FAKULTAS KEDOKTERAN GIGI

INSTITUT ILMU KESEHATAN BHAKTI WIYATA KEDIRI

STATUS DAN RENCANA PERAWATAN ILMU PENYAKIT MULUT

No. Rekam Medik :. ……………

Tanggal : ….... - ........ - …......

I. DATA PRIBADI

Nama : ...................................... Status : Belum menikah / Menikah

....
Suku Bangsa : ........................................
Alamat : ......................................
.... Telepon : ..........................................

Usia :....................................... Berat Badan : ......................................kg

....
Tinggi Badan : .....................................cm
Jenis Kelamin
: .......................................... Konsul dari
:....................................................
Pekerjaan : ......................................
... Dengan
suspek : ....................................................

II. RIWAYAT KASUS

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

2. Riwayat Penyakit : ..............................................................................................................................

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

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

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

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

3. Riwayat Perawatan :

a.
Gigi : ..........................................................................................................................................................
 b. Jaringan lunak mukosa
mulut : .................................................................................................................

c.
Lainnya : ....................................................................................................................................................

4. Obat-obatan yang telah / sedang

dijalani :......................................................................................................

5. Keadaan sosial &

kebiasaan : .......................................................................................................................

6. Riwayat Kesehatan Keluarga :

a. Kelainan Darah e. Kelainan Saraf

b. Kelainan Endokrin f. Alergi

c. Diabetes Mellitus g. Keganasan / Kanker

d. Kelainan Jantung h. Lain-

lain ......................................................................

III. PEMERIKSAAN KLINIS

1. EKSTRA ORAL *

a. Muka
: ................................................................................................................

b. Pipi kanan : ................................................................................................................

kiri : ..........................................................................................................
......

c. Bibir atas (1)

: ................................................................................................................

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

d. Sudut mulut
: ................................................................................................................

e. Kelenjar Limfe

- Submandibularis kanan
: ................................................................................................................

kiri
: ................................................................................................................

- Submentalis
: ................................................................................................................

- Leher
: ................................................................................................................
 f. Kelenjar Saliva

- Parotis kanan
: .............................................................................................................

kiri
: .............................................................................................................

- Sublingualis
: .............................................................................................................

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

2. INTRA ORAL *

a. Mukosa labial atas (3)

: .............................................................................................................

bawah (4)
: .............................................................................................................

b. Komisura kanan (5) : .............................................................................................................

kiri (6) : .............................................................................................................

c. Mukosa bukal kanan (7)

: .............................................................................................................

kiri (8)
: .............................................................................................................

d. Labial fold atas (9) : .............................................................................................................

bawah (10)
: .............................................................................................................

e. Bukal fold atas (11) : .............................................................................................................

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

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

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

rahang bawah (16), (17), (18): .............................................................................................................

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

g. Palatum (19), (20), (21), (22)

: .............................................................................................................

h. Arkus palatoglosus anterior (23)

: .............................................................................................................
 posterior (24)
: .............................................................................................................

i. Lidah (25), (26), (27), (28), (29)

: .............................................................................................................

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

j. Dasar mulut (30)

: .............................................................................................................

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

Keterangan :

* Lingkari nomor sesuai dengan lokasi lesi seperti yang ditunjukkan gambar pada halaman 3

GAMBAR PENAMPANG RONGGA MULUT

Daerah mukosa mulut yang terdapat lesi, harap digambar dengan spidol merah dan tuliskan tanggal ditemukannya lesi.
IV. DIAGNOSIS SEMENTARA

V. KASUS ILMU PENYAKIT MULUT NON TERAPI **

1. Linea Alba Bukalis ( .......... )

2. Fordyce’s spots ( .......... )

3. Geographic tongue ( .......... )

4. Fissured tongue ( .......... )

5. Crenated tongue ( .......... )

6. Varises sublingualis ( .......... )

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

8. Lain – lain, sebutkan : .......................................................................

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

VI. DIAGNOSIS AKHIR

VII. RUJUKAN

1. Pemeriksaan Penunjang ***

 Lab. Radiologi Umum

 Lab. Radiologi Dental

 Lab. Mikrobiologi

 Bakteri

 Virus

 Jamur

 Lab. Patologi Klinik

 Lab. Patologi Anatomi

 Sitologi

 Biopsi
 2. Poli dan Bagian Lain ***

 Poli Penyakit Dalam

 Poli THT

 Poli Kulit-Kelamin

 Poli Saraf

 Bag. Bedah Mulut

 Bag. Periodonsia

 Bag. Pedodonsia

 Bag. Konservasi Gigi

 Bag. Prostodonsia

 Bag. Ortodonsia

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

LEMBAR PERAWATAN

TANGGAL PERAWATAN TANDA TANGAN

INSTRUKTUR