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1 З АТВ ЕР ДЖЕН О o n c o l o g i c a l d i a g n o s i s n o t f o u n d Наказ Міністерства охорони здоров’я України 14 лю тог о 2020 рок у № 110 Найменування міністерства, іншого органу виконавчої влади, підприємства, установи, організації, до сфери управління якого належить заклад охорони здоров’я МЕДИ Ч Н А ДОК У МЕН ТАЦ ІЯ Форма первинної облікової документації № 087/о Найменування та місцезнаходження (повна поштова адреса) закладу охорони здоров’я, де заповнюється форма З АТВ ЕР ДЖЕН О Код за ЄДРПОУ Наказ МОЗ України № Medical card of dental patient №___087____ _________ NAME 1. Name, surname 2. Gender: male – 1; female – 2 1 3. Date of birth 1 1 1 1 9 6 (date month year) 4. Address, phone number 5. Diagnosis 6. Complaints Telkha 75 0038063967899 Acute generalized catarrhal gingivitis Pain,Bleeding when touched , and when brushing his front teeth of both jaw hyperemia ,inflammation and swelling “gingival enlargement” Patient think that teeth grow up higher , feels heaviness , pressure on gums because of exudative inflammation 7. Postponed and concomitant diseases 8. Development of the current disease Hepatitis, TB,AIDS,HIV Patient said two days ago, i complained from pain and gum reddening, bleeding when touched the front teeth on both jaws or when brushing his teeth 2 Продовження форми № 087/о Face is proportional symmetrical without any visually deformation 9. Objective examination, extra oral and intra oral examination Lymphnodes not painful, movable,not enlarge,normal size, soft palate Trigminus not painful ,hard soft palate,alveolar bone without any visible changes Gum reddening, color changes , initial bright red erythema , hyperemia, edema by probing 13.05.2020 date 13.05.2020 G 13 8 7 6 G 12 G 11 G 21 G 22 G 23 5(V) 4(IV) 3(III) 2(II) 1(I) 1(I) 2(II) 3(III) 4(IV) 5(V) 43 G 42 G 41 G 31 G 32 G 33 G 6 7 8 3 Продовження форми № 087/о 10. Bite orthognathic 11. The state of hygiene of the oral cavity, the condition of the mucous membrane of the oral cavity, gums, alveolar sprouts and palate. Indices: GI and PMA Bleeding gums and foul smell gingival mucosa is hyperemic , gingival enlargement , gum reddening , PMA papillary marginal alveolar index is 60% its heavy degree, hygiene index according to fedorov and volodkina is 3,5 marks alveolar gums 12. Data of X-ray examination, laboratory research 13. Color on a scale Vita Absence of resorption , no pathological changes A3 14. Date of studying oral hygiene 13.05 15. Date of check of training in oral hygiene 13.05 4 Продовження форми № 087/о 16. Treatment dairy Date 13.05.2020 Symptoms Pain Bleeding Probing Duration of pain Anamnesis, status, diagnosis, treatment and recommendations Acute generalized catarrhal gingivitis Pain, gum reddening, bleeding, color changes. Initial bright red erythema , hyperemia , edema + + + Sometimes but specific when touched or brushing Продовження форми № 043/о 5 Treatment dairy Date Anamnesis, status, diagnosis, treatment and recommendations 24.03.20 1.Etiotrophic ; professional cleaning of teeth , oral hygiene , Antiseptics :hydrogen peroxide 1% or 3% ,cholerhexidin 0.05 2. Pathogenic : solution of citrac , analagics 3. Anti-inflammatory therapy :Antibacterial gums tricho.lamblia, Antiseptics so patient Rinse by mouth wash which i prescribed above 4. In early stages of inflammation : vit c ascorbic acid regeneration Vit A epithelization 5. in the reparative phase Vitamins c,A, PP, b,E IMMUNODELATORY DRUGS,imedol,imonole sol.for oral cavity stomathophyte maraslain 17. Epicrisis Doctor_________________________________________ 6 Date “_____”_____________ 20____р. Продовження форми № 043/о Examination plan Treatment plan