KNEE Appearance* Normal Swelling Redness Erythema Deformity Scars OtherPalpation* 1. MCL R L 2. LCL R L 3. Pes Anserine R L 4. Lateral Tibial Plateau R L 5. Medial Tibial Plateau R L 6. Inferior Pole of the Patella R L 7. Superior Pole of the Patella R L 8. Other Observed Abnormality? Yes No Sensation Intact? Yes No Moves Extremities w/o Deficit? Yes No Strength 1 2 3 4 5 Range of MotionValgus Stress Laxity No Laxity LevelPainPlease enter a number from 0 to 10.ExplainVarus Stress Laxity No Laxity LevelPainPlease enter a number from 0 to 10.ExplainAnterior Drawer Laxity No Laxity LevelPainPlease enter a number from 0 to 10.ExplainPosterior Drawer Laxity No Laxity LevelPainPlease enter a number from 0 to 10.ExplainOther Laxity No Laxity LevelPainPlease enter a number from 0 to 10.ExplainProcedure Note Consent Skin Cleaned with Chlohexadine Other Tender Points Injected with: Dextrose PRP Joint Injection: Dextrose PRP Stem Cell Resolution of Symptoms? Yes No Tolerated Well? Yes No Medication 1AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose Medication 2AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose Medication 3AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose
