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Complete medical evaluation includes a medical history, a physical examination, appropriate laboratory o studies, analysis of data and medical decision making to obtain diagnoses, and treatment plan.

The components of the medical history are:

Chief complaint the reason for the current medical visit.
History of present illness - the chronological order of events of symptoms. A mnemonic PQRST is sometimes helpful in obtaining the history:
Provocative-palliative factors - what makes a symptom worse or better.
Quality - description of the symptom Region - which part of the body is affected Severity - what is the intensity of the symptom; using a scale of 0-10
Timing - what is the course of the symptom
Current activity - occupation, hobbies, what the patient actually does.
Medications - what drugs including OTCs, and home remedies, as well as herbal remedies such as St. John's Wort. Allergies are recorded.
Past medical history (PMH/PMHx) - other medical diagnoses, past hospitalizations and operations, injuries, past infectious diseases and/or vaccinations, history of known allergies.
Review of systems (ROS) - an outline of additional symptoms to ask which may be missed on HPI, generally following the body's main organ systems (heart, lungs, digestive tract, urinary tract, etc).
Social history (SH) - birthplace, residences, marital history, social and economic status, habits (including diet, drugs, tobacco, alcohol).
Family history (FH) - listing of diseases in the family that may impact the patient. A family tree is sometimes used.
The physical examination is the examination of the patient looking for signs of disease. The doctor uses his senses of sight, hearing, touch, and sometimes smell (taste has been made redundant by the availability of modern lab tests). Four chief methods are used: inspection, palpation, percussion, and auscultation; smelling may be useful (e.g. infection, uremia, diabetic ketoacidosis). The clinical examination involves study of:

Vital signs include height, weight, body temperature, , plse, respiration rate, hemoglobin oxygen saturation
General appearance of the patient

Head, eye, ear, nose, and throat
Cardiovascular - heart and blood vessels
Respiratory - lungs
Abdomen and rectosigmoid
Spine and extremities - musculoskeletal
Neurological and psychiatric
Laboratory and imaging studies 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), along with an idea of what needs to be done to obtain a definitive diagnosis that would explain the patient's problem.

The treatment plan may include ordering additional laboratory tests and studies, starting therapy, referral to a specialist, or watchful observation. 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 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.

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