Dumb semantic question about ASA classification

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How many ASA-3-worthy medical problems does it take to be ASA 4?

Poorly controlled DM = 3.
Poorly controlled DM + Poorly controlled HTN= 3(?)
Poorly controlled DM+HTN+ESRD=3(???)
DM+HTN+ESRD+COPD+EF 35=? Still a 3? Seriously?

I’d call the last one a 4 but I’ve never seen any good rule about where to draw the line with just too much going on to call them 3s.
 
ASA 4 is, for example, a septic patient. Is your patient as sick as one of those? If yes, ASA 4, if no, ASA 3.

For example, a poorly-controlled hypervolemic/acidemic/hyperkalemic etc. ESRD patient would be a 4. A ketoacidotic DM would be a 4. A hypertensive crisis would be a 4.

There must be something that is ongoing (i.e. constant) and could result in death soon, if untreated (i.e. threat to life).
 
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