- Vital signs including height, weight, body temperature, blood pressure (BP; sometimes referred to as “arterial blood pressure,” the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs), pulse (in medicine, it represents the tactile arterial palpation of the heartbeat by trained fingertips), respiration rate, hemoglobin oxygen saturation/dissolved oxygen (DO; a relative measure of the amount of oxygen that is dissolved or carried in a given medium)
- General appearance of the patient and specific indicators of disease (nutritional status, presence of jaundice, pallor or nail clubbing, which in medicine, is a deformity of the fingers and fingernails associated with a number of diseases, mostly of the heart and lungs)
- Human skin, the outer covering of the body
- Head, eye, ear (the organ that detects sound), nose, and throat–HEENT
- Cardiovascular, or the circulatory system, an organ system that passes nutrients (such as amino acids, electrolytes and lymph), gases, hormones, blood cells, etc. to and from cells in the body to help fight diseases, stabilize body temperature and pH, and to maintain homeostasis: heart, a hollow muscle that pumps blood throughout the blood vessels by repeated, rhythmic contractions; and blood vessels, the part of the circulatory system that transports blood throughout the body
- Respiratory, or the respiratory/ventilatory system, the biological system of an organism that introduces respiratory gases to the interior and performs gas exchange: large airways and lungs, the essential respiration organ in many air-breathing animals, including most tetrapods, a few fish and a few snails
- Abdomen, in vertebrates such as mammals, constitutes the part of the body between the thorax (chest) and pelvis; and rectum, the final straight portion of the large intestine in some mammals, and the gut in others
- Genitalia (and pregnancy if the patient is or could be pregnant)
- Musculoskeletal system (including spine and extremities; also known as the “locomotor system”), an organ system that gives animals (and humans) the ability to move using the muscular and skeletal systems
- Neurological, medical specialty dealing with disorders of the nervous system: consciousness; awareness; brain; vision; cranial nerves, or nerves that emerge directly from the brain, in contrast to spinal nerves, which emerge from segments of the spinal cord; spinal cord; and the “peripheral nervous system” (“PNS,” or occasionally “PeNS”), consisting of the nerves and ganglia outside of the brain and spinal cord
- Psychiatry, the medical specialty devoted to the study and treatment of mental disorders: orientation; mental status examination (USA), or “mental state examination” (rest of the world), abbreviated “MSE,” an important part of the clinical assessment process in psychiatric practice; evidence perception or thought
It is to likely focus on areas of interest highlighted in the medical history and may not include everything listed above.
A medical/clinical laboratory, a laboratory where tests are done on clinical specimens in order to get information about the health of a patient ads pertaining to the diagnosis, treatment, and prevention of disease; and imaging studies (“medical imaging”), the technique and process used to create images of the human body (or parts and function thereof) for clinical purposes (medical procedures seeking to reveal, diagnose, or examine disease) or medical science (including the study of normal anatomy and physiology), results may be obtained, if necessary.
The medical decision-making (MDM) process involves analysis and synthesis of all the above data to come up with a list of possible diagnoses (the differential diagnoses; sometimes abbreviated “DDx,” “ddx,” “DD,”” D/Dx,” or ΔΔ), a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible (and the process may be termed “differential diagnostic procedure”), and may also refer to any of the included candidate alternatives (which may also be termed “candidate condition”); along with an idea of what needs to be done to obtain a definitive diagnosis that would explain their patient’s problem.
The treatment plan may include ordering additional laboratory tests and studies, starting therapy, referral to a specialist, or watchful observation; a laboratory is a facility that provides controlled conditions in which scientific research, experiments, and measurements may be performed. Follow-up may be advised.
This process is used by primary care providers as well as specialists. It may take only a few minutes if the problem is simple and straightforward. On the other hand, it may take weeks in a patient who has been hospitalized with bizarre symptoms or multi-system problems, with involvement by several specialists.
On subsequent visits, the process may be repeated in an abbreviated manner to obtain any new history, symptoms, physical findings, and lab or imaging results, or specialist consultations.