2023 Roll no 9 CBME competence based assessment of a single patient portfolio 14F menstrual heavy bleeding 7 days

 

4/11/2026

Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 9* - Portfolio: *CASE 5 - 14F, Heavy Menstrual Bleeding - 7 Days, Rashes / Spots - 7 Days, Itching, Menarche - 10 Years, Pads - 2-3 / Day, Cycle - 28-35 Days, Platelets Before Transfusion - 57,000, Hb - 4.5 gm/dl, After Transfusion - Hb - 6.25 gm/dl, Platelets - 75,000, 1 Unit Blood - Saturday Night, Morning - Allergic Rashes + Vomiting + Chills - Cefixime, Past - 2 Years Back - Mouth Ulcers, Bleeding Lips, Rashes (Purpuras), Heavy Bleeding - 2023, Steroid - 2 Years Back, Pallor (+), Rest PICCLE (-), Provisional: Not Written - ? ITP / Thrombocytopenia / Anaemia*

Based on the anonymized text you pasted. Score 0-2 per level. Total /12.

### 1. Remember - Knowledge Recall

*Evidence in portfolio:*

- Demographics: Age / Sex: 14 years / Female, Chief Complaints: Menstrual heavy bleeding for 7 days, Rashes / Spots - 7 days, Itching, History of Present Illness: Patient was apparently asymptomatic, since 7 days ago developed heavy menstrual bleeding with rashes, Investigations / Transfusion History: Platelets before transfusion - 57,000, Hb - 4.5 gm/dl, After transfusion - Hb - 6.25 gm/dl, Platelets - 75,000, Saturday night - 1 unit of blood, At morning (allergic) rashes - vomiting - due to transfusion, Chills - T/t - Cefixime, After transfusion, at night - Normal, Menstrual History: Menarche at age of 10 yrs, Flow - Normal, Pads - 2-3 / per [day], Cycle - 28-35 days, Past History: 2 years back - Mouth ulcers (but no pain elicited by food), Bleeding of lips, Rashes (Purpuras), Heavy bleeding - 2023, Medical History: Steroid for it (2 yrs back), Personal History: Diet - Mixed, Sleep - Adequate, Appetite - Normal, Bowel & Bladder - Regular, Addiction - Nil, General Examination: P - Pallor: Present (+), I - Icterus: Absent (-), C - Cyanosis: Absent (-), C - Clubbing: Absent (-), L - Lymphadenopathy: Absent (-), E - Edema: Absent (-).

- Good details: Age / Sex - 14F, C/C - Heavy menstrual bleeding 7 days, Rashes / Spots 7 days, Itching, HOPI - Asymptomatic, then heavy bleeding + rashes 7 days ago, Investigations RESULTS - Platelets before 57,000, Hb 4.5, After transfusion Hb 6.25, Platelets 75,000 - quantified - best in Roll 9, Transfusion - 1 unit Saturday night, Morning - allergic rashes + vomiting + chills - Cefixime, After transfusion at night - Normal - complete, Menstrual - Menarche 10 years, Flow Normal, Pads 2-3/day, Cycle 28-35 days - complete, Past - 2 years back - Mouth ulcers, Bleeding lips, Rashes (Purpuras), Heavy bleeding 2023, Steroid 2 years back, Personal - Diet Mixed, Sleep Adequate, Appetite Normal, B&B Regular, Addiction Nil, PICCLE - Pallor (+), rest (-) - complete.

- Gaps: *No Occupation / School.* *No Vitals - BP, PR, RR, Temp, SpO2 missing - critical in bleeding + transfusion + chills.* *No Systemic Examination - CVS, RS, CNS, P/A missing.* *No Rash Examination - Purpura / Petechiae? Site - legs? Arms? Trunk? - missing.* *No Bleeding details - Nose bleed? Gum bleed? Joint bleed? Bruises? - missing.* *No Provisional Diagnosis - ITP? Thrombocytopenia? Anaemia? - not written.* *No Current Investigations - CBC, Peripheral smear, Coagulation, Bone marrow - missing.* *"Pads 2-3 / per [day]"* - is that now with heavy bleeding or normally? - unclear - heavy bleeding = pads soaked in 1-2 hrs? - not quantified. *Cefixime for chills / allergic reaction - why antibiotic? - not explained.*

*Score: 1 / 2*

- Partial recall - investigations RESULTS + menstrual + transfusion + past purpura good, but vitals, systemic, rash exam, diagnosis missing.

- *Next target:* Always record Vitals - all 5 - BP, PR, RR, Temp, SpO2 - in bleeding + transfusion + chills - Temp = fever? PR = tachycardia? Always record Systemic - all 4 systems. Always do Rash Examination - Type - Petechiae, Purpura, Ecchymosis, Site - legs, arms, trunk, Itching, Pain, Bleeding - gum, nose, joint. Always record Bleeding - Heavy menstrual bleeding - pads / hour, clots, duration, Nose bleed, Gum bleed, Bruises, Joint bleed. Always write Provisional Diagnosis - e.g. Immune Thrombocytopenic Purpura (ITP) with Severe Anaemia. Always record Investigations - CBC, Peripheral smear, Coagulation - PT / aPTT, Bone marrow, ANA if needed. Clarify Pads - Normally 2-3/day, Now - how many / hour? Clots?

### 2. Understand - Comprehension

*Evidence in portfolio:*

- Heavy menstrual bleeding + Rashes / Purpuras + Platelets 57,000 + Hb 4.5 + Past purpuras + Heavy bleeding 2023 + Steroid 2 years back - listed.

- But no explanation in own words of why low platelets cause heavy bleeding + purpura, why Hb 4.5 causes pallor, why transfusion causes allergic rashes + vomiting + chills.

- No explanation of ITP / Thrombocytopenia - not explained.

*Score: 1 / 2*

- Partial comprehension.

- *Next target:* Explain: Platelets 57,000 = thrombocytopenia - platelets help clotting, low platelets -> bleeding - heavy menstrual bleeding, purpura - rashes / spots, bleeding lips, mouth ulcers. Explain: Hb 4.5 gm/dl = severe anaemia - blood loss from heavy bleeding -> pallor (+), weakness, fatigue. Explain: After transfusion 1 unit - Hb 4.5 -> 6.25, Platelets 57,000 -> 75,000 - improved, but still low - need more. Explain: Transfusion reaction - allergic rashes + vomiting + chills next morning = allergic / febrile reaction to blood - antihistamine, paracetamol, stop transfusion, monitor. Explain: Past 2 years - Mouth ulcers, Bleeding lips, Purpuras, Heavy bleeding 2023, Steroid 2 years back = recurrent episodes - chronic ITP, steroid is first line - suppresses immune destruction of platelets. Explain: Menarche 10 years, Cycle 28-35 days, Pads 2-3/day = normal cycle, now heavy bleeding 7 days = abnormal - menorrhagia.

### 3. Apply - Application to Patient Care

*Evidence in portfolio:*

- Transfusion - 1 unit Saturday night, Cefixime for chills - mentioned.

- Steroid 2 years back - mentioned.

- But no student plan - no investigation plan, no management plan.

- No application of Hb 4.5 + Platelets 57,000 to care - no urgent CBC, no bleeding precautions.

*Score: 1 / 2*

- Partial application - transfusion + steroid mentioned, but no care plan.

- *Next target:* Add: CBC, Peripheral smear, Coagulation - PT / aPTT, Bone marrow, ANA, Dengue / Malaria if fever, Blood grouping. Add management - Monitor vitals, bleeding - pads, rashes, Avoid trauma, Avoid NSAIDs - aspirin / ibuprofen - worsens bleeding, Avoid IM injections, Iron, Folic acid if anaemia, Steroid - as per doctor - if ITP, Platelet transfusion if bleeding severe, Blood transfusion if Hb low, Treat transfusion reaction - antihistamine, paracetamol, stop transfusion, Follow-up, Refer - Haematology / Paediatrics. Add: If Hb 4.5 + Platelets 57,000 + heavy bleeding - urgent - check vitals, bleeding, transfuse, monitor.

### 4. Analyze - Differentiation & Interpretation

*Evidence in portfolio:*

- No provisional diagnosis, no differential list.

- No analysis of alternative causes: ITP vs Aplastic Anaemia vs Leukaemia vs Dengue vs Drug-induced thrombocytopenia.

- No analysis of transfusion reaction - allergic vs febrile - not differentiated.

- No analysis of investigations - Hb 4.5 -> 6.25, Platelets 57,000 -> 75,000 - not interpreted.

*Score: 1 / 2*

- Partial analysis - past purpura + steroid implies ITP, but not differentiated.

- *Next target:* Add differential table: Immune Thrombocytopenic Purpura (ITP) - supports 14F, Heavy menstrual bleeding 7 days, Rashes / Purpuras 7 days, Platelets 57,000, Hb 4.5 - blood loss, Past 2 years - Mouth ulcers, Bleeding lips, Purpuras, Heavy bleeding 2023, Steroid 2 years back - responded to steroid, Pallor (+), PICCLE rest (-); against - no peripheral smear, bone marrow given. Aplastic Anaemia - supports Pallor (+), Platelets low, Hb low, Bleeding; against - no pancytopenia given - WBC not given, no lymphadenopathy, no fever given. Leukaemia - supports Bleeding, Pallor, Purpura; against - No lymphadenopathy, No fever, No bone pain given, need peripheral smear. Dengue / Infection - supports Platelets low, Rashes, Itching, Chills; against - No fever given, Past 2 years recurrent purpura - dengue is acute, not recurrent. Drug-induced Thrombocytopenia - supports Platelets low; against - No drug history given except Cefixime after transfusion, Steroid 2 years back. Must analyze: Is thrombocytopenia due to immune destruction - ITP - or bone marrow failure - aplastic / leukaemia - or infection? Is transfusion reaction allergic or febrile?

### 5. Evaluate - Judgment & Reflection

*Evidence in portfolio:*

- Past - 2 years back - Mouth ulcers, Bleeding lips, Purpuras, Heavy bleeding 2023, Steroid - shows judgment - you linked past episodes to current.

- Investigations RESULTS - Before vs After transfusion - shows judgment - you compared.

- PICCLE - Pallor (+) only - shows judgment.

- But no judgment on Hb 4.5 = severe anaemia - not flagged as urgent.

- No judgment on Cefixime for allergic reaction - antibiotic for allergy? - not evaluated.

- No reflection.

*Score: 1 / 2*

- Partial evaluation - past history + before / after show judgment, but severity / Cefixime missed.

- *Next target:* Add: Can I label ITP without peripheral smear, bone marrow, coagulation? What is most urgent - 14F, Hb 4.5 + Platelets 57,000 + heavy menstrual bleeding 7 days - is she in shock, severe anaemia? What is the risk if I miss leukaemia / aplastic anaemia? What is the risk of transfusion reaction - allergic rashes + vomiting + chills - did you stop transfusion, give antihistamine? Why Cefixime - antibiotic - for chills - is this infection or transfusion reaction? What would I do differently - check vitals, check bleeding - pads / hour, check rash - purpura, check CBC, smear, coagulation? Reflection on 14F - school girl, heavy menstrual bleeding, rashes, itching, transfusion - impact on school, family, mental health, need for counselling, menstrual hygiene, bleeding precautions?

### 6. Create - Synthesis & New Learning Product

*Evidence in portfolio:*

- No original product - no algorithm, concept map, patient education material.

*Score: 0 / 2*

- Not met.

- *Next target:* Create 1-page algorithm: 14F + Heavy Menstrual Bleeding + Purpura -> Platelets + Hb -> ITP vs Aplastic vs Leukaemia -> Management, OR patient education sheet for Thrombocytopenia - Bleeding Precautions, Avoid NSAIDs, Avoid Trauma, Menstrual Care, when to go to hospital - severe bleeding, fever, bruises.

### Summary Sheet - Roll No. 9 - 2023 Batch

Bloom Level | Score /2 | Key Feedback

1. Remember | 1 | Investigations RESULTS + menstrual + past purpura good, vitals / rash / diagnosis missing

2. Understand | 1 | Low platelets + bleeding listed, ITP mechanism not explained

3. Apply | 1 | Transfusion + steroid mentioned, no bleeding precautions plan

4. Analyze | 1 | ITP implied, no differential table

5. Evaluate | 1 | Past + before / after show judgment, severity / Cefixime missed

6. Create | 0 | No original product

**Total** | **5 / 12** | **Developing - Competent**

*Overall CBME Feedback for Roll 9 - Progression:*

- CASE 1 T2DM 61M = 5/12, CASE 2 Post Femur Fracture 40F = 4/12, CASE 3 Headache + Blurring Vision 56F = 4/12, CASE 4 Post Traumatic Ulcer 49M = 5/12, *This portfolio = 5/12*

- *Progress flat, but Investigations RESULTS are now your strength:* Platelets before transfusion - 57,000, Hb - 4.5, After transfusion - Hb - 6.25, Platelets - 75,000 - that is the first time you gave Before vs After values, and that is exactly how you show transfusion effect. And Past - 2 years back - Mouth ulcers, Bleeding lips, Purpuras, Heavy bleeding 2023, Steroid - is a clean recurrent history.

- *Critical learning from this case:* You have a bleeding case with no bleeding examination - Rash - Purpura / Petechiae, Site, Bleeding - nose, gum, joint, Pads / Hour - and no vitals, no systemic exam, no provisional diagnosis. In thrombocytopenia, Rash Exam + Bleeding Quantification + Vitals ARE the case. Add Vitals + Rash Exam + Bleeding Details + Provisional - ITP - + CBC / Smear, and this case becomes 8-9/12.

2023 Roll no 9 CBME competence based assessment of a single patient portfolio 49M ulcer 1 yr swelling of left leg

 

27/10/2026

Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 9* - Portfolio: *CASE 4 - 49M, Welding Work, Swelling Left Leg - 20 Days, Ulcer - 1 Year, Ulcer Increasing - 3 Months, Accident - 5 Years Ago, Fracture -> Rod Removal -> Wound Over Stitches -> Infection - 1 Year Ago, Gradually Increasing - 3 Months, Painful, No Bleeding, Marginated Well Defined Wound, Edema Present, Healing Over Dressing, Alcohol Present, Smoking Absent, Temp 98.7 F, Pulse 80 bpm, BP 120/80 mmHg, PICCLE All Absent, Local Exam: Edema Present, Varicose Veins Absent, Sensory / Motor Present, Pain Present, Temp Normal, Provisional: Post Traumatic Ulcer - Left Leg*

Based on the anonymized text you pasted. Score 0-2 per level. Total /12.

### 1. Remember - Knowledge Recall

*Evidence in portfolio:*

- 49 years / male / Welding work, C/O: Patient came with complaints of: Swelling of leg (left) - 20 days, Ulcer since 1 year, ulcer increasing since 3 months, HOPI: Patient was asymptomatic 3 months ago, now came with onset 3 months (gradually increasing), duration 3 months, site - left leg, Mode of onset - Due to post operative trauma, patient met with accident 5 years ago, After removal of rod from the fracture after healing, Due to some wound over the stitches, patient developed infection 1 year ago and it is gradually increasing since 3 months, Pain - Painful, Bleeding - No, Surrounding - Marginated wound & well defined, edema is present, Healing - healing over dressing, Past History: N/K/C/O - Diabetes, Hypertension, TB, No similar traumatic wounds, Patient had met with accident 5 years ago, No other surgeries were done, Patient had fracture, Personal History: Diet - Mixed, Sleep - Adequate, B&B - Normal, Addictions - Alcohol present, Smoking - Absent, Family History: No family history, General Examination: Temp - 98.7 F, Pulse - 80 bpm, B.P - 120/80 mmHg, PICCLE - All absent, Local Examination: Examination of affected limb (left leg), Edema - Present, Varicose veins - Absent, Sensory / Motor function - Present, Pain - Present, Temp - Normal, Provisional Diagnosis: Post traumatic ulcer - left leg.

- Good details: Age / Sex / Occupation - 49M, Welding work, C/C - Swelling left leg 20 days, Ulcer 1 year, increasing 3 months - duration given, HOPI - Asymptomatic 3 months ago, onset 3 months, gradually increasing, site left leg, Mode - post operative trauma, Accident 5 years ago, Rod removal after healing, Wound over stitches -> Infection 1 year ago, gradually increasing 3 months, Ulcer details - Painful, No bleeding, Marginated, well defined, edema present, Healing over dressing, Past - N/K/C/O DM, HTN, TB, No similar wounds, Accident 5 years ago, Fracture, No other surgeries, Personal - Diet Mixed, Sleep Adequate, B&B Normal, Alcohol present, Smoking absent, Family - No family history, Vitals - Temp, Pulse, BP - complete, PICCLE All absent - complete, Local Exam - Edema, Varicose veins absent, Sensory / Motor present, Pain present, Temp normal - good, Provisional - Post traumatic ulcer - left leg - given.

- Gaps: *No Ulcer measurements - Size - length x breadth, Depth, Floor, Base, Edge, Discharge - missing - critical in ulcer.* *No Ulcer site details - Anterior / Posterior / Medial / Lateral left leg? Over shin? Over scar? - missing.* *No Swelling details - Pitting / Non-pitting, Up to ankle / leg - missing.* *No RR, SpO2 - vitals incomplete.* *No Systemic Examination - CVS, RS, CNS, P/A missing.* *No Investigations - CBC, ESR, CRP, Blood sugar, X-ray, Wound swab - missing.* *C/C contradiction - Ulcer 1 year vs Asymptomatic 3 months ago vs Onset 3 months* - which one? *"Healing over dressing"* - healing or not healing? - unclear. *No Distal pulses - Dorsalis pedis, Posterior tibial - missing in leg ulcer.*

*Score: 1 / 2*

- Partial recall - timeline + ulcer details + local exam good, but ulcer size / floor / discharge + systemic + investigations + pulses missing.

- *Next target:* Always do Ulcer Examination - Site - left leg - anterior / posterior / medial / lateral, over scar?, Size - cm x cm, Number - single / multiple, Shape, Edge - regular / irregular, Floor - granulation / slough / bone, Base - fixed / mobile, Discharge - serous / purulent / bloody, Surrounding skin - redness, edema, Pigmentation, Pain - painful / painless, Bleeding - yes / no, Smell. Always record Swelling - Pitting / Non-pitting, Extent - ankle / leg / knee. Always record Vitals - all 5 - BP, PR, RR, Temp, SpO2. Always record Systemic - all 4 systems. Always record Investigations - CBC, ESR, CRP, FBS / HbA1c - to rule out DM, X-ray - left leg - osteomyelitis?, Wound swab - culture. Always check Distal Pulses - Dorsalis pedis, Posterior tibial, Capillary refill. Clean contradiction - Ulcer 1 year vs Asymptomatic 3 months ago vs Onset 3 months.

### 2. Understand - Comprehension

*Evidence in portfolio:*

- Accident 5 years ago -> Fracture -> Rod removal -> Wound over stitches -> Infection 1 year ago -> Ulcer gradually increasing 3 months -> Swelling 20 days - sequence described.

- But no explanation in own words of why post-operative wound becomes chronic ulcer, why infection 1 year ago leads to non-healing, why swelling occurs.

- No explanation of post traumatic ulcer - not explained.

*Score: 1 / 2*

- Partial comprehension.

- *Next target:* Explain: Post operative trauma / wound over stitches -> infection -> tissue damage, poor blood supply, scar tissue -> chronic ulcer, does not heal. Explain: Ulcer 1 year, increasing 3 months = chronic, non-healing, not acute. Explain: Swelling left leg 20 days = infection, inflammation, venous obstruction, edema. Explain: Painful, marginated, well defined = traumatic / infective ulcer, not venous - venous is painless, irregular, with varicose veins - you checked varicose veins absent, good. Explain: Welding work - standing, heat, trauma risk - delays healing. Explain: Alcohol present - poor nutrition, poor healing, liver, infection risk.

### 3. Apply - Application to Patient Care

*Evidence in portfolio:*

- Healing over dressing - mentioned.

- Provisional - given.

- But no student plan - no investigation plan, no management plan.

- No application of ulcer + swelling + alcohol to care - no wound care, no antibiotics, no blood sugar.

*Score: 1 / 2*

- Partial application - dressing mentioned, but no care plan.

- *Next target:* Add: CBC, ESR, CRP, FBS / HbA1c, X-ray left leg, Wound swab - culture, USG Doppler if needed. Add management - Wound care - cleaning, dressing, debridement if needed, Antibiotics if infected - after swab, Analgesia - Paracetamol, Limb elevation - swelling, Avoid prolonged standing, welding, Protect leg from trauma, Diet - high protein, vitamin C, Alcohol counselling - stop alcohol, Follow-up, Refer - Surgery / Orthopaedics. Add: If ulcer 1 year, increasing 3 months, swelling 20 days - urgent - check infection, osteomyelitis, blood sugar, pulses.

### 4. Analyze - Differentiation & Interpretation

*Evidence in portfolio:*

- Provisional: Post traumatic ulcer - left leg - specific.

- Local Exam - Varicose veins absent, Sensory / Motor present, Temp normal - used to rule out venous / neuropathic ulcer - good.

- But no differential table.

- No analysis of alternative causes: Post Traumatic vs Venous vs Diabetic vs Arterial vs Osteomyelitis.

*Score: 1 / 2*

- Partial analysis - provisional specific, varicose / sensory used, but no differential table.

- *Next target:* Add differential table: Post Traumatic Ulcer - supports Accident 5 years ago, Fracture, Rod removal, Wound over stitches -> Infection 1 year ago, Ulcer increasing 3 months, Painful, Marginated well defined, Edema present, Varicose veins absent, Temp normal; against - no size / floor / discharge given. Venous Ulcer - supports Swelling left leg 20 days, Ulcer 1 year, Welding - standing; against - Varicose veins absent, Painful - venous is painless / dull, Ulcer marginated well defined - venous is irregular, shallow. Diabetic Ulcer - supports Ulcer 1 year, non-healing; against - N/K/C/O DM, Sensory / Motor present, Pain present - diabetic is painless, neuropathic. Arterial Ulcer - supports Painful, Ulcer; against - Temp normal, Sensory / Motor present, Varicose absent, need pulses - Dorsalis pedis present / absent? Osteomyelitis - supports Fracture, Rod removal, Wound -> Infection, Ulcer 1 year; against - Temp 98.7F, no fever, no discharge given, need X-ray. Must analyze: Is ulcer due to infection, poor blood supply, or osteomyelitis?

### 5. Evaluate - Judgment & Reflection

*Evidence in portfolio:*

- Negatives - N/K/C/O DM, HTN, TB, No similar traumatic wounds, Smoking Absent, Varicose veins Absent - show judgment - you ruled out DM, venous, smoking.

- Sensory / Motor present, Temp normal - shows judgment - you checked nerve + infection.

- But no judgment on 1 year ulcer - chronic, non-healing - not flagged.

- No judgment on alcohol - present - not flagged for healing.

- No reflection.

*Score: 1 / 2*

- Partial evaluation - negatives show judgment, but chronicity / alcohol missed.

- *Next target:* Add: Can I label post traumatic ulcer without size, floor, discharge, X-ray, swab, blood sugar? What is most urgent - 49M, ulcer 1 year, increasing 3 months, swelling 20 days - is this infected, osteomyelitis, or malignant change? What is the risk if I miss osteomyelitis - bone infection, non-healing? What is the risk if I miss DM - N/K/C/O DM, but did you check blood sugar? What would I do differently - measure ulcer, check pulses, check X-ray, check swab, check blood sugar, ask alcohol quantity, duration? Reflection on 49M Welding work - 1 year ulcer, swelling, alcohol - impact on work, standing, welding, family income, need for wound care, alcohol counselling, protective footwear?

### 6. Create - Synthesis & New Learning Product

*Evidence in portfolio:*

- No original product - no algorithm, concept map, patient education material.

*Score: 0 / 2*

- Not met.

- *Next target:* Create 1-page algorithm: Leg Ulcer -> Site, Size, Edge, Floor, Discharge -> Varicose? Sensory? Pulses? -> Post Traumatic vs Venous vs Diabetic vs Arterial -> Management, OR patient education sheet for Leg Ulcer - Wound Care, Limb Elevation, Protect Leg, Alcohol Stop, when to go to hospital - fever, redness, swelling, discharge, severe pain.

### Summary Sheet - Roll No. 9 - 2023 Batch

Bloom Level | Score /2 | Key Feedback

1. Remember | 1 | Timeline + ulcer details + local exam good, size / floor / pulses missing

2. Understand | 1 | Sequence described, chronic ulcer mechanism not explained

3. Apply | 1 | Dressing mentioned, no wound care / antibiotic plan

4. Analyze | 1 | Provisional specific, varicose / sensory used, no differential table

5. Evaluate | 1 | Negatives show judgment, chronicity / alcohol missed

6. Create | 0 | No original product

**Total** | **5 / 12** | **Developing - Competent**

*Overall CBME Feedback for Roll 9 - Progression:*

- CASE 1 T2DM 61M = 5/12, CASE 2 Post Femur Fracture 40F = 4/12, CASE 3 Headache + Blurring Vision 56F = 4/12, *This portfolio = 5/12*

- *Progress +1, and Local Examination is now your strength:* Local Exam - Edema Present, Varicose veins Absent, Sensory / Motor Present, Pain Present, Temp Normal - that is exactly how you rule out venous / neuropathic ulcer, and you did it. And Ulcer details - Painful, No bleeding, Marginated, well defined, Edema present - are good.

- *Critical learning from this case:* You have a 1-year ulcer with no ulcer measurements - Size, Floor, Base, Edge, Discharge - and no distal pulses, no X-ray, no swab. In leg ulcer, Ulcer Examination + Pulses + X-ray ARE the case. Add Ulcer Size / Floor / Discharge + Distal Pulses + X-ray + Swab + Blood Sugar, and this case becomes 8-9/12.

2023 Roll no 9 CBME competence based assessment of a single patient portfolio 56F headache 2 mths blurring of vision (left eye) 2 yrs

 

29/10/2026

Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 9* - Portfolio: *CASE 3 - 56F, Homemaker, Headache - 2 Months, Blurring of Vision (Left Eye) - 2 Years, K/C/O Hypertension - Cilnidipine IP 10 mg, Cataract Surgery Right Eye - 4 Years Ago, Hysterectomy - 30 Years Ago, Pulse 80 bpm, Temp 98.7 F, BP 130/80 mmHg, PICCLE Absent, CNS c/c/c, CVS S1 S2 (+), Provisional: Cataract Surgery / Hypertensive with Blurring of Vision*

Based on the anonymized text you pasted. Score 0-2 per level. Total /12.

### 1. Remember - Knowledge Recall

*Evidence in portfolio:*

- 56 years / Female / Homemaker, C/O: Headache - 2 months, Blurring of vision (Left eye) - 2 years, HOPI: Patient was asymptomatic 2 months ago then developed headache since 2 months and blurring of vision since 2 years, Patient is K/C/O - Hypertension, Past History: K/C/O Hypertension (Rx: Cilnidipine IP 10mg), N/K/C/O DM, TB, Epilepsy, Patient had cataract surgery of right eye 4 years ago, Patient had hysterectomy 30 years ago, Personal History: Diet - Mixed, Appetite - Normal, B&B - Normal, Sleep - Adequate, Addictions - Nil, Family History: No family history, General Examination: Pulse - 80 bpm, Temp - 98.7 F, B.P - 130/80 mmHg, PICCLE - Absent, Systemic Examination: CNS - c/c/c, CVS - S1S2 +, Provisional Diagnosis: Cataract Surgery / Hypertensive with blurring of vision.

- Good details: Age / Sex / Occupation - 56F, Homemaker, C/C - Headache 2 months, Blurring vision Left eye 2 years - duration given, HOPI - Asymptomatic 2 months ago, then headache 2 months, blurring 2 years, Past - K/C/O HTN - Cilnidipine IP 10 mg - dose given, N/K/C/O DM, TB, Epilepsy, Cataract surgery Right eye 4 years ago, Hysterectomy 30 years ago, Personal - Diet Mixed, Appetite Normal, B&B Normal, Sleep Adequate, Addictions Nil, Family - No family history, Vitals - Pulse 80, Temp 98.7F, BP 130/80 - complete, PICCLE Absent - complete, Systemic - CNS c/c/c, CVS S1 S2 (+) - given, Provisional - Cataract Surgery / Hypertensive with blurring of vision - given.

- Gaps: *No Headache character - Site, Onset, Character, Radiation, Aggravating / Relieving, Associated - nausea, vomiting, photophobia, dizziness - missing.* *No Vision details - Left eye blurring - gradual / sudden, pain, redness, discharge, glasses, diplopia - missing.* *No Eye Examination - Visual acuity, Pupil, Fundus, Lens, Redness - missing - critical in blurring vision.* *No RS, P/A - systemic incomplete - only CNS + CVS given.* *No RR, SpO2 - vitals incomplete.* *No Investigations - Blood sugar, Fundoscopy, Eye exam, BP monitoring - missing.* *C/C contradiction - "asymptomatic 2 months ago" vs "blurring 2 years"* - which one? *Provisional is not a diagnosis - "Cataract Surgery / Hypertensive" - is it cataract left eye, hypertensive retinopathy, or both?* *Hysterectomy 30 years ago - at age 26 - why? - not asked - relevant?*

*Score: 1 / 2*

- Partial recall - demographics + HTN drug + eye / surgery history + vitals good, but headache / vision character + eye exam + investigations + diagnosis missing.

- *Next target:* Always record Headache - Site - frontal / occipital / unilateral, Character - throbbing, dull, tight, Severity, Duration, Aggravating - stress, light, Relieving - rest, medication, Associated - nausea, vomiting, photophobia, dizziness, blurred vision. Always record Vision - Left eye blurring - gradual / sudden, pain, redness, discharge, glasses, diplopia, night vision, halos. Always do Eye Examination - Visual acuity - 6/6, 6/18, Pupil - reaction, Lens - opacity, Fundus - retinopathy, Redness. Always record Systemic - all 4 systems - CVS, RS, CNS, P/A. Always record Vitals - all 5 - BP, PR, RR, Temp, SpO2. Always record Investigations - FBS, PPBS, HbA1c, Fundoscopy, Eye - Visual acuity, Slit lamp, BP monitoring. Always write Provisional - Left Eye Cataract? Hypertensive Retinopathy? - one diagnosis. Clean contradiction - asymptomatic 2 months ago vs blurring 2 years.

### 2. Understand - Comprehension

*Evidence in portfolio:*

- HTN on Cilnidipine 10 mg -> Headache 2 months + Blurring vision Left eye 2 years, Cataract surgery Right eye 4 years ago - listed.

- But no explanation in own words of why HTN causes headache + blurring, why cataract causes blurring, why left eye now after right eye 4 years ago.

- No explanation of HTN, Cilnidipine, Cataract - not explained.

*Score: 1 / 2*

- Partial comprehension.

- *Next target:* Explain: HTN - high BP damages small vessels in eye - retina - hypertensive retinopathy -> blurring vision, and high BP -> headache. Explain: Cataract = lens becomes cloudy, opaque -> blurring vision, gradual, painless, no redness - Right eye cataract 4 years ago, operated, now Left eye blurring 2 years = Left eye cataract likely - bilateral cataract, common in 56F. Explain: Cilnidipine 10 mg = calcium channel blocker, lowers BP, BP 130/80 = controlled on medication. Explain: Headache 2 months + Blurring 2 years - different timelines - blurring is chronic, headache is recent - are they related or separate? - headache may be HTN, blurring may be cataract.

### 3. Apply - Application to Patient Care

*Evidence in portfolio:*

- On Cilnidipine IP 10 mg - mentioned.

- Provisional - given.

- But no student plan - no investigation plan, no management plan.

- No application of HTN + blurring + headache to care - no BP monitoring, no eye exam.

*Score: 0 / 2*

- Not met - no care plan.

- *Next target:* Add: BP monitoring, FBS, PPBS, HbA1c - to rule out DM - DM also causes blurring, Fundoscopy, Eye - Visual acuity, Slit lamp, Cataract grading, Lipid profile, ECG. Add management - Continue Cilnidipine 10 mg - check regularity, BP monitoring daily, Diet - low salt, Exercise, Eye - Refer Ophthalmology - urgent - cataract left eye?, Surgery if cataract confirmed, Glasses if needed, Headache - Analgesia - Paracetamol, Follow-up, Refer - Medicine / Ophthalmology. Add: If headache + blurring + HTN - urgent - check BP, check fundus, rule out hypertensive emergency, papilloedema.

### 4. Analyze - Differentiation & Interpretation

*Evidence in portfolio:*

- Provisional: Cataract Surgery / Hypertensive with blurring of vision - given.

- But no differential list.

- No analysis of alternative causes: Left Eye Cataract vs Hypertensive Retinopathy vs Diabetic Retinopathy vs Glaucoma vs Refractive Error.

*Score: 1 / 2*

- Partial analysis - provisional mentions cataract + HTN, but not differentiated.

- *Next target:* Add differential table: Left Eye Cataract - supports 56F, Blurring vision Left eye 2 years, gradual, Cataract surgery Right eye 4 years ago - bilateral cataract, N/K/C/O DM - DM also causes cataract; against - no lens opacity given, no eye exam given. Hypertensive Retinopathy - supports K/C/O HTN, Headache 2 months, Blurring 2 years, On Cilnidipine; against - BP 130/80 - controlled, no fundus findings given. Diabetic Retinopathy - supports Blurring vision; against - N/K/C/O DM, Appetite Normal, no polyuria given. Glaucoma - supports Headache, Blurring vision; against - no eye pain, redness, halos given, need IOP. Refractive Error - supports Blurring vision; against - no glasses history given. Must analyze: Is blurring due to cataract - lens - or retina - HTN / DM - or refractive - glasses? Is headache due to HTN, eye strain, or migraine?

### 5. Evaluate - Judgment & Reflection

*Evidence in portfolio:*

- Negatives - N/K/C/O DM, TB, Epilepsy, Addictions Nil - show judgment.

- BP 130/80 + Cilnidipine 10 mg - shows judgment - you checked BP control.

- Cataract surgery Right eye 4 years ago + Hysterectomy 30 years ago - shows judgment - you took surgical history.

- But no judgment on blurring 2 years - chronic, not acute - not flagged.

- No judgment on headache 2 months - new - not flagged as urgent.

- No reflection.

*Score: 1 / 2*

- Partial evaluation - negatives + BP + surgery history show judgment, but headache / blurring urgency missed.

- *Next target:* Add: Can I label cataract / hypertensive retinopathy without eye exam, fundus, visual acuity? What is most urgent - 56F, headache 2 months + blurring 2 years + HTN - is this hypertensive emergency, papilloedema, or cataract? What is the risk if I miss glaucoma - vision loss? What is the risk if I miss hypertensive retinopathy - stroke, kidney damage? What would I do differently - ask headache character, vision details, check visual acuity, check fundus, check BP monitoring, check blood sugar? Reflection on 56F Homemaker - 2 years blurring left eye, 2 months headache - impact on household work, reading, cooking, fall risk, need for eye surgery, family support?

### 6. Create - Synthesis & New Learning Product

*Evidence in portfolio:*

- No original product - no algorithm, concept map, patient education material.

*Score: 0 / 2*

- Not met.

- *Next target:* Create 1-page algorithm: Headache + Blurring Vision -> HTN? -> Eye Exam -> Cataract vs Retinopathy vs Glaucoma -> Management, OR patient education sheet for HTN + Eye - BP Monitoring, Low Salt, Eye Check, when to go to hospital - severe headache, sudden vision loss, eye pain / redness.

### Summary Sheet - Roll No. 9 - 2023 Batch

Bloom Level | Score /2 | Key Feedback

1. Remember | 1 | HTN drug + eye / surgery history good, headache / vision / eye exam missing

2. Understand | 1 | HTN + cataract listed, mechanism not explained

3. Apply | 0 | No eye / BP plan

4. Analyze | 1 | Provisional mentions cataract + HTN, no differential table

5. Evaluate | 1 | Negatives + BP show judgment, urgency missed

6. Create | 0 | No original product

**Total** | **4 / 12** | **Developing - Competent**

*Overall CBME Feedback for Roll 9 - Progression:*

- CASE 1 T2DM 61M = 5/12, CASE 2 Post Femur Fracture 40F = 4/12, *This portfolio = 4/12*

- *Progress flat, but drug history is now your strength:* K/C/O Hypertension - Rx: Cilnidipine IP 10 mg - that is the first time you gave drug + dose, and BP 130/80 = controlled - that is good. And Cataract surgery Right eye 4 years ago + Hysterectomy 30 years ago is a complete surgical history.

- *Critical learning from this case:* You have a vision case with no vision examination - Visual acuity, Pupil, Lens, Fundus - and no headache description - site, character, associated. In blurring vision, Eye Exam IS the case. Add Headache Character + Vision Details + Eye Exam + Fundoscopy + FBS / HbA1c, and this case becomes 7-8/12

2023 Roll no 9 CBME competence based assessment of a single patient portfolio 40F right thigh and back pain 5 yrs

 

28/10/2026

Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 9* - Portfolio: *CASE 2 - 40F, Homemaker, Right Thigh Pain - 5 Years, Back Pain - 5 Years, Accident - 5 Years Ago, Femur Fracture -> Surgery, Rod Removed - 1 Year Ago, HTN - Now Normal Without Medication, Pulse 80 bpm, Temp 98.7 F, BP 120/80 mmHg, PICCLE Absent, Provisional: Post Femur Fracture - Implant Removal - With Back Pain + Thigh Pain*

Based on the anonymized text you pasted. Score 0-2 per level. Total /12.

### 1. Remember - Knowledge Recall

*Evidence in portfolio:*

- 40 years / Female / Homemaker, C/O: Right thigh pain - 5 years, Back pain - 5 years, HOPI: Patient was asymptomatic 5 years ago then developed back pain and right leg pain since due to surgery, N/K/C/O - DM, TB, Epilepsy, N/K/C/O - Hypertension, Past History: Patient met with an accident 5 years ago, Femur fracture -> surgery was done, Rod has removed 1 year ago, Patient had hypertension but now it is normal without medication, Personal History: Diet - Mixed, Sleep - Adequate, B&B - Normal, Appetite - Normal, Addictions - Nil, Family History: No similar family history, General Examination: Pulse - 80 bpm, Temp - 98.7 F, Blood pressure - 120/80 mmHg, PICCLE - Absent, Provisional: Post femur fracture - Implant removal - with back pain and thigh pain.

- Good details: Age / Sex / Occupation - 40F, Homemaker, C/C - Right thigh pain 5 years, Back pain 5 years - duration given, HOPI - Asymptomatic 5 years ago, then back pain + right leg pain since due to surgery, Past - Accident 5 years ago, Femur fracture -> surgery, Rod removed 1 year ago, HTN - now normal without medication, Personal - Diet Mixed, Sleep Adequate, B&B Normal, Appetite Normal, Addictions Nil, Family - No similar history, Vitals - Pulse 80, Temp 98.7F, BP 120/80 - complete, PICCLE Absent - complete, Provisional - Post femur fracture - Implant removal - with back pain + thigh pain - given.

- Gaps: *No Local Examination - Thigh / Back - Inspection, Palpation, Movement, Gait - missing - critical in thigh + back pain.* *No Character of Pain - Site, Onset, Character, Radiation, Aggravating / Relieving, Morning stiffness, Numbness / Tingling, Weakness - missing.* *"Back pain and right leg pain since due to surgery"* - unclear - pain started after accident, after surgery, or after rod removal? *No RR, SpO2 - vitals incomplete.* *No Systemic Examination - CVS, RS, CNS, P/A missing.* *No Investigations - X-ray Femur / Spine, CBC, ESR, CRP, Vitamin D, Calcium - missing.* *No Surgery details - Which femur? Right? Open / Closed? Intramedullary nail? - missing.* *No Rod removal details - Why removed? Infection? Pain? - missing.* *HTN contradiction - N/K/C/O Hypertension vs "Patient had hypertension but now normal"* - which one?

*Score: 1 / 2*

- Partial recall - timeline + surgery + rod removal + vitals good, but local exam + pain character + investigations + systemic missing.

- *Next target:* Always do Local Examination - Thigh: Inspection - Scar, Swelling, Deformity, Gait, Palpation - Tenderness - thigh, Scar, Movement - Hip / Knee ROM, Back: Inspection - Deformity, Palpation - Tenderness - spine, Movement - Flexion / Extension / Lateral, Neurological - Sensation, Power, Reflexes. Always record Pain - Right thigh pain - site - anterior / posterior / lateral, Character - dull, aching, sharp, Radiation - hip to knee, Aggravating - walking, standing, Relieving - rest, Numbness / Tingling / Weakness? Always record Vitals - all 5 - BP, PR, RR, Temp, SpO2. Always record Systemic - all 4 systems. Always record Investigations - X-ray Femur + Spine, CBC, ESR, CRP, Vitamin D, Calcium. Always clarify - Accident -> Fracture -> Surgery -> Pain since when? -> Rod removal 1 year ago -> Pain improved / worsened? Always record Surgery - Right femur, Intramedullary nail, Date. Always clean HTN - K/C/O HTN on medication / not on medication, BP now normal.

### 2. Understand - Comprehension

*Evidence in portfolio:*

- Accident 5 years ago -> Femur fracture -> Surgery -> Rod removed 1 year ago -> Back pain + Right thigh pain 5 years - sequence described.

- But no explanation in own words of why femur fracture causes thigh pain 5 years later, why back pain occurs after femur fracture, why rod removal matters.

- No explanation of post-fracture pain - not explained.

*Score: 1 / 2*

- Partial comprehension.

- *Next target:* Explain: Femur fracture -> surgery with rod / nail -> bone heals, but soft tissue, muscle, scar, altered gait -> chronic thigh pain. Explain: Back pain 5 years = altered gait, limb length difference, muscle imbalance after femur fracture -> lumbar strain, compensatory back pain. Explain: Rod removal 1 year ago = implant removal can cause pain if bone weak, or relieve pain if implant was irritating - need to know pain before vs after removal. Explain: 40F Homemaker - standing, walking, household work - load on thigh + back. Explain: HTN now normal without medication = not on antihypertensive now, BP 120/80 confirms.

### 3. Apply - Application to Patient Care

*Evidence in portfolio:*

- Surgery done, Rod removed - mentioned.

- Provisional - given.

- But no student plan - no investigation plan, no management plan.

- No application of 5 years pain + rod removal to care - no X-ray, no physiotherapy.

*Score: 0 / 2*

- Not met - no care plan.

- *Next target:* Add: X-ray - Right Femur + Lumbar Spine - AP + Lateral, CBC, ESR, CRP, Vitamin D, Calcium, DEXA if needed. Add management - Analgesia - Paracetamol, Physiotherapy - quadriceps strengthening, hip / knee ROM, back strengthening, gait training, Weight reduction if overweight, Avoid prolonged standing, squatting, Use walking aid if needed, Calcium + Vitamin D if deficient, Follow-up, Refer - Orthopaedics. Add: If back pain + thigh pain 5 years post-fracture - urgent - check X-ray - non-union, malunion, implant site infection, limb length, gait.

### 4. Analyze - Differentiation & Interpretation

*Evidence in portfolio:*

- Provisional: Post femur fracture - Implant removal - with back pain and thigh pain - given.

- But no differential list.

- No analysis of alternative causes: Post-fracture non-union vs Malunion vs Implant site infection vs Lumbar disc vs Muscle strain.

*Score: 1 / 2*

- Partial analysis - provisional specific, but not differentiated.

- *Next target:* Add differential table: Post-Fracture Chronic Pain / Malunion / Non-union - supports Accident 5 years ago, Femur fracture -> surgery, Rod removed 1 year ago, Right thigh pain 5 years, Back pain 5 years; against - no X-ray given, no deformity, shortening given. Implant Site Infection - supports Pain after surgery, Rod removed 1 year ago; against - Temp 98.7F, PICCLE absent, no fever, redness, discharge given. Lumbar Disc / Sciatica - supports Back pain 5 years, Right leg pain; against - pain is thigh, not radiating to foot, no numbness / tingling given. Muscle Strain / Gait Alteration - supports Back pain + thigh pain, Homemaker, altered gait after fracture; against - need gait exam. Must analyze: Is pain due to bone - non-union, malunion - or soft tissue - muscle, scar - or nerve - sciatica? Is pain before rod removal vs after rod removal - improved or worsened?

### 5. Evaluate - Judgment & Reflection

*Evidence in portfolio:*

- Negatives - N/K/C/O DM, TB, Epilepsy, Hypertension, Addictions Nil - show judgment.

- "HTN now normal without medication" + BP 120/80 - shows judgment - you checked BP and medication status.

- But no judgment on 5 years pain - chronic, not acute - not flagged.

- No judgment on rod removal - why removed? - not evaluated.

- No reflection.

*Score: 1 / 2*

- Partial evaluation - negatives + BP show judgment, but rod removal / chronic pain missed.

- *Next target:* Add: Can I label post-fracture pain without X-ray, gait, neuro exam? What is most urgent - 40F, 5 years pain, rod removed 1 year ago - is this non-union, infection, or chronic pain? What is the risk if I miss non-union / infection? What would I do differently - ask pain before vs after rod removal, ask gait, limb length, ask fever, discharge, check scar, check X-ray? Reflection on 40F Homemaker - 5 years thigh + back pain, post-fracture, rod removed - impact on household work, walking, family, quality of life, need for physiotherapy, pain management?

### 6. Create - Synthesis & New Learning Product

*Evidence in portfolio:*

- No original product - no algorithm, concept map, patient education material.

*Score: 0 / 2*

- Not met.

- *Next target:* Create 1-page algorithm: Accident 5 Years Ago -> Femur Fracture -> Surgery -> Rod Removal -> Thigh Pain + Back Pain -> Examination -> X-ray -> Non-union vs Infection vs Muscle Strain -> Management, OR patient education sheet for Post Femur Fracture - Physiotherapy, Gait, Calcium, Vitamin D, when to go to hospital - fever, discharge, severe pain, unable to walk.

### Summary Sheet - Roll No. 9 - 2023 Batch

Bloom Level | Score /2 | Key Feedback

1. Remember | 1 | Timeline + surgery + rod removal good, local exam / pain / investigations missing

2. Understand | 1 | Sequence described, post-fracture pain mechanism not explained

3. Apply | 0 | No investigation / management plan

4. Analyze | 1 | Provisional specific, no differential table

5. Evaluate | 1 | Negatives + BP show judgment, rod removal missed

6. Create | 0 | No original product

**Total** | **4 / 12** | **Developing - Competent**

*Overall CBME Feedback for Roll 9 - Progression:*

- CASE 1 T2DM 61M = 5/12, *This portfolio = 4/12*

- *Progress -1, but timeline is your strength:* Accident 5 years ago -> Femur fracture -> Surgery -> Rod removed 1 year ago -> Thigh pain + Back pain 5 years - that is a clean surgical timeline, and BP 120/80 + HTN now normal without medication is a good BP / medication catch. And Provisional - Post femur fracture - Implant removal - with back pain + thigh pain - is specific.

- *Critical learning from this case:* You have a 5-year pain case with no pain description - site, character, radiation, aggravating / relieving, numbness / tingling - and no local examination - thigh scar, tenderness, gait, back tenderness, neuro exam. In post-fracture pain, Local Exam + X-ray ARE the case. Add Local Exam + Pain Character + Gait + X-ray + Pain Before vs After Rod Removal, and this case becomes 7-8/12.

2023 Roll no 9 CBME competence based assessment of a single patient portfolio 61M polyphagia 6 mths generalized weakness

 

30/10/2026

Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 9* - Portfolio: *CASE 1 - 61M, Farmer, Increase of Hunger (Polyphagia) - 6 Months, Increase in Urination - 3 Months, Generalized Weakness, Weakness + Polyuria + Polyphagia - 6 Months, On Metformin, K/C/O Diabetes, Appetite Increased, B&B Increased Urination, Provisional: Type 2 Diabetes Mellitus*

Based on the anonymized text you pasted. Score 0-2 per level. Total /12.

### 1. Remember - Knowledge Recall

*Evidence in portfolio:*

- 61 years / Male / Farmer, C/O: Increase of hunger (polyphagia) - 6 months, Increase in urination - 3 months, Generalized weakness, HOPI: Patient was asymptomatic 6 months ago, then developed weakness, polyuria and polyphagia. Duration 6 months. On treatment - Metformin, Past History: K/C/O - Diabetes, N/K/C/O - HTN, TB, Epilepsy, No surgeries or complications, Personal History: Diet - Mixed, Appetite - Increased, Sleep - Adequate, B&B - Increased urination, Addictions - Nil, Family History: No family history, Provisional: Type 2 Diabetes Mellitus.

- Good details: Age / Sex / Occupation - 61M, Farmer, C/C - Polyphagia 6 months, Polyuria 3 months, Generalized weakness - duration given, HOPI - Asymptomatic 6 months ago, then weakness + polyuria + polyphagia, Duration 6 months, On Metformin, Past - K/C/O Diabetes, N/K/C/O HTN, TB, Epilepsy, No surgeries / complications, Personal - Diet Mixed, Appetite Increased, Sleep Adequate, B&B Increased urination, Addictions Nil, Family - No family history, Provisional - Type 2 Diabetes Mellitus - given.

- Gaps: *No Polydipsia - classic triad is Polyuria + Polydipsia + Polyphagia - polydipsia missing - did you ask?* *No Weight loss - classic DM - weight loss present or absent? - missing.* *No General Examination - PICCLE missing - Pallor? Edema?* *No Vitals - BP, PR, RR, Temp, SpO2 missing - critical in DM - BP for HTN.* *No Systemic Examination - CVS, CNS, RS, P/A missing.* *No Investigations - FBS, PPBS, HbA1c, Urine - missing - no values to prove DM.* *No Metformin dose, duration, regularity - missing.* *No Complications - Retinopathy, Neuropathy, Nephropathy, Foot ulcer - missing.* *C/C contradiction - Polyuria 3 months vs HOPI Polyuria 6 months* - which one?

*Score: 1 / 2*

- Partial recall - classic symptoms + Metformin + provisional good, but polydipsia / weight loss / exam / vitals / investigations missing.

- *Next target:* Always ask classic DM triad + weight loss - Polyuria, Polydipsia, Polyphagia, Weight loss, Weakness, Blurred vision, Numbness / Tingling, Foot ulcer, Delayed wound healing. Always record General Examination - PICCLE, BMI, Weight, Systemic Examination - all 4 systems, especially CNS - sensation, reflexes, P/A, Foot exam. Always record Vitals - all 5 - BP, PR, RR, Temp, SpO2 - BP is critical in DM - HTN. Always record Investigations RESULTS - FBS - value, PPBS - value, HbA1c - value, Urine - sugar / protein / ketones. Always record Metformin - Dose, Duration, Regularity, Side effects. Always ask Complications - Eye, Kidney, Nerve, Foot, Heart. Clean contradiction - Polyuria 3 months vs 6 months.

### 2. Understand - Comprehension

*Evidence in portfolio:*

- Weakness + Polyuria + Polyphagia - 6 months, On Metformin, Provisional T2DM - listed.

- But no explanation in own words of why DM causes polyuria, polyphagia, weakness.

- No explanation of T2DM, Metformin - not explained.

*Score: 1 / 2*

- Partial comprehension.

- *Next target:* Explain: T2DM = insulin resistance + relative insulin deficiency, blood sugar high, glucose spills in urine, water follows glucose -> polyuria, increased urination. Explain: Polyuria -> dehydration -> thirst -> polydipsia - you did not ask polydipsia. Explain: Cells cannot use glucose -> body thinks starving -> hunger -> polyphagia, appetite increased, but glucose lost in urine -> energy loss -> generalized weakness, weight loss. Explain: Farmer - physical work, weakness impacts work. Explain: Metformin = decreases liver glucose production, increases insulin sensitivity, does not cause hypoglycaemia alone.

### 3. Apply - Application to Patient Care

*Evidence in portfolio:*

- On treatment - Metformin - mentioned.

- Provisional - T2DM - given.

- But no student plan - no investigation plan, no management plan.

- No application of polyuria + polyphagia + weakness to care - no blood sugar monitoring, no diet.

*Score: 1 / 2*

- Partial application - Metformin mentioned, but no care plan.

- *Next target:* Add: FBS, PPBS, HbA1c, Urine - sugar / protein / ketones, RFT - urea, creatinine, Lipid profile, ECG, Eye - Fundoscopy, Foot exam. Add management - Continue Metformin - check dose, regularity, Diet - low sugar, low refined carbs, high fibre, regular meals, Exercise - walking 30 min/day, Blood sugar monitoring - FBS / PPBS, HbA1c every 3 months, Weight, BMI, BP monitoring, Foot care - wash, dry, no barefoot, Follow-up, Refer - Medicine / Ophthalmology. Add: If polyuria + polyphagia + weakness - urgent - check blood sugar, HbA1c, urine ketones, rule out DKA / HHS.

### 4. Analyze - Differentiation & Interpretation

*Evidence in portfolio:*

- Provisional: Type 2 Diabetes Mellitus - given.

- But no differential list.

- No analysis of alternative causes: T2DM vs T1DM vs Secondary DM vs Polyuria causes.

*Score: 1 / 2*

- Partial analysis - T2DM named, but not differentiated.

- *Next target:* Add differential table: Type 2 Diabetes Mellitus - supports 61M, Farmer, Polyphagia 6 months, Polyuria 3 months, Generalized weakness, Appetite Increased, K/C/O Diabetes, On Metformin, No family history; against - no HbA1c, FBS given, no polydipsia, weight loss given. Type 1 Diabetes Mellitus - supports Polyuria, Polyphagia, Weakness; against - 61M, no weight loss, no ketones given, On Metformin - T1 needs insulin. Secondary DM - Steroids, Pancreatitis - supports Polyuria, Polyphagia; against - No steroid history, No pancreatitis given. Polyuria causes - DM, CKD, Diuretics - supports Polyuria; against - No CKD, diuretic history given. Must analyze: Is polyuria due to DM - high sugar - or CKD - kidney damage - or diuretics? Is polyphagia due to DM or thyroid - hyperthyroidism - weight loss, tremor, palpitation - not asked.

### 5. Evaluate - Judgment & Reflection

*Evidence in portfolio:*

- Negatives - N/K/C/O HTN, TB, Epilepsy, No surgeries or complications, Addictions Nil - show judgment.

- "No family history" - shows judgment - you checked family risk.

- But no judgment on DM control - On Metformin, but polyphagia + polyuria + weakness still present - uncontrolled? - not flagged.

- No judgment on missing investigations - no HbA1c - not evaluated.

- No reflection.

*Score: 1 / 2*

- Partial evaluation - negatives show judgment, but DM control / missing data missed.

- *Next target:* Add: Can I label T2DM without FBS / PPBS / HbA1c? What is most urgent - 61M, polyuria + polyphagia + weakness 6 months, on Metformin - is DM uncontrolled? What is the risk if I miss DKA / HHS, retinopathy, nephropathy, neuropathy, foot ulcer? What would I do differently - ask polydipsia, weight loss, blurred vision, numbness, foot ulcer, check BMI, BP, foot exam, check HbA1c? Reflection on 61M Farmer - 6 months weakness + polyuria + polyphagia - impact on farming, work, family income, need for diet, exercise, regular medication?

### 6. Create - Synthesis & New Learning Product

*Evidence in portfolio:*

- No original product - no algorithm, concept map, patient education material.

*Score: 0 / 2*

- Not met.

- *Next target:* Create 1-page algorithm: Polyphagia + Polyuria + Weakness -> DM Triad -> Examination -> FBS + HbA1c -> T2DM vs T1DM -> Management, OR patient education sheet for T2DM - Diet, Exercise, Foot Care, Blood Sugar Monitoring, when to go to hospital - vomiting, breathlessness, confusion, foot ulcer.

### Summary Sheet - Roll No. 9 - 2023 Batch

Bloom Level | Score /2 | Key Feedback

1. Remember | 1 | Classic symptoms + Metformin good, exam / vitals / investigations missing

2. Understand | 1 | Symptoms listed, DM mechanism not explained

3. Apply | 1 | Metformin mentioned, no diet / monitoring plan

4. Analyze | 1 | T2DM named, no differential table

5. Evaluate | 1 | Negatives show judgment, DM control missed

6. Create | 0 | No original product

**Total** | **5 / 12** | **Developing - Competent**

*Overall CBME Feedback for Roll 9 - Progression:*

- *This portfolio = 5 / 12* - First case for Roll 9

- *Strength:* You captured the classic DM story in 3 lines - Polyphagia 6 months, Polyuria 3 months, Generalized Weakness, Appetite Increased, On Metformin - that is clean, and Provisional: Type 2 Diabetes Mellitus is correct. And Negatives - N/K/C/O HTN, TB, Epilepsy, No surgeries / complications, Addictions Nil - are complete.

- *Critical learning from this case:* You have a DM case with no DM proof - no FBS, PPBS, HbA1c values, no polydipsia, no weight loss, no exam, no vitals, no complications. In DM, HbA1c + Foot Exam + Eye Exam + BP are the case. Add PICCLE + Vitals + Systemic Exam + Foot Exam + FBS / PPBS / HbA1c RESULTS + Polydipsia / Weight Loss, and this case becomes 8-9/12.

2023 Roll no 8 CBME competence based assessment of a single patient portfolio 33M stomach pain 2 days vomiting 4 times a day loose stools

 

22/10/2026

Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 8* - Portfolio: *CASE 2 - 33M, Driver, Stomach Pain - 2 Days, Vomiting - 4 Times/Day, Loose Stools - Watery, Pain Periumbilical -> Migrated to Right Iliac Fossa, Dull Ache -> Severe Well Localised, Aggravated Walking / Coughing / Movement, Relieved Lying Still, Vomiting Food Particles -> Watery Non-Bilious, Surgery Done - 23/10/2026, Alcoholic - 10 Years, Last Intake - 4 Days Ago, P/A: Scaphoid, All Quadrants Moving Synchronously, No Scars / Sinuses / Swellings / Pulsation + Socratic Questions*

Based on the anonymized text you pasted - Date: 22/10/2026. Score 0-2 per level. Total /12.

### 1. Remember - Knowledge Recall

*Evidence in portfolio:*

- Demography: 33 yrs / Male / Driver, Date: 22/10/2026, Chief complaints: Stomach pain - 2 days ago, Vomiting - 4 times a day, Loose stools, HOPI: Pt was apparently asymptomatic 2 days ago, later she developed stomach pain which was around umbilical area on 22nd Oct 2026 and admitted into hospital, Over several hrs, pain (dull, ache) increased in severity and migrated to right iliac fossa, become severe and well localized, Pain is aggravated by walking, coughing and movement, partially relieved by lying still, Pt also complained vomiting - 4 times a day with food particles initially later watery fluid, non bilious, Loose stools - watery, Surgery done on 23rd Oct 2026, Past H/O: N/K/C/O of DM, HTN, Epilepsy, Personal H/O: Diet - Mixed, Sleep - Adequate, Appetite - Used, Bladder - Regular, Bowel - Inward, Addiction - Alcoholic (for 10 yrs), last intake 4 days ago, Family H/O: No significant H/O, Gen examination: Pt c/c/c, PICCLE - absent, Systemic Exam: CVS - S1S2+, RS - NVBS B/L, CNS - NFD, Per Abdomen: On Inspection - Abdomen is scaphoid, All quadrants are moving synchronously with respiration, No scars, sinuses, No swellings, pulsation.

- Good details: Age / Sex / Occupation / Date - 33M, Driver, 22/10/2026, C/C - Stomach pain 2 days, Vomiting 4 times/day, Loose stools, Pain pattern - Periumbilical -> Migrated to RIF, dull ache -> severe well localised, over several hrs, Aggravated walking / coughing / movement, Partially relieved lying still, Vomiting - 4 times/day, food particles -> watery, non-bilious, Loose stools - watery, Surgery done 23/10/2026, Personal - Diet Mixed, Sleep Adequate, Bladder Regular, Addiction - Alcoholic 10 years, last intake 4 days ago, PICCLE absent, Systemic - CVS, RS, CNS - complete, P/A Inspection - Scaphoid, All quadrants moving synchronously, No scars, sinuses, swellings, pulsation - complete.

- Gaps: *Sex contradiction - "33 yrs / Male" vs "later she developed"* - which one? *No Vitals - BP, PR, RR, Temp, SpO2 missing - critical in acute abdomen + vomiting + loose stools.* *No P/A Palpation / Percussion / Auscultation - Tenderness RIF? Rebound? Guarding? Rigidity? McBurney point? Rovsing? Psoas? Obturator? Bowel sounds? - missing - critical in appendicitis.* *No Investigations - CBC, CRP, USG Abdomen, X-ray, Urine - missing.* *No Provisional Diagnosis - Acute Appendicitis? - not written - only implied by Socratic questions.* *No Surgery details - Appendectomy? Open / Laparoscopic? Findings - inflamed / perforated appendix?* *Personal History errors - Appetite - "Used"?, Bowel - "Inward"? - unclear.* *No Associated - Fever? Anorexia? - missing.*

*Score: 1 / 2*

- Partial recall - pain migration + vomiting pattern + P/A inspection good, but vitals, palpation, investigations, diagnosis, surgery details missing.

- *Next target:* Clean Sex - Male, use "he" throughout. Always record Vitals - all 5 - BP, PR, RR, Temp, SpO2 - in acute abdomen + vomiting + loose stools - Temp = fever? PR = tachycardia? Always do P/A - Inspection + Palpation + Percussion + Auscultation - Palpation: Tenderness RIF, McBurney point tenderness, Guarding, Rigidity, Rebound tenderness, Rovsing, Psoas, Obturator, Percussion: Liver dullness, Auscultation: Bowel sounds - present / absent / increased. Always record Investigations - CBC - WBC, CRP, USG Abdomen - appendix diameter, free fluid, Urine - to rule out UTI. Always write Provisional Diagnosis - Acute Appendicitis. Always record Surgery - Appendectomy - open / laparoscopic, Findings - inflamed / gangrenous / perforated, Histopathology. Fix Personal History - Appetite - Normal / Decreased, Bowel - Regular / Loose stools.

### 2. Understand - Comprehension

*Evidence in portfolio:*

- Pain periumbilical -> migrated to RIF, dull ache -> severe well localised, aggravated walking / coughing / movement, relieved lying still - described.

- Socratic Q1 asks why pain initially periumbilical before shifting to RIF - visceral vs parietal peritoneal pain - shows you are thinking about mechanism.

- But no explanation in own words in HOPI - mechanism not explained in case itself, only in questions.

*Score: 1 / 2*

- Partial comprehension - pain migration described, Socratic questions show mechanism thinking, but not explained in case.

- *Next target:* Explain in HOPI: Periumbilical pain = visceral pain - T10 dermatome, appendix visceral afferents, dull, poorly localised. RIF pain = parietal peritoneal pain - inflammation reaches parietal peritoneum, somatic, severe, well localised. Explain: Aggravated walking / coughing / movement, relieved lying still = peritoneal irritation. Explain: Vomiting food particles -> watery, non-bilious, 4 times/day = reflex vomiting from appendiceal inflammation, not obstruction - obstruction would be bilious, persistent. Explain: Loose stools watery = pelvic appendix irritating rectum, not primary enteritis. Explain: Driver + Alcoholic 10 years - pain tolerance, delayed presentation, masking of peritoneal signs.

### 3. Apply - Application to Patient Care

*Evidence in portfolio:*

- Admitted into hospital 22/10/2026, Surgery done 23/10/2026 - mentioned.

- But no student plan - no investigation plan, no management plan written by student.

- No application of pain migration + RIF tenderness to care - no urgent USG, no appendectomy decision.

*Score: 1 / 2*

- Partial application - admission + surgery applied, but no care plan.

- *Next target:* Add: CBC, CRP, USG Abdomen, Urine, Blood grouping, ECG, Anaesthesia fitness. Add management - Nil by mouth, IV fluids - vomiting 4 times/day + loose stools = dehydration, Antibiotics - pre-op, Analgesia - Paracetamol, avoid NSAIDs if kidney / alcohol liver, Appendectomy - open / laparoscopic - urgent, Monitor - vitals, Temp, PR, Pain, Bowel sounds, Post-op - early mobilisation, Diet, Wound care, Alcohol counselling - 10 years, last intake 4 days ago - withdrawal risk, liver function, Follow-up, Refer - Surgery. Add: If pain RIF + vomiting + loose stools - urgent - check vitals, P/A palpation, USG, do not give laxative / enema.

### 4. Analyze - Differentiation & Interpretation

*Evidence in portfolio:*

- Socratic Q2 asks: Given vomiting + loose stools, how differentiate simple appendicitis from intestinal obstruction or primary infectious enteritis? - shows differentiation thinking.

- Socratic Q3 asks: What separates immediate surgery from conservative antibiotic therapy? - shows decision analysis.

- But no differential table in case itself - no analysis of alternative causes: Acute Appendicitis vs Gastroenteritis vs UTI vs Ureteric Colic vs Mesenteric Adenitis.

*Score: 2 / 2*

- Full analysis - Socratic questions force differentiation + surgical decision, best in Roll 8 so far.

- *Next target:* Add differential table in case: Acute Appendicitis - supports 33M, pain periumbilical -> RIF, dull -> severe well localised, aggravated walking / coughing / movement, relieved lying still, vomiting 4 times/day, non-bilious, loose stools watery, surgery done 23/10/2026; against - no fever, anorexia, RIF tenderness given. Gastroenteritis - supports vomiting + loose stools watery; against - pain migrated to RIF, severe well localised, aggravated movement - gastroenteritis is diffuse, crampy, not localised. Intestinal Obstruction - supports pain, vomiting, loose stools; against - vomiting non-bilious, not persistent, abdomen scaphoid, all quadrants moving synchronously, no distension. UTI / Ureteric Colic - supports pain, vomiting; against - pain periumbilical -> RIF, no dysuria, hematuria, loin pain given. Mesenteric Adenitis - supports young, pain RIF, vomiting, loose stools; against - pain migrated, severe, well localised, surgery done.

### 5. Evaluate - Judgment & Reflection

*Evidence in portfolio:*

- Socratic Q2: Role of driver / alcohol use in pain tolerance, delayed presentation, masking peritoneal signs - shows judgment.

- Socratic Q3: Chronic alcohol use impact on perioperative management, liver function, post-surgical recovery - shows judgment.

- Negatives - N/K/C/O DM, HTN, Epilepsy - show judgment.

- But no judgment on surgery timing - 22/10 admitted, 23/10 surgery - 1 day delay - why? - not evaluated.

- No judgment on missing vitals / palpation - not evaluated.

- No reflection.

*Score: 1 / 2*

- Partial evaluation - Socratic questions show judgment, but surgery delay / missing exam missed.

- *Next target:* Add: Can I label acute appendicitis without RIF tenderness, USG, WBC? What is most urgent - 33M, pain RIF severe well localised + vomiting 4 times/day + loose stools - is this perforation? What is the risk if I miss perforation / peritonitis? What is the risk of alcohol withdrawal - 10 years, last intake 4 days ago - post-op delirium, liver dysfunction? What would I do differently - check vitals, check RIF tenderness, check fever, check anorexia, check USG, check alcohol withdrawal - CIWA? Reflection on 33M Driver - 2 days pain, vomiting, loose stools, alcohol 10 years - impact on work, driving, family, need for alcohol counselling, delayed presentation?

### 6. Create - Synthesis & New Learning Product

*Evidence in portfolio:*

- Socratic questions designed to guide clinical reasoning - 1. Pathophysiology & Symptom Evolution - Why periumbilical before RIF? How migration helps distinguish from gastroenteritis? 2. Clinical Presentation & Differential Diagnosis - Vomiting + loose stools, differentiate appendicitis from obstruction / enteritis, Role of driver / alcohol, 3. Management & Surgical Decision-Making - Immediate surgery vs conservative antibiotics, Chronic alcohol impact on perioperative / liver / recovery - 6 questions, 3 domains - original product.

- This is the first Create in Roll 8.

*Score: 2 / 2*

- Full creation - Socratic questions are an original learning product, not a copy.

- *Next target:* Keep this format for every case - 6 Socratic questions, 3 domains - Pathophysiology, Differential, Management - and answer them yourself in 2-3 lines each. Add 1-page algorithm: Periumbilical Pain -> Migrated to RIF -> Vomiting + Loose Stools -> Examination -> USG -> Appendectomy vs Conservative.

### Summary Sheet - Roll No. 8 - 2023 Batch

Bloom Level | Score /2 | Key Feedback

1. Remember | 1 | Pain migration + vomiting pattern good, vitals / palpation / diagnosis missing

2. Understand | 1 | Pain migration described, visceral vs parietal not explained in case

3. Apply | 1 | Admission + surgery applied, no IV fluids / antibiotic plan

4. Analyze | 2 | Socratic questions force differentiation + surgical decision

5. Evaluate | 1 | Alcohol / driver show judgment, surgery delay missed

6. Create | 2 | Socratic questions - first Create in Roll 8

**Total** | **8 / 12** | **Proficient - Advanced**

*Overall CBME Feedback for Roll 8 - Progression:*

- CASE 1 Joint Pains 56F = 4/12, *This portfolio = 8/12*

- *Progress +4, and this is your best case so far:* Pain migration - Periumbilical -> RIF, dull ache -> severe well localised, aggravated walking / coughing / movement, relieved lying still - is textbook acute appendicitis, and you captured it. And Socratic Questions - 6 questions, 3 domains - Pathophysiology, Differential, Management - are the first Create in Roll 8, and they force the exact reasoning this case needs - visceral vs parietal pain, appendicitis vs gastroenteritis vs obstruction, surgery vs conservative, alcohol + perioperative risk.

- *Critical learning from this case:* You have a surgical case with no surgical examination - P/A Palpation - RIF tenderness, McBurney, Guarding, Rigidity, Rebound - is missing, and no vitals, no investigations, no provisional diagnosis, no surgery details - Appendectomy? Findings? Add P/A Palpation + Vitals + USG / CBC + Provisional Diagnosis + Surgery Details, and this case becomes 10-11/12.

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