PRISM GOOD Example: Early Detection of Primary Aldosteronism
This synthetic case represents a GOOD example for primary aldosteronism screening - a patient whose early symptoms prompted timely aldosterone/renin testing, leading to rapid diagnosis and treatment that prevented complications and maintained excellent long-term outcomes.
Clinical Narrative
A 45-year-old female marketing manager in Florida who developed hypertension that showed early signs of treatment resistance. Her primary care physician recognized the combination of inadequate blood pressure response, borderline low potassium, and muscle cramps as a pattern that warranted investigation for secondary causes of hypertension. The early aldosterone/renin testing revealed primary aldosteronism, enabling prompt treatment with spironolactone that quickly normalized her blood pressure and prevented the cardiovascular complications that often develop when this condition goes undiagnosed.
Five Ws Data Sequence
| ⚪ | ASL | WHEN | WHO | WHERE | WHAT | WHY |
|---|---|---|---|---|---|---|
| 45/F/FL | 2022-01-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99395: Periodic comprehensive preventive medicine reevaluation and management of an individual; 40-64 years | ICD10-Z00.00: Encounter for general adult medical examination without abnormal findings; | |
| 45/F/FL | 2022-01-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-80053: Comprehensive metabolic panel | ICD10-Z00.00: Encounter for general adult medical examination without abnormal findings; | |
| 45/F/FL | 2022-01-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-85025: Complete blood count (CBC) with differential WBC count | ICD10-Z00.00: Encounter for general adult medical examination without abnormal findings; | |
| 45/F/FL | 2022-01-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-81003: Urinalysis, automated, without microscopy | ICD10-Z00.00: Encounter for general adult medical examination without abnormal findings; | |
| 45/F/FL | 2022-03-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; | |
| 45/F/FL | 2022-03-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-93000: Electrocardiogram, complete | ICD10-I10: Essential (primary) hypertension; | |
| 45/F/FL | 2022-03-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 10mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 45/F/FL | 2022-05-10 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; |
| 🟡 | 45/F/FL | 2022-05-10 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-I10: Essential (primary) hypertension; |
| 45/F/FL | 2022-05-10 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 45/F/FL | 2022-07-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; ICD10-R25.2: Cramp and spasm; |
| 🟡 | 45/F/FL | 2022-07-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-I10: Essential (primary) hypertension; |
| 45/F/FL | 2022-07-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 45/F/FL | 2022-07-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-59762172701: Amlodipine 5mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 45/F/FL | 2022-08-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; ICD10-R25.2: Cramp and spasm; |
| 🟡 | 45/F/FL | 2022-08-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-I10: Essential (primary) hypertension; |
| 🔵 | 45/F/FL | 2022-08-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84374: Renin | ICD10-I10: Essential (primary) hypertension; |
| 🔵 | 45/F/FL | 2022-08-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-82088: Aldosterone | ICD10-I10: Essential (primary) hypertension; |
| 45/F/FL | 2022-09-10 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-99244: Office consultation for a new or established patient | ICD10-I10: Essential (primary) hypertension; | |
| 45/F/FL | 2022-09-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-99204: Office or other outpatient visit for evaluation and management of a new patient | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 45/F/FL | 2022-09-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 🟢 | 45/F/FL | 2022-09-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | NDC-00904659061: Spironolactone 25mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; |
| 45/F/FL | 2022-10-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 45/F/FL | 2022-10-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 45/F/FL | 2022-10-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-80053: Comprehensive metabolic panel | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 45/F/FL | 2022-10-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | NDC-00904659061: Spironolactone 50mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 45/F/FL | 2022-12-10 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 45/F/FL | 2022-12-10 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 45/F/FL | 2022-12-10 | NUCC-207RE0101X: Endocrinology | POS-11: Office | NDC-00904659061: Spironolactone 50mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-02-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-02-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-02-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00904659061: Spironolactone 50mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-05-20 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-05-20 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-05-20 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-93000: Electrocardiogram, complete | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-05-20 | NUCC-207RE0101X: Endocrinology | POS-11: Office | NDC-00904659061: Spironolactone 50mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-08-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-08-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-08-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00904659061: Spironolactone 50mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-11-10 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-11-10 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-11-10 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-80053: Comprehensive metabolic panel | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 46/F/FL | 2023-11-10 | NUCC-207RE0101X: Endocrinology | POS-11: Office | NDC-00904659061: Spironolactone 50mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 47/F/FL | 2024-01-25 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99395: Periodic comprehensive preventive medicine reevaluation and management of an individual; 40-64 years | ICD10-Z00.00: Encounter for general adult medical examination without abnormal findings; | |
| 47/F/FL | 2024-01-25 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-80053: Comprehensive metabolic panel | ICD10-Z00.00: Encounter for general adult medical examination without abnormal findings; | |
| 47/F/FL | 2024-01-25 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-85025: Complete blood count (CBC) with differential WBC count | ICD10-Z00.00: Encounter for general adult medical examination without abnormal findings; | |
| 47/F/FL | 2024-01-25 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00904659061: Spironolactone 50mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 47/F/FL | 2024-04-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 47/F/FL | 2024-04-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 47/F/FL | 2024-04-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00904659061: Spironolactone 50mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; |
Key Pattern Recognition Elements
What makes this a strong GOOD example:
Early Pattern Recognition: The primary care physician identified concerning signs (inadequate blood pressure response despite escalating medications, low-normal potassium, muscle cramps) and acted promptly rather than continuing to add more blood pressure medications.
Timely Testing: Aldosterone/renin testing occurred only 5 months after initial hypertension diagnosis and after just two medication adjustments, representing optimal timing for secondary hypertension evaluation.
Rapid Specialist Referral: Once testing suggested primary aldosteronism, immediate endocrinology referral enabled expert confirmation and management within weeks rather than months.
Effective Treatment Response: Spironolactone therapy quickly controlled blood pressure and resolved symptoms, with the patient maintaining excellent control on a single medication.
Prevented Complications: Early diagnosis and treatment prevented the cardiovascular complications (heart failure, kidney disease, stroke) that commonly develop when primary aldosteronism goes unrecognized for years.
Streamlined Long-term Management: The patient transitioned to routine primary care management with periodic endocrinology monitoring, demonstrating the simplicity of well-controlled primary aldosteronism.
Contrast with Delayed Diagnosis: This early detection prevented the typical progression seen in undiagnosed primary aldosteronism: escalating blood pressure medications, emergency room visits for hypertensive crises, development of heart failure or kidney disease, and the complex medical management required once complications develop.
Teaching Value: This case demonstrates the optimal pattern for PRISM to recognize - early signs of treatment-resistant hypertension with subtle secondary features that warrant immediate investigation rather than empirical medication escalation. The rapid resolution with specific therapy validates the diagnostic approach and illustrates the significant benefit of early detection.