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Chapter 3: Patient Assessment and

Evaluation

Introduction

Patient assessment and evaluation are fundamental components of orthopaedic technology,
forming the basis for effective treatment and management of musculoskeletal injuries.
Orthopaedic technologists play a crucial role in assisting physicians by gathering essential
patient information, conducting preliminary assessments, and identifying signs of orthopaedic
conditions. The ability to accurately assess a patient's condition not only contributes to efficient
diagnosis but also ensures timely and appropriate intervention, ultimately improving patient
outcomes.

Understanding the various elements of patient assessment—ranging from obtaining a detailed
medical history to conducting physical examinations and recognizing urgent orthopaedic
conditions—is vital for an orthopaedic technologist. A systematic approach to evaluation helps
in determining the appropriate course of action, whether it involves immobilization, referral for
further imaging, or emergency intervention. Additionally, maintaining clear and professional
communication with patients and healthcare teams is essential for seamless care coordination.

This chapter will provide an in-depth overview of key aspects of patient assessment, including
history taking, physical examination techniques, recognizing signs and symptoms of orthopaedic
injuries, effective communication with healthcare professionals, and the legal and ethical
considerations in patient evaluation. By mastering these skills, orthopaedic technologists can
enhance their ability to contribute effectively within a multidisciplinary healthcare team.

Obtaining Patient History

A thorough patient history is critical in orthopaedic assessment, as it provides valuable context
for understanding the nature and severity of an injury or condition. The history-taking process
should be conducted in a systematic and comprehensive manner to ensure all relevant details are
captured. Effective history-taking not only aids in diagnosis but also helps in planning
appropriate management strategies.

Components of a Comprehensive Patient History

1. Chief Complaint (CC)
o The primary reason for the patient’s visit, stated in their own words.
o Documented verbatim to avoid misinterpretation.
o Establishes the focus of the clinical assessment.