The clinical examination involves the study of: Vital signs including height, weight, body temperature, blood pressure, pulse, respiration rate, and hemoglobin oxygen saturation General appearance of the patient and specific indicators of disease (nutritional status, presence of jaundice, pallor or clubbing) Skin Head, eye, ear, nose, and throat (HEENT) Cardiovascular (heart and blood vessels) Respiratory (large airways and lungs) Abdomen and rectum Genitalia (and pregnancy if the patient is or could be pregnant) Musculoskeletal (including spine and extremities) Neurological (consciousness, awareness, brain, vision, cranial nerves, spinal cord and peripheral nerves) Psychiatric (orientation, mental state, evidence of abnormal perception or thought). It is to likely focus on areas of interest highlighted in the medical history and may not include everything listed above. The treatment plan may include ordering additional medical laboratory tests and medical imaging studies, starting therapy, referral to a specialist, or watchful observation. Follow-up may be advised. Depending upon the health insurance plan and the managed care system, various forms of "utilization review", such as prior authorization of tests, may place barriers on accessing expensive services. 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. 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. Institutions Color fresco of an ancient hospital setting The Hospital of Santa Maria della Scala, fresco by Domenico di Bartolo, 1441–1442 Contemporary medicine is in general conducted within health care systems. Legal, credentialing and financing frameworks are established by individual governments, augmented on occasion by international organizations, such as churches. The characteristics of any given health care system have significant impact on the way medical care is provided.