WRIST & HAND Appearance* Normal Swelling Redness Erythema Deformity Scars OtherPalpation*Observed Abnormality? Yes No Sensation Intact? Yes No Moves Extremities w/o Deficit? Yes No Strength 1 2 3 4 5 Flexion Full Limited LevelPainPlease enter a number from 0 to 10.ExplainExtension Full Limited LevelPainPlease enter a number from 0 to 10.ExplainSupination Full Limited LevelPainPlease enter a number from 0 to 10.ExplainPronation Full Limited LevelPainPlease enter a number from 0 to 10.ExplainUlnar Deviation Full Limited LevelPainPlease enter a number from 0 to 10.ExplainRadial Deviation Full Limited 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 Proceedural Sedation:Medication 1AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose Medication 2AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose Medication 3AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose
