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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