PRISM BAD Example: Delayed Diagnosis of Primary Aldosteronism
This synthetic case represents a BAD example for primary aldosteronism screening - a patient whose early symptoms were treated empirically with escalating medications for several years, resulting in the development of serious complications before the underlying condition was finally diagnosed. This delayed recognition led to permanent organ damage and much more complex ongoing management.
Clinical Narrative
A 58-year-old male construction supervisor in Ohio whose hypertension was initially treated as essential hypertension with standard medication escalation protocols. Despite early signs that might have suggested secondary hypertension (medication resistance, low-normal potassium), the focus remained on adding more blood pressure medications rather than investigating underlying causes. Over three years, he developed increasingly severe hypertensive episodes requiring emergency care, eventual heart failure, and chronic kidney disease before primary aldosteronism was finally diagnosed. By then, the complications had become permanent, requiring ongoing complex medical management that could have been prevented with earlier recognition.
Five Ws Data Sequence
| ⚪ | ASL | WHEN | WHO | WHERE | WHAT | WHY |
|---|---|---|---|---|---|---|
| 58/M/OH | 2020-02-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99396: 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; | |
| 58/M/OH | 2020-02-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-80053: Comprehensive metabolic panel | ICD10-Z00.00: Encounter for general adult medical examination without abnormal findings; | |
| 58/M/OH | 2020-02-15 | 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; | |
| 58/M/OH | 2020-03-01 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; | |
| 58/M/OH | 2020-03-01 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 10mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 58/M/OH | 2020-05-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; |
| 58/M/OH | 2020-05-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 58/M/OH | 2020-08-10 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; ICD10-R51.9: Headache, unspecified; |
| 58/M/OH | 2020-08-10 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 58/M/OH | 2020-08-10 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-59762172701: Amlodipine 5mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 58/M/OH | 2020-11-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 58/M/OH | 2020-11-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-I10: Essential (primary) hypertension; |
| 58/M/OH | 2020-11-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 58/M/OH | 2020-11-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-59762172701: Amlodipine 10mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 59/M/OH | 2021-01-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; ICD10-R51.9: Headache, unspecified; |
| 59/M/OH | 2021-01-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-01-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-59762172701: Amlodipine 10mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-01-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-61570004201: Hydrochlorothiazide 25mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 59/M/OH | 2021-04-05 | 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; |
| 🟡 | 59/M/OH | 2021-04-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-I10: Essential (primary) hypertension; |
| 59/M/OH | 2021-04-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-04-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-59762172701: Amlodipine 10mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-04-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-61570004201: Hydrochlorothiazide 25mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 59/M/OH | 2021-07-15 | NUCC-207P00000X: Emergency Medicine | POS-23: Emergency Room - Hospital | CPT-99283: Emergency department visit for evaluation and management | ICD10-R51.9: Headache, unspecified; ICD10-I10: Essential (primary) hypertension; |
| 59/M/OH | 2021-07-15 | NUCC-207P00000X: Emergency Medicine | POS-23: Emergency Room - Hospital | CPT-93000: Electrocardiogram, complete | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-07-25 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-07-25 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-07-25 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-59762172701: Amlodipine 10mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-07-25 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-61570004201: Hydrochlorothiazide 25mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-07-25 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-68180051301: Metoprolol 50mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-10-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 59/M/OH | 2021-10-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-I10: Essential (primary) hypertension; |
| 59/M/OH | 2021-10-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-10-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-59762172701: Amlodipine 10mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-10-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-61570004201: Hydrochlorothiazide 25mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 59/M/OH | 2021-10-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-68180051301: Metoprolol 100mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 60/M/OH | 2022-01-10 | NUCC-207P00000X: Emergency Medicine | POS-23: Emergency Room - Hospital | CPT-99284: Emergency department visit for evaluation and management | ICD10-R51.9: Headache, unspecified; ICD10-I10: Essential (primary) hypertension; ICD10-R50.9: Fever, unspecified; |
| 60/M/OH | 2022-01-10 | NUCC-207P00000X: Emergency Medicine | POS-23: Emergency Room - Hospital | CPT-80053: Comprehensive metabolic panel | ICD10-I10: Essential (primary) hypertension; | |
| 60/M/OH | 2022-01-10 | NUCC-207P00000X: Emergency Medicine | POS-23: Emergency Room - Hospital | CPT-93000: Electrocardiogram, complete | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 60/M/OH | 2022-02-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; ICD10-R06.02: Shortness of breath; |
| 60/M/OH | 2022-02-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-93000: Electrocardiogram, complete | ICD10-I10: Essential (primary) hypertension; | |
| 60/M/OH | 2022-02-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-80053: Comprehensive metabolic panel | ICD10-I10: Essential (primary) hypertension; | |
| 60/M/OH | 2022-02-15 | NUCC-207RC0000X: Cardiovascular Disease | POS-11: Office | CPT-99204: Office or other outpatient visit for evaluation and management of a new patient | ICD10-I10: Essential (primary) hypertension; ICD10-R06.02: Shortness of breath; | |
| 60/M/OH | 2022-02-15 | NUCC-207RC0000X: Cardiovascular Disease | POS-11: Office | CPT-93307: Echocardiography, transthoracic, real-time with image documentation | ICD10-I10: Essential (primary) hypertension; | |
| 60/M/OH | 2022-03-05 | NUCC-207RC0000X: Cardiovascular Disease | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I50.9: Heart failure, unspecified; ICD10-I10: Essential (primary) hypertension; | |
| 60/M/OH | 2022-03-05 | NUCC-207RC0000X: Cardiovascular Disease | POS-11: Office | NDC-00078021505: Atorvastatin 20mg tablet | ICD10-I50.9: Heart failure, unspecified; | |
| 60/M/OH | 2022-03-05 | NUCC-207RC0000X: Cardiovascular Disease | POS-11: Office | NDC-00904518461: Furosemide 20mg tablet | ICD10-I50.9: Heart failure, unspecified; | |
| 60/M/OH | 2022-04-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I50.9: Heart failure, unspecified; ICD10-I10: Essential (primary) hypertension; | |
| 60/M/OH | 2022-04-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-I50.9: Heart failure, unspecified; | |
| 60/M/OH | 2022-04-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-80053: Comprehensive metabolic panel | ICD10-I50.9: Heart failure, unspecified; | |
| 60/M/OH | 2022-07-15 | NUCC-207P00000X: Emergency Medicine | POS-23: Emergency Room - Hospital | CPT-99284: Emergency department visit for evaluation and management | ICD10-I50.9: Heart failure, unspecified; ICD10-R06.02: Shortness of breath; | |
| 60/M/OH | 2022-07-16 | NUCC-207Q00000X: Family Medicine | POS-21: Inpatient Hospital | CPT-99223: Initial hospital care | ICD10-I50.9: Heart failure, unspecified; ICD10-N18.3: Chronic kidney disease, stage 3 (moderate); | |
| 60/M/OH | 2022-07-18 | NUCC-207Q00000X: Family Medicine | POS-21: Inpatient Hospital | CPT-99238: Hospital discharge day management | ICD10-I50.9: Heart failure, unspecified; ICD10-N18.3: Chronic kidney disease, stage 3 (moderate); | |
| 60/M/OH | 2022-08-05 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-99204: Office or other outpatient visit for evaluation and management of a new patient | ICD10-I50.9: Heart failure, unspecified; ICD10-I10: Essential (primary) hypertension; ICD10-N18.3: Chronic kidney disease, stage 3 (moderate); | |
| 🔵 | 60/M/OH | 2022-08-05 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-84374: Renin | ICD10-I10: Essential (primary) hypertension; |
| 🔵 | 60/M/OH | 2022-08-05 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-82088: Aldosterone | ICD10-I10: Essential (primary) hypertension; |
| 60/M/OH | 2022-08-05 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-82530: Cortisol; free | ICD10-I10: Essential (primary) hypertension; | |
| 60/M/OH | 2022-09-10 | 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; ICD10-I50.9: Heart failure, unspecified; ICD10-N18.3: Chronic kidney disease, stage 3 (moderate); | |
| 🔴 | 60/M/OH | 2022-09-10 | NUCC-207RE0101X: Endocrinology | POS-11: Office | NDC-00904659061: Spironolactone 100mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; |
| 60/M/OH | 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; ICD10-I50.9: Heart failure, unspecified; ICD10-N18.3: Chronic kidney disease, stage 3 (moderate); | |
| 60/M/OH | 2022-10-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 60/M/OH | 2022-10-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-80053: Comprehensive metabolic panel | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 60/M/OH | 2022-10-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | NDC-00904659061: Spironolactone 100mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 61/M/OH | 2023-01-20 | NUCC-207RC0000X: Cardiovascular Disease | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-I50.9: Heart failure, unspecified; ICD10-E26.09: Other primary hyperaldosteronism; | |
| 61/M/OH | 2023-01-20 | NUCC-207RC0000X: Cardiovascular Disease | POS-11: Office | CPT-93307: Echocardiography, transthoracic, real-time with image documentation | ICD10-I50.9: Heart failure, unspecified; | |
| 61/M/OH | 2023-01-20 | NUCC-207RC0000X: Cardiovascular Disease | POS-11: Office | NDC-00904518461: Furosemide 40mg tablet | ICD10-I50.9: Heart failure, unspecified; | |
| 61/M/OH | 2023-04-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-E26.09: Other primary hyperaldosteronism; ICD10-I50.9: Heart failure, unspecified; ICD10-N18.3: Chronic kidney disease, stage 3 (moderate); | |
| 61/M/OH | 2023-04-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 61/M/OH | 2023-04-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | CPT-80053: Comprehensive metabolic panel | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 61/M/OH | 2023-04-15 | NUCC-207RE0101X: Endocrinology | POS-11: Office | NDC-00904659061: Spironolactone 100mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 61/M/OH | 2023-07-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-E26.09: Other primary hyperaldosteronism; ICD10-I50.9: Heart failure, unspecified; ICD10-N18.3: Chronic kidney disease, stage 3 (moderate); | |
| 61/M/OH | 2023-07-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 61/M/OH | 2023-07-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-80053: Comprehensive metabolic panel | ICD10-N18.3: Chronic kidney disease, stage 3 (moderate); | |
| 61/M/OH | 2023-07-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00904659061: Spironolactone 100mg tablet | ICD10-E26.09: Other primary hyperaldosteronism; | |
| 61/M/OH | 2023-07-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00904518461: Furosemide 40mg tablet | ICD10-I50.9: Heart failure, unspecified; |
Key Pattern Recognition Elements
What makes this a tragic BAD example:
Missed Early Opportunities: Early signs of secondary hypertension (medication resistance, low potassium, muscle cramps) were present as early as 2020-2021 but were not investigated. Instead, medications were continually escalated.
Emergency Department Visits: Multiple ER visits for severe headaches and hypertensive episodes represented missed opportunities for comprehensive secondary hypertension evaluation.
Development of Irreversible Complications: By the time testing was finally ordered in 2022, the patient had already developed heart failure and chronic kidney disease - permanent complications that early diagnosis could have prevented.
Complex Long-term Management: The delayed diagnosis resulted in the need for multiple specialists (cardiology, endocrinology, nephrology), multiple medications, and ongoing management of complications rather than the simple single-medication management seen in early detection cases.
Late Testing Trigger: Aldosterone/renin testing was finally ordered only after complications developed, representing a reactive rather than proactive approach to secondary hypertension evaluation.
Higher Treatment Requirements: The patient required high-dose spironolactone (100mg vs 25-50mg in early cases) plus continued management of heart failure and kidney disease.
Contrast with Early Detection: This case demonstrates exactly what PRISM aims to prevent - the progression from treatable early disease to permanent complications requiring lifelong complex medical management.
Teaching Value: This case provides PRISM with a clear example of the consequences of delayed pattern recognition. The system learns that certain early patterns (resistant hypertension + low potassium + symptoms) should trigger immediate investigation rather than empirical medication escalation, helping it recognize similar situations before complications develop.
The billing pattern shows the dramatic difference in healthcare utilization between early and late diagnosis - from simple outpatient management to emergency visits, hospitalizations, and multiple specialist involvement.