Three Clinical States Model

Chronic Diseases with Acute Exacerbations

Classify First Then Manage Accordingly Control Prevents the Next Flare
Reminder

If a known asthmatic comes wheezing —
it is asthma until proven otherwise.

The rule Stabilise the horse before searching for zebras. Do not delay emergency management to chase rare diagnoses.
The question Before anything else — which clinical state is this patient in? The answer determines your entire mindset.
The goal Not just to treat the acute episode. To prevent the next one from ever happening.
Core Concept

Ther are paediatric diseases which are chronic conditions with intermittent acute exacerbations. They do not present once — they recur. And whether they recur depends largely on what happens between episodes.

Every encounter with such a patient belongs to one of three states. Different state → different mindset → different management. Confusing the states is one of the most common sources of clinical error at the house officer level.

Disease Course

The Consequence of Poor Maintenance

Disease Activity POOR MAINTENANCE GOOD MAINTENANCE Intervene Intervene Baseline Controlled Optimise maintenance State 1: First Dx State 2: Flare State 2: Flare State 3: Maintained TIME
First presentation — State 1 — Diagnose & treat
Acute flare — State 2 — Intervene immediately
Controlled baseline — State 3 — Goal of maintenance
The key insight: The two peaks on the left are not inevitable. They are the consequence of failed maintenance. A patient kept in State 3 — truly controlled — does not spike back into State 2. Every acute admission is a question about what happened to State 3.
The Model

Three States — three mindsets, three priorities

01

First Presentation

Diagnostic Phase
Mindset

Diagnose

  • Confirm the diagnosis
  • Exclude important differentials
  • Start standard first-line therapy
  • Educate patient and family
  • Set up a maintenance plan
02

Acute Exacerbation

Emergency Phase
Mindset

Stabilise

  • Treat the acute episode immediately
  • Do not delay for rare diagnoses
  • Identify the trigger after stabilisation
  • Review and adjust long-term therapy
  • Ask: why did maintenance fail?
03

Maintenance Phase

Preventive Phase
Mindset

Prevent

  • Optimise medication adherence
  • Adjust dose to achieve control
  • Identify and avoid triggers
  • Monitor for long-term complications
  • Educate — control is the goal
The Critical Relationship

If State 3 fails —
the patient returns to State 2.

State 3 — Maintained Patient is controlled. Disease activity low. No acute episodes.
→
Maintenance Fails Poor adherence. Missed medications. Uncontrolled triggers. No follow-up.
→
State 2 — Acute Flare Emergency presentation. Avoidable admission. Preventable suffering.
Every acute admission in a known chronic disease patient is a question about State 3. Was the patient actually maintained? Were they adherent? Were triggers addressed? The acute episode is the symptom — the failed maintenance is the cause.
Summary

At a glance — classify first, manage accordingly

State Patient Presentation Mindset Priority Action
First Presentation Never diagnosed before. New symptoms. Diagnostic Diagnose correctly
Acute Exacerbation Known chronic patient, acutely unwell. Emergency Stabilise immediately
Maintenance Phase Stable or partially controlled between episodes. Preventive Prevent recurrence
Examples

Same model — across every chronic disease

01 — First Presentation

First wheezing episode. Diagnose, start controller therapy, educate on inhaler technique and triggers.

02 — Acute Exacerbation

Known asthmatic + wheeze + breathlessness. Treat acute asthma immediately. Identify trigger after stabilisation. Adjust long-term therapy.

03 — Maintenance

Step-up or step-down inhaler therapy. Assess control at every visit. Address adherence, technique, trigger avoidance.

Known asthmatic + wheeze → treat as asthma first. Do not delay bronchodilator while considering rare diagnoses.
01 — First Presentation

First unprovoked seizure. Evaluate cause. Decide on antiepileptic therapy. Not every first seizure needs immediate treatment — context matters.

02 — Acute Exacerbation

Known epileptic + seizure. Treat the seizure. Then ask: missed medication? Fever? Sleep deprivation? Do not immediately assume brain tumour.

03 — Maintenance

Drug level monitoring. Adherence review. Seizure diary. Lifestyle counselling. Adjust therapy if breakthrough seizures occur.

Known epileptic + seizure → treat the seizure first. Do not defer emergency management to investigate rare causes.
01 — First Presentation

First episode of oedema + proteinuria. Diagnose, check for red flags, start steroids. Educate family on relapse recognition.

02 — Acute Exacerbation

Known nephrotic child + oedema. Most likely: relapse. Treat the relapse. Review long-term strategy after response.

03 — Maintenance

Prevent frequent relapses. Monitor urine protein at home. Steroid-sparing agents if frequent relapser. Watch for complications.

Known nephrotic child + oedema → relapse until proven otherwise. Start steroid protocol.
01 — First Presentation

First unexplained joint bleed or unusual bleeding. Confirm clotting factor deficiency. Type (A or B) and severity guide the management plan.

02 — Acute Exacerbation

Known haemophiliac + joint swelling. Replace factor immediately. Do not delay for extensive investigation. Time is joint tissue.

03 — Maintenance

Prophylactic factor replacement to prevent bleeds. Protect target joints. Physiotherapy. Inhibitor screening. Avoid NSAIDs.

Known haemophiliac + joint bleed → replace factor first. Do not delay while investigating extensively.
Common House Officer Errors This Prevents

What state confusion leads to

Over-investigating a known flare before stabilising the patient
Missing a relapse in a known chronic disease patient
Treating only the acute episode without addressing maintenance
Failing to ask why maintenance failed after each acute admission
Final Take-Home Message
"Classify the state first.
Then manage accordingly."

The acute flare is not bad luck. It is the consequence of a state that was not maintained.
Your job does not end when the patient leaves the ward.

Diagnose · Stabilise · Prevent Control prevents the next flare Safe medicine is structured medicine
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