Hip Front Back Side Appearance NormalSwellingRednessErythemaDeformityScars Palpation 1. Greater Trochanter R L 2. Pubis R R L 3. Ilia R R L 4. Other Observed Abnormality? Yes No Sensation Intact? Yes No Moves Extremities w/o Deficit? Yes No Strength - Select - 1 2 3 4 5 Range of Motion Flexion FullLimited LevelPainExplain Extension FullLimited LevelPainExplain Avduction FullLimited LevelPainExplain Aduction FullLimited LevelPainExplain Internal Rotation FullLimited LevelPainExplain External Rotation FullLimited LevelPainExplain Procedure 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 Procedural Sedation: Medication 1: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 2: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 3: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Δ
