Framingham Criteria for Congestive Heart Boston Criteria for Diagnosing Heart Failure

Failure
Criteria Point
Diagnosis of CHF requires the simultaneous presence of at least 2 value
major criteria or 1 major criterion in conjunction with 2 minor criteria. Category I: history

Major criteria: Rest dyspnea 4

 Paroxysmal nocturnal dyspnea Orthopnea 4
 Neck vein distention Paroxysmal nocturnal dyspnea 3
 Rales Dyspnea while walking on level area 2
 Radiographic cardiomegaly (increasing heart size on chest Dyspnea while climbing 1
radiography) Category II: physical examination
 Acute pulmonary edema
 S3 gallop Heart rate abnormality (1 point if 91 to 110 beats per 1 or 2
 Increased central venous pressure (>16 cm H2O at right atrium) minute; 2 points if more than 110 beats per minute)
 Hepatojugular reflux Jugular venous elevation (2 points if greater than 6 cm 2 or 3
 Weight loss >4.5 kg in 5 days in response to treatment H2O; 3 points if greater than 6 cm H2O plus hepatomegaly
or edema)
Minor criteria: Lung crackles (1 point if basilar; 2 points if more than 1 or 2
 Bilateral ankle edema basilar)
 Nocturnal cough
Wheezing 3
 Dyspnea on ordinary exertion
Third heart sound 3
 Hepatomegaly
 Pleural effusion Category III: chest radiography
 Decrease in vital capacity by one third from maximum recorded
 Tachycardia (heart rate>120 beats/min.) Alveolar pulmonary edema 4
Interstitial pulmonary edema 3
Bilateral pleural effusion 3
Minor criteria are acceptable only if they cannot be attributed to
another medical condition (such as pulmonary hypertension, chronic Cardiothoracic ratio greater than 0.50 3
lung disease, cirrhosis, ascites, or the nephrotic syndrome). Upper zone flow redistribution 2

The Framingham Heart Study criteria are 100% sensitive and 78%
specific for identifying persons with definite congestive heart failure.
No more than 4 points are allowed from each of three categories; hence the
composite score (the sum of the subtotal from each category) has a possible
maximum of 12 points. The diagnosis of heart failure is classified as "definite" at a
score of 8 to 12 points, "possible" at a score of 5 to 7 points, and "unlikely" at a
score of 4 points or less.
 Criteria for the Diagnosis of Diabetes Mellitus

1. Symptoms of diabetes plus casual plasma glucose concentration

200 mg/dl (11.1 mmol/l). Casual is defined as any time of day
without regard to time since last meal. The classic symptoms of
diabetes include polyuria, polydipsia, polyphagia and unexplained
weight loss.
OR
2. Fasting Plasma Glucose (FPG) 126 mg/dl (7.0 mmol/l). Fasting is
defined as no caloric intake for at least 8 h.
OR
3. 2-h postload glucose 200 mg/dl (11.1 mmol/l) during an Oral
Glucose Tolerance Test (OGTT). The test should be performed as
described by WHO, using a glucose load containing the equivalent
of 75 g anhydrous glucose dissolved in water.

In the absence of unequivocal hyperglycemia, these criteria should be

confirmed by repeat testing on a different day. The third measure
(OGTT) is not recommended for routine clinical use.

* HbA1c (> 6.5%) examination by ADA 2011 has become one of the
criteria for DM diagnosis, if it is done at a laboratory that has been
standardized properly.
 Cardiovascular Major Risk Factors
 Hypertension
 Cigarette smoking
 Obesity (BMI >/=30): indicates body mass index
calculated as weight in kilograms divided by the
square of height in meters
 Physical inactivity
 Dyslipidemia
 Diabetes mellitus
 Microalbuminuria or estimated glomerular filtration
rate (GFR) <60 mL/min
 Age (>55 years for men, >65 years for women)
 Family history of premature cardiovascular disease
(men <55 years or women 65 years)
 Classification Criteria for the Diagnosis of Child-Pugh Score
Systemic Lupus Erythematosus (SLE)

Child–Pugh score (or the Child–Turcotte–Pugh score or Child

1. Malar rash: Fixed erythema, flat or raised, over the malar Criteria) is used to assess the prognosis of chronic liver disease,
eminences mainly cirrhosis. Although it was originally used to predict mortality
2. Discoid rash: Erythematous circular raised patches with during surgery, it is now used to determine the prognosis, as well as
adherent keratotic scaling and follicular plugging; atrophic the required strength of treatment and the necessity of liver
scarring may occur transplantation.
3. Photosensitivity: Exposure to ultraviolet light causes rash
4. Oral ulcers: Includes oral and nasopharyngeal ulcers, observed Points assigned
by physician Parameter
1 2 3
5. Arthritis: Nonerosive arthritis of two or more peripheral joints, Ascites Absent Slight Moderate
with tenderness, swelling, or effusion Bilirubin (mg/dL) </= 2 2-3 >3
6. Serositis: Pleuritis or pericarditis documented by ECG or rub or Albumin (g/dL) >3.5 2.8-3.5 <2.8
evidence of effusion Prothrombin time
7. Renal disorder: Proteinuria >0.5 g/d or 3+, or cellular casts * Seconds over 1-3 4-6 >6
8. Neurologic disorder: Seizures or psychosis without other control <1.8 1.8-2.3 >2.3
causes * INR
9. Hematologic disorder: Hemolytic anemia or leukopenia Encephalopathy None Grade 1-2 Grade 3-4
(<4000/L) or lymphopenia (<1500/L) or thrombocytopenia
(<100,000/L) in the absence of offending drugs A total score of 5-6 is considered grade A (well-compensated disease); 7-9 is grade B
10. Immunologic disorder: Anti-dsDNA, anti-Sm, and/or anti- (significant functional compromise); and 10-15 is grade C (descompensated disease).
phospholipid These grades correlate with one- and two-year patient survival.
11. Antinuclear antibodies: An abnormal titer of ANA by
immunofluorescence or an equivalent assay at any point in time Points Class One year survival Two year survival
in the absence of drugs known to induce ANAs
5–6 A 100% 85%
Any combination of 4 or more of 11 criteria, well-documented at any 7–9 B 80% 60%
time during a patient's history, makes it likely that the patient has SLE
(specificity and sensitivity are 95% and 75%, respectively). 10–15 C 45% 35%
A: well-compensated disease
Note: ECG, electrocardiography; dsDNA, double-stranded DNA; ANA, B: significant functional compromise
antinuclear antibodies. C: decompensated disease
Definition and Stages of Chronic Kidney Disease
(CKD)

NKF Definition of Chronic Kidney Disease Risk Factors for Chronic Kidney Disease and Its Outcomes
 Kidney damage for three or more months, as defined by structural or
functional abnormalities of the kidney, with or without decreased GFR,
manifested by pathologic abnormalities or markers of kidney damage, Type Definition Examples
including abnormalities in the composition of the blood or urine or Susceptibility Factors that increase Older age, family history of
abnormalities in imaging tests factors susceptibility to kidney chronic kidney disease, reduction
 GFR < 60 mL per minute per 1.73 m2 for three months or more, with or damage in kidney mass, low birth weight,
without kidney damage U.S. racial or ethnic minority
status, low income or educational
level
NKF Classification of Chronic Kidney Disease
Initiation Factors that directly Diabetes mellitus, high blood
factors initiate kidney damage pressure, autoimmune diseases,
Stage Description† GFR (mL per Action plan systemic infections, urinary tract
minute per infections, urinary stones,
1.73 m2) obstruction of lower urinary tract,
- At increased > 60 (with risk Screening, reduction of risk drug toxicity
risk for chronic factors for factors for chronic kidney Progression Factors that cause Higher level of proteinuria, higher
kidney disease chronic kidney disease factors worsening kidney blood pressure level, poor
disease) damage and faster glycemic control in diabetes,
1 Kidney damage > 90 Diagnosis and treatment, decline in kidney smoking
with normal or treatment of comorbid function after kidney
elevated GFR conditions, interventions to slow damage has started
disease progression, reduction End-stage Factors that increase Lower dialysis dose (Kt/V)*,
of risk factors for cardiovascular factors morbidity and mortality temporary vascular access,
disease in kidney failure anemia, low serum albumin level,
2 Kidney damage 60 to 89 Estimation of disease late referral for dialysis
with mildly progression
decreased GFR
*-In Kt/V (accepted nomenclature for dialysis dose), "K" represents urea clearance,
3 Moderately 30 to 59 Evaluation and treatment of "t" represents time, and "V" represents volume of distribution for urea.
decreased GFR disease complications
4 Severely 15 to 29 Preparation for kidney
NKF = National Kidney Foundation; GFR = glomerular filtration rate.
decreased GFR replacement therapy (dialysis,
transplantation)
5 Kidney failure < 15 (or Kidney replacement therapy if
dialysis) uremia is present
 Definitions for the Terms Bacteremia, Sepsis, Severe
Sepsis, Septic Shock, and Other Related Disorders
 Secondary MODS is organ failure not in direct response to the insult itself,
A 1992 American College of Chest Physicians/Society of Critical Care Medicine
consensus panel defined the following terms which are relevant to the discussion of
septic shock:
Infection: Infection is a microbial phenomenon characterized by an inflammatory
response to the presence of microorganisms or the invasion of normally sterile host
tissue by those organisms.
 Primary MODS is the result of a well-defined insult in which organ
dysfunction occurs early and can be directly attributable to the insult itself
(eg, renal failure due to rhabdomyolysis).
but as a consequence of a host response. In the context of the definitions of
sepsis and SIRS, MODS represent the more severe end of the spectrum of
severity of illness characterized by SIRS/sepsis.

Bacteremia: Bacteremia refers to the presence of viable bacteria in the blood.

Systemic inflammatory response syndrome: Systemic inflammatory response

syndrome (SIRS) is a widespread inflammatory response to a variety of severe
clinical insults. This syndrome is clinically recognized by the presence of two or more
of the following:
 Temperature >38°C or <36°C
 Heart rate >90 beats/min
 Respiratory rate >20 breaths/min or PaCO2 <32 mmHg
 WBC >12,000 cells/mm3, <4000 cells/mm3, or >10 percent immature
(band) forms

Sepsis: Sepsis is the systemic response to infection. Thus, in sepsis, the clinical
signs describing SIRS are present together with definitive evidence of infection.

Severe sepsis: Sepsis is considered severe when it is associated with organ

dysfunction, hypoperfusion, or hypotension. The manifestations of hypoperfusion
may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in
mental status.

Septic shock: Septic shock is sepsis with hypotension despite adequate fluid
resuscitation. It includes perfusion abnormalities such as lactic acidosis, oliguria, or
an acute alteration in mental status. Patients receiving inotropic or vasopressor
agents may not be hypotensive at the time that perfusion abnormalities are
measured.

Hypotension: Hypotension is defined as a systolic BP of <90 mmHg or a reduction

of >40 mmHg from baseline, in the absence of other causes for the fall in blood
pressure.

Multiple organ dysfunction syndrome: Multiple organ dysfunction syndrome

(MODS) refers to the presence of altered organ function in an acutely ill patient such
that homeostasis cannot be maintained without intervention. The multiple organ
dysfunction syndrome is classified as either primary or secondary.
 Diagnostic Criteria for Sepsis Diagnostic Criteria for Tuberculosis Disease
Infection,a documented or suspected, and some of the following:b

General variables
 Fever (core temperature >38.3°C)
Definite diagnosis
 Hypothermia (core temperature <36°C)
 Heart rate >90 /min or >2 SD above the normal value for age
 Tachypnea  Clinical picture consistent with tuberculosis; bacteriologic
 Altered mental status
confirmation (culture, gene probe/NAA + AFB smear);
 Significant edema or positive fluid balance (>20 mL/kg over 24 hrs)
 Hyperglycemia (plasma glucose >120 mg/dL or 7.7 mmol/L) in the absence of histologic findings
diabetes
Inflammatory variables Probable diagnosis
 Leukocytosis (WBC count >12,000 /mm3)
 Leukopenia (WBC count <4000 /mm3)
 Normal WBC count with >10% immature forms  Clinical picture consistent with tuberculosis; exclusion of other
 Plasma C-reactive protein >2 SD above the normal value
diagnostic considerations; presence of highly specific
 Plasma procalcitonin >2 SD above the normal value
Hemodynamic variables
tuberculosis (surrogate) marker
 Arterial hypotensionb (SBP <90 mm Hg, MAP <70, or an SBP decrease >40
mm Hg in adults or <2 SD below normal for age) Likely diagnosis
 SvO2 >70%b
 Cardiac index (CI) >3.5 L.min-1.M-23
Organ dysfunction variables  Clinical picture consistent with tuberculosis; exclusion of other
 Arterial hypoxemia (PaO2/FIO2 <300) diagnostic considerations; typical response to antituberculosis
 Acute oliguria (urine output <0.5 mL.kg-1.hr-1 or 45 mmol/L for at least 2 hrs)
 Creatinine increase >0.5 mg/dL
treatment (in absence of other treatment)
 Coagulation abnormalities (INR >1.5 or aPTT >60 secs)
 Ileus (absent bowel sounds) NOTE. AFB, acid-fast bacilli; NAA, nucleic acid amplification.
 Thrombocytopenia (platelet count <100,000 /mm3)
 Hyperbilirubinemia (plasma total bilirubin >4 mg/dL or 70 mmol/L)
Tissue perfusion variables
 Hyperlactatemia (>4 mmol/L)
 Decreased capillary refill or mottling

WBC, white blood cell; SBP, systolic blood pressure; MAP, mean arterial blood
pressure; SvO2, mixed venous oxygen saturation; INR, international normalized
ratio; aPTT, activated partial thromboplastin time.
aInfection defined as a pathologic process induced by a microorganism;
bSvO2 sat >70% is normal in children (normally, 75–80%), and CI 3.5–5.5 is normal

in children; therefore, NEITHER should be used as signs of sepsis in newborns or

children;
cdiagnostic criteria for sepsis in the pediatric population are signs and symptoms of

inflammation plus infection with hyper- or hypothermia (rectal temperature >38.5 or

< 35°C), tachycardia (may be absent in hypothermic patients), and at least one of
the following indications of altered organ function: altered mental status, hypoxemia,
increased serum lactate level, or bounding pulses.
 Diagnostic Criteria for Essential
Thrombocytopaenia (ET)
Positive criteria
Polycythemia Vera Study Group (PVSG) Diagnostic Criteria for
Essential Thrombocytopaenia (ET)
All of the following criteria must be fulfilled to make a diagnosis of ET
Criteria of exclusion
1. Platelet count greater than 600 x 109/L
2. Hematocrit less than 40 or normal red blood cell mass
3. Stainable iron in the marrow or normal RBC mean corpuscular
volume (If these measurements suggest iron deficiency,
polycythemia vera cannot be excluded unless a trial of iron
therapy fails to increase the red blood cell mass into the
polycythemic range.)
4. No Philadelphia chromosome or bcr/abl gene rearrangement
5. Collagen fibrosis of the bone marrow absent or less than one
third of the biopsy area without both marked splenomegaly
and a leukoerythroblastic blood film
6. No cytogenetic or morphologic evidence for a myelodysplastic
syndrome
7. No cause for a reactive thrombocytosis
WHO Diagnostic Criteria for Essential
Thrombocytopaenia (ET)
1. Sustained platelet count > 600x 109/l
2. Bone marrow biopsy specimen showing proliferation mainly of
the megakaryocytic lineage with increased numbers of
enlarged, mature megakaryocytes
1. No evidence of polycythaemia vera (PV)
 Normal red cell mass or Hb <18.5 g/dl in men, 16.5g/dl in
women
 Stainable iron in marrow, normal serum ferritin or normal
mean corpuscular volume (MCV)
 If the former is not met, failure of iron trial to increase red
cell mass or hemoglobin levels to the PV range
2. No evidence of CML
 No evidence of Philadelphia chromosome and no BCR/ABL
fusion gene
3. No evidence of idiopathic myelofibrosis
 Collagen fibrosis absent
 Reticulin fibrosis minimal or absent
4. No evidence of myelodysplastic syndrome
 No del(5q), t(3;3)(q21;26),inv(3)(q21q26)
 No significant granulocytic dysplasia; few, if any,
micromegakaryocytes
5. No evidence that thrombocytosis is reactive due to:
 Underlying inflammation or infection
 Underlying neoplasm
 Prior splenectomy
 CURB-65 and CRB-65 Severity Scores for Criteria for Acute Kidney Injury
Community-Acquired Pneumonia (CAP)

Clinical factor Points

Confusion 1
Blood urea nitrogen > 19 mg per dL 1
Respiratory rate > 30 breaths per minute 1
Systolic blood pressure < 90 mm Hg 1
or
Diastolic blood pressure < 60 mm Hg
Age > 65 years 1
Total points:

CURB-65 Mortality (%) Recommendation

score
0 0.6
1 2.7
2 6.8
3 14.0
4 or 5 27.8
Low risk; consider home treatment
Short inpatient hospitalization or closely
supervised outpatient treatment
Severe pneumonia; hospitalize and consider
admitting to intensive care

CRB-65 score Mortality (%) Recommendation

0 0.9
1 5.2
2 12.0
3 or 4 31.2
Very low risk of death; usually does not
require hospitalization
Increased risk of death; consider
hospitalization
High risk of death; urgent hospitalization

CURB-65 = Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of

age and older.

CRB-65 = Confusion, Respiratory rate, Blood pressure, 65 years of age and older.

PSI/PORT Score: Pneumonia Severity
Index for CAP
GOLD Staging System for Chronic Obstructive
Lung Disease (COPD) Severity
Definition
COPD is a disease state characterized by airflow limitation that is not fully
reversible. The airflow limitation is usually both progressive and associated with
an abnormal inflammatory response of the lungs to noxious particles or gases.
GOLD Staging System for COPD Severity
Stage Description Findings (based on postbronchodilator
FEV1)
0 At risk Risk factors and chronic symptoms but normal
spirometry
I Mild FEV1/FVC ratio less than 70 percent
FEV1 at least 80 percent of predicted value
May have symptoms
II Moderate FEV1/FVC ratio less than 70 percent
FEV1 50 percent to less than 80 percent of
predicted value
May have chronic symptoms
III Severe FEV1/FVC ratio less than 70 percent
FEV1 30 percent to less than 50 percent of
predicted value
May have chronic symptoms
IV Very severe FEV1/FVC ratio less than 70 percent
FEV1 less than 30 percent of predicted value
or
FEV1 less than 50 percent of predicted value
plus severe chronic symptoms
GOLD = Global Initiative for Chronic Obstructive Lung Disease; COPD = chronic
obstructive pulmonary disease; FEV1 = forced expiratory volume in one
second; FVC = forced vital capacity.
 Global Initiative for Asthma (GINA)
Classification of Asthma Severity

Symptoms/Day Symptoms/ PEF or PEF

Night FEV1 variabilit
y
STEP 1 < 1 time a week </= 2 times a >/= < 20%
month 80%
Asymptomatic and
Intermittent
normal PEF
between attacks
STEP 2 > 1 time a week > 2 times a >/= 20-30%
but < 1 time a month 80%
day
Mild Persistent
Attacks may affect
activity
STEP 3 Daily > 1 time a 60%- > 30%
week 80%
Attacks affect
Moderate Persis
activity
tent
STEP 4 Continuous Frequent </= > 30%
60%
Limited physical
Severe
activity
Persistent

PEF, Peak Expiratory Flow; FEV1, Forced Expiratory Volume in the first second.
• The presence of one of the features of severity is sufficient to place a patient
in that category.
• Patients at any level of severity-even intermittent asthma-can have severe
attacks.