................................................................................................................................

f. Kelenjar Saliva
2. Riwayat Penyakit : ..............................................................................................................................
- Parotis kanan : .............................................................................................................
.......................................................................................................................................................................
kiri : .............................................................................................................
.......................................................................................................................................................................
- Sublingualis : .............................................................................................................
.......................................................................................................................................................................
g. Lain-lain : .............................................................................................................
.......................................................................................................................................................................
2. INTRA ORAL *
3. Riwayat Perawatan :
a. Mukosa labial atas (3) : .............................................................................................................
a. Gigi : ..........................................................................................................................................................
bawah (4) : .............................................................................................................
b. Jaringan lunak mukosa mulut : .................................................................................................................
b. Komisura kanan (5) : .............................................................................................................
c. Lainnya : ....................................................................................................................................................
kiri (6) : .............................................................................................................
4. Obat-obatan yang telah / sedang dijalani :......................................................................................................
c. Mukosa bukal kanan (7) : .............................................................................................................
5. Keadaan sosial & kebiasaan : .......................................................................................................................
kiri (8) : .............................................................................................................
6. Riwayat Kesehatan Keluarga :
d. Labial fold atas (9) : .............................................................................................................
 bawah (10) : .............................................................................................................

e. Bukal fold atas (11) : ............................................................................................................. IV. DIAGNOSIS SEMENTARA

bawah (12) : .............................................................................................................

f. Gingiva rahang atas (13), (14), (15) : ............................................................................................................

...................................................................................................................................................................... V. KASUS ILMU PENYAKIT MULUT NON TERAPI **

rahang bawah (16), (17), (18) : ............................................................................................................. 1. Linea Alba Bukalis ( .......... )

...................................................................................................................................................................... 2. Fordyce’s spots ( .......... )

g. Palatum (19), (20), (21), (22) : ............................................................................................................. 3. Geographic tongue ( .......... )

h. Arkus palatoglosus anterior (23) : ............................................................................................................. 4. Fissured tongue ( .......... )

posterior (24) : ............................................................................................................. 5. Crenated tongue ( .......... )

i. Lidah (25), (26), (27), (28), (29) : ............................................................................................................. 6. Varises sublingualis ( .......... )

...................................................................................................................................................................... 7. Hiperpigmentasi gingiva ( .......... )

j. Dasar mulut (30) : ............................................................................................................. 8. Lain – lain, sebutkan : .......................................................................

...................................................................................................................................................................... Keterangan :** Bila terdapat lesi isilah dengan tanda ü,bila tidak ada lesi, isilah dengan tanda –
Keterangan :

* Lingkari nomor sesuai dengan lokasi lesi seperti yang ditunjukkan gambar pada halaman 3
VI. DIAGNOSIS AKHIR
GAMBAR PENAMPANG RONGGA MULUT

VII. RUJUKAN

1. Pemeriksaan Penunjang ***

1 Lab. Radiologi Umum

1 Lab. Radiologi Dental

1 Lab. Mikrobiologi

1 Bakteri

1 Virus

1 Jamur
Daerah mukosa mulut yang terdapat lesi, harap digambar dengan spidol merah dan tuliskan tanggal
ditemukannya lesi. 1 Lab. Patologi Klinik

1 Lab. Patologi Anatomi

1 Sitologi

1 Biopsi
 2. Poli dan Bagian Lain ***

1 Poli Penyakit Dalam

1 Poli THT

1 Poli Kulit-Kelamin

1 Poli Saraf

1 Bag. Bedah Mulut

1 Bag. Periodonsia

1 Bag. Pedodonsia

1 Bag. Konservasi Gigi

1 Bag. Prostodonsia

1 Bag. Ortodonsia

1 Lain-lain : ............................................................
Keterangan :*** Bila terdapat rujukan ke laboratorium / bagian di atas, isilah dengan tanda ü, dan tulislah tanggal pengirimannya.

LEMBAR PERAWATAN

TANGGAL PERAWATAN TANDA TANGAN

INSTRUKTUR