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    This document appears to be a medical record form from the dental clinic at the Faculty of Medicine, Diponegoro University. It collects patient data including name, age, religion, education, occupation, address, chief complaint, dental and medical history, social history, and results of physical and oral examinations. Examination findings are documented for extra oral structures, intraoral soft tissues, tongue, floor of mouth, and periodontal status.

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    This document appears to be a medical record form from the dental clinic at the Faculty of Medicine, Diponegoro University. It collects patient data including name, age, religion, education, occupation, address, chief complaint, dental and medical history, social history, and results of physical and oral examinations. Examination findings are documented for extra oral structures, intraoral soft tissues, tongue, floor of mouth, and periodontal status.

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    5 views6 pages

    Status Klinik PM

    Uploaded by

    deboraveee
    This document appears to be a medical record form from the dental clinic at the Faculty of Medicine, Diponegoro University. It collects patient data including name, age, religion, education, occupation, address, chief complaint, dental and medical history, social history, and results of physical and oral examinations. Examination findings are documented for extra oral structures, intraoral soft tissues, tongue, floor of mouth, and periodontal status.

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    of 6

    STATUS KLINIK PENYAKIT MULUT

    PROGRAM STUDI PROFESI DOKTER GIGI


    FAKULTAS KEDOKTERAN UNIVERSITAS DIPONEGORO

    Tanggal: .......................................................... No. RM: .......................................................

    DATA PASIEN

    Nama :.................................................. Agama : ................................................


    Umur/TTL :.................................................. Pendidikan : ………………………………
    Jenis kelamin :................................................... Pekerjaan : .................................................
    Alamat :.................................................. Status perkawinan: ........................................

    ANAMNESIS/PEMERIKSAAN SUBJEKTIF

    Chief Complaint/CC
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    Present Ilness/PI
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    Past Medical History/PMH
    ............................................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................
    Riwayat dental (Past Dental History/PDH)
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    Family History/FH
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    Social History/SH
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………
    ………………………………………………………………………………………………………

    PEMERIKSAAN OBJEKTIF

    Pemeriksaan Umum
    Keadaan umum: ..............................................................................................................
    TB : .............................. cm BB : .................... kg
    Tekanan Darah : .............................. mm Hg Suhu : .................... oC
    Nadi : ............................... x/menit Pernapasan : .................... x/menit

    Ekstra Oral
    Kelenjar Limfa :
    • Submentalis : teraba +/- lunak/kenyal/keras sakit +/-
    • Submandibularis: Kanan : teraba +/- lunak/kenyal/keras sakit +/-
    Kiri : teraba +/- lunak/kenyal/keras sakit +/-
    • Servikal : Kanan : teraba +/- lunak/kenyal/keras sakit +/-
    Kiri : teraba +/- lunak/kenyal/keras sakit +/-

    Wajah : simetris/tidak
    Mata/konjungtiva : ...................................................................................................................
    TMJ : ...................................................................................................................
    Sirkum oral : ...................................................................................................................
    Intra Oral
    Mukosa labial:
    ▪ Bawah : .................................................................................................................................
    ................................................................................................................................................
    ................................................................................................................................................
    ................................................................................................................................................
    ▪ Atas : .................................................................................................................................
    ................................................................................................................................................
    ................................................................................................................................................
    ................................................................................................................................................
    .
    Mukosa bukal:
    ▪ Kanan : ..................................................................................................................................
    ................................................................................................................................................
    ................................................................................................................................................
    ...............................................................................................................................................
    ▪ Kiri : ..................................................................................................................................
    ................................................................................................................................................
    ................................................................................................................................................
    ................................................................................................................................................
    Lidah :
    ▪ Dorsal ....................................................................................................................................
    ................................................................................................................................................
    ................................................................................................................................................
    ................................................................................................................................................
    ▪ Lateral : .................................................................................................................................
    ................................................................................................................................................
    ................................................................................................................................................
    ................................................................................................................................................
    ▪ Ventral: .................................................................................................................................
    ...............................................................................................................................................
    ................................................................................................................................................

    Dasar mulut : .....................................................................................................................................


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

    Gingiva: .............................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................
    Palatum durum : ................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................
    Palatum molle : .................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................

    Orofaring : .........................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................

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

    Keterangan :
    Pemeriksaan Gigi Geligi
    ➢ Higiene oral: baik/sedang/buruk

    Keterangan :

    PEMERIKSAAN PENUNJANG DAN HASIL

    DIAGNOSIS/DD/EC
    RENCANA PERAWATAN DAN PENATALAKSANAAN

    Operator Supervisor/DPJP

    ( ................................................ ) (...........................................................)

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