PRISM NOPE Example: Sleep Apnea Presenting as Resistant Hypertension
This synthetic case represents a NOPE example for primary aldosteronism screening - a patient whose resistant hypertension and fatigue symptoms reasonably prompted aldosterone/renin testing, but whose underlying condition was obstructive sleep apnea rather than primary aldosteronism.
Clinical Narrative
A 49-year-old male accountant in Texas who developed gradually worsening hypertension despite treatment escalation. His presentation included classic features that could suggest secondary hypertension: treatment resistance, fatigue, and the need for multiple medications. When his primary care physician ordered a comprehensive secondary hypertension workup including aldosterone and renin testing, this represented appropriate clinical decision-making given his presentation. However, the concurrent sleep study revealed severe obstructive sleep apnea as the underlying cause of his resistant hypertension.
Five Ws Data Sequence
| ⚪ | ASL | WHEN | WHO | WHERE | WHAT | WHY |
|---|---|---|---|---|---|---|
| 49/M/TX | 2022-03-15 | 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; | |
| 49/M/TX | 2022-03-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-80053: Comprehensive metabolic panel | ICD10-Z00.00: Encounter for general adult medical examination without abnormal findings; | |
| 49/M/TX | 2022-03-15 | 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; | |
| 49/M/TX | 2022-04-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; | |
| 49/M/TX | 2022-04-20 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 10mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 49/M/TX | 2022-06-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; |
| 49/M/TX | 2022-06-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 49/M/TX | 2022-08-10 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; ICD10-R53.83: Other fatigue; |
| 49/M/TX | 2022-08-10 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 49/M/TX | 2022-08-10 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-59762172701: Amlodipine 5mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 49/M/TX | 2022-10-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; ICD10-R53.83: Other fatigue; ICD10-R51.9: Headache, unspecified; |
| 🟡 | 49/M/TX | 2022-10-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-I10: Essential (primary) hypertension; |
| 49/M/TX | 2022-10-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 49/M/TX | 2022-10-05 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-59762172701: Amlodipine 10mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 🟡 | 49/M/TX | 2022-12-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; ICD10-R53.83: Other fatigue; ICD10-G47.00: Sleep hypersomnia, unspecified; |
| 🟡 | 49/M/TX | 2022-12-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-I10: Essential (primary) hypertension; |
| 49/M/TX | 2022-12-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 49/M/TX | 2022-12-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-59762172701: Amlodipine 10mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 49/M/TX | 2022-12-15 | NUCC-207Q00000X: Family Medicine | POS-11: Office | NDC-61570004201: Hydrochlorothiazide 25mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 50/M/TX | 2023-02-20 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-99204: Office or other outpatient visit for evaluation and management of a new patient | ICD10-I10: Essential (primary) hypertension; ICD10-R53.83: Other fatigue; | |
| 50/M/TX | 2023-02-20 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-93000: Electrocardiogram, complete | ICD10-I10: Essential (primary) hypertension; | |
| 50/M/TX | 2023-02-20 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-80053: Comprehensive metabolic panel | ICD10-I10: Essential (primary) hypertension; | |
| 50/M/TX | 2023-03-10 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; | |
| 🔵 | 50/M/TX | 2023-03-10 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-84374: Renin | ICD10-I10: Essential (primary) hypertension; |
| 🔵 | 50/M/TX | 2023-03-10 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-82088: Aldosterone | ICD10-I10: Essential (primary) hypertension; |
| 50/M/TX | 2023-03-10 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-84146: Prolactin | ICD10-I10: Essential (primary) hypertension; | |
| 50/M/TX | 2023-03-15 | NUCC-207P50000X: Sleep Medicine | POS-11: Office | CPT-99204: Office or other outpatient visit for evaluation and management of a new patient | ICD10-G47.00: Sleep hypersomnia, unspecified; ICD10-I10: Essential (primary) hypertension; | |
| 50/M/TX | 2023-03-25 | NUCC-207P50000X: Sleep Medicine | POS-11: Office | CPT-95810: Polysomnography; sleep staging with 4 or more additional parameters of sleep | ICD10-G47.30: Sleep apnea, unspecified; | |
| 50/M/TX | 2023-04-05 | NUCC-207P50000X: Sleep Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-G47.33: Obstructive sleep apnea (adult); | |
| 50/M/TX | 2023-04-05 | NUCC-207P50000X: Sleep Medicine | POS-11: Office | HCPCS-E0601: Continuous positive airway pressure (CPAP) device | ICD10-G47.33: Obstructive sleep apnea (adult); | |
| 50/M/TX | 2023-04-20 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-99214: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; ICD10-G47.33: Obstructive sleep apnea (adult); | |
| 50/M/TX | 2023-04-20 | NUCC-207R00000X: Internal Medicine | POS-11: Office | NDC-00378514501: Lisinopril 20mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 50/M/TX | 2023-04-20 | NUCC-207R00000X: Internal Medicine | POS-11: Office | NDC-59762172701: Amlodipine 5mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 50/M/TX | 2023-06-15 | NUCC-207P50000X: Sleep Medicine | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-G47.33: Obstructive sleep apnea (adult); | |
| 50/M/TX | 2023-06-15 | NUCC-207P50000X: Sleep Medicine | POS-11: Office | HCPCS-A7030: Full face mask used with positive airway pressure device | ICD10-G47.33: Obstructive sleep apnea (adult); | |
| 50/M/TX | 2023-07-20 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; ICD10-G47.33: Obstructive sleep apnea (adult); | |
| 50/M/TX | 2023-07-20 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-84132: Potassium; serum, plasma or whole blood | ICD10-I10: Essential (primary) hypertension; | |
| 50/M/TX | 2023-07-20 | NUCC-207R00000X: Internal Medicine | POS-11: Office | NDC-00378514501: Lisinopril 10mg tablet | ICD10-I10: Essential (primary) hypertension; | |
| 50/M/TX | 2023-10-15 | NUCC-207R00000X: Internal Medicine | POS-11: Office | CPT-99213: Office or other outpatient visit for evaluation and management | ICD10-I10: Essential (primary) hypertension; ICD10-G47.33: Obstructive sleep apnea (adult); | |
| 50/M/TX | 2023-10-15 | NUCC-207R00000X: Internal Medicine | POS-11: Office | NDC-00378514501: Lisinopril 10mg tablet | ICD10-I10: Essential (primary) hypertension; |
Key Pattern Recognition Elements
What makes this a valid NOPE example:
Reasonable Clinical Suspicion: The progression from single-agent to triple-agent therapy with persistent symptoms (fatigue, headaches) provided legitimate reasons to consider secondary hypertension including primary aldosteronism.
Appropriate Timing: The aldosterone/renin testing occurred during the peak clinical concern when symptoms were worsening and medication requirements were escalating.
Concurrent Alternative Discovery: The sleep study was ordered around the same time as the hormonal workup, representing a comprehensive approach to secondary hypertension evaluation.
Clear Resolution Pattern: CPAP therapy led to meaningful improvement in blood pressure control, demonstrating that sleep apnea was indeed the underlying driver of the resistant hypertension.
Medication De-escalation: The reduction from triple therapy back to single-agent control provides strong evidence that the alternative diagnosis explained the clinical picture.
Teaching Value: This case helps PRISM learn that patterns suggesting primary aldosteronism (resistant hypertension, escalating medications, fatigue) can have alternative explanations. The key distinguishing feature may be the temporal relationship between alternative diagnosis and clinical improvement, rather than the initial presenting pattern itself.