Medical Examination: an appraisal or evaluation of a patient's condition by a physician or registered nurse, based on clinical and laboratory data, medical history, and the patient's account of symptoms. (NCIt)

Diagnostic techniques and procedures include methods, procedures, and tests performed to diagnose disease, disordered function, or disability. (MeSH) Clinicians adhere to a fairly standard format when presenting cases so that all of the essential information can be succinctly communicated. Although the basic structure is always the same, the emphasis varies depending on the specialty. The patient should always be treated as a whole, and … much can be learned about “neurologic” illness from other parts of the physical exam. (Blumenfeld, 4) Also referred to as ‘history and physical exam’ and ‘general history and physical exam.’ Editor’s note - includes the elements listed below in the order of occurrence.

Chief Complaint: succinct statement that includes the patient’s age, sex, and presenting problem. (Blumenfeld, 5)

Medical History: a collection of information about a person's health. It may include information about allergies, illnesses and surgeries, and dates and results of physical exams, tests, screenings, and immunizations. It may also include information about medicines taken and about diet and exercise. (NCIt) Also referred to as ‘history and physical exam.’  

Current Medications and Allergies: list of all medications currently being taken by the patient including herbal or over-the-counter drugs. Includes any know general or drug allergies. (Blumenfeld, 5)

Family History: illnesses of all immediate relatives. (Blumenfeld, 5) A record of the relationships among family members along with their medical histories. Includes current and past illnesses. A family history may show a pattern of certain diseases in a family. (NCIt)

History of Present Illness (HPI): complete history of the current medical problem. (Blumenfeld, 5)

Past Medical History: prior medical and surgical problems not directly related to the HPI. (Blumenfeld, 5)

Review of Systems: brief, head-to-toe review of all medical systems. (Blumenfeld, 5)

Social Environmental History: includes the patient’s occupation, family situation, travel history, sexual history and habits. (Blumenfeld, 5)

Physical Exam: systematic and thorough inspection of the patient for physical signs of disease or abnormality. (MeSH) A systemic evaluation of the body and its functions using visual inspection, "palpation," 'percussion' and 'auscultation.' The purpose is to determine the presence or absence of physical signs of disease or abnormality for an individual's health assessment. (NCIt) Generally proceeds from head to toe and includes the following sections: general appearance; vital signs; head, eyes, ears, nose and throat; neck; back and spine; lymph nodes; breasts; lungs; heart; abdomen; extremities; pulses; neurologic exam; rectal; pelvic and genitalia; and dermatologic. (Blumenfeld, 5) Also referred to as ‘physical examination.’

Neurological Exam: a series of questions and tests to check "brain," "spinal cord," and "nerve" function. The exam checks a person's mental status, coordination, ability to walk, and how well the muscles, sensory systems, and deep tendon reflexes work. (NCIt) Part of the physical exam portion of the history and physical exam. Should always be performed and interpreted in the context of a more general assessment. (Blumenfeld, 50)

Coordination and Gait Exam: (tests for clues to) “cerebellar” disorders that can disrupt coordination or gait while leaving other motor functions relatively intact. (Blumenfeld, 68)

Cranial Nerves Exam: testing that can suggest specific neurologic “dysfunction” rather than a systemic disorder. Documents olfaction, vision, hearing, articulation, facial sensation, etc. (Blumenfeld, 58-63)

Mental Status Exam: organized around the anatomy of the brain. Documents level of alertness, "attention" and cooperation, orientation, "memory," "language," calculations, right-left confusion, “finger agnosia,” “agraphia,” “apraxia,” “neglect,” sequencing tasks and frontal release signs, logic and abstraction, "delusions" and "hallucinations," and "mood." (Blumenfeld, 52-58)

Motor Exam: includes observation, inspection, palpation, and functional testing of muscles and muscle groups. (Blumenfeld, 63-65)

Palpation: the process of examining part of the body by careful feeling with the hands and fingertips. (OxfordMed) A method of feeling with the hands during a physical examination. The health care provider touches and feels the patient's body to examine the size, consistency, texture, location and tenderness of an organ or body part. (NCIt)

Reflexes Exam: includes testing deep “tendon” reflexes and “plantar” response. (Blumenfeld, 66-68) An involuntary movement or exercise of function in a part, excited in response to a stimulus applied to the periphery and transmitted to the brain or spinal cord. (MeSH)

Sensory Exam: tests performed on all extremities, as well as on the face and trunk. Includes primary sensation (pain, temperature, vibration, and light touch), and “cortical” sensation. (Blumenfeld, 71)

Laboratory Data: all diagnostic tests, including blood work, urine tests, electrocardiogram, and radiological tests (chest X-rays, and CT scans). (Blumenfeld, 5)

Medical Assessment: one or two-sentence summary that (includes) the patient’s main clinical features and most likely diagnosis. In more diagnostically uncertain cases, a brief discussion is added to the assessment, including a 'differential diagnosis.' (Blumenfeld, 5)

Medical Plan: a list of problems and proposed interventions and diagnostic procedures. (Blumenfeld, 5)